of 2 /2
811 - the places they have left. With this object, Dr. .Fraser favours the appointment of a well-paid manager trained in Octavia Hill’s methods before any of the houses are let, so that she can make herself acquainted with prospective tenants and decide on the type of house best suited to each. The result will be followed with attention by housing reformers elsewhere. ____ THE OBSTINACY OF PARENTS. THE reluctance of parents to the provision of treatment for their children is a difficulty that extends to all kinds of medical practice, and is a trial to the dentist, the oculist, the surgeon, and the school medical officer, as well as to the private general prac- -titioner. It is perhaps the dentist working for an education authority who feels it most. In many .areas where facilities are adequate less than half the parents are willing to make use of them. There may be various reasons for this-e.g., the fact that a small charge is made, the trouble of taking the child i to the clinic, the desire to spare him what is deemed unnecessary pain, and perhaps the influence of the - child’s fears and protests. But the chief obstacle ,seems to lie in a curiously misapplied independence of spirit that rebels against interference, and still more in a deep ignorance of the need for any measures except in the emergency of acute toothache. The oculist has to face somewhat similar difficulties, the - child’s fear of a painful extraction being replaced by unwillingness to bear the ridicule of his fellows -wbp,n he first appears in goggles. The parent is more directly concerned about paying for the glasses- a situation greatly eased by a plan of deferred payments. Many parents incur heavy responsibility from their failure to carry out the treatment of squint by periodically shading the better eye. The :fault here is want of faith and persistence rather than obstinate refusal. On the other hand it was sheer recalcitrancy that caused a mother in Rutland, as recently noted in one of our summaries,’- to refuse to allow her child to wear the glasses which she had been forced to obtain. Operations for tonsils and adenoids may be resisted on some of the grounds already cited, but more often because the risks of surgical treatment are exaggerated and its value insufficiently appreciated. The family doctor may :feel it his duty to urge operation while he knows well that he will be blamed if minor ill-consequences result. He has not behind him the resources for persuasion possessed by the medical officer of an education authority-few of the school medical staff fail to testify their debt to the efforts of the teachers-but the family doctor has the advantage that parents regard him as a friend and not as an official. All doctors alike are hindered by the propaganda and specious promises of unqualified practitioners, and the greatest weapon in the cause of health and improvement lies in the enlightenment of public opinion. In public health and school work approved methods to this end are the travelling lecturer with cinematograph, the issue of leaflets, the writing of essays by the children with the inducement of prizes, and the award of honours, flags, or medals to schools with the best records. When all is said and done it remains the personal exhortation by the doctor, however much expenditure of time it requires, from which the best value is to be expected. A I troublesome proclivity of a certain type of parent I is to seize upon some unguarded comment made by I 1 THE LANCET, August 23rd, p. 425. one medical man, and repeat it with exaggeration to another. It behoves both sides to avoid playing into the hands of mischief makers, the one by exercis- ing great discretion in his remarks, the other by remembering how the phrases that reach him are likely to have been distorted. SCLEROSING SOLUTIONS IN THE NOSE. INJECTION of sclerosing solutions has been widely adopted in the treatment of varicose veins and piles, and the method has recently been advocated by Dr. L. H. Leroux,l of Paris, for cases of vascular hypertrophy of the inferior turbinals. The condi- tions here seem to be by no means the same, for in the treatment of the turbinals the needle is inserted until it is in contact with the bone, and the injection is made into connective tissue and not into the vessel. Leroux employs a 5 per cent. solution of the double hydrochloride of quinine and urea, giving two to four injections of 2-3 c.cm., according to the size and tumefaction of the turbinal. He claims to obtain a great diminution in size after 8 to 10 days, without breach of surface, inflammatory reaction, or ulcera- tion, and without risk of the sepsis or adhesions which may result from the galvanocautery. Some nasal obstruction follows from reactionary swelling, and he advises that a week’s interval should elapse between treatment of the two nares. SURGICAL FEES. IN his presidential address to the sixtieth annual meeting of the Colorado State Medical Society, held at Pueblo, last month, Dr. W. A. Kickland, of Fort Collins, presented a forceful and independent point of view on the disparity between medical and surgical fees. The high cost of surgery, he remarked, is not new. A surgeon in the thirteenth - century was able to charge the equivalent of$200 for an operation and to claim in addition an annuity of 825 a year. But in modern times the difference in the fee paid for the difficult and skilled work of diagnosis and for surgery, which may involve no more skill nor the use of more costly apparatus, has led to abuses. Fee-splitting, he thought, was originally an attempt to correct the injustice and for a while it worked well. The patient was not submitted to operation without consultation ; surgery was confined to the trained specialist and medical relations were happy. However, abuses crept in. The operator might be selected less by his skill than by the share of his fee which he would offer. The medical man was tempted to urge operations for the sake of the profit which might come to him. When, therefore, the American College of Surgeons was founded in 1913, stringent regulations against fee-splitting were made, and in the State of Colorado fee-splitting is now punishable by a heavy fine, or a gaol sentence, or both. Dr. Kickland is not altogether satisfied with the consequences of this severe repression, which still leaves untouched the injustice of unequal fees. The general practitioner in Colorado has now resorted to the practice of surgery himself. In one city, Dr. Kickland said, where there were only three men doing major surgery 12 years ago, there are now 28 surgeons of whom 19 engage in major surgery. The patient is liable to be deprived of the advantage of consultation and of the operative skill which comes with adequate surgical training and a practice 1 Presse Méd., August 2nd, p. 1046.

