541

THE LANCET.

LONDON: SATURDAY, AUGUST 24, 1912.

The Out-patient Departments ofLondon Hospitals.

THE OUT-PATIENT DEPARTMENTS OF LONDON HOSPITALS.

SOME 18 months ago King Edward’s Hospital Fund

appointed a committee to consider and report as to the

conditions under which patients are admitted to the out-

patient departments of the hospitals of London. The com-

mittee has recently issued its report and it is signed bythe two surviving members of its body, Lord MERSFY andthe Bishop of STEPNEY. It would have been wiser if a

medical man had been appointed a member of the com-

mittee, for the findings would have gained much in authoritythereby, but the commissioners have shown an exhaustiveand accurate appreciation of the medical aspect of the

questions, and their report deserves the most careful studyby all those who are responsible for the administration

of the charitable relief of London. The out-patientdepartments of hospitals have assumed large proportionsonly within the last hundred years, and during the earlierdecades of the nineteenth century the number of patientswas small, but there has been a steady increase and nowthe number has become very great, until in 1910 more thanone and three-quarter millions of persons attended the

ont-patient departments of the voluntary hospitals of

London. Even when allowance is made for the fact that

the same patient may attend at different hospitals or at thesame hospital on more than one occasion, it is clear that itcannot be right that the number of out-patients should formsuch a large percentage of the population of any city, evenof London, which is alike as populous as many kingdoms,and the uncomplaining refuge of the sick and miserable ofall races and degrees. Also in any investigation of this

subject the casualty cases must be considered with the out-

patients, for the distinction between them is not alwaysclear. The multitude of casualties and other patients whichare treated in London hospitals has proved a great burdenon the resources of these institutions, and any changeswhich will diminish the numbers without impairing the

functions of the hospitals will be warmly welcomed byhospital managers.

There are several classes of patients who apply for treat-ment in the out-patient department who are unsuited for it.In the first place, the opinion is held very widely that manypersons who are well able to pay for medical treatment

attend as out-patients. It is certain that this is true,

though it is probable that the proportion has been

largely over-estimated, but those hospitals which haveinstituted a form of inquiry by almoners find that this

form of abuse does exist. It must not, however, be

forgotten that the ailment from which the patient

is suffering must be taken into account when his

suitability for treatment is being considered. Lrgencyand severity of symptoms are claims on the charities whichmust be recognised, while certain classes of obscure casesare sent to the hospitals by general practitioners, who are

rightly using the out-patient departments in a consultingcapacity. Otherwise it is of the greatest importancethat a patient who is able to pay the fees of a

medical practitioner should not be allowed to participatein the benefits of a medical charity, for by appro-

priating a - share of these benefits he is deprivingsome deserving case of needed treatment, and at

the same time he makes the hospital exert a harmful

influence on the practice of medical men in the neighbour-hood, whereas it should be a centre at which the practi-tioner can receive all the help and coun sel he may requireupon application. Provident dispensaries offer to a certainclass of patient an efficient treatment for, at all events, allbut the most serious diseases, and there is the further

advantage that in most cases the patients of these insti-

tutions are attended at their homes when necessary.Provident dispensaries should certainly be developed. Their

small payments call for thrift on the part of the patient,and they might easily be made to relieve the hospitals verygreatly. Those who are receiving Poor-law relief and arenot in a position to receive real benefit from hospital out-

patient treatment should be as charily received at the

out-patient departments as those whose means make themunsuitable subjects. Some statistics seem to show that

these may form as much as 10 per cent. of out-patients.We have a system of Poor-law medical relief, and it is wrongto admit as out-patients those cases which are not in a

position to profit fully by the treatment, and which are

already provided with medical treatment elsewhere.A very large section of the patients which are really

unsuitable for hospital treatment comprises the trivial cases.

