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OTOLOGY AND LARYNGOLOGY.
THE BRITISH MEDICAL ASSOCIATION.
one-half were cured in one week, a further in the fortnight, only 5 per cent. dragged on for months, and these were the cases of phlyctenular keratitis occurring in children who were justly called " strumous" at sight. Next the cure was obtained by the simplest means, yellow cintment ; in some cases he had experimented with plain castor oil with equally satisfactory results. Further, the cases had an "age-peak," the maximum occurring at six years of age, a fact that had no relation to tubercle, but a very definite one to the decay of the first dentition and the eruption of the second. Lastly, the lesions had a "seat of election," one that had a specific relation to the distribution of the fifth nerve to the teeth. These things led him to conclude that the common phlyctenular conjunctivitis of children was not tuberculous in any real sense ; it was a herpetiform eruption due to irritation of collateral branches of the fifth nerve. In a residuum of cases there were genuine tuberculous bases, particularly in those lesions which occurred in later years of life ; and there were the pustular lesions and the combined episcleral and corneal lesions, which were often, but probably " erroneously, called phlyctenules. He felt that to assign a simple lesion to a grave cause and then claim cure for it by vaccine treatment when it was more easily cured by the simplest therapeutic measures was to discredit vaccine treatment. A paper on The Treatment of Word-blindness, Acquired and Congenital, was read by Dr. JAMES HINSHELWOOD (Glasgow), who said that the old idea was that nothing could be done for the education of persons suffering from these serious defects. Much, however, could be done if the treatment were conducted on proper lines, and he indicated what line, in his experience, was the best to adopt. Pure cases of acquired word-blindness almost always came to the ophthalmic surgeon in the first instance, as it was supposed that the defect lay in the eyes. The lesion, however, was either in the brain, in the angular gyrus itself, or it was due to the interruption of the communicating fibres between it and the ganglia. In right-handed people the lesion was on the left side. He related the case of a man, aged 58 years, who awoke one morning with the power of reading quite lost. He had right lateral homonymous hemianopsia, but no other symptoms were discoverable. He started to re-educate himself, learning letters and words like a child. After six months he was able to recognise the letters of the alphabet, but never learned to read words by sight. He could read only by spelling words out letter by letter and thus stimulating his auditory memory. After a year he gave it up as hopeless ; still he had re-acquired the visual memory of the letters and of a few short words. Another patient was a woman, aged 34 years, who had been completely word and letter blind for 14 months ; she had right homonymous hemianopsia. A schoolmaster took great interest in her re-education. It was found that the effort of eduction was very great, and could not be continued for more than 10 minutes at a time. Ultimately she learned to read simple Bible texts by spelling out the words. Her progress has been steady but slow from that point of attainment ; but now, after an interval of ten years, she could read a newspaper fairly fluently, only occasionally she was compelled to spell words. The third case was that of a girl, aged 14 years, who had rightided paralysis and loss of speech 18 months before. Previously she had been a good reader. When first seen she was completely letter blind and had right homonymous hemianopsia. Her auditory memory was unaffected. Reeducation was started. After learning the alphabet she was allowed to spell out words letter by letter. In four months she had made considerable progress and could recognise any letter and many small words. Longer words she had to spell so as to get the aid of her ear. Two years later she could read as well as ever but the hemianopsia persisted. Age evidently was a very important factor in the ability with which the patients were able to regain their lost powers. The cause in all these cases was cerebral haemorrhage. In such cases the process of re-education should be delayed until all signs of acute brain symptoms had disappeared. In these cases it could be accomplished only by bringing into play the corresponding centre on the other side of the brain. He argued from these cases of acquired word blindness and the experience of re-education that
all the
quarter
cases
453
both in these and in congenital cases neither the old system ’’ nor that known as the look-and-saymethod was suitable for all cases. A great deal depended upon the degree of defect in the visual memory, and upon the condition of the auditory memory. When the visual memory was very defective and the auditory good, then the old system would give the best results ; but when the auditory was not good" the best results might be obtained by the "look-and-say" system. Lastly, personal teaching was necessary in all cases, and a number of short reading lessons during the day was better than one long one, for the brain rapidly became exhausted. Dr. F. W. EDRIDGE-GREEN (London) quite agreed with the methods suggested for training the memory. He had found that it was of the greatest importance to put as little strain as possible on a weak faculty. It should be remembered that the retina was represented in the cerebrum, " so that we might almost speak of a cerebral retina."
