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BATTLE OF THE BARBITURATES

To the Editor of THE LANCETSIR,-Dr. Macintosh says, rather ungraciously to

my way of thinking, that, " with one exception, thearticle by Sir James Purves-Stewart and Sir WilliamWillcox in THE LANCET of Jan. 6th (p. 6) provesnothing but that fantastically large doses of thebarbiturates may be combated successfully byenergetic measures." He gives no credit to the greatskill of two physicians who succeeded in saving thelife of a woman who had taken 475 grains of a

barbiturate. The mere fact that they have shownwhat energetic measures can do in a desperate caseof this sort is a very definite advance in the treatmentof a common and dangerous form of poisoning-the knowledge of which I am certain the professionwill be most grateful for.The fact that Dr. Macintosh does not give nembutal

by the mouth does not, so far as I can see, give thatprocedure its death blow. I know of anaesthetistswho do adopt this procedure-and with safety.

I am, Sir, yours faithfully,Ulster-place, N.W., Jan. 17th, A. &RAHAM-STEWART.A. GRAHAM-STEWART.

M.M.S.A. AND D.C.O.G.

To the Editor of THE LANCETSIR,-The leading article in your issue of Jan. 20th

concerning the institution of the diploma of the

College of Obstetricians and Gynaecologists is some-

what misleading in that it would appear to suggestthat up to the present no provision had been madewhich embraced the objects of the new diploma andthe ground covered by the proposed examination.May I, therefore, be allowed to recall that the diplomaof Mastery of Midwifery of the Society of Apothe-caries, examinations for which have been held twiceyearly since 1928, was in like manner designed toassist the public health authorities and others in theselection of practitioners who have made a specialstudy of, and proved themselves expert in, ante-natal care, obstetrics, and infant welfare ?The public health side of the examination for the

Mastery of Midwifery was further strengthened bythe introduction last year of a special examinationpaper on "public health aspects of maternity andchild welfare," which is set and marked by examinersof wide experience holding public health appoint-ments. The examination therefore now has threewritten papers (obstetrics, paediatrics, and publichealth aspects) followed by full oral and clinical tests,and candidates are not admissible unless they are onthe British Register and have held a registrablediploma for at least three years, and have compliedwith the regulations with regard to the appointmentsthey have held.

I am, Sir, yours faithfully,HENRY COOPER,

Group Captain ; Registrar, Society ofJan. 23rd, 1934. Apothecaries of London.

HENRY COOPER,Group Captain ; Registrar, Society of

Apothecaries of London.

PANEL AND CONTRACT PRACTICE

Doctors and Chemists

A COMMON experience for an insurance doctor isto be asked by an insured person whether his medi-cine had been altered as the last bottle looked andtasted differently from the previous. The positionwhich then arises is not quite easy to deal with.The practitioner may have written somethingdifferent in the last prescription, and in the absence ofa note to the contrary on the patient’s FMR he maynot remember, at the time the question is asked,exactly what was ordered. Here the presumptionis that the change in medicament initiated by thedoctor has been properly dispensed. Supposing,however, he is certain that he did order the samemedicine as before, he is still to be strongly advisednot to jump to the conclusion that the medicine hasbeen incorrectly dispensed. The taste of a patientvaries in its acuity from day to day, and is not atrustworthy basis for an accusation against thechemist. In a recent case the doctor seizedthe medicine alleged to be faulty and sent it up tothe insurance committee for analysis. Meanwhile thepatient was advised to change his chemist, and theimpression obviously left on his mind by the doctor’saction and advice that the chemist had made amistake-not a difficult impression to foster as thepatient had stated in his complaint that his medicinelooked and tasted differently from that to whichhe was accustomed. The analysis, when completed,showed that the medicine seized had been accuratelydispensed. Assuming that the doctor had writtenthree identical prescriptions at weekly intervals, andthat the third bottle was correctly stated by thepatient to be different from the first, then since thethird was found to be correctly dispensed, it musthave been the first or the second (or both) that werewrong. And of these, unfortunately for the doctor,there was no sample to examine. The matter had

to be left resting upon the patient’s impression ofdifferences in the mixtures he obtained.

