borhood, but admitting that an epidemic of chicken-pox had been in progress for some months. The State Board of Health thereupon caused the steamboat service to Rock Hall to be suspended. Among the signers of the manifesto were a justice of the peace, the postmaster of Rock Hall and Dr. Beall. Dr. Beall was active in vaccinating the people before and after having signed the manifesto. He had also accompanied the representative of the State Board of Health, visiting a number of houses, and concurring in the diagnosis of smallpox. GENERAL. THE typhoid mortality of Philadelphia was quite heavy in 1906, about 75 per 100,000. PITTSBURG is said to have more than 1000 cases of typhoid fever. A good situation for January. DR. W. W. KEEN has resigned as professor of surgery in Jefferson Medical College, Philadelphia, and has been elected professor emeritus. This action comes after 27 years of active services which have brought great distinction to the college as well as to Dr. Keen. THE St. Louis Medical Review for January 5 publishes as a supplement a fine half-tone reproduction of the portrait of Lorenz Heister, belonging to the Surgeon-General's Library in Washington. To the same number Dr. F. J. Lutz contributes an article on the work of Heister, whom he considers the founder of scientific surgery in Germany. PITTSBURG firemen were exposed to an unfamiliar danger recently when fire broke out in the Mercy Hospital. An explosion of chemicals broke some culture tubes in the bacteriological laboratory and scattered their contents over the walls and floor. Disinfecting solutions were sprinkled about before the firemen were allowed to enter the laboratory, and the firemen so exposed were placed under medical observation for a period after the exposure. THE Montefiore Home for Consumptives, New York, recently had a narrow escape from destruction by fire. A pile of clothing in one of the dormitories had been saturated with coal oil and set on fire. Fortunately the blaze was discovered and extinguished before much damage was done. Four porters, just dis charged by the hospital authorities, were arrested as the probable authors of the crime. PHILADELPHIA's death rate for 1906 was 18.63 per 1000, considerably higher than that of 1905. If the death rate continues at 18.5 or higher, the truly businesslike way to reduce it is to count the people and get a bigger divisor. It is easier to do that than to prevent some of the deaths and so get a smaller dividend. If one cannot count the living more than once, the next best plan is to count the dead less than once. This also is a handier method than that of saving lives. The methods can be combined, but it is imprudent. THE Woman's Medical Association of New York held a memorial meeting on January 4 in honor of the late Dr. Mary Putnam Jacobi. The Association has undertaken to raise a fund of $25,000 for the purpose of establishing a Mary Putnam Jacobi fellowship in medicine. The income is to be used to enable a woman to pursue the study of medicine. The speakers at the meeting were Dr. William Osler, Dr. Elizabeth M. Cushier, Mrs. Florence Kelley, Dr. Felix Adler, Dr. Charles L. Dana and Mr. Richard Watson Gilder. PHYSICIANS Who have experience with the injuries which occur in jostling crowds will be interested in a recent decision of the Supreme Court of Massachusetts. Suit was brought against a suburban railway company on account of an injury sustained in a station by being thrown down in the crowd. The lower court gave a verdict in favor of the plaintiff. This judgment was sustained by the Supreme Bench, thus establishing the liability of a transportation company under such conditions. DISCOURAGED by the difficulty of convicting persons accused of criminal abortion, the New York District Attorney's office has tried the experiment of charging such offenders under the nuisance law. A midwife was tried recently under the code provisions relating to common nuisances, and was sentenced to a fine of $500 and a year's imprisonment. A witness who had been employed in the prisoner's house testified that in three months 50 women had been operated on, and one had died. By this procedure the State is not restricted to the very precise line of inquiry laid down for capital proceedings, and can reveal the general character of the accused person's practice. MARYLAND MEDICAL JOURNAL A Journal of Medicine and Surgery Vol. L, No. 3 BALTIMORE, MARCH, 1907 Whole No. 1066 SUGGESTIONS FOR THE REORGANIZATION OF HOSPITAL OUT-PATIENT DEPARTMENTS, WITH SPECIAL REFERENCE ΤΟ THE IMPROVEMENT OF TREATMENT. By Richard C. Cabot, M.D., Boston. READ BY INVITATION BEFORE THE MARYLAND MEDICAL SOCIETY, DEC. 4, 1906. I. OUT-PATIENT WORK USUALLY SLIPSHOD, YET PUBLIC. Out-patient departments are, as a rule, neglected. There are