SPECIAL EVENING SESSION

Otago Witness, Issue 3804, 8 February 1927, Page 27

SPECIAL EVENING SESSION

A special session was held in the Allen Hall on Friday evening, when there was a discussion on the relationship between the State, the hospitals, and practitioners. ADDRESS BY DR M. H. WATT Dr'M. H. Watt, Deputy Director-general" of Health for New Zealand, took as his subject “The Relationship of the Private Practitioner to the State.” During the past quarter of a century, said the speaker, State medicine has shown a definite tendency to include measures of nersonal hygiene within its scope, until by imperceptible stages, its emphasis has come to be upon the individual rather than upon the environment and the erstwhile limited subject of public health had broadened out into the important one of preventive medicine. To-day the State takes an active interest in the prevention and treatment ot disease, infectious and non-infectious alike, as witness its many schemes dealing with" such matters 3s ante-natal care, maternity, and infant welfare, medical inspection of school children, treatment -of tuberculosis and venereal diseases, etc. The State is notoriously conservative, and it can safely be said that its incursions into the domain.! of medical practice were because of the crying need for reform and in recognition of the fact, that existing agencies were unable to provide the public with the standard of medical care which they required and demanded. The private practitioner turns a watchful eye upon these activities of the State, • and has an uneasy feeling that they foreshadow a continuing restriction of his o« n sphere of influence or possibly even his enforced incorporation in some scheme ot State medical service. The position is not so black as he imagines, but there is certainly need for thought on his part. Opportunity has knocked at his door in the past and has at times gone unheeded. Oppoi tunity still knocks, and it is for him to .say whether he will answer the call and adapt himself to altered conditions of practice or will ignore the summons and leave it to be .answered by the State with consequent further inroads on his livelihood. , L n Lnis article it is proposed to discuss the relationship of the private practitioneito the State with a view to stressing the new outlook in medicine and pointing out how the profession may best cope with the situation which . now confronts it. The matter is dealt with from the point or view of New Zealand, which has a hospital system peculiar to itself, consequently the remarks which follow may not be wholly applicable to other places. speaker dealt with tho registering of the medical practitioner by the State, and referred to the responsibility placed on Lhe practitioner in regard to notification of diseases. I he State required notification in 33 separate diseases, and he considered that it should review periodically its methods and not demand notification unless some purpose was served thereby. Reference was made to the duty of the practitioner in the treatment of his private patient, and the speaker then proceeded to speak of the case . of the hospital where, he said, the position bristle with difficulties, and there were all the elements- for discord betreen the private practitioner and State. The hospital system of New Zealand, he said, provides a most excellent service for the public, but is not always quite fair to the doctor. The private practitioner complains in the first P‘ ace that some of the hospitals are staffed by full-time medical officers, thus' depriving him of the opportunity of clinical experience and in the second place that the State competes unfairly with him in so far as patients able to pay for private treatment are at times admitted to the public hospitals. As regards the first complaint there is no doubt that it is in the interests of the community as a whole that the privileges of hospital practice should not be confined to a few full-time medical officers of the boards, but that as many private practitioners as possible, compatible with the smooth and efficient working of the institution, should be on the staff. In this way the hospital takes its rightful place as the most important force in post-graduate medical education and skill and experience acquired in the hospital are spread over the whole community to the benefit of all parties concerned. As regards the second complaint the principle. behind the hospital system of the Dominion is that the resident of a hospital district may ; irrespective of his financial position, claim as his right that he shall be admitted to the public hospital for treatment. . This principle is too deeply rooted to be lightly overthrown. The State, which in its ultimate resort is public opinion, may sympathise with the doctor in his dilemma, but certainly is not likely, while remedying an injustice to one limited section of- the community, to impose a greater injustice upon a larger body of people. It would appear then that there is an impassable barrier in the way of a smooth relationship between the private practitioner and the State, but as so often happens in the case of impassable barriers, there is a way round. The way round in New Zealand is the paying ward for private patients. This system whereunder the patient who is prepared to pay for the special'- privileges he obtains, can" be accommodated in a private room in a public hospital and be. attended there by the doctor of .his choice, is coming by evolution. It is unlikely that there will ever be large blocks of private wards in connection with our public hospitals, but there certainly will be a few beds available for the accommodation of tho patient who requires special facilities for diagnosis or treatment which otherwise are not obtainable by him, for example, extensive biochemical or X-ray examinations, radium therapy, and so forth. Tho existing private hospitals are able to accommodate ordinary patients at cheaper rates than the public hospital can ever hope to do, and

