42

NEW WORK ON HORMONES : REFERENCES (continued from previous page)8. Butenandt, A. : Zeits. Physiol. Chem., 1931, ccviii., 129,

and 1932, ccx., 268 ; Chem. and Indust., 1932, li., 464.9. Schwenk and Hildebrandt: Naturwiss., 1932 (in the press).

10. Marrian, G. F. : Biochem. Jour., 1930, xxiv., 1021.11. Girard, A., and others : C.R. Acad. Sci., 1932, cxciv., 909,

1020.12. Laqueur, E. : Biochem. Zeits., 1931, ccxl., 258.13. Martian: Chem. and Indust., 1932.14. Loewe, S., and others : Biochem. Zeits., 1927, clxxx., 1.15. Dohrn, M. : Med. Klin., 1926, xxxvii., 1417.16. Aschheim : Vortr. Gynäk. Kongr. Frankfurt, 1931; and Biol.

Colloq. Dahlem, 1931-32 ; Forsch. u. Fortschr., 1932,viii., 130 (shortly to appear in Deut. med. Woch.).

17. Schoeller, W., and Goebel, H. : Biochem. Zeits., 1931,ccxl., 1, and 1932, ccl., 223.

18. Went, S. : Rev. Trav. bot. néerl., 1928, xxv. ; and Zeits.angew. Chem., 1931, xliv., 279.

19. Kögl, F.: Proc. Konink. Akad. v. Wetensch., Amsterdam,1931, xxxiv.

20. Fränkel, L. : Arch. Gynäk., 1910, xci., 705.21. Bouin, P., and Ancel, P.: Jour. physiol. et path. gén.,

1911, xiii.22. Hammond, J., and Marshall, F. H. A.: Reproduction in

the Rabbit, London, 1925.23. Clauberg, C. : Zentralbl. Gynäk., 1931, lv., 459.24. Knaus, H. : Arch. Path. u. Pharm., 1931.25. Fels, E., and Slotta, K. H. : Zentralbl. Gynäk., 1931,

p. 2765.26. Steinach, E., and Kun, H. : Pflüg. Arch., 1931, ccxxvii.,

266.27. Womack, E. B., and Koch, F. C.: Endocrin., 1932, xvi.,

273.28. Dingemanse, E., and Laqueur: Biochem. Zeits., 1931,

coxxxi., 1.29. Kaufmann, C. : Personal communication.30. Berthold, A. A. : Arch. Anat. u. Physiol., 1849, p. 42.

31. Brown-Séquard, C. E. : Arch. de Physiol. norm. et path.,1889, ser. 5, vol. i., 651, 739.

32. Koch, Moore, C. R., and Gallagher, T. F. : Amer. Jour.Anat., 1929, xlv., 39 ; and Amer. Jour. Physiol., 1929,lxxxvii., 436.

33. Funk, C., and others : Amer. Jour. Physiol., 1930, xcii.,440 ; and Proc. Soc. Exper. Biol. and Med., 1929, p. 569.

34. Laqueur : Pflüg. Arch., 1930, ccxxv., 740.35. Loewe, S., and Voss, H. E. : Biochem. Zeits., 1930, ccxxi.,

461.36. Butenandt : Zeits. angew. Chem., 1931, xliv., 905.37. Schoeller and Gehrke : Zahnärzt. Mitt., March, 1931.38. Evans, H. M., Engle, E. T., Smith, P. E., and Steinach :

Med. Klin., 1928, No. 14.39. Aschheim and Zondek : Die Hormone des Ovariums und

des Hypophysenvorderlappens, Berlin, 1931.40. Fichera, S. : Arch. di Biol., 1905, xliii., 405.41. Evans and Simpson, M. E.: Amer. Jour. Physiol., 1929,

lxxxix., 371.42. Hohlweg, W., and Dohrn : Wien. Arch. inn. Med., 1931,

xxi., 3 ; and Klin. Woch., 1932, xi., 233.43. Hohlweg and Junkmann, K. : Klin. Woch., 1932, xi., 321.44. Teel, H. M., and Cushing, H. : Endocrinologie, 1930, vi.,