OTOLOGY AND LARYNGOLOGY.
THURSDAY, JULY 25TH.
President, Mr.
HUGH EDWARD JONES (Liverpool).
On this clay the Otological Section combined with the section of Laryngology under the chairmanship of Dr. J. MIDDLEMASS HUNT (Liverpool) to discuss jointly the Education
of the Specialist in Laryngology
and
Otology.
opening the discussion Dr. HOLGER MYGIND (Copenhagen) surveyed the education of the specialist on the continent, where there was no uniform system. Countries, he said, might be divided into three groups : (1) Those (Germany, Austria-Hungary, Scandinavia, Holland, Switzerland, and Roumania) where the universities had chairs of Otology and Laryngology (in this group were 44 such chairs) ; (2) those (Italy, France, Spain, and Belgium) in which some of the universities (19 in number) possessed such chairs ; and (3) those (Russia, Greece, and Portugal) where there was no systematised teaching. This was not, however, the sole expression of the state of education in Europe. The highest standard was undoubtedly reached in Germany, but Austria was not far behind. On the continent it was a rare thing to find a man recognised as a specialist who had not passed some time as an assistant in a special clinic, and a man with a high reputation might remain as assistant for 12 or 14 years. In some countries an assistantship, followed by the publication of a dissertation, qualified him as "privat-docent,"a valuable distinction, as it carried with it the right of teaching. Dr. Mygind then discussed the defects of the continental system. He considered that the preliminary education of the student at the university should be the first stage of special training. The first fault was a superficiality in the examination of the patient, due to want of time on the part of the teacher. The second was the laying of too great stress upon lectures. Text-books were plentiful now, and detailed instruction in practical work was most required. Thirdly, the course did not end in examination, save in Germany, where it was conducted by surgeons and physicians, and not by specialists. In the final stages the assistants had too scanty training in general work, appointments were often of too short duration, and the great majority of the out-patient departments were overcrowded and experienced assistants As a consequence, cases were badly too few in number. recorded and were treated by too many specialists. The remedies suggested by Dr. Mygind were the following : 1. A more thorough and more individual teaching of the young student, in classes of 10 to 12, with experienced assistants to the professor. 2. Beginners to study every detail, to avoid superficiality, only ordinary cases to be demonstrated at first, as a few cases examined thoroughly taught more than many badly gone over. 3. Compulsory final examination by specialists for every student. 4. Free post-graduate courses supported by the university or the State. 5. No appointment of an assistant to be made without a year and a half as a general assistant (nine months being spent in surgery), the minimum duration of special assistantship to be one year. 6. The provision of enough salaried assistants in proportion to the number of patients. 7. The provision of wards attached to each clinic. Dr. Mygind also discussed the connexion between laryngology and otology which, in In
454
THE BRITISH MEDICAL ASSOCIATION.
