449 Mr. YEARSLEY and Dr. FREY replied. The PRESIDENT summed up the discussion. From the opinions that had been expressed he gathered that the general ...

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449 Mr. YEARSLEY and Dr. FREY replied. The PRESIDENT summed up the discussion. From the opinions that had been expressed he gathered that the general view of the meeting was that if temporary improvement to the hearing could be obtained by inflating the middle ear then nasal treatment should be adopted, and even if not much improvement followed inflation, then nasal obstruction should be dealt with. The residuum of hearing should be cultivated, and, if possible, improved, and the patients encouraged to keep up their general health. Operative measures upon the ear itself appeared to stand very much where they were before. Dr. JOBSON HORNE exhibited Simplified Insufflator for Use in tlae Treatment of Diseases of the Throat, Nose, and Ear. The instrument consists of glass-tubes of various lengths, shapes, curves, and calibre to meet the requirements of the regions in which they were to be used. The distal end of the tubes is roughened on the inner surface for an inch or This roughening of the inner surface of the tube more. permits of the powder being retained in sattc, and also of a The advantages known quantity of powder being used. - claimed for this insufflator are : simplicity, cleanliness, simplicity of auto-insufflation, precise dosage, and cheapThe instrument has been made by Mr. F. Rogers of ness. Oxford-street. ____


SOCIOLOGY. THURSDAY, JULY 27TH. President, Dr. GEORGE REID (Stafford). Hospital Reform in Relation to the National Insurance Bill was the subject upon which distinguished speakers, medical and lay, addressed the Section at its second session. The question was dealt with both from the points of view of the medical staffs and of the governing bodies of hospitals, and there was evidently some difference of opinion as to whether hospitals will be wise in accepting grants-in-aid from the State in respect of insurance patients. Dr. GEORGE REID

that the insured person had definitely engaged medical practitioner to attend him, to undertake his treatment except with the sanction of, and in coöperation with, that attendant. To deal entirely on independent lines with another man’s patient, even in the sacred name of charity, could hardly be tolerated in the altered circumstances created by the Bill. From the social side the public, which had to maintain the insurance fund, was equally interested with the profession in securing coöperation between the insurance and hospital doctor. It would be obviously unfair and detrimental to the insurance service (Dr. Shaw went on) that the hospital should be in direct competition with it. The fact that hospital treatment was given by men who were consultants and usually charged private patients higher fees than the insurance doctor did, the glamour of the place, and the ritual observed in teaching students would, even if the actual service were inferiorinstead of being as a rule, for suitable cases, superiorstrongly impress the patient with its superiority. To avoid On the disaster systematic cooperation was essential. question of the nationalisation of hospitals Dr. Shaw said that while believing that in the interests of medical research and education the voluntary system should be maintained, he recognised that its continuance was imperilled. The transformation of voluntary hospitals into truly consultative institutions, taking no independent part in the treatment or investigation of disease, but cooperating always with institutions or private practitioners undertaking ordinary medical treatment, would provide them with a new lease of useful life, and would probably postpone indefinitely the nationalisation or municipalisation of that higher class of institution which was capable of adopting that line of professional work. Even if the hospitals did become nationalised, it would still be essential to define their relation to the insurance service. For the State to provide side by side an institutional and a domiciliary service, and to allow the patient to chose which he would use, would be a most unreasonable and unbusinesslike proceeding. Unless the voluntary hospitals would relinquish voluntarily all treatment such as was to be provided by the insurance scheme, and would cooperate with its officers in providing on consultative lines the additional special professional help which they were best fitted to provide, they would seriously handicap the insurance service and imperil their own future as



again presided, but the attendance was still disappointing-it was suggested because the Section had been" skied:" The meeting-place was on one of the topmost floors of the University buildings. Dr. LAURISTON E. SHAW (London), in a brief opening independent institutions. Mr. J. COURTNEY BUCHANAN (secretary of the Metropolitan paper, asserted that the Insurance Bill must profoundly alter the position of the hospitals. Even if the Bill Hospital) contributed a paper on did not pass, the prominence given by its discussion to T7te Future of Voluntary Hospitals, the unsatisfactory provision of medical treatment for large must to of the lead the institusections He urged that hospital managers should follow the shortly community tion of some alternative to the present chaotic jumble of wise course of the British Medical Association and indiscriminate charity, inadequately paid contract service, set themselves to define beforehand the work their and a mutually unpopular Poor-law medical service. experience taught them they could do best. After touching Assuming that the Bill would pass-modified, of course, in on the effect of the Bill in drying up the sources whence accordance with the strictly moderate demands of the hospitals derive their funds, Mr. Buchanan declared that medical profession-the hospitals would find there was still the introduction of a system of charging insured patients was much work for them to do on a voluntary basis. The Bill inevitable. In future hospitals would be forced to act provided only, except in the case of consumption, for solely in a consultative capacity towards the poorer classes. ordinary domiciliary medical treatment. For other cases Trivial cases need no longer be treated at the hospitals ; these further provision of some sort must be forthcoming, and it would be seen by the insurance doctors. As he understood, seemed probable that, at any rate at the outset, it would be the doctors would prefer to see the insured patients at some made by means of the voluntary hospitals. It had long been centre; these might be institutions conducted very much