401.45. Philipp, E. : Zentralbl. Gynäk., 1930, liv., 450.46. Freud, J. : Deut. med. Woch., 1932, lviii., 974.47. Loeb, L. : Proc. Soc. Exper. Biol. and Med., 1929, xxvi.,

860.48. Aron, M. : C.R. Soc. Biol., 1929, cii., 682, ciii., 145 ;

1930, civ., 96, cv., 974 ; 1931, cvi., 609, 1044, cvii., 64;1932, cviii., 1216.

49. Janssen, S., and Loeser, A. : Klin. Woch., 1931, x., 2046 ;Aepp., 1930, cli., 175.

50. Junkmann and Schoeller : Klin. Woch., 1932.51. Schittenhelm, A. : Deut. med. Woch., 1932, lviii., 803

Klin. Woch., 1932, xi., 1092.

OUT-PATIENT DEPARTMENTSTHEIR USE AND ABUSE

1N January last the Prince of Wales, as presidentof King Edward’s Hospital Fund, appointed a specialcommittee 11 to inquire into and report upon themethods in use in the London voluntary hospitalsregarding the attendance of patients in the out-patientand casualty departments, and the effect of thosemethods upon the suitability of the patients treatedand on the length of time during which patients waitbefore or after treatment." This committee has nowissued a report,l which includes a historical surveyof the out-patient department, a review of the presentposition, and a general description of procedure, aswell as a full discussion of the committee’s terms ofreference.The report points out, in the first place, that the

question of suitability falls into two parts-medicaland financial-and that the out-patient departmentproper must be considered separately from thecasualty department. Secondly, it stresses the gradualchange that has come over the out-patient depart-ments of voluntary hospitals, which were originallyplaces for the simple treatment of the sick-poor, butare now available to members of contributory schemesand to patients who pay a moderate fee, and whichprovide every year an increasing amount of complexservice and treatment which is not available elsewhereat a reasonable charge.The committee has no doubt that the hospitals

maintain their popularity, and all the evidenceconfirmed the statement that they had the confidenceof the working-class population. The annual attend-ances at the twelve teaching hospitals have increasedfrom two and a half million in 1911 to nearly fourmillion in 1931. There was, however, a drop inthe number of medical patients after the passing ofthe National Health Insurance Act, and this has not

1 King Edward’s Hospital Fund for London. Report of theCommittee appointed to inquire into Out-patient Methods atLondon Voluntary Hospitals as affecting suitability of patientsand time of waiting. London. 1932. Pp. 76. 4s. 6d.

been made up, although the figure has been risingsince 1917. The surgical figures were not affectedby the Act. The discrepancy between patientsand attendances since 1911 and the increase in medicalpatients since 1917 probably reflect the increasingnumber of complex diagnostic measures which requirehospital attendance, and of special treatments thatneed repeated visits, as well as a rise in the averageseriousness of the hospital medical case. Very fewcomplaints have been received from patients, andthese were mostly concerned with waiting and over-crowding, and not with any inefficiency or inadequacyof service. The committee realises, however, thatthere is no channel for complaints and thinks itimportant that there should be one.

TIME OF WAITING

There seems to be no doubt, despite the vaguenessof some of the evidence, that patients do have towaste a good deal of time in out-patient departments,though not in casualty departments or specialdepartments, except those for eye and ear.Four chief theories of the cause of delay have been

put forward to the committee. One regards waitingas inevitable and only to be obviated by quiteimpracticable increases in staff and accommodation ;another puts it down to overcrowding and thinksthat it could be remedied by improvements in

accommodation ; a third ascribes it to remediabledefects in procedure; and a fourth to unsatisfactoryselection of patients, many being sent to the con-sultant when they could properly be treated elsewhere.There -are hospitals which still maintain that theirdoors must always be open to all-comers, and thereare others who will admit only patients bearing aletter from a medical man. On the whole, hospitalsare tending more and more towards the latter extreme,and emphasising the consultative nature of the servicethey offer. The British Medical Association has

suggested that doctors’ letters should be compulsoryexcept in cases of emergency. The committee isnot able to accept this view, although it supportsthe movement towards the more consultative useof the out-patient department. It thinks thatpatients who cannot pay a consultant fee and who