It should be remembered that there are certainstock preparations, made by different firms quiteaccurately according to B.P. standards, which varyboth in colour and taste. Such a preparation is thecompound infusion of gentian. If a chemist boughthis infus. gent. co. from firm A and, when that stockwas used up, changed to firm B, the resulting mixtureaccurately dispensed from identical prescriptions willappear and taste quite differently. In such a caseit would be prudent to visit the chemist and inquirethe reason for the change complained of before

assuming that the prescription was not accuratelydispensed or advising the patient to go to anotherchemist. It has always been held that no doctor isentitled to advise a patient to go to a particularchemist, although a search of the regulations fails toreveal any such rule. There is in the Terms of Service§ 9 (10) a regulation in which " Rep. Mist." is pro-hibited, and it has been suggested that this was

prohibited because it did not enable an insuredperson to go to any chemist he liked, for obviouslyno chemist could repeat a mixture if he had notmade up the original mixture. But this appears tobe reading a great deal into the regulation. Thereis ample reason for prohibiting "Rep. Mist." with-out the help of " the selection of chemist " argument;the use of the formula is liable to cause mistakes byputting the onus on the chemist to repeat the propermedicine. Now that it is prohibited there does notappear to be any reason why a doctor should not tellhis insured patient the name of a chemist to go to.

In his last quarterly report to the London PanelCommittee Dr. A. F. Heald returns to the difficultythat exists in London in getting medicines dispensedafter 8 P.M. Some insured persons, he says, unableto reach their homes until late in the evening, con-sult their doctor and get a prescription which they

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then can find no chemist to dispense. The questionof urgency scarcely arises. Whether the prescriptionis marked urgent or not they cannot get it made up.This is a matter for the insurance committee totake up with the chemists. There is no difficultywith the Shop Hours Act, as this relates only to thesale of ordinary non-perishable goods and would notprevent a chemist remaining open (by rota) for thedispensing of medicines. The hours of service sub-committee if it were to meet would find this late

dispensing problem give them something to discuss.

Changing DoctorsPractitioners still find these regulations irksome.

It frequently happens that an insured person givesnotice to his insurance committee on (say) Nov. 15thto change his doctor and forwards his medical card.This card is returned to him with instructions. Heperhaps does not read these instructions or mis-understands them, but considers himself (with the

return of the card) to have been placed on the newdoctor’s list. When necessity arises for treatmentwith the new doctor he is told he is not on the newdoctor’s list, and he has to go through the wholeprocess again. The fault here is of course with theinsured person who has not read his instructions.But there is this excuse for him. He can say, I havebeen to the new doctor and told him I wanted to

change to his list, and I have told the insurancecommittee I want to change, why could not theyput the matter through at the time without myhaving to go again to the doctor with the returnedmedical card containing this red slip. The regula-tions are really designed to make the change not tooeasy, to give the insured person in fact some troublein making it. It would seem that he might say whenwriting to the insurance committee that he had beento Dr. X who had agreed to accept him, and thatthe insurance committee could then forward hiscard to Dr. X for acceptance.

MEDICAL NEWSUniversity of OxfordThe vice-chancellor has appointed Mr. P. N. B. Odgers,

reader in human anatomy in the university, to be deputyfor the Dr. Lee’s professor of anatomy during the Hilaryterm.The Francis Gotch memorial prize for 1933 has been

awarded to E. H. Leach, Oriel College.

University of LondonOn Mondays, at 5 P.M., from Feb. 12th to March 19th,

Mr. H. R. Ing, D.Phil., will lecture on chemical structureand pharmacological action in the physiology theatre ofUniversity College, Gower-street, W.C. On Wednesdaysfrom Feb. 7th to March 14th, at 5 P.M., six lectures oncytology will be given by Mr. R. J. Ludford, D.Sc., Mr. E. S.Horning, and Dr. K. C. Richardson. These lectures willalso be given at University College.

University of BirminghamDr. F. W. M. Lamb. lecturer in pathology in the univer-

sity, has been appointed professor of toxicology and medicaljurisprudence in the University of Cairo.Hunterian SocietyA banquet to commemorate the 206th anniversary of

the birth of John Hunter will be held at the May FairHotel, Berkeley-street, London, W.I., on Thursday,Feb. 8th. The hon. secretary may be addressed at

79, Wimpole-street, W.I.

Royal Microscopical SocietyThe new president of this society is Prof. W. A. F.

Balfour-Browne, and the vice-presidents Mr. J. E. Barnard,F.R.S., Mr. Conrad Beck, Prof. D. M. Blair, M.B., andDr. G. M. Findlay. The senior hon. secretary is Prof.R. T. Hewlett, M.D., and the council includes Dr. A. S.Burgess and Dr. J. E. McCartney.