Slight ailments and injuries can be perfectly well treated bythe general practitioner, who is in many cases deprived offees that could easily be paid, while it is a waste of the timeof the hospital to devote it to their treatment. These cases

are much more numerous than is usually supposed, and theycost the hospitals time and money that can ill be spared.Self-respecting persons, it might be thought, would feelashamed to invoke the aid of the hospital for the treatmentof trifles, but with many persons in large towns the habitof hospital abuse has become ingrained. A hospital shouldserve, as we have already said, as a consulting centre, towhich the practitioners of the neighbourhood may send foran opinion as to diagnosis or treatment those of their

patients who are not in a position to afford the

fee of a consultant; but it is not a place where those whocan pay should go in circumstances where no consultation

can be necessary. The consultative function of hospitals isexercised at the present time, but it is doubtful if it is

employed nearly as much as it should be. It is said that

the practitioner is afraid that he may lose his patient, butthere need be little risk of this if a letter stating the objectof the visit to the hospital is sent with the patient. The out-

patient department of a hospital used in this way serves well

one of its most important functions: it helps the education

542 THE MEDICAL APPLICATIONS OF RADIOLOGY.

<f the medical student and the advancemment of medical

- science. The training of the student is not only one of the<1l&Igrave;uLies of a hospital, it is also one of its privileges, and the

presence of students in a hospital leads to an enhance-ment of the value of the work there carried out ; so that

it is important that cases suited for instruction should be.admitted. No better cases can come than those where the

-practitio,i3eT has been himself desirous of a second opinion.The report of the King Edward’s Hospital Fund Committee

9’i’ees a very lucid account of the whole subject, but the

question remains, What is the best method of carrying outthe reforms which will exclude from the department those<Ea.ses unsuitable, and which will cooperate with other

cmt&Me .agencies in the work of assisting the poor? The

3R&Wer given by the report is that by the use of almonersit will be possible to accomplish much, if not all, that is

Mqtured to reform the out-patient department. Many(}5pitals already employ almoners to some extent, but theirtMBEbers must be greatly increased if they are to carry,3-at the work of reform. Almoners of intelligence and ex-perience -can eliminate the applications for out-patient treat-ment of those who are in a position to pay for advice ;tltey can refer to provident dispensaries those who appear1:!) be suitable ; they can find out if the Poor-law patient needs

something more than he can obtain from the Poor-law’s mini-

3tratiou; and when the patient needs charitable assistance

to piocure food or work the almoner can put him in touchwith Stable charitable agencies. The more the authorities

of the hospital know of the means and chances of the

perxons applying for treatment, the better position they willbe m to give the patients that treatment which will do themthe uost good. We agree with the conclusion of the reportthat the appeintment of sufficient almoners will relieve the:train on the out-patient department, and at the same timewill be’nent the patients, but we are perfectly certain thatthe wb(>7e trouble cannot be removed in this simple way. Theeducation of the public is also necessary, and a far closer

relationship than at present exists between the general.practitioners 0f a locality and the hospital in the locality.

The Medical Applications of

Radiology.THE scope of specialism in medicine widens almost con-

’" ta.utly, such is the activity of research and so close is

the. assiduity with which abstract scientific discoveries are

.employed practically. Each technical advance, which be-Cimtes establisl2ed @y experience as useful in diagnosis and

trea.tmer.t, brings in its train the need for special knowledgeIrn. its application and for special training in the interpretationof the results obtained by its aid. It becomes increasinglyapparent that technical specialism in medicine must be

accepted and fully recognised. Within recent years the

<d.epa.itBaeBts of pathology and bacteriology have becomemore and more specialised, while the new department of

rarliology has been evolved and has developed into a highlyimportant branch of medical practice. Although such

special departments of practice are becoming more and

mare technical, it is still as necessary as ever that the

worker should first acquire a thorough grounding in,and general knowledge of, his profession before em-

barking upon the actual practice of the branch of his

choice. It is true that some of the developments of

modern medical science and practice require a wider andmore comprehensive preliminary training than that whichis necessary for the general practice of medicine ; for

example, the technique of radiology demands an effective

knowledge of applied physics and electricity that is beyondthe ordinary syllabus in these subjects prescribed in the

curriculum of the medical student. This may be an argu-ment in’ favour of an early decision to adopt a particularcareer, but it does not modify the truth of the principlethat special practice should follow on general knowledge.

