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WAITING AT OUT-PATIENT DEPARTMENTS.
79
WAITING AT OUT-PATIENT DEPARTMENTS.
otherwise than by meter or special agreement if any part of the dwelling-house was used for any trade or business purposes. The argument for the defendant that " trade or business " did not include " " profession seems to have been unsuccessful. There is, by the way, a reported case which declares that water used by a medical practitioner for washing a motor-car in connexion with his practice is not used for a trade or business. THE DIAPHRAGM IN HEALTH AND DISEASE. MODERN advances in the study of respiratory disease have given the diaphragm a much more important position in medicine than it had 20 years ago when Sir Arthur Keith1 wrote his chapter on the mechanism of respiration in man. It is to the chest specialist that the stimulus of interest has of late Advances in the study of lung years been due. collapse therapy in all its branches, and radiological technique have enlarged our knowledge, to which the practice of pneumoperitoneum has also to some extent contributed. In a recent monograph2 with a valuable bibliography, Dr. Karl Hitzenberger, of Vienna, has collected a large amount of information on the diaphragm in health and disease, illustrating his points with helpful radiograms and simple line diagrams. Beginning with its anatomy he summarises what is known of the embryological structure of the diaphragm and goes on to give a long account of the mechanism of its movements, its functions, abnormalities, and diseases. Its movement is by no means the simple piston-like downward and forward action formerly described. There is a potentially different respiratory reserve on the two sides and the costophrenic sinus varies in extent, whilst many modifications of movement are now recognised. The study of these movements in the cat under experimental conditions led Lady Briscoe to the conclusion (THE LANCET,7 926, ii., 57) that in most clinical cases of unilateral phrenic paralysis the paralysis is partial rather than complete. The whole of Dr. Hitzenberger’s monograph resolves itself into a plea for a careful clinical study of the diaphragm in chest disease. Adhesions, paralysis of the phrenic nerve from various causes, the different operations performed on the phrenic nerve, relaxatio diaphragmatica, suppuration above and below the muscle, and numerous other clinical conditions are discussed and figured, but it is clear that much research on the subject is still required. For instance, little has been done to advance our knowledge of intrapleural pressure in normal respiration. Again, the subject of lymphatic drainage of the diaphragmatic regions, including the pleura and thoracic wall, is not as well understood as it might be, though it has an intimate bearing on major operations in the chest.
’
’
WAITING AT OUT-PATIENT DEPARTMENTS. ONE of the subjects discussed at the Baby Week
Conference, reported elsewhere in our columns, was the distress caused to mothers and their families by prolonged waiting at out-patient departments" The reality and urgency of the problem was admitted by every speaker, including the chairman, Sir Arthur Stanley, who referred to the tenfold increase in outpatient attendances since the premises at St. Thomas’s Hospital were erected. Illustrations of actual hardship were given by speakers representing the Women’s ’ Cooperative Guild and the Women Sanitary Inspectors’ i and Health Visitors’ Association, and other bodies. ’, Minor attempts to remedy the evil were described by Dr. A. G. Maitland-Jones, of the London Hospital, and Mr. A. H. Leaney, house governor of the Birmingham General Hospital. Dr. Maitland-Jones, who ’ deplored having to attend to irritated mothers and 1
Further Advances in Physiology.
Edited by Dr. Leonard
Hill, London, 1909. 2
Das Zwerchfell im gesunden und kranken Zustand. Vienna. M.18.
Pp. 206.
