42

will be a strong case for organising ambulanceservices by larger units. The present system of

summoning help on the fringe of the metropolisseems to demand more knowledge than many peoplepossess. The London Telephone Directory, instructingus how to contend with emergencies of fire, crime, oraccident, bids us ask the Exchange for " Fire

Brigade," "Police," or "Ambulance" as the case

may be, " specifying, if known, the appropriate fire

brigade or police station or ambulance authority."How many travellers on the Kingston by-pass couldspecify the correct ambulance authority with confi-dence ? Few of us, at any rate, would be otherthan dissatisfied if the fire-engine or the policeman,summoned in emergency, passed by on the other sideout of excessive respect for boundaries and jurisdic-tions. The good Samaritans of the ambulanceservice must not be Pharisees.

A Technically Pauper PatientThe -How county court judge gave judgment last

week in a curious case where the Essex CountyCouncil was suing a former patient of the WhippsCross Hospital. To his surprise the patient foundhimself classed as a pauper (or, as we must nowadayssay, a rate-aided person) malgré lui. He had beenknocked down in a London street by a tram lastyear and had been taken to the Whipps CrossHospital with a broken leg and detained for eightweeks. At his admission the hospital authoritieswent through his pockets and found E7 in notesand 8s. in silver which they retained. When hewas discharged he asked for his money but was toldthat it had been applied towards his maintenance.A fortnight later he received a bill for E25 4s. 8d.for the balance of the cost of his maintenance inthe hospital. This he refused to pay. He sued theEssex County Council for the money which had beentaken from his pockets. The defendant counciltold him that having been treated in a poor-lawhospital he was technically a pauper and must handover the property found upon him. He answered thathe was not an able-bodied pauper but a certificatedpublic accountant with a broken leg, who hadnever applied for relief by way of public assistance.The solicitor to the West Ham Corporation explainedto the court that the Local Government Act of 1929had abolished boards of guardians and that the

Whipps Cross Hospital had been transferred toWest Ham. It was intended to appropriate thehospital as a Public Health Act institution, but thebuilding had not been so appropriated. It thereforeremained a workhouse infirmary, and anybody whocrossed its threshold automatically became a pauperby virtue of his admission as a patient. Consequentlythe authorities were right to take away his money.This argument the judge found himself obliged touphold. It was, he said, unfortunate for the plaintiffthat the place to which he was taken in emergencyfor treatment was a poor-law institution and not ageneral hospital.The Local Government Act has created an impres-

sion that all pauperdom has been removed and thatall public hospitals have now pooled their resources.The case may help to stir the public conscience inthe matter of the liability to pay for hospital treat-ment for traffic casualties. There is an idea that theservices of hospitals (and of the doctors and surgeonswho administer treatment in this connexion) are

a fairy gift miraculously available at no cost to thepatient. This obscures the sense of obligation to

pay on the part of those patients who can afford todo so.

IRELAND

(FROM OUR OWN CORRESPONDENT)

NATIONAL HEALTH INSURANCE

INTERESTING evidence was given recently before

a Select Committee of the Senate in reference to the

National Health Insurance Bill now before that

body. Sir Joseph Glynn, for many years chairmanof the National Health Insurance Commission,pointed out that there was no medical benefit inthe Irish Free State, and said that the absence ofmedical benefit tended to vitiate the system ofcertification of incapacity. He said also that thewhole question of unemployment went with sickness.As unemployment increased, sickness increased.It was the same in all countries. Mr. L. J. Duffy,chairman of the Association of Trade Union ApprovedSocieties, welcomed the abolition of the voluntarysocieties. He believed that the increase in sicknessbenefits was in part due to irresponsible certification.Mr. M. P. O’Donnell and Mr. T. Hutchinson, onbehalf of the Approved Societies’ Association ofIreland, also criticised the system of medical certifica-tion. Dr. R. J. Rowlette, President of the IrishMedical Association, said that national healthinsurance should be something more than mere