, Not very long ago. when the X rays were first discovered

by Professor ROENTGEN, together with the facts that certaintissues and substances were pervious to them while others

were opaque and could therefore be shadowed upon a

photographic plate, their application to the investigationand treatment of fractures of bones and to the surgical treat-ment of deformities was at once apparent. It is improbable,however, that even the most far-seeing of the earlier medicalworkers with these rays, wonderful as their possibilities.appeared, could have foretold their surprising applications tothe elucidation of obscure problems in anatomy, physiology,and pathology, to the exact diagnosis of deep-seated morbidconditions, and to the treatment of many forms of disease,which are now matters of common knowledge and everydayexperience. The proceedings of the Section of Electro-

therapeutics at the recent meeting of the British MedicalAssociation, which are reported in this number of

THE LANCET, afford some interesting and striking examplesof the modern developments and applications of radiology.It will be seen that the first paper, that by Dr. A. F. HERTZ

upon the normal stomach, was read and discussed before a

joint meeting of the sections of Electro-therapeutics and

Anatomy, in itself an interesting recognition of the scientificvalue of the X rays in medicine, and an illustration of what

might be called the quickening spirit at present at work inthe sciences ancillary to medicine. Just as the pathologistof to-day tends to deal more with the morbid anatomy ofthe living tissues than with the altered conditions found

at necropsy, so the anatomists tend more and more to

study structure in relation to function ; as Dr. HERTZ

happily expressed it, they have attempted to discover the

anatomy of the organs as they exist in life. At first sightit seems surprising, if not almost incredible, that the X raysshould be capable of giving more exact and reliable informa-tion in regard to the anatomical characters of the normalstomach than dissection after death and operation duringlife, but it becomes intelligible when we remember thatthe stomach is a muscular organ capable of distension,

showing variations in form in association with its own

movements and with the presence of food within its cavity,and variations in position in association with the postureof the body. The study of the stomach by the X raysafter the administration of bismuth oxychloride, which doesnot alter the tone of the muscular coat of the stomach,has considerably modified the views previously held as

to the position, shape, and relations of that organ.

543THE MEDICAL APPLICATIONS OF RADIOLOGY.

Dr. HERTZ, in his interesting remarks, was careful to say

that the information obtained from the X rays requiredcorrection with the aid of that derived from ordinaryanatomical methods, because the shadow produced by the

rays merely represented the stomach projected upon a flat

surface. ’ He explained that he had adopted the anatomicalnomenclature used by CUNNINGHAM, and suggested thatthe term pyloric antrum," which is now so variouslyapplied, should be discarded. He described the stomach

as being divided into a larger cardiac part and

a smaller pyloric part, the former consisting of the

fundus and body. The fundus is that segment of

the stomach which is situated above a horizontal planepassing through the cardiac orifice, while the body is placedentirely ta the left of the middle line and is nearly verticalin the erect position, though it becomes oblique in the

recumbent position. The incisura angularis, a well-marked

depression on the lesser curvature, separates the body fromthe pyloric part of the stomach, which consists of the pyloricvestibule and pyloric canal. In the empty condition the

upper third of the stomach is pear-shaped and contains gas,while the rest of the organ passes to the pylorus in the formof a collapsed tube. When the stomach is partially filledwith a standard bismuth meal half a pint in volume the

body is almost uniform in diameter, its axis correspondingwith that of the organ in its empty condition ; but whenthe stomach is filled by a large meal it expands chiefly in the

direction of the greater curvature, though the dome of the

diaphragm is pushed upwards. From this very brief

abstract of Dr. HERTZ’ conclusions, the general accuracy ofwhich appears to have been accepted by the anatomistswho discussed his paper, it will be seen how

different is the natural position of the normal

stomach in the erect position in life from that which

is generally represented in anatomical plates.Dr. REGINALD MoRTOX read a paper on the X Ray

Diagnosis of Some Forms of Arthritis, which illustrated

another useful application of this agent in medicine.