restless children, set out the system adopted at the children’s department of his Hospital, whereby old patients attend in batches at 9, 10, 11, and 12 o’clock respectively, whilst he emphasised the difficulty of arranging to see new case by appointment and the fact that in teaching hospitals the new cases are used for instruction in methods of diagnosis, failing which the education of the medical practitioners of the future must suffer. To imitate American methods would, he said, entail great expense, the keeping open of out-patient departments throughout the day, larger premises, and an increase in the medical and administrative staffs. Mr. Leaney thought we had much to learn from other countries in this matter. His own view was that out-patient departments should be consultative only, that a social service department should relieve the doctors of clerical work, that new patients should be seen at half-hourly intervals on definite days and old patients in halfhourly batches, that well qualified assistants should relieve their chiefs, and that the doctors should be paid-with a corollary of a much greater demand upon their time. The present practice was indefensible and unacceptable, both to donors and patients. Moreover, the service was no longer really " free" owing to mass subscriptions of workmen and individual contributions levied upon those who could pay. We had in this country the strongest possible foundation on which to build a really good system, and he would like to see an experiment made by giving a large grant to one selected hospital, conditional on the establishment of as perfect a system
possible, with which the other hospitals would gradually come into line. Overcrowding of departments by unsuitable cases was brought out by other speakers at the Conference, and in order to secure as
their restriction to consultative use the extension of the contract system to the dependents of insured In some districts already persons was advocated. public medical services are having this result. But the fact that a considerable number of hospitals have established canteens for their outpatients is an admission of the reality of the evil. The present time, when the whole hospital service of the country is to come under review owing to changes in local government, may be opportune for a study of the defects in our service, in the light of the experience of other countries. All are agreed as to the want of a better system. From what source the funds for its provision are to come will remain to be considered after some representative committee makes its report. ____
EARLY
OPERATION FOR ACUTE SUPPURATION OF THE MIDDLE EAR. ONE of the most difficult decisions which the otologist is called upon to make is whether and when to operate on the mastoid in severe acute suppurative otitis. The complications of this condition which endanger life are usually the result of mastoiditis, though the possibility of labyrinthitis and an endocranial spread of infection from the tympanum must be remembered. The usual practice is to open the antrum if swelling, severe pain, tenderness, and fever persist for more than three or four days after a. free discharge is established with or without paracentesis of the membrane. But Prof. Ludwig Haymann,l of Munich, is a strong opponent of operation at thiss stage, and claims that a large series of cases of this kind under his care have cleared up and become soundly healed without operation. In his opinion the only indication for opening the mastoid at the beginning of an acute otitis is the certainty or strong probability of some endocranial complication such as meningitis or sinus thrombosis; the recognition of such a complication is sometimes extremely difficult, and in doubtful cases it is better to operate too early than too late, but this necessity is exceptional. Pain, tenderness, and even high fever, he says, are not of 1
Münch. med.
Woch., June 7th, p. 947.
WAITING AT OUT-PATIENT DEPARTMENTS.
otherwise than by meter or special agreement if any part of the dwelling-house was used for any trade or business purposes. The argument for the defendant that " trade or business " did not include " " profession seems to have been unsuccessful. There is, by the way, a reported case which declares that water used by a medical practitioner for washing a motor-car in connexion with his practice is not used for a trade or business. THE DIAPHRAGM IN HEALTH AND DISEASE. MODERN advances in the study of respiratory disease have given the diaphragm a much more important position in medicine than it had 20 years ago when Sir Arthur Keith1 wrote his chapter on the mechanism of respiration in man. It is to the chest specialist that the stimulus of interest has of late Advances in the study of lung years been due. collapse therapy in all its branches, and radiological technique have enlarged our knowledge, to which the practice of pneumoperitoneum has also to some extent contributed. In a recent monograph2 with a valuable bibliography, Dr. Karl Hitzenberger, of Vienna, has collected a large amount of information on the diaphragm in health and disease, illustrating his points with helpful radiograms and simple line diagrams. Beginning with its anatomy he summarises what is known of the embryological structure of the diaphragm and goes on to give a long account of the mechanism of its movements, its functions, abnormalities, and diseases. Its movement is by no means the simple piston-like downward and forward action formerly described. There is a potentially different respiratory reserve on the two sides and the costophrenic sinus varies in extent, whilst many modifications of movement are now recognised. The study of these movements in the cat under experimental conditions led Lady Briscoe to the conclusion (THE LANCET,7 926, ii., 57) that in most clinical cases of unilateral phrenic paralysis the paralysis is partial rather than complete. The whole of Dr. Hitzenberger’s monograph resolves itself into a plea for a careful clinical study of the diaphragm in chest disease. Adhesions, paralysis of the phrenic nerve from various causes, the different operations performed on the phrenic nerve, relaxatio diaphragmatica, suppuration above and below the muscle, and numerous other clinical conditions are discussed and figured, but it is clear that much research on the subject is still required. For instance, little has been done to advance our knowledge of intrapleural pressure in normal respiration. Again, the subject of lymphatic drainage of the diaphragmatic regions, including the pleura and thoracic wall, is not as well understood as it might be, though it has an intimate bearing on major operations in the chest.