opinion, could never be entirely separated ; the question technique and should be attached to his chief for private work as well. Opportunities for special grounding in anatomy was, to a great extent, a practical one. Dr. P. WATSON-WILLIAMS (Clifton) referred to the valuable and physiology, clinical examination, and the use of instriiarticles which had appeared in the Jo?trgtal of Laryngology, ments did not exist in the United Kingdom. Dr. JOBSON HoRrrE (London) deprecated going abroad for and confined himself to the position in Great Britain and Ireland. There were at least 54 British hospitals with 696 teaching. He insisted upon a sound groundwork of anatomy beds for throat, nose, and ear cases, proving that laryngo- and physiology and the combating of the idea that ’’anylogy and otology were now generally conceded to be special body could do our work." Dr. R. H. WOODS (Dublin) agreed with what had beeii departments. The labours of specialists had yielded abundant fruit and fullyjustified their existence. He com- said, and suggested the early training of eyes and fingers in, plained that most British special clinics were merely out- the school workshop. Mr. W. PERMEWAN (Liverpool) realised from Dr. Mygind patient departments and beds were grudgingly conceded, whilst cases were not always referred to the specialist as how far they were behind other countries. He alluded to the they should be. He formulated the wants of laryngology unsatisfactory position of specialists in general hospitals. Sir STCLAIR THOMSON (London) thought teachers should and otology as (1) their due recognition in the students’ curriculum ; (2) the more complete organisation and equip- express their views. Dr. Watson-Williams’s suggestions were ment of the special departments in many of our teaching rather severe. In this country things went slowly. They clinics ; and (3) systematic post-graduate training of practi- must first be physicians and surgeons and show it in theirtioners who desired to become specialists, and a distinctive work and in societies. They should insist on the dignity of degree or qualifications for those who had rendered them- their work. Otology and laryngology should be compulsory selves worthy of .such distinction. The want of proper for the ordinary pass examination. Mr. GEORGE JACKSON (Plymouth) advised approaching the training of students was, save in a few isolated instances, a Dr. General Medical Council and deprecated multiplying degrees. grave reflection upon the bodies responsible for it. Dr. DAN McKENZIE (London) thought the subject scarcely Watson-Williams then gave his views as to the training of specialists, and suggested a course and details of examination. ripe for discussion. It fell under two heads, the education He criticised the method of the Royal College of Surgeons of of the student and the education of the specialist. Dr. J. WALKER DOWNIE (Glasgow) asked if laryngology Edinburgh in its Fellowship Examination, and compared it with that of the University of London, which granted an and otology had not recently been made compulsory by the M.S. in odontology. General Medical Council. Dr. MIDDLEMASS HUNT complained of the want of freeDr. H. S. BIRKETT (Montreal) considered it time for instruction. A man ought to be able to spend, to an post-graduate of this matter, specialists give expression opinion upon and they must realise the danger of building too rapidly a two or three years working at a specialty and be able also to> suggested the foundation of scholarships or fellowcomplicated structure with ill-seasoned materials. He pro- live. HeWhat was the good of asking the State to protect to deal ships. with the conditions in the Canada and posed existing United States. In the former the question of education in the specialist when it did not protect against the quack’E’ opinion required educating. laryngology and otology was not considered because the Public Mr. H. TILLEY (London) agreed with Sir StClair Thomson amount of material did not permit of it. In Montreal there as to the raising of the quality of the work. was a post-graduate course of two months in which only Mr. E. B. WAGGETT thought that as a rule therudiments were taught, so that the physician could recognise what was pathological and what normal. Canada was not specialist was made by natural selection, and that sevenyet able to undertake the training of specialists. In the tenths of their cases ought to be diagnosed by the general United States, St. John Roosa initiated post-graduate practitioner. Mr. MACLEOD YEARSLEY (London) said that the matter teaching in New York 30 years ago, and now such insti- was one of evolution, and before discussing the education of tutions existed in every town of any size. The best postthe specialist it was necessary to educate the general prac-graduate teaching of otology and laryngology was in the titioner. with and it Otology and laryngology should be made combegan physiological patholargest centres ; and find places in the examination. Their broacl followed pulsory in the clinical studies laboratory, by logical instruction in the out-patient departments, and con- principles should be taught when the student mind was. and this was better than post-graduate courses. cluding with operations on the cadaver. As the student plastic, Dr. A. WYLIE (London) said the subjects were already progressed he became a clinical assistant, doing minor British teaching was superior to continental. at the ones. compulsory. Resident and major assisting operations What was wanted were more post-mortem examinations. Courses some institutions. lasted in followed posts The openers of the discussion then replied briefly, Dr. from 6 to 12 months, and concluded with a severe examination and certificate. Evidently the ideal course, WATSON-WlLLlAMS pointing out that unless otology and was not yet reached. In