recognised that the attempt to combine the dual function of ministering to minor ailments, and at the same time dealing with cases requiring the highest resources of medical and surgical skill, had handicapped the development of the professional side of the hospital, while the avoidance of imposition and abuse in these conditions had become quite impossible. The provision of insurance for ordinary treatment for a large section of the present hospital clientèle should greatly simplify the selection of suitable cases. Inquiries into the economic position of the patient would be reduced in many cases to determining ’.he status of the patient under the insurance scheme, and there would be przma facie ground for insisting that the hospital should exercise its proper function of providing special medical service only. Dr. Shaw laid stress on the necessity from both professional and social points of view of dealing with the insured persons at the hospital on a consultative basis in cooperation with the insurance doctor. From the professional point of view it might well be regarded as a breach of medical etiquette for a member of the hospital staff,

the lines of provident dispensaries. These should be around and be in touch with voluntary hospitals. School medical treatment might also be carried out in them. In his opinion it would be little short of a calamity if hospitals were subjected to any municipal control, but he could see no objection to hospitals being paid for work done for the insurance authorities, or even to State grants-in-aid for specific purposes, always provided that if the hospitals had to be subjected to public inspection it was carried out by experienced people. A central council might be established for this purpose ; it would leave hospitals free to develop their own particular characteristics, while securing uniformity in matters where uniformity was really desirable, such as The day had gone by, he feared, methods of admission, &c. when the provision of help for the sick would suffice to draw enough money for the hospitals’ support. The only reasonable ground for hoping that the hospitals could still be maintained by voluntary contributions lay in the attraction that the more expensive forms of medical treatment and the advancement of medical education and scientific research on



longer by the bogey of a public scandal following on a "spiteful death on the doorstep." He did not think the expense or the numbers of the out-patient departmentswould greatly decrease. There would be a larger number of difficult, protracted, and expensive cases, but the hospitals highest perfection. Mr. NEVLLLE CHAMBERLAIN (Birmingham) contributed a would be relieved of the greater portion of the trivial cases which were now such a clog upon their working. Subscrip-paper on The I?efornb of Out-patient Departments of Hospitals, tions, however, must decrease owing to direct taxation of of hospital income. He did not agree with a system remarking by way of preface that while the Insurance Bill sources would render impossible the remedies he had in mind before of per capita contributions from the State as likely to give its introduction, it would also, he hoped, remove in large rise to disputes. He would like to see sums of money allotted to part the evil those remedies were designed to meet. Probably universities. hospitals on the lines of State grants to would that the work of everyone agree out-patient departDr. E. D, KIRBY (Birmingham) read a paper on ments was the least satisfactory part of modern hospital Some Local Aspects of Hospital Reform. routine, whether looked at from the point of view of the hospital, the medical profession, or the patients who came to In Birmingham, he said, the medical institutions had allowed the departments for treatment. Instead of confining them- themselves gradually to be perverted from charities into pro-selves to consultation and cases of immediate urgency, as was vident institutions. That was to say, the working classesintended originally, the out-patient departments, with their had been permitted to subscribe to them for their own elaborate and expensive apparatus, their trained nurses and benefit. It might be regarded as an intelligent anticipation experienced consultants, had allowed themselves to be turned of the Insurance Bill, with the significant exception that no into great free dispensaries. Really serious and important provision at all was made for any payment to the medical cases were jostled and thrust aside by people with cut fingers profession. In illustration of this statement Dr. Kirby gave or common colds, or, what was perhaps worse, by chronics an account of the history of the General Dispensary showingwhose chances of cure lay rather in careful nursing and home how the practice of compulsorily deducting a penny a week treatment than in periodic visits to a distant institution. from workmen’s wages towards the Hospital Saturday Fund The result was an ever-increasing crowd of applicants for had led to people claiming as a right services which were relief with a corresponding diminution of the amount of time instituted as a charity. devoted to each individual. Hospital managers chafed under Dr. J. B. BRIERLEY (Manchester), opening the discussion, a sense that the money of the subscribers was being wasted, remarked that the reason the medical profession had been patients grumbled at the long waiting, while the medical dubious of provident dispensaries was that they had not been practitioner outside bitterly commented on the difficulty able to secure an income limit for members. of earning a livelihood in competition with an institution Dr. J. H. KEAY (Greenwich) thought the spirit animating which was not run on commercial lines, but offered the papers read augured well for hearty cooperation being gratis the knowledge and experience he had spent secured between medical men and hospital managers in his time and money in acquiring. Proceeding to con- meeting the altered circumstances brought about by the sider remedies for this state of things, Mr. Chamberlain Insurance Bill. As to the reform of out-patient departments, he. mentioned how difficult it had been found in practice thought a few prosecutions of well-to-do people who abused at the Birmingham General Hospital to get the staff to them would be highly effectual. sort out applicants for relief and advise trivial cases to Dr. D. J. MACKINTOSH (Glasgow) said that the Bill would apply to their own doctor, to a dispensary, or elsewhere. assist in doing away with hospital abuse if it existed. The only chance appeared to lie in applying pressure on the Voluntary hospitals had a hand-to-mouth existence at present, people themselves. Mr. Chamberlain outlined "an ideal and they could not continue to exist unless funds were forth-system of medical relief " as follows :coming. He objected to hospitals accepting grants from the 1. Every person should contribute towards the cost of treatment. State, but saw no difficulty in their receiving payment for his own 2. should be attended in the first instance held for wealthy and philanthropic people. The future of the hospitals should be to show clearly that the work they did was for the benefit of the whole community, and for this purpose to maintain their special services in the now