43OUT-PATIENT DEPARTMENTS

want a second opinion should be able to get one athospital without having to obtain a letter fromgeneral practitioner; they may be shy of askiuhim, or they may not be in touch with a doctor ; anthe doctor is by no means necessarily the best persoto decide whether or not a hospital opinion is desirable

THE " MINOR AILMENT " CASE

An undoubted cause of overcrowding and cor

sequent waiting is, in the opinion of the committefthe treatment of large numbers of " minor " cases

and the question of alternative provision for these itherefore a very pertinent one. It is bound up tsome extent with the problem of financial suitabilitySome hospitals feel that a patient who is so poothat he cannot obtain the necessaries of life or pa;the smallest fee is not likely to benefit from treatmeniand had better be dealt with by the public assistancauthority, which can supply both medical treatmenand any form of relief required to make it effectiveOther hospitals hold to the older idea that they wer,founded for the treatment of the sick-poor and musturn no one away. A far larger class comes withijthe "income range" established by the hospital,and could, in the opinion of the British MedicaAssociation, afford to pay general practitioners to:treatment for these minor ailments or could obtaiiwhat they need by means of an insurance or providendispensary scheme. There is yet a third class witlincomes above the range of public assistance who yeifind a general practitioner’s fees a severe charge ortheir incomes. Nevertheless, when all exceptionshave been excluded, there remains, in the opiniorof the committee, a very considerable number oj

patients attending hospitals for minor complaintswhich could properly be treated elsewhere. ThE

report discusses at some length the alternative pro.vision available for these people.

In so far as they are not treated by the consultantspersonally, they must be referred either to generalpractitioners or to the junior staff of the hospital.Some authorities argue that the junior staff are moreup to date and efficient than the general practi-tioners ; others that they lack the breadth of viewand experience of the man outside. While not feelingcalled upon to express an opinion on the merits ofthe practitioner, the committee points out thattreatment of minor ailments by the junior staff willnot greatly assist the problem under consideration :overcrowding of the hospital. The report thereforeurges greater cooperation between hospitals andpractitioners-for the benefit of both.

Besides private practitioners, there are providentdispensaries, public medical services, charitabledispensaries, voluntary and public clinics, publicassistance provision, and nursing services. All ofthese could play their part in relieving hospitalcongestion, and the committee stresses the importanceof cooperation with them all. It further recom-mends that hospitals should do all they can to letdoctors know the hours of the various consultants,so that patients are not sent up with personal letterson the wrong days, and to send reports on cases,while doctors should supply adequate case-notes whensending their patients to hospital. A vicious circleis very apt to develop, and goodwill and a realisationof the value of each to the other is necessary ifpractitioners and hospitals are to make the bestpossible use of each other for the best service of theirpatients. Against the additional work required forcooperation might be set the reduction in numbers.The more competent and experienced the doctor

a who does the sifting, the less the likelihood of mistakea or dissatisfaction. Sifting takes time, but the timeg is probably saved in other departments. The problemd of minor cases cannot be considered without referencen to the needs of the medical student, but the com-. mittee is of opinion that, although the minor case is

necessary for education, great reduction in the presentnumbers could be effected without harming the

1- teaching work. DELAY DUE TO PROCEDURE AND LACK OF

ACCOMMODATIONs The report discusses carefully the various pro-0 cedures by which out-patients are received, registered,’ and interviewed, but is unable, amidst the diversity,r to pronounce a judgment on the best method. ItYdesires further records of time-counts showing howi, long each way takes, and advises all hospitals toe consider whether changes in procedure might nott accelerate the service. Time may be saved by" arranging special sessions for special classes ofB patient-e.g., discharged in-patients, young peoplet between 14 and 16, and so on. The appointments1 system has been warmly defended by some hospitals,1 whether the appointment be given to individuals or1 to groups, and the committee feels that this possibilityr demands attention. Some hospitals limit the number of patients that may be seen at a session, and otherst offer a number of improvements in general organisa-

tion that the committee recommends to the considera-’ tion of those who have not adopted them already.l Even if the time of waiting is not reduced thereby,; the grumbling at it may be effectually stopped by seeing that the waiting-hall is warm and comfortable, and that refreshments are available.’