several reasons for this: (a) A position as out-patient physician is taken chiefly as a stepping-stone to something higher, and treated, as stepping-stones usually are, cursorily, full attention being directed elsewhere ahead. (b) As a feeder for hospital wards the dispensary demands but a preliminary examination and makeshift treatment for cases which will soon be more thoroughly dealt with in the wards, and this hasty and makeshift character naturally extends to the work done for the much larger number of patients who do not enter the wards at all. (c) In most out-patient clinics the number of patients is so large and the number of physicians and assistants so small that no good work can possibly be done within the time limits prescribed by the other and more lucrative business to which physicians must also attend. (d) Very often I have found out-patient physicians discouraged because their patients come to the hospital but once, and are seen for so short a time that no thorough diagnosis is possible. (e) If we inveigh against these slipshod methods we are met with "what can they expect? Time is money. They pay nothing, and are too ignorant to profit by careful advice. The conditions and the patients being such as they are, our work is good enough." This is rarely said, but usually acted on. Yet we must remember that dispensary work is essentially public work, and that it is sure. sooner or later to be affected by II. THE MODERN CONCEPTION OF PUBLIC WORK. As long as work done without pay is thought of primarily as "charity"-i. e., as something which it is to a man's credit to do at all-we readily pardon its poor quality. With the gradual transformation of our habits of thought, hospital work has now begun to be thought of not as "charity," but as public work-work called for by the public, and therefore demanding the best we have to give. A private road, a private way, is "dangerous passing." Only the public roads are guaranteed to be of standard quality. We now demand that public education shall be equal to the best anywhere attainable, and in public institutions for the feeble-minded, the epileptic or the tuberculous the standard is sometimes higher than that easily obtainable in private enterprises. When we want standard quality of vaccine or of diphtheria antitoxin, we turn (at any rate in Massachusetts) to our State Board of Health. Such is the tendency in many fields of work, and the tendency is beginning to make itself felt in one of the last strongholds of the old regime. Beginning with perfection of equipment in the surgical operating-rooms of modern hospitals, the reform movement is spreading via the wards to that forgotten corner of the hospital, the dispensary. Reform of record systems has begun, though I will venture to say that there are not a dozen dispensaries in the country where the records are properly kept, used, indexed and filed. The number and quality of assistants and the amount of space for examining rooms is increasing in many dispensaries. But despite these reforms, I suppose no one would today maintain that the public work done by physicians in dispensaries is anywhere as good as the private work they do in their offices for their private patients. Why should the public tolerate this? I see no good reason. The public insists that the public work done by the lawyer as attorneygeneral or district attorney shall be up to the standard of private law practice. If we had reason to believe that State and city laboratories did other than the best work in their examinations of diphtheria cultures, sputa and blood, we, the public, would be up in arms-indignant. Why should not dispensary work be tried by the same standards? Primarily, I believe, because the public does not pay for dispensary work. The public pays for the buildings and equipment, but the physicians do the work for nothing, and such work is usually poor. Here and there a hospital or one man in a hospital will keep up to professional standards, although he is doing his work as a minor item in his life, but in the long run not often. The only paid dispensary work that I know of in this country is that done by the Tuberculosis Dispensary established by the Board of Health in New York city, and by the nurses who work in connection with the Children's Hospital, Mt. Sinai Hospital and Berkeley Infirmary in Boston and Vanderbilt Clinic, Bellevue, Presbyterian and other New York hospitals. When the dispensary is used largely for teaching purposes, as at Harvard, Cornell and Johns Hopkins, we get some good work done, because the paid teachers are part of the dispensary staff. I have no hesitation in saying that if the good of the patient is what we chiefly have at heart, the public medical work of our dispensaries must be done in part by competent, well-paid