SURGICAL FEES

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- the places they have left. With this object, Dr..Fraser favours the appointment of a well-paid managertrained in Octavia Hill’s methods before any of thehouses are let, so that she can make herself acquaintedwith prospective tenants and decide on the typeof house best suited to each. The result will befollowed with attention by housing reformerselsewhere.

____

THE OBSTINACY OF PARENTS.

THE reluctance of parents to the provision oftreatment for their children is a difficulty that extendsto all kinds of medical practice, and is a trial to thedentist, the oculist, the surgeon, and the schoolmedical officer, as well as to the private general prac--titioner. It is perhaps the dentist working for aneducation authority who feels it most. In many.areas where facilities are adequate less than half theparents are willing to make use of them. There maybe various reasons for this-e.g., the fact that asmall charge is made, the trouble of taking the child ito the clinic, the desire to spare him what is deemedunnecessary pain, and perhaps the influence of the- child’s fears and protests. But the chief obstacle,seems to lie in a curiously misapplied independenceof spirit that rebels against interference, and stillmore in a deep ignorance of the need for any measuresexcept in the emergency of acute toothache. Theoculist has to face somewhat similar difficulties, the- child’s fear of a painful extraction being replacedby unwillingness to bear the ridicule of his fellows-wbp,n he first appears in goggles. The parent ismore directly concerned about paying for the glasses-a situation greatly eased by a plan of deferredpayments. Many parents incur heavy responsibilityfrom their failure to carry out the treatment of

squint by periodically shading the better eye. The:fault here is want of faith and persistence rather thanobstinate refusal. On the other hand it was sheerrecalcitrancy that caused a mother in Rutland,as recently noted in one of our summaries,’- to refuseto allow her child to wear the glasses which shehad been forced to obtain. Operations for tonsilsand adenoids may be resisted on some of the groundsalready cited, but more often because the risks ofsurgical treatment are exaggerated and its valueinsufficiently appreciated. The family doctor may:feel it his duty to urge operation while he knows wellthat he will be blamed if minor ill-consequencesresult. He has not behind him the resources forpersuasion possessed by the medical officer of aneducation authority-few of the school medicalstaff fail to testify their debt to the efforts of theteachers-but the family doctor has the advantagethat parents regard him as a friend and not as

an official. All doctors alike are hindered by thepropaganda and specious promises of unqualifiedpractitioners, and the greatest weapon in the cause ofhealth and improvement lies in the enlightenment ofpublic opinion. In public health and school workapproved methods to this end are the travellinglecturer with cinematograph, the issue of leaflets, thewriting of essays by the children with the inducementof prizes, and the award of honours, flags, or medalsto schools with the best records. When all is said anddone it remains the personal exhortation by thedoctor, however much expenditure of time it requires,from which the best value is to be expected. A

I

troublesome proclivity of a certain type of parent Iis to seize upon some unguarded comment made by I

1 THE LANCET, August 23rd, p. 425.

one medical man, and repeat it with exaggeration toanother. It behoves both sides to avoid playinginto the hands of mischief makers, the one by exercis-ing great discretion in his remarks, the other byremembering how the phrases that reach him arelikely to have been distorted.