Waiting time is certainly reduced by the provision’ of adequate dressing rooms and examination rooms,,

and by the existence of suitable special accommodationfor special departments. Time is saved if patients do

. not have to traverse long corridors from one room toanother.another.

THE COMMITTEE’S CONCLUSIONS

In summary, therefore, the chief conclusion of thecommittee is that the out-patient problem can bematerially reduced by sifting out a large proportion(but not all) of the minor cases and arranging for theirtreatment elsewhere than in the consultant’s room.The hospital should be prepared to use to the utmostall coordinated services to which patients can bereferred, and should particularly endeavour to satisfythe requirements of the general practitioner who,in his turn, should do all in his power to use andaccelerate the service the hospital can render him.The committee thinks the present movement towardsa more consultative service is a movement in theright direction, but does not recommend carrying itto the extreme of excluding patients who desire asecond opinion and cannot afford it privately. Itviews with favour the proposal to supply both practi-tioners and consultants with standard forms to sendwith the patients. Every hospital, it considers,should study the procedure in use at other hospitalsand consider whether there is not room for improve-ment in its own routine. The King’s Fund is advisedto see how it can help the hospitals to carry out thecommittee’s recommendations.

NORTHAMPTON GENERAL HOSPITAL.-The report ,

for 1932 shows 4629 in-patients, an increase of 422 on lastyear ; of these 1772 were accidents and emergencies.Average stay, 18 days, cost iJ7 14s. 5d., and cost per bed perday 8s. 10d.--small reductions under each head. Out-patientsexceeded 19,000, an increase of more than 800, who cost7s. 2d. each. Ordinary income JS43,143, expenditure S44,278.

44 REPORT OF THE CONFERENCE ON RADIUM

THE VALUE OF MASSIVE RADIATIONFINAL REPORT OF THE CONFERENCE ON RADIUM

THIS Conference owed its origin to doubts publiclyexpressed as to the soundness of the decision of theRadium Commission to withdraw the 4-grammebomb, then in use for massive radiation at theWestminster Hospital, and subdivide it into fourunits of 1 gramme each. It consisted of the followingmembers :-

Lord Dawson of Penn, President of the RoyalCollege of Physicians of London, in the chair.Lord Moynihan-now succeeded by Sir Holburt

Waring-President of the Royal College of Surgeonsof England. ,

Mr. Wilfred Trotter, representing the MedicalResearch Council.

Sir Frederick Menzies, Chief Medical Officer, L.C.C.Dr. Watts Eden, President of the Royal Society

of Medicine.Mr. H. S. Souttar, representing the B.M.A.Prof. Arthur Hall, Mr. Ernest Miles, and Prof.

Woodburn Morison, representing the Radium Com-mission.

INTERIM REPORT

In an interim report, dated March 4th, 1932,1the Conference decided unanimously :—

(1) That the Radium Commission arrived at a

sound conclusion in discontinuing the use of the

4-gramme bomb at the present juncture, though thisdecision is without prejudice to the question of thetherapeutic value of 4 gramme or even largeraggregations of radium.

(2) That in the opinion of this Conference a fullyequipped radium institute is needed in London,where the more difficult and speculative problemsconnected with radium and ray therapy can bestudied by the combined efforts of a trained staff.The Conference appointed a technical committee

as follows :-Chairman.-Mr. H. S. Souttar.Physics.-Lord Rayleigh, F.R.S., Prof. J. C.