Royal Sanitary InstituteA meeting will be held at this institute, 90, Buckingham

Palace-road, London, S.W., on Thursday, Feb. 15th, at

5.15 P.M., when Dr. James Fenton, medical officer of healthfor Kensington, will open a discussion on the administration,of the Housing Acts in relation to unfit individual houses.Lord Balfour of Burleigh will be in the chair.The health congress arranged by this institute will be

held at Bristol from July 9th-14th under the presidency ofMr. Stanley Badock, pro-chancellor of the university.The work of the congress will be divided into sections,dealing with preventive medicine; engineering, architecture,and town planning ; maternity, child welfare, and schoolhygiene ; veterinary hygiene ; national health insurance ;and hygiene of food. Among the special conferenceswhich will be arranged will be one for medical officers ofhealth. The secretary of the institute may be addressedat 90, Buckingham Palace-road, London, S.W.I.

Society of Apothecaries of LondonAt recent examinations the following candidates were

successful :-Surgery.-E. H. E. Cross, St. Mary’s Hosp. ; D. P. King,

Univ. of Cambridge and Guy’s Hosp. ; 1. B. McCrae, CharingCross Hosp. ; H. Paroulakis, Univ. of Innsbruck and St. Mary’sHosp. ; and P. H. Willcox, Univ. of Cambridge and St. Mary’sHosp.

Medicine.-E. C. Dax, St. Mary’s Hosp. ; E. G. Houghton,Univ. of Cambridge and St. George’s Hosp. ; 1. B. McCrae,Charing Cross Hosp.; and S. Smith, Univ. of Liverpool.

Forensic Medicine.-T. Gardner, Univ. of Leeds ; G. R.Greene, St. Mary’s Hosp. ; E. G. Houghton, Univ. of Cambridgeand St. George’s Hosp. ; H. R. Kasday, Middlesex Hosp. ;I. B. McCrae, Charing Cross Hosp. ; R. M. Outfin and T.Sherman, Guy’s Hosp. ; and D. Walton, Univ. of Manchester.Midwifery.-F. G. S. Alderson, Univ. of Leeds; S. A.

De Souza, St. Mary’s Hosp. ; H. 0. Dole, Univ. of Manchester ;J. C. Harvey, St. George’s Hosp. ; I. B. McCrae, Charing CrossHosp. ; J. R. Owen, Univ. of Cambridge and St. Mary’s Hosp. ;H. Sobhi, Univ. of Cairo and St. Bart.’s Hosp. : and H. M. R.Waddell, Univ. of Manchester and Charing Cross Hosn.The following candidates, having completed the final

examination, are granted the diploma of the society entitlingthem to practise medicine surgery, and midwifery : T. Gardner,E. G. Houghton, 1. B. McCrae, and S. A. De Souza.

Mental After Care AssociationThis association, which was founded in 1879, is appealing

for help to carry on and extend its work for recoveredpatients, and also for the early care of those suffering fromnervous and mental illness, for whom it provides homesof recovery and expert care. Particulars of its work maybe had from the secretary, at Church House, Dean’s-yard,Westminster, S.W.I.

Medical Congresses in GermanyThe forty-sixth meeting for the Deutsche Gesellschaft

fur Innere Medizin is to be held at Wiesbaden fromApril 9th-llth under the presidency of Prof. Schittenhelmof Kiel. The first day will be devoted to the discussion ofproblems relating to heredity, with papers by Prof. EugenFischer (Berlin), Freiherr von Verschuer (Berlin), andProf. Otto Naegeli (Zurich). On Tuesday Prof. OtfriedFoerster (Breslau) will read a paper on localisation in thenervous system. On the third day papers will be read onthe sex hormones by Prof. A. Butenandt (Danzig) and onovarian function by Prof. Robert Schroder (Kiel). Onthe last day of the congress there will be a joint meetingwith the Gesellschaft fur Verdauungs- und Stoffwech-selkrankheiten, when there will be a discussion on vitamins.The secretary is Dr. A. Geronne of Wiesbaden.The seventh congress of the Deutsche Gessellschaft fiir

Kreislaufforschung will take place at Bad Kissingen onApril 16th and 17th under the presidency of Prof. J. Norrof Munich. The main subject for discussion will bethrombosis and embolism and the principal speakers willbe Prof. L. Aschoff (Freiburg), Prof. P. Morawitz (Leipzig),and Prof. L. Niirnberger (Halle L The hon. secretary forthe congress is Prof. Eb. Koch, Bad Nauheim.