SCLEROSING SOLUTIONS IN THE NOSE.

INJECTION of sclerosing solutions has been widelyadopted in the treatment of varicose veins and piles,and the method has recently been advocated byDr. L. H. Leroux,l of Paris, for cases of vascularhypertrophy of the inferior turbinals. The condi-tions here seem to be by no means the same, forin the treatment of the turbinals the needle is inserteduntil it is in contact with the bone, and the injectionis made into connective tissue and not into the vessel.Leroux employs a 5 per cent. solution of the doublehydrochloride of quinine and urea, giving two tofour injections of 2-3 c.cm., according to the size andtumefaction of the turbinal. He claims to obtaina great diminution in size after 8 to 10 days, withoutbreach of surface, inflammatory reaction, or ulcera-tion, and without risk of the sepsis or adhesions whichmay result from the galvanocautery. Some nasalobstruction follows from reactionary swelling, andhe advises that a week’s interval should elapse betweentreatment of the two nares.

SURGICAL FEES.

IN his presidential address to the sixtieth annualmeeting of the Colorado State Medical Society,held at Pueblo, last month, Dr. W. A. Kickland,of Fort Collins, presented a forceful and independentpoint of view on the disparity between medical andsurgical fees. The high cost of surgery, he remarked,is not new. A surgeon in the thirteenth - centurywas able to charge the equivalent of$200 for anoperation and to claim in addition an annuity of 825a year. But in modern times the difference in thefee paid for the difficult and skilled work of diagnosisand for surgery, which may involve no more skillnor the use of more costly apparatus, has led toabuses. Fee-splitting, he thought, was originallyan attempt to correct the injustice and for a whileit worked well. The patient was not submitted tooperation without consultation ; surgery was confinedto the trained specialist and medical relations werehappy. However, abuses crept in. The operatormight be selected less by his skill than by the shareof his fee which he would offer. The medical manwas tempted to urge operations for the sake of theprofit which might come to him. When, therefore,the American College of Surgeons was founded in1913, stringent regulations against fee-splitting weremade, and in the State of Colorado fee-splitting isnow punishable by a heavy fine, or a gaol sentence,or both. Dr. Kickland is not altogether satisfiedwith the consequences of this severe repression,which still leaves untouched the injustice of unequalfees. The general practitioner in Colorado has nowresorted to the practice of surgery himself. In one

city, Dr. Kickland said, where there were only threemen doing major surgery 12 years ago, there are now28 surgeons of whom 19 engage in major surgery.The patient is liable to be deprived of the advantageof consultation and of the operative skill whichcomes with adequate surgical training and a practice

1 Presse Méd., August 2nd, p. 1046.

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limited to surgery, while the temptation to urgesurgical interference with undue frequency has notbeen removed. At the same time the man whodevotes years of his life to preparation for specialpractice is handicapped by unfair competition.Dr. Kickland’s solution of a difficult problem is forthe State to sanction special surgical practice onlyon production of a diploma granted after post-graduate study. ____

THE MEDICAL DEFENCE UNION.

Sir Herbert Waterhouse, happily recovered fromhis accident in the early summer, presided on Oct. 2ndat the annual general meeting of the Medical DefenceUnion, when a year of continued success and

prosperity was reported. A membership of more than16,000 testifies to the confidence which is placed inthe Union by the rank and file of the medical profes-sion, and the - increasing membership has made it

possible for the Union to improve its financial position. IFor some years the Union has had an agreement withthe Yorkshire Insurance Company, whereby the firstcharge for indemnity against damages was borneby the funds of the Union up to an amount equal to50 per cent. of the subscription income of the previousyear. In consequence of the steady growth of thereserve fund it has now become possible to undertakea liability up to the entire amount of the subscriptionincome of the preceding year, thus enabling theUnion to insure against any claims in excess of thatamount for a considerably smaller premium than hasbeen paid hitherto.Some of the cases quoted in the report give an

