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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 improve-ment to the hearing could be obtained by inflating themiddle ear then nasal treatment should be adopted, and evenif not much improvement followed inflation, then nasalobstruction should be dealt with. The residuum of hearingshould be cultivated, and, if possible, improved, and thepatients encouraged to keep up their general health. Opera-tive measures upon the ear itself appeared to stand verymuch where they were before.

Dr. JOBSON HORNE exhibited

Simplified Insufflator for Use in tlae Treatment of Diseasesof the Throat, Nose, and Ear.

The instrument consists of glass-tubes of various lengths,shapes, curves, and calibre to meet the requirements of theregions in which they were to be used. The distal end ofthe tubes is roughened on the inner surface for an inch ormore. This roughening of the inner surface of the tube

permits of the powder being retained in sattc, and also of aknown quantity of powder being used. The advantages- claimed for this insufflator are : simplicity, cleanliness,simplicity of auto-insufflation, precise dosage, and cheap-ness. The instrument has been made by Mr. F. Rogers ofOxford-street.

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MEDICAL SOCIOLOGY.

THURSDAY, JULY 27TH.President, Dr. GEORGE REID (Stafford).

Hospital Reform in Relation to the National Insurance Billwas the subject upon which distinguished speakers, medicaland lay, addressed the Section at its second session. The

question was dealt with both from the points of view of themedical staffs and of the governing bodies of hospitals, andthere was evidently some difference of opinion as to whetherhospitals will be wise in accepting grants-in-aid from theState in respect of insurance patients. Dr. GEORGE REID

again presided, but the attendance was still disappointing-itwas 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

paper, asserted that the Insurance Bill must profoundlyalter the position of the hospitals. Even if the Billdid not pass, the prominence given by its discussion tothe unsatisfactory provision of medical treatment for largesections of the community must lead shortly to the institu-tion of some alternative to the present chaotic jumble ofindiscriminate charity, inadequately paid contract service,and a mutually unpopular Poor-law medical service.

Assuming that the Bill would pass-modified, of course, inaccordance with the strictly moderate demands of themedical profession-the hospitals would find there was stillmuch work for them to do on a voluntary basis. The Billprovided only, except in the case of consumption, for

ordinary domiciliary medical treatment. For other cases

further provision of some sort must be forthcoming, and itseemed probable that, at any rate at the outset, it would bemade by means of the voluntary hospitals. It had long beenrecognised that the attempt to combine the dual function ofministering to minor ailments, and at the same time dealingwith cases requiring the highest resources of medical andsurgical skill, had handicapped the development of the pro-fessional side of the hospital, while the avoidance of impositionand abuse in these conditions had become quite impossible.The provision of insurance for ordinary treatment for a largesection of the present hospital clientèle should greatlysimplify the selection of suitable cases. Inquiries into the economic position of the patient would be reduced in manycases to determining ’.he status of the patient under theinsurance scheme, and there would be przma facie groundfor insisting that the hospital should exercise its

proper function of providing special medical service only.Dr. Shaw laid stress on the necessity from both pro-fessional and social points of view of dealing with theinsured persons at the hospital on a consultative basis incooperation with the insurance doctor. From the professionalpoint of view it might well be regarded as a breach ofmedical etiquette for a member of the hospital staff,

knowing that the insured person had definitely engageda medical practitioner to attend him, to undertake histreatment except with the sanction of, and in coöpera-tion with, that attendant. To deal entirely on independentlines with another man’s patient, even in the sacredname of charity, could hardly be tolerated in the alteredcircumstances created by the Bill. From the social sidethe public, which had to maintain the insurance fund, wasequally interested with the profession in securing coöpera-tion 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 wasgiven by men who were consultants and usually chargedprivate patients higher fees than the insurance doctor did,the glamour of the place, and the ritual observed in teachingstudents would, even if the actual service were inferior-instead of being as a rule, for suitable cases, superior-strongly impress the patient with its superiority. To avoiddisaster systematic cooperation was essential. On thequestion of the nationalisation of hospitals Dr. Shaw saidthat while believing that in the interests of medicalresearch and education the voluntary system should bemaintained, he recognised that its continuance was im-

perilled. The transformation of voluntary hospitals into

truly consultative institutions, taking no independent part inthe treatment or investigation of disease, but cooperatingalways with institutions or private practitioners undertakingordinary medical treatment, would provide them with a newlease of useful life, and would probably postpone indefinitelythe nationalisation or municipalisation of that higher class ofinstitution which was capable of adopting that line of pro-fessional work. Even if the hospitals did become nationalised,it would still be essential to define their relation to theinsurance service. For the State to provide side by side aninstitutional and a domiciliary service, and to allow the

patient to chose which he would use, would be a mostunreasonable and unbusinesslike proceeding. Unless the

voluntary hospitals would relinquish voluntarily all treat-ment such as was to be provided by the insurance scheme,and would cooperate with its officers in providing on con-sultative lines the additional special professional help whichthey were best fitted to provide, they would seriously handi-cap the insurance service and imperil their own future asindependent institutions.