payment when a person was sick. It should attemptto improve the health of the country as a whole,and particularly of a class which came under theinsurance. It should be coordinated with the publichealth system of the country. The present Billwould create an extremely powerful body whose dutywould be only to carry out one part of the healthwork of the country without being in contact at allwith the other health activities. The societies hadnever concerned themselves very much with thehealth of their members, and contented themselveswith the provisions of benefit. In answer to questionshe said that if there was going to be unification thereshould be a nationalised State system of insurance.The provision of medical benefit was an essentialpart of any scheme of national health insurance.As regards certification, he did not question thatevidence of laxity and remissness in their issue couldbe got. It was not, however, representative of thepresent system as a whole. Mr. S. T. O’Kelly,Minister for Local Government and Public Health,said that they were attempting to deal with a crisisthat was threatening in national health insurance.When he came into office as Minister he was advisedby the officials of his Department that a Bill of thissort was urgent. The danger was that if they didnot tackle the problem in this way there might bereduced benefits. They thought it would be moreequitable to bring all the insured persons into onesociety, sharing credits and losses all over. SenatorDowdall said there was a consensus of opinion thatunemployment caused the greater drain on benefits.It had been suggested that this was due to laxcertification. He himself thought that a medicalofficer was entitled to give a certificate on borderlinecases. The Minister said that was a matter thatrested with the conscience of the doctor, and hebelieved that the mass of medical men were humani-tarian. Personally, his inclination would be to actgenerously, but as Minister he would be boundby the law. He mentioned a case where he hadheard that a doctor had signed a book of certificates,and left it on his hall table, so that certificates couldbe given to people calling.

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HONORARY DEGREES AT THE NATIONAL UNIVERSITY

The Senate of the National University of Irelandhas decided to confer honorary degrees on the

following on the occasion of the visit of the BritishMedical Association to Dublin :-D.Se.: Prof. JosephBarcroft, Dr. Rufus Cole, Prof. Dean Lewis, Prof.T. H. Milroy, and Sir Edward Sharpey-Schafer.D.Sc. (Public Health) : Prof. J. M. Beattie, SirLeslie Mackenzie, and Sir John Moore: ];1.D.: : SirRobert Bolam and Sir Henry Brackenbury. X.Ch. :Mr. J. F. O’Malley and Sir Hugh Rigby. LE.D. :Prof. T. G. Moorhead and Sir Humphry Rolleston.D.Z. : Dr. T. P. C. Kirkpatrick.

A REPORT ON THE

CLINICAL VALUE OF "EVIPAN"

(FROM THE ANESTHETICS COMMITTEE, MEDICALRESEARCH COUNCIL)

ENCOURAGING accounts of the action of a barbi-turate anaesthetic, "evipan," which came fromGerman surgeons and anaesthetists seemed to theAnaesthetics Committee to warrant a thoroughclinical trial. Twenty-five thousand cases are

reported from that country, with one death attributedto

" evipan." Accordingly, the offer of BayerProducts, Ltd., was accepted and supplies of thenew drug were put at the disposal of the Committee.In making use of these the Committee had thecooperation of a number of anaesthetists and otherswho have sent details of their cases. At St. Bartholo-mew’s, Messrs. F. T. Evans and Rait-Smith ; at

Guy’s, Mr. R. C. Brock ; and at St. George’s,Messrs. Douglas Belfrage and E. Landauhave assistedin this way ; and Dr. J. M. Barlet, Mr. C. Borland,and Dr. R. Jarman are others who, with Mr. C.Pannett and Sir Francis Shipway, Dr. C. F. Hadfieldand Dr. J. Blomfield, members of the Committee,have furnished the material for this report.Evipan sodium is the sodium salt of N-methyl-C-C-

cyclo-hexenyl-methyl barbituric acid, and dissolves

freely in water, but the solution is stable only foran hour or two. Thorough pharmacological workcarried out in Germany showed the drug to have ahigh therapeutic quotient in cats and dogs. In theformer 25 mg. gave full anaesthesia, while the lethaldose was from 100 to 110 mg., a quotient of 4, andin dogs the quotient was 3-3. Parsons found thatin the cat 01 c.cm. of a 10 per cent. solution causeda fall in B.P. of 25 mm. Hg, with slow recovery andapnoea for 20 seconds. After a total of 0-6c.cm.of 10 per cent. solution artificial respiration wasneeded and the B.P. fell until death. The anaestheticaction of the drug was rapid in onset and short induration. It is not a volatile anaesthetic but it is

