1209PANEL AND CONTRACT PRACTICE

surveyed population during the year 16 were amongpersons never vaccinated and only 1 among personswho had been vaccinated (in this one case forty yearspreviously). The chief risk of variola major to theStates comes, according to Hedrich, from Mexicoand, in lesser degree, the Asiatic ports, if immigration,including smuggled labour from these sources, shouldbe resumed with the return of more prosperous times.

Small-pox in East Sussex

Among the Registrar-General’s notifications ofinfectious diseases for the week ended May 2ndappeared two cases of small-pox in Brighton and onein Hove. We learn that the cases arose in this way.Mrs. A, who had been vaccinated and revaccinated-the last time in 1930, when it seems doubtful if ittook-was returning from India and probably wasinfected at Port Said. She left the boat at Plymouthon April 1st, felt tired on the 5th, definitely unwellon the 6th, and on the 7th she had what she thoughtwas an attack of malaria for which she took quinine.A doctor was called in on the 8th and prescribedfurther doses of quinine, which the patient tookin more rapid sequence than was prescribed. By the10th the temperature fell and spots appeared. Therash was considered suspicious of small-pox by thedoctor but, as he had never seen a case of it himself,on April 13th he called in a consultant who diagnoseda quinine rash.The first warning received by the local health

authorities was when a nurse, who had been withMrs. A on the llth, 12th, and 13th, developed arash on the 28th. On this occasion the doctor inattendance called in the medical officer of health forHove. Small-pox was diagnosed and the case wasremoved to hospital on the 30th. The medicalofficer of health for Brighton then went to see Mrs A,found numerous quite typical seeds in the soles ofher feet, and learned that one of her maids was ather home ill. This illness was also found to be small-pox with onset on the 26th. Practitioners in Brightonand Hove were at once informed of the occurrence ofsmall-pox and asked to notify any doubtful rashes.No further case of small-pox has been notified todate except the husband of the nurse who had beenkept under observation and was removed on

suspicion at onset and before the development of therash.The vaccinal history of the four cases should be

mentioned. Mrs. A, as already noted, had beenvaccinated several times. The nurse had beenvaccinated in infancy and revaccinated ; she hada typical mild attack. The maid, aged 65, had beenvaccinated in infancy; she had a typical severe

attack and for a time was seriously ill. The nurse’shusband had been vaccinated in infancy and at theage of 9 ; he developed only a few spots. Contactswere kept under close observation in the intervalbetween the end of the incubation period and afortnight after vaccination. All known contacts

accepted vaccination. Further spread of small-poxis now improbable.

INFECTIOUS DISEASE

IN ENGLAND AND WALES DURING THE WEEK ENDED

MAY 9TH, 1936Notifications.-The following cases of infectious

disease were notified during the week : Small-pox, 0 ;scarlet fever, 1996 ; diphtheria, 926 ; enteric fever,27 ; pneumonia (primary or influenzal), 931 ; puer-peral fever, 48 ; puerperal pyrexia, 110 ; cerebro-spinal fever, 30 ; acute polio-encephalitis, 1 ; encepha-litis lethargica, 6 ; dysentery, 16; ophthalmia neo-natorum, 109. No case of cholera, plague, or typhusfever was notified during the week.The number of cases in the Infectious Hospitals of the London

County Council on May 15th was 5812, which included : Scarletfever, 1066 diphtheria, 809; measles, 2677 ; whooping-cough, 559 ; puerperal fever, 22 mothers (plus 15 babies) ;encephalitis lethargica, 283 ; poliomyelitis, 2. At St. Margaret’sHospital there were 26 babies (plus 12 mothers) with ophthalmianeonatorum.

Deaths.-In 122 great towns, including London,there was no death from small-pox, 2 (1) from entericfever, 63 (28) from measles, 10 (3) from scarlet fever,29 (7) from whooping-cough, 32 (4) from diphtheria,56 (20) from diarrhoea and enteritis under two years,and 41 (5) from influenza. The figures in parenthesesare those for London itself.Measles is now definitely on the wane, the number of deaths

for the last eight weeks (working backwards) being 63, 83, 104,102, 103, 81, 104, 114, for the country as a whole, and 40, 70,68, 60, 43, 62, 62 for Greater London. Deaths from diphtheriawere reported from 19 great towns, 4 from Liverpool, 3 fromWest Bromwich. Rochdale reported the only death fromtyphoid outside London.The number of stillbirths notified during the weekwas 299 (corresponding to a rate of 42 per 1000 totalbirths), including 47 in London.