McGill University the fourth year laryngology were put in the qualifying examinations it was. student was taught only what was normal by anatomicall useless to make them compulsory. studies, tests of normal hearing, and the use of instruments OTOLOGY. in perfectly normal conditions. In the fifth year common were in conditions demonstrated and patients pathological FRIDAY, JULY 26TH. specimens. The two years’ work was done in small groups Mr. HUGH E. JONES (Liverpool). President, of six men each. A clinical examination by specialists was Dr. J. KERR LOVE (Glasgow) read a paper on compulsory at the end of the fourth, a clinical and written The Prevention of Deafness in Non-s1bppurative Cages,. one at the end of the fifth year. Such courses met the needs He said that, as 10,000 children died in England alone every of the general practitioner very well. In Canada the were in the all examinations for year of meningitis, he thought that for the purposes of study subjects compulsory licence to practise. The preparation of specialists was then and treatment meningitis of every kind occurring in children discussed. The study should be gradual, should give depth should be compulsorily notifiable. With regard to syphilis, and background, and higher ideals should be stimulated. he thought deafness due to the congenital form of the The plan sketched out could be followed only by the few. disease was often proof of a dying or expiring poison, and There was, and would be, a large number who would enter that it was the exception to find its presence proved by thespecial work by the shortest route and quickest method ; Wassermann reaction. He had, however, been able tothey must be feared and suffered, but could be prevented ascertain its presence by that reaction. On the other hand, he had nearly always found that recent deafness and keratitis only by legislation. Mr. HUGH E. JONE8 (Liverpool) then took the chair during due to congenital syphilis could be demonstrated by the the discussion. Wassermann test. For the study of true hereditary deafness Mr. MARK HovELL (London) supported Dr. Birkett in he thought that an institution was required in this country making otology and laryngology subjects of examination and like the American Eugenics Record Office. He did not think the prevention of the marriage of the deaf or the sterilisation considered them inseparable. Mr. F. H. WESTMACOTT (Manchester) thought the require. of the deaf was practicable, because the hearing members of ments for all the special branches needed careful considera. deaf fraternities would have to be dealt with similarly, but The student he thought special education should be given to the heretion to avoid overburdening the student. specialist should have a year’s hospital appointment to lean ditarily deaf and to their relatives during the later schcol
his
(London)
,
,
.
.
one-half were cured in one week, a further in the fortnight, only 5 per cent. dragged on for months, and these were the cases of phlyctenular keratitis occurring in children who were justly called " strumous" at sight. Next the cure was obtained by the simplest means, yellow cintment ; in some cases he had experimented with plain castor oil with equally satisfactory results. Further, the cases had an "age-peak," the maximum occurring at six years of age, a fact that had no relation to tubercle, but a very definite one to the decay of the first dentition and the eruption of the second. Lastly, the lesions had a "seat of election," one that had a specific relation to the distribution of the fifth nerve to the teeth. These things led him to conclude that the common phlyctenular conjunctivitis of children was not tuberculous in any real sense ; it was a herpetiform eruption due to irritation of collateral branches of the fifth nerve. In a residuum of cases there were genuine tuberculous bases, particularly in those lesions which occurred in later years of life ; and there were the pustular lesions and the combined episcleral and corneal lesions, which were often, but probably " erroneously, called phlyctenules. He felt that to assign a simple lesion to a grave cause and then claim cure for it by vaccine treatment when it was more easily cured by the simplest therapeutic measures was to discredit vaccine treatment. A paper on The Treatment of Word-blindness, Acquired and Congenital, was read by Dr. JAMES HINSHELWOOD (Glasgow), who said that the old idea was that nothing could be done for the education of persons suffering from these serious defects. Much, however, could be done if the treatment were conducted on proper lines, and he indicated what line, in his experience, was the best to adopt. Pure cases of acquired word-blindness almost always came to the ophthalmic surgeon in the first instance, as it was supposed that the defect lay in the eyes. The lesion, however, was either in the brain, in the angular gyrus itself, or it was due to the interruption of the communicating fibres between it and the ganglia. In right-handed people the lesion was on the left side. He related the case of a man, aged 58 years, who awoke one morning with the power of reading quite lost. He had right lateral homonymous hemianopsia, but no other symptoms were discoverable. He started to re-educate himself, learning letters and words like a child. After six months he was able to recognise the letters of the alphabet, but never learned to read words by sight. He could read only by spelling words out letter by letter and thus stimulating his auditory memory. After a year he gave it up as hopeless ; still he had re-acquired the visual memory of the letters and of a few short words. Another patient was a woman, aged 34 years, who had been completely word and letter blind for 14 months ; she had right homonymous hemianopsia. A schoolmaster took great interest in her re-education. It was found that the