indication of the charges which the conscientiouspractitioner may be called upon to face. One memberhad occasion to give an emergency certificate forremoval to a mental hospital of a patient whosedelusions made him dangerous to himself and others ;he was detained for a week, and after his release thepractitioner received a claim from a solicitor for thecharges made by the guardians for the maintenanceof the patient. The solicitor was advised that thecertificate was given in good faith and with reasonablecare, and the case was abandoned. Another memberfound it necessary to report a district nurse to thesecretary of the local nursing association for criticisinghis methods, disobeying his instructions, and neglectingthe patient, with the result that she was requestedto resign. Two days later he received a solicitor’sletter claiming damages for alleged slander. Thesolicitor was informed that the case would be defendedby the Union, and nothing further was heard. Yearafter year the President finds it needful to emphasisethe importance of an X ray examination in all casesof injury to a bone or a joint. In cases of refusal bythe patient he advises all practitioners to preservesome definite record of the fact. Claims of allegedneglect are made repeatedly on the grounds thatradiography was not advised, and that subsequentexamination revealed a fracture. During the pastyear one member asked whether it was advisable torender his professional account to a patient with aninjury of the ankle which he had failed to recogniseas a fracture. An X ray taken a week later on herreturn home showed an incomplete fracture of theexternal malleolus with displacement. The memberwas advised to send in his account in the usual way,but the case serves to emphasise the President’swarning.

Incorrect treatment is often alleged as an excusefor refusing payment of fees ; a patient who had beentreated by a member for a resistant patch of ringworm

for about one month, afterwards consulted anotherdoctor ; when he received the account for the earlierattention he refused payment on the grounds thattreatment had been faulty. On the advice of theUnion the member threatened legal proceedings, withthe result that the account was paid in full. Opinionssometimes differ on the question of what constitutesadequate care of a case, but it is remarkable to findthat the charge of insufficient attention was madeagainst one member who, for services including anantenatal visit, attendance at the confinement, eightsubsequent visits, and a fee for an anaesthetist, sentin an account of five guineas. Upon the issue of adefault summons on the advice of the Union theaccount was paid in full. Both the gratitude and theingratitude of patients are proverbial and embarrass-ing, but the Medical Defence Union can shield theconscientious practitioner from at least one of them.

INTERNATIONAL CONGRESS OF HISTORY

OF MEDICINE.

THIS congress was held at Rome from Sept. 22ndto 27th, under the Presidency of Sign. Mussolini anda committee of honour, including such well-knownnames as Profs. R. Alessandri, V. Ascoli, and R.Bastianelli, while the executive committee consistedof Prof. P. Capparoni, A. Castiglioni, A. Casarini,and D. B. Roncali. The work of the congress wasdivided among three sections : (1) Leprosy and thecompulsory study of the history of medicine in theuniversities. (2) The cultural relations between Italyand other European nationalities in connexion withmedicine and the natural sciences during the scientificrenaissance of the sixteenth and seventeenth centuries.-(3) Miscellaneous communications, such as papers onplague, the handwriting of Leonardo da Vinci, theinfluence of folklore on the evolution of medicine, on-madder and spongia somnifera. The congress was

granted a special audience by the Pope, who addressedthe members on the importance and value of studyingthe history of medicine, and also had the advantageof inspecting the rare medical works in the Casanatelibrary. Among those present at the congress wereDr. J. D. Rolleston, British delegate representing theRoyal College of Physicians and the Royal Society ofMedicine, Prof. G. E. Gask, the University of Londonand the Royal College of Surgeons, Dr. VincentDickinson, the Society of Apothecaries, and Dr. R.Whitehead the University of Manchester. The-

congress concluded by a banquet at the Hotel deRussie, at which about 140 guests were present.

PHARMACEUTICAL SOCIETY OF GREAT BRITAIN.-A course of lectures, entitled Some Newer TherapeuticAgents, their pharmacological identification and tests,with some account of their uses in medicine, will be givenby Dr. J. H. Burn, director of the pharmacological labora-tories of this society, in the Lecture Theatre, 17, Blooms-bury-square, on Monday, Oct. 13th, and succeedingMondays, at 5.30 P.M. Admission to the first lecturewill be without ticket, but to subsequent lectures byticket only. _

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A COURSE ON VENEREAL DISEASES.-A course ofpost-graduate lectures and demonstrations on ModernMethods in the Diagnosis and Treatment of VenerealDiseases is being given at the V.D. Treatment Centre,Municipal Clinic, 155, Regent-road, Salford, by Lieut.-Colonel E. Tytler Burke, director of the clinic, on

Thursday, Oct. 9th, at 7 P.M., and at the same timeeach Thursday for 15 weeks. In addition, a course offour lectures and demonstrations on Congenital Syphilisis being given at the clinic on -Oct. 9th, 38th;-23rd;and 30th.