Mr. J. COURTNEY BUCHANAN (secretary of the MetropolitanHospital) contributed a paper on

T7te Future of Voluntary Hospitals,He urged that hospital managers should follow thewise course of the British Medical Association andset themselves to define beforehand the work theirexperience taught them they could do best. After touchingon the effect of the Bill in drying up the sources whencehospitals derive their funds, Mr. Buchanan declared thatthe introduction of a system of charging insured patients wasinevitable. In future hospitals would be forced to actsolely in a consultative capacity towards the poorer classes.Trivial cases need no longer be treated at the hospitals ; thesewould be seen by the insurance doctors. As he understood,the doctors would prefer to see the insured patients at somecentre; these might be institutions conducted very muchon the lines of provident dispensaries. These should begrouped 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 hecould see no objection to hospitals being paid for work donefor the insurance authorities, or even to State grants-in-aidfor specific purposes, always provided that if the hospitalshad to be subjected to public inspection it was carried out

by experienced people. A central council might be establishedfor this purpose ; it would leave hospitals free to developtheir own particular characteristics, while securing uniformityin matters where uniformity was really desirable, such asmethods of admission, &c. The day had gone by, he feared,when the provision of help for the sick would suffice to drawenough money for the hospitals’ support. The only reason-able ground for hoping that the hospitals could still bemaintained by voluntary contributions lay in the attractionthat the more expensive forms of medical treatment and theadvancement of medical education and scientific research

450

now held for wealthy and philanthropic people. The future

policy of the hospitals should be to show clearly that thework they did was for the benefit of the whole community,and for this purpose to maintain their special services in thehighest perfection.

Mr. NEVLLLE CHAMBERLAIN (Birmingham) contributed apaper on

The I?efornb of Out-patient Departments of Hospitals,remarking by way of preface that while the Insurance Billwould render impossible the remedies he had in mind beforeits introduction, it would also, he hoped, remove in largepart the evil those remedies were designed to meet. Probablyeveryone would agree that the work of out-patient depart-ments was the least satisfactory part of modern hospitalroutine, whether looked at from the point of view of thehospital, the medical profession, or the patients who came tothe departments for treatment. Instead of confining them-selves to consultation and cases of immediate urgency, as wasintended originally, the out-patient departments, with theirelaborate and expensive apparatus, their trained nurses andexperienced consultants, had allowed themselves to be turnedinto great free dispensaries. Really serious and importantcases were jostled and thrust aside by people with cut fingersor common colds, or, what was perhaps worse, by chronicswhose chances of cure lay rather in careful nursing and hometreatment than in periodic visits to a distant institution.The result was an ever-increasing crowd of applicants forrelief with a corresponding diminution of the amount of timedevoted to each individual. Hospital managers chafed undera sense that the money of the subscribers was being wasted,patients grumbled at the long waiting, while the medicalpractitioner outside bitterly commented on the difficultyof earning a livelihood in competition with an institutionwhich was not run on commercial lines, but offeredgratis the knowledge and experience he had spenthis time and money in acquiring. Proceeding to con-

sider remedies for this state of things, Mr. Chamberlainmentioned how difficult it had been found in practiceat the Birmingham General Hospital to get the staff tosort out applicants for relief and advise trivial cases to

apply to their own doctor, to a dispensary, or elsewhere.The only chance appeared to lie in applying pressure on thepeople themselves. Mr. Chamberlain outlined "an ideal

system of medical relief " as follows :-1. Every person should contribute towards the cost of treatment.

’

2. Every person should be attended in the first instance by his owndoctor, but should have power to change his doctor at intervals.

3. Drugs should not be dispensed by a doctor but by a chemist ordispensary.

4. Patients requiring institutional treatment should be admitted tothe hospital as in-patients, or should obtain consultation or treatmenton the recommendation of any q-ualified medical man without thenecessity for subscribers’ letters, &c.