effort of eduction was very great, and could not be continued for more than 10 minutes at a time. Ultimately she learned to read simple Bible texts by spelling out the words. Her progress has been steady but slow from that point of attainment ; but now, after an interval of ten years, she could read a newspaper fairly fluently, only occasionally she was compelled to spell words. The third case was that of a girl, aged 14 years, who had rightided paralysis and loss of speech 18 months before. Previously she had been a good reader. When first seen she was completely letter blind and had right homonymous hemianopsia. Her auditory memory was unaffected. Reeducation was started. After learning the alphabet she was allowed to spell out words letter by letter. In four months she had made considerable progress and could recognise any letter and many small words. Longer words she had to spell so as to get the aid of her ear. Two years later she could read as well as ever but the hemianopsia persisted. Age evidently was a very important factor in the ability with which the patients were able to regain their lost powers. The cause in all these cases was cerebral haemorrhage. In such cases the process of re-education should be delayed until all signs of acute brain symptoms had disappeared. In these cases it could be accomplished only by bringing into play the corresponding centre on the other side of the brain. He argued from these cases of acquired word blindness and the experience of re-education that
all the
quarter
cases
453
both in these and in congenital cases neither the old system ’’ nor that known as the look-and-saymethod was suitable for all cases. A great deal depended upon the degree of defect in the visual memory, and upon the condition of the auditory memory. When the visual memory was very defective and the auditory good, then the old system would give the best results ; but when the auditory was not good" the best results might be obtained by the "look-and-say" system. Lastly, personal teaching was necessary in all cases, and a number of short reading lessons during the day was better than one long one, for the brain rapidly became exhausted. Dr. F. W. EDRIDGE-GREEN (London) quite agreed with the methods suggested for training the memory. He had found that it was of the greatest importance to put as little strain as possible on a weak faculty. It should be remembered that the retina was represented in the cerebrum, " so that we might almost speak of a cerebral retina."
OTOLOGY AND LARYNGOLOGY.
THURSDAY, JULY 25TH.
President, Mr.
HUGH EDWARD JONES (Liverpool).
On this clay the Otological Section combined with the section of Laryngology under the chairmanship of Dr. J. MIDDLEMASS HUNT (Liverpool) to discuss jointly the Education
of the Specialist in Laryngology
and
Otology.
opening the discussion Dr. HOLGER MYGIND (Copenhagen) surveyed the education of the specialist on the continent, where there was no uniform system. Countries, he said, might be divided into three groups : (1) Those (Germany, Austria-Hungary, Scandinavia, Holland, Switzerland, and Roumania) where the universities had chairs of Otology and Laryngology (in this group were 44 such chairs) ; (2) those (Italy, France, Spain, and Belgium) in which some of the universities (19 in number) possessed such chairs ; and (3) those (Russia, Greece, and Portugal) where there was no systematised teaching. This was not, however, the sole expression of the state of education in Europe. The highest standard was undoubtedly reached in Germany, but Austria was not far behind. On the continent it was a rare thing to find a man recognised as a specialist who had not passed some time as an assistant in a special clinic, and a man with a high reputation might remain as assistant for 12 or 14 years. In some countries an assistantship, followed by the publication of a dissertation, qualified him as "privat-docent,"a valuable distinction, as it carried with it the right of teaching. Dr. Mygind then discussed the defects of the continental system. He considered that the preliminary education of the student at the university should be the first stage of special training. The first fault was a superficiality in the examination of the patient, due to want of time on the part of the teacher. The second was the laying of too great stress upon lectures. Text-books were plentiful now, and detailed instruction in practical work was most required. Thirdly, the course did not end in examination, save in Germany, where it was conducted by surgeons and physicians, and not by specialists. In the final stages the assistants had too scanty training in general work, appointments were often of too short duration, and the great majority of the out-patient departments were overcrowded and experienced assistants As a consequence, cases were badly too few in number. recorded and were treated by too many specialists. The remedies suggested by Dr. Mygind were the following : 1. A more thorough and more individual teaching of the young student, in classes of 10 to 12, with experienced assistants to the professor. 2. Beginners to study every detail, to avoid superficiality, only ordinary cases to be demonstrated at first, as a few cases examined thoroughly taught more than many badly gone over. 3. Compulsory final examination by specialists for every student. 4. Free post-graduate courses supported by the university or the State. 5. No appointment of an assistant to be made without a year and a half as a general assistant (nine months being spent in surgery), the minimum duration of special assistantship to be one year. 6. The provision of enough salaried assistants in proportion to the number of patients. 7. The provision of wards attached to each clinic. Dr. Mygind also discussed the connexion between laryngology and otology which, in In
454
THE BRITISH MEDICAL ASSOCIATION.