should not be


doctor, but should have power to change his doctor at intervals. 3.

dispensed by


doctor but





dispensary. 4. Patients requiring institutional treatment should be admitted to the hospital as in-patients, or should obtain consultation or treatment on the recommendation of any q-ualified medical man without the necessity for subscribers’ letters, &c. 5. Paying wards should be established for those in better circumstances.

An endeavour had been made to fulfil some of these conditions in Birmingham by the establishment of a provident dispensary. Mr. Chamberlain described the methods of this institution, which a medical speaker later in the meeting paid the tribute of describing as free from the defects of most similar undertakings. Among the hindrances to the success of the dispensary Mr. Chamberlain mentioned the apathy of the medical profession and the stringency of medical etiquette which made no distinction between canvassing for a private individual for his personal benefit and canvassing for a properly managed provident institution primarily for the Medical men had benefit of the members themselves. failed to recognise the trend of modern legislation and to see that the only alternatives open to them were an extension of the provident dispensary system and some form of State interference. The growth of dispensaries had been checked and the consequence was that the community had been led to interfere more and more in medical relief. Already in Birmingham the number of beds in rate-supported hospitals far exceeded those in voluntary hospitals. The Insurance Bill, following the lines of previous legislation, had brought the State at one bound to the doors of the hospitals, and by the introduction of the compulsory principle had rendered superfluous the provident dispensary. What would be the effect of the new system upon the outpatient departments’.’ He hoped it would bring about the reforms they all desired. Every man would go first to his own doctor ; if he came to the hospital first it would be easy to refuse treatment, and the staff would be haunted noi

individual cases. Dr. J. H. TAYLOR (Salford) thought control of hospitals by the Insurance Commissioners would not be as objectionable as State control, because on the former body there would be medical representation. Mr. JAMES NEAL (Birmingham), Dr. WALLACE HENRY, (Leicester), and Mr. G. JACKSON (Plymouth) also took part in the discussion, all emphasising the point that if insurance patients in hospitals were paid for, the medical staffs could not be expected to give their services voluntarily. The readers of papers then replied, and on the question of the method of payment, if it was found that the State must come to the aid of the hospitals if the Bill was passed, Mr. CHAMBERLAIN pointed out that the estimated loss of income at different hospitals varied widely. A per capita grant would therefore not compensate some of the hospitals for their loss. ____

NEUROLOGY AND PSYCHOLOGICAL MEDICINE. THURSDAY, JULY 27TH. President, Dr. EDWIN GOODALL (Mental Hospital, Cardiff). The subject set down for discussion was Trauma in Relation to Nervous and Mental Affections, which was introduced by Dr. F. W. MOTT (London), who began by emphasising the importance of distinguishing between cause and coincidence of head injury in relation to nervous and mental disease, also of recognising that head injuries are not infrequently the result of nervous or mental disease. His experience was drawn chiefly from asylum work, and it was curious how few actual cases of head injury with trephining for it he had observed. Out of 20,000 cases there were less than 20 of this kind, and in a series of 2000 necropsies on insane cases there was only one. That head injuries might cause insanity was admitted, although it was- of the first importance to elicit the details-