5. Paying wards should be established for those in better circum-stances.

An endeavour had been made to fulfil some of these con-ditions in Birmingham by the establishment of a providentdispensary. Mr. Chamberlain described the methods of thisinstitution, which a medical speaker later in the meeting paidthe tribute of describing as free from the defects of mostsimilar undertakings. Among the hindrances to the successof the dispensary Mr. Chamberlain mentioned the apathy ofthe medical profession and the stringency of medical etiquettewhich made no distinction between canvassing for a privateindividual for his personal benefit and canvassing for a

properly managed provident institution primarily for thebenefit of the members themselves. Medical men hadfailed to recognise the trend of modern legislation and tosee that the only alternatives open to them were an exten-sion of the provident dispensary system and some form ofState interference. The growth of dispensaries had beenchecked and the consequence was that the community hadbeen led to interfere more and more in medical relief.

Already in Birmingham the number of beds in rate-supportedhospitals far exceeded those in voluntary hospitals. TheInsurance Bill, following the lines of previous legislation,had brought the State at one bound to the doors of thehospitals, and by the introduction of the compulsoryprinciple had rendered superfluous the provident dispensary.What would be the effect of the new system upon the out-patient departments ’.’ He hoped it would bring about thereforms they all desired. Every man would go first to hisown doctor ; if he came to the hospital first it would be easyto refuse treatment, and the staff would be haunted no i

longer by the bogey of a public scandal following on a"spiteful death on the doorstep." He did not think theexpense or the numbers of the out-patient departments-would greatly decrease. There would be a larger number ofdifficult, protracted, and expensive cases, but the hospitalswould be relieved of the greater portion of the trivial caseswhich were now such a clog upon their working. Subscrip--tions, however, must decrease owing to direct taxation ofsources of hospital income. He did not agree with a systemof per capita contributions from the State as likely to giverise to disputes. He would like to see sums of moneyallotted to hospitals on the lines of State grants touniversities.

Dr. E. D, KIRBY (Birmingham) read a paper onSome Local Aspects of Hospital Reform.

In Birmingham, he said, the medical institutions had allowedthemselves gradually to be perverted from charities into pro--vident institutions. That was to say, the working classes-had been permitted to subscribe to them for their ownbenefit. It might be regarded as an intelligent anticipationof the Insurance Bill, with the significant exception that noprovision at all was made for any payment to the medicalprofession. In illustration of this statement Dr. Kirby gavean account of the history of the General Dispensary showing-how the practice of compulsorily deducting a penny a weekfrom workmen’s wages towards the Hospital Saturday Fundhad led to people claiming as a right services which wereinstituted as a charity.

Dr. J. B. BRIERLEY (Manchester), opening the discussion,remarked that the reason the medical profession had beendubious of provident dispensaries was that they had not beenable to secure an income limit for members.

Dr. J. H. KEAY (Greenwich) thought the spirit animatingthe papers read augured well for hearty cooperation beingsecured between medical men and hospital managers inmeeting the altered circumstances brought about by theInsurance Bill. As to the reform of out-patient departments, he.thought a few prosecutions of well-to-do people who abusedthem would be highly effectual.

Dr. D. J. MACKINTOSH (Glasgow) said that the Bill wouldassist in doing away with hospital abuse if it existed.Voluntary hospitals had a hand-to-mouth existence at present,and they could not continue to exist unless funds were forth--coming. He objected to hospitals accepting grants from theState, but saw no difficulty in their receiving payment forindividual cases.

Dr. J. H. TAYLOR (Salford) thought control of hospitals bythe Insurance Commissioners would not be as objectionableas State control, because on the former body there would bemedical representation.Mr. JAMES NEAL (Birmingham), Dr. WALLACE HENRY,

(Leicester), and Mr. G. JACKSON (Plymouth) also took part inthe discussion, all emphasising the point that if insurancepatients in hospitals were paid for, the medical staffs couldnot 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 mustcome to the aid of the hospitals if the Bill was passed, Mr.CHAMBERLAIN pointed out that the estimated loss of incomeat different hospitals varied widely. A per capita grantwould therefore not compensate some of the hospitals fortheir loss.

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NEUROLOGY AND PSYCHOLOGICAL MEDICINE.

THURSDAY, JULY 27TH.

President, Dr. EDWIN GOODALL (Mental Hospital, Cardiff).The subject set down for discussion wasTrauma in Relation to Nervous and Mental Affections,

which was introduced by Dr. F. W. MOTT (London),who began by emphasising the importance of distin-guishing between cause and coincidence of head injury inrelation to nervous and mental disease, also of recognisingthat head injuries are not infrequently the result of nervousor mental disease. His experience was drawn chiefly fromasylum work, and it was curious how few actual cases ofhead injury with trephining for it he had observed. Out of20,000 cases there were less than 20 of this kind, and in aseries 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-