It is becoming more and more generally recognisedthat the conditions to which the names of rheumatoid

arthritis and osteo-arthritis are now respectively appliedare pathologically distinct, although until recently the

two terms were used more or less synonymously. Dr.

MoRTOX demonstrated the important points of differ-

ence which the X rays revealed in the changes of

the joints in these two conditions, and also affirmed thatthe rays formed the most reliable and accurate means of

diagnosis at our disposal at the present time, a con-

clusion it would be hard to ’dispute. In rheumatoid

arthritis he stated that there is a narrowing of the

normal spaces between the articular ends of the bones,due to absorption of the articular cartilages, while in

osteo-arthritis the narrowing is much less, since the

cartilaginous changes are of the nature of fibrillation

and disintegration rather than absorption. Erosion of the

bones is more common in rheumatoid arthritis than in

osteo-arthritis, and Dr. MORTON considered that in generalthe latter disease is the less destructive of the two, and

that there is more tendency to repair, as shown by the

absence of rarefaction of the cancellous tissue, by theformation of osteophytes tending to support the ’joint, and

by eburnation serving to compensate for the loss of the

articular cartilage. This interpretation of the pathologicalchanges in the joints in the light of the X ray appear-ances observed during life affords a suggestive example ofthe value of the rays in skilled hands ; and another was-

supplied by Dr. A. C. JORDAN, who, at the same meeting’..read a paper on "Peribronchial Phthisis," is3 which he-

claimed that pulmonary tuberculosis was in most cases

primarily a disease of the hilum of the langs- stui not of

the apices. He further stated that in at least 4D per-

cent. of the cases of this disease it commenced as a

peribronchial mottling, and sooner or later reached the-

apex by the ascending bronchioles. Dr. JORDA’5 conclu-

sions, though suggestive, seem to us to require conRrmation!from the pathological side, but the observations which herecorded should lead to more careful inquiry into the siteand mode of onset and spread of the initial lesions in tbis.

disease, matters about which there is at the present time

great difference of opinion.It is obvious that with constantly improving’ apparatus:

and technique X ray methods are yielding information of

increasing accuracy and of more and more definite signi-ficance. The introduction of stereoscopic methods is

already diminishing the difficulties of interpretation in sense-instances, as mentioned in an interesting paper upon this

subject by Dr. C. F. BAILET. It must, however, be apparentthat radiology will tend to become more and more specialised,since not only is technique a matter of great importance, but

experience in determining the best form of examination in,each case and in interpreting the results obtained is bsc3=

lutely essential. These things merely emphasise the necessityfor an adequate grounding in general medicine and surgeryfor those who practise radiology, the more so" that the ays-

are now employed in treatment and have, as is-well knO>Wl1,proved themselves potent for harm as well as good’. o The-

progress of radiology has been such that all concerned may

be proud of their achievements, carried out in the face ofdifficulties and danger as they have often &8en. The

specialism has a brilliant record in its brief past historyand bears the promise of great advances in the future.

THE ROYAL CORNWALL I1TFIRMAR19 TRURC",&mdash;The annual meeting of the subscribers of the Royal CornwallInfirmary was held on August 12th’. The medical reportshowed that 592 in-patients, 2081 out-patients., and 1027ophthalmic cases had been treated during 1911, being in allthe numbers an increase compared with 1910. The income-

amounted to .E.2424, and there was an adverse balance off,31. 111 patients were sent to the male convalescent homeat Perranporth in connexion with the infirmary. The com-mittee state that the ophthalmic department was openedlast year. The institution had to undergo some buildingalterations in consequence, which necessitated an expendi-ture of &1544, but with the exception of &pound;91 this sum was

raised by special donations. During the past year Mr. T.Dorrington bequeathed about E6500 for the erection of aconvalescent home for women at Perranporth, the land forthe erection of which has recently been given by Mr-J. D. Enys.