PANEL AND CONTRACT PRACTICE

Spinal Jackets AgainTHE Ministry of Health have recently informed an

insurance committee that the Minister’s medicaladvisers regard the term " spinal jacket " used inthe Medical Benefit Regulations as including appli-ances known in the trade as " spinal braces." Careshould however be exercised in ordering on an

insurance prescription either a jacket or a brace forit is not in every case that the appliance mayproperly be prescribed. The regulation says " whenrequired for treatment of fractures, dislocations or

diseases of the spine." An insurance doctor recentlyreceived a letter from a hospital almoner sayingthat an insured person had been examined by thesurgeon and recommended a spinal brace. Thealmoner added, " As this appliance comes underMedical Benefit will you kindly arrange to apply forthe brace on your National Health Insurance form.Miss X is suffering from pseudo coxalgia of the righthip." The doctor in all good faith issued a prescrip-

tion which the patient took to a local chemist.Fortunately for the doctor the chemist, before

arranging for the supply of the appliance, consultedthe insurance committee, who pointed out that theaffection of the hip could hardly be described as afracture, dislocation, or disease of the spine. If thechemist had supplied the article he would have beenentitled to be paid for it and the insurance committeewould have had to surcharge the doctor-some

eight guineas !The moral is that in case of doubt it is prudent to

consult the insurance committee before issuing a

prescription for an appliance. It may be noted thatthe Scottish Department of Health is advised that

spinal jackets when used in the circumstances indicatedabove may be regarded as splints within the meaningof the Scottish Medical Benefit Regulations, which,unlike the English regulations, do not specificallyprovide for the ordering of spinal jackets. Theappliance must, however, be prescribed by insurancepractitioners in the course of treatment being given

1210 THE SERVICES

under their Terms of Service. For example, an

appliance may have been required not in the courseof medical treatment but for sesthetic purposes, orby way of a mechanical aid after any treatment hadceased ; or the appliance may have been requiredfor the purpose of treatment which the insured personwas receiving, not from his insurance practitioner,but from a specialist not under contract with theinsurance committee. In such cases the appliancewould not be held to be available under medicalbenefit.

Still Silent

Some months ago we referred (1935, ii., 1206) tothe case of Dr. A, against whom a complaint hadbeen made, who neither replied to the inquiries ofthe insurance committee nor attended their hearingby the medical service subcommittee. We pointedout that possibly Dr. A had a perfectly good answerin reply to his alleged failure to provide treatmentfor an insured person but he would now be asked

by the Ministry of Health to explain not only thisbut his attitude to the committee, and that he ranthe risk of removal from the medical list. The

inquiry committee appointed by the Minister heardthe case on Jan. 1st, but Dr. A neither appearednor was he represented ; all that he did was to senda letter saying that he wished to dispute any com-plaint brought against him with regard to profes-sional attendance. He admitted he had not repliedto the complaint. After the hearing by the inquirycommittee, a further letter was received from Dr. Abearing the date Dec. 30th, 1935, in which for thefirst time he communicated the line of his defence tothe charges which had been made. Certain commentsin that letter have received publicity in the lay press,particularly a statement that while he was acting assuperintendent of a hospital Dr. A had had to protect

and guide some panel practitioners ; there were, headded, many more in practice who might be quitegood as nurses, but not as diagnosticians who wouldtake responsibility for no case other than a cold or aningrowing toenail. He treated human beings to thebest of his knowledge which was wider than that ofthe average practitioner and, therefore, he resentedmud being slung at him.The inquiry committee found the charges made

by the insurance committee to be proved or admitted,and submitted that the conduct of Dr. A in the caseof the insured person regarding whom complaintwas made appeared to be a breach of Art. 8 (1) ofthe terms of service and to constitute negligencewithin the meaning of Art. 41 (5) of the regulations.They stated that the letter from Dr. A did not affectthe view of the case which was formed at the hearing.He had offered therein no satisfactory explanationwhy he failed to visit the insured person, or to makearrangements for the receipt of messages, or how hecame to charge an insured person a fee or why hefailed to attend before the inquiry committee TheMinister decided not to remove Dr. A’s name

from the medical list; he has been informed that itwas with some hesitation that this conclusion had

. been reached, and that he must not expect a similardegree of leniency in the event of any further repre-sentation for his removal being made and sub-

. stantiated. The sum of :S10 is to be withheld fromthe insurance committee and must be deducted

. from the remuneration payable to Dr. A, who alsoB has been required to pay :E5 towards the costs of theI inquiry. The sequel is worthy of record as an illus-i tration of the extent to which, under the present, administration of the Insurance Acts, justice has been tempered with mercy. But it seems a woefult waste of public time and money on Dr. A’s part.