opinion, could never be entirely separated ; the question technique and should be attached to his chief for private work as well. Opportunities for special grounding in anatomy was, to a great extent, a practical one. Dr. P. WATSON-WILLIAMS (Clifton) referred to the valuable and physiology, clinical examination, and the use of instriiarticles which had appeared in the Jo?trgtal of Laryngology, ments did not exist in the United Kingdom. Dr. JOBSON HoRrrE (London) deprecated going abroad for and confined himself to the position in Great Britain and Ireland. There were at least 54 British hospitals with 696 teaching. He insisted upon a sound groundwork of anatomy beds for throat, nose, and ear cases, proving that laryngo- and physiology and the combating of the idea that ’’anylogy and otology were now generally conceded to be special body could do our work." Dr. R. H. WOODS (Dublin) agreed with what had beeii departments. The labours of specialists had yielded abundant fruit and fullyjustified their existence. He com- said, and suggested the early training of eyes and fingers in, plained that most British special clinics were merely out- the school workshop. Mr. W. PERMEWAN (Liverpool) realised from Dr. Mygind patient departments and beds were grudgingly conceded, whilst cases were not always referred to the specialist as how far they were behind other countries. He alluded to the they should be. He formulated the wants of laryngology unsatisfactory position of specialists in general hospitals. Sir STCLAIR THOMSON (London) thought teachers should and otology as (1) their due recognition in the students’ curriculum ; (2) the more complete organisation and equip- express their views. Dr. Watson-Williams’s suggestions were ment of the special departments in many of our teaching rather severe. In this country things went slowly. They clinics ; and (3) systematic post-graduate training of practi- must first be physicians and surgeons and show it in theirtioners who desired to become specialists, and a distinctive work and in societies. They should insist on the dignity of degree or qualifications for those who had rendered them- their work. Otology and laryngology should be compulsory selves worthy of .such distinction. The want of proper for the ordinary pass examination. Mr. GEORGE JACKSON (Plymouth) advised approaching the training of students was, save in a few isolated instances, a Dr. General Medical Council and deprecated multiplying degrees. grave reflection upon the bodies responsible for it. Dr. DAN McKENZIE (London) thought the subject scarcely Watson-Williams then gave his views as to the training of specialists, and suggested a course and details of examination. ripe for discussion. It fell under two heads, the education He criticised the method of the Royal College of Surgeons of of the student and the education of the specialist. Dr. J. WALKER DOWNIE (Glasgow) asked if laryngology Edinburgh in its Fellowship Examination, and compared it with that of the University of London, which granted an and otology had not recently been made compulsory by the M.S. in odontology. General Medical Council. Dr. MIDDLEMASS HUNT complained of the want of freeDr. H. S. BIRKETT (Montreal) considered it time for instruction. A man ought to be able to spend, to an post-graduate of this matter, specialists give expression opinion upon and they must realise the danger of building too rapidly a two or three years working at a specialty and be able also to> suggested the foundation of scholarships or fellowcomplicated structure with ill-seasoned materials. He pro- live. HeWhat was the good of asking the State to protect to deal ships. with the conditions in the Canada and posed existing United States. In the former the question of education in the specialist when it did not protect against the quack’E’ opinion required educating. laryngology and otology was not considered because the Public Mr. H. TILLEY (London) agreed with Sir StClair Thomson amount of material did not permit of it. In Montreal there as to the raising of the quality of the work. was a post-graduate course of two months in which only Mr. E. B. WAGGETT thought that as a rule therudiments were taught, so that the physician could recognise what was pathological and what normal. Canada was not specialist was made by natural selection, and that sevenyet able to