’
’
WAITING AT OUT-PATIENT DEPARTMENTS. ONE of the subjects discussed at the Baby Week
Conference, reported elsewhere in our columns, was the distress caused to mothers and their families by prolonged waiting at out-patient departments" The reality and urgency of the problem was admitted by every speaker, including the chairman, Sir Arthur Stanley, who referred to the tenfold increase in outpatient attendances since the premises at St. Thomas’s Hospital were erected. Illustrations of actual hardship were given by speakers representing the Women’s ’ Cooperative Guild and the Women Sanitary Inspectors’ i and Health Visitors’ Association, and other bodies. ’, Minor attempts to remedy the evil were described by Dr. A. G. Maitland-Jones, of the London Hospital, and Mr. A. H. Leaney, house governor of the Birmingham General Hospital. Dr. Maitland-Jones, who ’ deplored having to attend to irritated mothers and 1
Further Advances in Physiology.
Edited by Dr. Leonard
Hill, London, 1909. 2
Das Zwerchfell im gesunden und kranken Zustand. Vienna. M.18.
Pp. 206.
restless children, set out the system adopted at the children’s department of his Hospital, whereby old patients attend in batches at 9, 10, 11, and 12 o’clock respectively, whilst he emphasised the difficulty of arranging to see new case by appointment and the fact that in teaching hospitals the new cases are used for instruction in methods of diagnosis, failing which the education of the medical practitioners of the future must suffer. To imitate American methods would, he said, entail great expense, the keeping open of out-patient departments throughout the day, larger premises, and an increase in the medical and administrative staffs. Mr. Leaney thought we had much to learn from other countries in this matter. His own view was that out-patient departments should be consultative only, that a social service department should relieve the doctors of clerical work, that new patients should be seen at half-hourly intervals on definite days and old patients in halfhourly batches, that well qualified assistants should relieve their chiefs, and that the doctors should be paid-with a corollary of a much greater demand upon their time. The present practice was indefensible and unacceptable, both to donors and patients. Moreover, the service was no longer really " free" owing to mass subscriptions of workmen and individual contributions levied upon those who could pay. We had in this country the strongest possible foundation on which to build a really good system, and he would like to see an experiment made by giving a large grant to one selected hospital, conditional on the establishment of as perfect a system
possible, with which the other hospitals would gradually come into line. Overcrowding of departments by unsuitable cases was brought out by other speakers at the Conference, and in order to secure as
their restriction to consultative use the extension of the contract system to the dependents of insured In some districts already persons was advocated. public medical services are having this result. But the fact that a considerable number of hospitals have established canteens for their outpatients is an admission of the reality of the evil. The present time, when the whole hospital service of the country is to come under review owing to changes in local government, may be opportune for a study of the defects in our service, in the light of the experience of other countries. All are agreed as to the want of a better system. From what source the funds for its provision are to come will remain to be considered after some representative committee makes its report. ____
EARLY
OPERATION FOR ACUTE SUPPURATION OF THE MIDDLE EAR. ONE of the most difficult decisions which the otologist is called upon to make is whether and when to operate on the mastoid in severe acute suppurative otitis. The complications of this condition which endanger life are usually the result of mastoiditis, though the possibility of labyrinthitis and an endocranial spread of infection from the tympanum must be remembered. The usual practice is to open the antrum if swelling, severe pain, tenderness, and fever persist for more than three or four days after a. free discharge is established with or without paracentesis of the membrane. But Prof. Ludwig Haymann,l of Munich, is a strong opponent of operation at thiss stage, and claims that a large series of cases of this kind under his care have cleared up and become soundly healed without operation. In his opinion the only indication for opening the mastoid at the beginning of an acute otitis is the certainty or strong probability of some endocranial complication such as meningitis or sinus thrombosis; the recognition of such a complication is sometimes extremely difficult, and in doubtful cases it is better to operate too early than too late, but this necessity is exceptional. Pain, tenderness, and even high fever, he says, are not of 1
Münch. med.
Woch., June 7th, p. 947.