officials, as the work of public diagnosis laboratories now is. Volunteer assistants and supervisory boards may well be unpaid, but there must be a permanent corps of men whose chief business in life is dispensary work if that work is to be well done. Men to whom it is a "side show," and who do it "by the way." may do it well, but in the long run will never do it as well as it can be done. III. ABOLITION OF HURRY AND MAKESHIFT POSSIBLE ONLY BY PAYING THOSE IN CHARGE. Firmly fixed in most dispensaries of this country is the tradition of hurry. Everything must be done fast, not only the fetching and carrying, the clerical work and all the low-grade jobs (which ought to be done swiftly), but also the examinations and the treatment, which can rarely be done at the rate prescribed by tradition in most dispensaries, without slovenliness, errors and failures to help the patient. As dispensaries are now organized, hurry and makeshift are indispensable, for if every patient were properly questioned, examined and advised, an average-sized clinic would take all day. But it cannot take all day, for the men in charge must earn their living, which means that they must get away from the dispensary in an hour or two, at most three, either leaving the bulk of the clinic to assistants and students, or rushing through the cases at a speed that makes accuracy and efficiency quite impossible. Why not have more physicians, so that each need treat but a few patients a day? Because the ablest physicians won't take the job on those terms. In order to make it worth while for an able (and therefore busy) physician to give time to dispensary work, you must allow him the privilege of "skimming the cream" off the clinic; that is, of controlling and rushing through a relatively large number of patients for the sake of the few "interesting cases" to be found in the bunch. The physician takes his pay in this form. He uses a dispensary clinic to furnish interesting cases for teaching or for scientific study. This is usually very good for the small minority of interesting cases, and very bad for the great majority of uninteresting ones, which are served in a slovenly or perfunctory way. Is there any good reason in the nature of public medicine why an examination of sputa should be done well at the public labora tory, while an examination of the chest is done badly (as most are) at the public dispensary? Why should we not demand standard quality of work in the one case as much as in the other? Both re free and public. The one is good, the other bad. The free public examination of sputa is fully as well done as it is in our office practice. What good reason can be adduced for treating a dispensary patient any less well than an office patient? At the Massachusetts General Hospital we have succeeded in raising the standard of diagnostic work in the dispensary nearly as high as it is in private office practice, but in treatment we are still woefully far behind what we ought to be, for it is in treatment that our system of carefully supervised student work breaks down. IV. THREE ERAS IN THE EVOLUTION OF DISPENSARY THERAPEUTICS AT THE MASSACHUSETTS GENERAL HOSPITAL. The era of wholesale drugging. I. 2. The tractarian or ritualistic era. 3. The beginning of better things. I. The Era of Wholesale Drugging.-When treatment was confined chiefly to drug treatment, and diagnosis went no further than symptoms, it was not difficult for a dispensary physician to "run off" 40 or 50 cases in a couple of hours. To tear off and hand out printed prescriptions for "Sol. o" or "Mist. 13" is easy and quick, and it pleases many patients much better than the present lengthy examinations and tedious waiting for a talk with the doctor at the end. The patient wants to get back to his home or his work as quickly as he can, and so long as he is kindly treatedthe briefer the preliminaries of all kinds before the coveted prescription is handed out-the better he likes it. Thus pressure from without and pressure from within (the doctor's need to get away and attend to his practice) combine to make the dispensary what its name suggests-chiefly an enlarged apothecary shop, a place for giving and getting medicine. This tendency to give drugs (either as curative, palliative or placebo) to almost every patient and at every visit used to produce a very comfortable revenue for those out-patient departments which dispense their own drugs. Of late, however, there is with us a noticeable abatement of the flood of drugs pouring out of the dispensary and into the community. The following figures show this: That this change is in line with the best tendencies of modern medicine I think few will deny. The change would be much more marked if the pernicious habit of placebo-giving could be checked. |