very rapidly detoxicated by the liver. Rabbitsdecompose half the narcotic dose within 13 minutes.Traces of the unchanged substance are excreted inthe urine. By-effects in animals were found to beslight. The blood pressure fell 15 to 20 mm. Hg.The pulse remained regular and full. Overdosecaused cessation of the breathing, the heart continuingits beat for a considerable time after. Blood-sugarwas unaltered and other evidence of effect on bodymetabolism was of the slightest.

TECHNIQUE AND DOSAGE

When used for anaesthesia evipan is given intra-venously. At first the drug was issued in ampoules,each of which contained 3-5 c.cm. of 33t per cent.

stable solution in methyl-di-glycol ; 3 c.cm. of thiscontained 1 g. of evipan sodium. Ampoules con-

taining 7-5 c.cm. of distilled water, but capable ofholding 10 c.cm., were also issued, and before use3 c.cm. of the concentrated solution were drawn intothe syringe and expelled into the ampoule containingthe distilled water. The evipan solution was stickyand required therefore a larger needle than the

ordinary hypodermic size. Now, however, the evipanis supplied in powder form in ampoules to which thedistilled water supplied in another ampoule is added.By aspirating and reinjecting once or twice, a solutionis obtained which passes easily through the ordinaryhypodermic needle. This is inserted into a suitablevein of the arm with due antiseptic precautions. Itis advisable to have the arm held steadily by a secondperson because of the twitching of muscle, whichoften comes on early after injection has begun.The solution is run in at the rate of 1 c.cm. in 15seconds. Dosage is determined by the character-istics of the patient and the results noticed. Actingon a definite scale arranged according to body-weightdoes not give satisfactory results. An average amountto produce unconsciousness is about 3 c.cm. A goodplan, recommended by Lauber of Konisberg who hashad a big experience, is to make the patient count.When the counting ceases through sleep the amountthat has been injected is noted, and the same amountis further added for a short operation and twice asmuch for a long one. In elderly and feeble peopleand those who have gone to sleep exceptionallyquickly, only half the amount which produced sleepis added. Most patients are asleep in about oneminute. There is often some twitching or jactitation,but often complete relaxation of the muscles of tongueand jaw occurs early and care is needed to preservea patent airway. Generally speaking 10 c.cm. are

regarded as the maximum dose. When it is desiredto complete a longish operation under evipan only,the needle must be left in situ and a further injectionmade when the anaesthetic effect of the first is

obviously wearing off. Used in this way, as muchas 20 c.cm. have been injected. There is, however,a fluctuation in the anaesthesia, and we do not seeevidence of any advantage in the use of evipan forother than short operations-i.e., of 20 minutes orso at the outside.

SYMPTOMS PRODUCED

A deep yawn just before the disappearance ofconsciousness is a common symptom. The greatmajority of patients fall asleep perfectly quietly.Twitching of face muscles is common and there issometimes jactitation of limbs. In one instancetonic contraction of many muscles and brief stoppageof respiratory movements were observed. The degreeof muscular relaxation varies but is rarely extremeor sufficient for an abdominal operation. The pupilis usually moderately dilated but active to light.In the early stages it is sometimes widely dilated.The conjunctival and generally the corneal reflexeshave disappeared at the moment of fullest effect.Even then reflex movement at the start of operationhas been seen many times. The eyelids are some-times widely separated.The effects on blood pressure are slight. There

is commonly a fall of about 20 to 30 mm. Hg whichis quickly recovered from. Respiration is oftensomewhat slowed, but there has been seen no seriousdepression except in one instance when unknownto the anaesthetist the patient, an elderly woman,had received a full dose of morphia and hyoscinebefore the evipan. The combined result was respiratory