THE SERVICES

ROYAL NAVAL MEDICAL SERVICE

Surg. Comdr. J. W. Tighe placed on the Retd. List.Surg. Lt. C. Ommanney-Davis to rank of Surg.

Lt.-Comdr.Surg. Lt. E. L. Littler to Pembroke for R.N.B. and to

President for R.A.F. Medical Officers’ course.Surg. Lt. (D) H. P. L. Rhodes to Victory for R.N.B.

ROYAL NAVAL VOLUNTEER RESERVE

Surg. Lt-Comdrs. T. C. Larkworthy to Pembroke forR.N.B.; and J. L. Cox to St. Angelo for R.N. Hospital,Malta.

Surg. Lts. R. Cormack and M. Godwin promoted toSurg. Lt.-Comdrs.; and D. R. Goodfellow to Victoryfor R.N.B.

Proby. Surg. Lt. D. R. Maitland to Caledon for training.Surg. Sub-Lts. R. A. Stenhouse (proby.) and P. H. K.

Gray to Victory for R.N. Hospital, Haslar.

ROYAL ARMY MEDICAL CORPS

Maj. E. H. W. Elkington retires receiving a gratuity.Short Service Commissions : Capt. F. Williams resigns

his commission.ROYAL AIR FORCE

Squadron Leader G. S. Strachan to Special Duty Listwhile in interchange duty with the Royal Australian Force.

Flight Lt. S. B. S. Smith to R.A.F. Station, Biggin Hill. *The vacancy as consultant in medicine, Central Medical

Establishment, which will be caused by the retirement ofGroup Capt. H. A. Treadgold, will be filled by the appoint-ment of Wim: Comdr. A. F. Rook with effect from

May 18th. He was appointed to the R.A.F. GeneralHospital, Palestine, last year. (Vide THE LANCET,Nov. 30th, p. 1262.)

INDIAN MEDICAL SERVICE

Lts. G. R. C. Palmer, J. Revans, and T. Sommervilleare restd. to the estabt.To be Lts. (on prob.) : A. C. Taylor, E. N. Brockway

(secd.), L. S. F. Woodhead, J G. Thompson, J. R. Kerr(secd.), L. M. Kelly, and K. I. E. Macleod.The notification in the Gazette of May 1st, 1936, regarding

Lt. S. C. Misra, is cancelled.The undermentioned officers have vacated appts.

in India : D.D.M.S. : Maj.-Gen. T. G. F. Paterson, C.B.,D.S.O., K.H.P., I.M.S. (since retd.). A.D.M.S.: Col.W. T. McCowen, V.H.S., I.M.S. A.D.H. and P.: Maj.J. S. K. Boyd, R.A.M.C. A.D.P. : Lt.-Col. L. Dunbar,O.B.E.,R.A.M.C. D.A.D.H. : Lt.-Col. J. G. Gill, D.S.O.,O.B.E., M.C., R.A.M.C. D.A.D.P. : Lt.-Col. R. B. Price,D.S.O., R.A.M.C. M.O., A.Sch. of Education: Capt.G. B. W. Fisher, I.M.S.The undermentioned appts. have been made in India :

A.D.M.S. : Col. J. B. Grogan, Brit. Serv. A.D.H. and P. :Lt..Col. J. G. Gill, D.S.O., O.B.E., M.C., R.A.M.C. A.D.P. :Lt.-Col. R. B. Price, D.S.O., R.A.M.C. D.A.D.H. :Lt.-Col. K. Comyn, R.A.M.C. D.A.D.P. : Maj. C. D. M.Buckley, M.C., R.A.M.C.Embn. Med. Offr., Kiamari: Maj. J. McFadden,

R.A.M.C., March 9th, 1935.

COLONIAL MEDICAL SERVICEThe following appointments have been made : Medical

Officers, West Africa : Dr. R. J. C. Campbell, Dr. J. W.Pickles, and Dr. A. B. Weir ; Uganda : Dr. D. G. Snell ;Northern Rhodesia: Dr. K. C. P. Thomson. DistrictMedical Officer, Windward Islands : Dr. L. M. Commissiong.Dr. J. M. Mackay becomes Deputy-Director of HealthService, Gold Coast, and Dr. P. S. Selwyn-Clarke Deputy-Director of Health Service, Nigeria.