M’Lennan, F.R.S.Radiotherapy and Medicine.-Dr. Roy Ward,

Radium Institute ; Dr. G. F. Stebbing, LambethHospital, L.C.C. ; Dr. B. W. Windeyer, MiddlesexHospital.

’

Surgery.-Mr. Cecil Rowntree, Cancer Hospital;Mr. Geoffrey Keynes, St. Bartholomew’s Hospital.

Gyncecology.-Mr. Louis Rivett, Middlesex Hospital;Dr. Elizabeth Hurdon, Marie Curie Hospital.

Experimental Radiation.-Dr. W. Cramer, ImperialCancer Research Fund Laboratory.

Representatives of the Conference.-Lord Dawsonand Lord Moynihan.

FINAL REPORT

This committee reported finally on Dec. 19th, 1932.After considering their findings, which are set outbelow, the Conference has issued a short statementwhich runs :-

" It is clear that there is a field of usefulness forradiation from massive units of radium, given anadequate equipment and men and means. Weadopt the view of our technical committee that it isdesirable that a radium unit containing not less than5 grammes of radium element should be established.

" An institute specially constructed for the purposesof such radiotherapy and within easy reach of thefuture Post-graduate School and Hospital is an idealto be aimed at, but for the moment it may be imprac-ticable upon financial grounds. It would, however,

1 See THE LANCET, 1932, i., 1110.

be feasible to organise existing institutions for thetime being, provided they were near enough to eachother for efficient cooperation. The amount of radium

required for a large unit might mean that the allotmentof radium by the Radium Commission would needto be further concentrated.

" Both X ray and radium therapy are at presentadvancing so rapidly that it is impossible to decidethe position which each will occupy in the future.The whole field is one for the fullest investigation,and it is one in which results of the first importancehave already been obtained.

" In drawing up this report," which is signed byLord Dawson, " the Conference has purposelyrefrained from considering the relative places occupiedby surgery and radiotherapy in the treatment ofmalignant disease."

Two Questions Submitted to the TechnicalCommittee

The technical committee were asked for a replyto these questions :-

1. What is the scientific case for mass radiationby radium, and what are the advantages and dangersattaching to the use of such radiation ? P

2. What are the advantages and risks of massivesurface radiation by radium compared with thoseof radium needles and radon seeds ?

Their report, which is a reply to the questions, is asfollows :-

Selective action of radiation upon malignant cells.-The use of radium in the treatment of malignanttumours depends upon the empirical observation thatin a large number of instances the cells of malignanttumours are destroyed by an amount of radiationinsufficient to destroy the normal tissue. This pro-position is generally true over a very large range ofwave-lengths, and certainly holds over a range whichextends from X rays with a wave-length of 1 A.U.to hard gamma rays with a wave-length of 0-04 A.U.or less. In spite of an immense amount of researchdevoted to this particular point, it is still uncertainwhether there is any specific difference between thelonger and shorter waves in their effect upon the cells,although there is a general impression that radiationof short wave-lengths has a higher degree of selectiveaction upon the cells of malignant tumours in virtueof their rapid growth.

Penetrating power of short waves.-What is, however,quite certain is the physical fact that radiation ofshort wave-length has a higher penetrating power,and is therefore capable of conveying energy intothe deeper tissues, whilst radiation of longer wave-length is absorbed in the more superficial tissuesand there expends a large part of its energy. It isfor this reason that X ray apparatus is being madeto generate X rays of shorter and shorter wave-

length, but no apparatus has yet been devised togenerate waves as short as the gamma rays of radium.These short wave generators are still on trial, andit is of importance that we should be able to comparethe results obtained from them with those obtainablefrom mass radiation by radium.

PROBLEM OF THE UNIFORM FIELD

The margin between general destruction of the’

tissues and selective destruction of the malignantl cells which are invading them is very small, and it

is therefore an essential factor in treatment that.

every element of tissue throughout the region treated’ should receive exactly the same amount of radiation,

for if at any point there is a defect some malignant