undertake the training of specialists. In the tenths of their cases ought to be diagnosed by the general United States, St. John Roosa initiated post-graduate practitioner. Mr. MACLEOD YEARSLEY (London) said that the matter teaching in New York 30 years ago, and now such insti- was one of evolution, and before discussing the education of tutions existed in every town of any size. The best postthe specialist it was necessary to educate the general prac-graduate teaching of otology and laryngology was in the titioner. with and it Otology and laryngology should be made combegan physiological patholargest centres ; and find places in the examination. Their broacl followed pulsory in the clinical studies laboratory, by logical instruction in the out-patient departments, and con- principles should be taught when the student mind was. and this was better than post-graduate courses. cluding with operations on the cadaver. As the student plastic, Dr. A. WYLIE (London) said the subjects were already progressed he became a clinical assistant, doing minor British teaching was superior to continental. at the ones. compulsory. Resident and major assisting operations What was wanted were more post-mortem examinations. Courses some institutions. lasted in followed posts The openers of the discussion then replied briefly, Dr. from 6 to 12 months, and concluded with a severe examination and certificate. Evidently the ideal course, WATSON-WlLLlAMS pointing out that unless otology and was not yet reached. In McGill University the fourth year laryngology were put in the qualifying examinations it was. student was taught only what was normal by anatomicall useless to make them compulsory. studies, tests of normal hearing, and the use of instruments OTOLOGY. in perfectly normal conditions. In the fifth year common were in conditions demonstrated and patients pathological FRIDAY, JULY 26TH. specimens. The two years’ work was done in small groups Mr. HUGH E. JONES (Liverpool). President, of six men each. A clinical examination by specialists was Dr. J. KERR LOVE (Glasgow) read a paper on compulsory at the end of the fourth, a clinical and written The Prevention of Deafness in Non-s1bppurative Cages,. one at the end of the fifth year. Such courses met the needs He said that, as 10,000 children died in England alone every of the general practitioner very well. In Canada the were in the all examinations for year of meningitis, he thought that for the purposes of study subjects compulsory licence to practise. The preparation of specialists was then and treatment meningitis of every kind occurring in children discussed. The study should be gradual, should give depth should be compulsorily notifiable. With regard to syphilis, and background, and higher ideals should be stimulated. he thought deafness due to the congenital form of the The plan sketched out could be followed only by the few. disease was often proof of a dying or expiring poison, and There was, and would be, a large number who would enter that it was the exception to find its presence proved by thespecial work by the shortest route and quickest method ; Wassermann reaction. He had, however, been able tothey must be feared and suffered, but could be prevented ascertain its presence by that reaction. On the other hand, he had nearly always found that recent deafness and keratitis only by legislation. Mr. HUGH E. JONE8 (Liverpool) then took the chair during due to congenital syphilis could be demonstrated by the the discussion. Wassermann test. For the study of true hereditary deafness Mr. MARK HovELL (London) supported Dr. Birkett in he thought that an institution was required in this country making otology and laryngology subjects of examination and like the American Eugenics Record Office. He did not think the prevention of the marriage of the deaf or the sterilisation considered them inseparable. Mr. F. H. WESTMACOTT (Manchester) thought the require. of the deaf was practicable, because the hearing members of ments for all the special branches needed careful considera. deaf fraternities would have to be dealt with similarly, but The student he thought special education should be given to the heretion to avoid overburdening the student. specialist should have a year’s hospital appointment to lean ditarily deaf and to their relatives during the later schcol
his
(London)
,
,
.
.