will not be displaced, but will rather ba supplemented in the direction indicated. 'And now a word in conclusion about the bogey of nationalisation which over and anon rears its head. It is the firm belief of the writer that nationalisation -of the profession, by which is meant the replacement of the private practitioner, either w-holly or in part, by full-time salaried medical officers paid out of public funds, is not in tho interests of the profession or the community. Competition means progress, while nationalisation would almost inevitably tend towards stagnation. Fortunately the intimate personal relationship between patients and doctor of his ; pwa choice which is the basis of private-prac-tice, is too strong a force to be easily overthrown by any specious demand for nationalisation. The remedy for such ills, as are at present found in the medical world is not to do away with the private practitioner, but rather to widen his sphere, oE duties and to fit him into the existing scheme of things in such a way that his services can be used to the . fullest advantage. The ideal towards which we should strive is, in effect, for the private practitioner to function as a medical officer of health interesting himself with the prevention of disease as. much as with that cure and care of the patient. PAPER BY DR MORRIS-. Dr Morris, honorary surgeon to outpatients. St. Vincent’s Hospital, Melbourne, read a paper on “The Role of the Medical Practitioner in the Prevention of Disease.” He said: There is a growing conviction: of the need to recognise the essential unity of the preventive and curative activities of the medical profession. A survey of soma of the literature of preventive medicine shows a unanimous insistence on this blending which has been increasingly manifest since the close of the Great War.-- The successful application of the methods for the prevention of disease amongst the armies in this and other recent campaigns was the greatest practical demonstration the world has ever seen. In a larger army than had ever before been in the field,, the incidence of disease was often lower than in times of peace. The desire'lo repeat these results in the civil population has been baulked by the impossibility of applying military methods to the ordinary citizen and to the medical profession. There is also an obstacle in the absence of an educated public opinion on the part of .the one and a definite preventive programme on the part of the other. Although public health work was originally performed by the general practitioner, its direction has gradually passed into, the hands of specialists who devote their whole time to it. Notable work in the prevention of disease has been and is still being done by individual general practitioners, but the primary objective of the practising profession is the cure of disease. The problem which. confronts the leaders of the campaign, for prevention is how best to -enlist the general body of the practising profession in the work of the prevention of disease. A very great deal of propaganda work has been done in this direction and some practical suggestions have been made. It is generally recognised that the relative importance of the prevention of disease is. not sufficiently emphasised in the training of the medical practitioner and the recent request of the General Medical Council is designed to remedy this defect. The medical student ends his undergraduate days in an intense concentration on the diagnosis and treatment of established disease in sick people, spends a year or two in hospital which is not concerned with prevention, and passes into practice to earn his livelihood, not by preventing but by diagnosing and treating disease, the work for which he has been trained. There is no trend towards prevention in his mind. Tho desire to prevent disease does not possess him, and it is actually opposed to his economic needs. If his “highest aim” is to be prevention, then there must be a steady inculcation of the ideal of prevention from the day he starts his medical studies. In no medical school is thia done. It is, therefore, necessary to stimulate the interest of the general practitioner in the prevention of .disease. - An educated public opinion on matter* of health promotion and disease prevention is a sine qua non. It has been said that “the most perfect system of preventive medicine _jn the world would not reduce preventible disease more than 20 pei’ cent. The other 80 per cent, depends on individual knowledge and action.” It is probably true that the greater part of the knowledge of health possessed bv the ordinary private citizen is learned from his family doctor, to whom he will listen when he will not read the literature or listen to the lectures of health promotion propagandists. The family doctor is, as Newman says, “the missionary of , opportunity should be lost or telling the facts of the prevention of disease, and even at the risk of losing patients the profound belief in the bottle of medicine as the chief preventive and curative agent should be eradicated. . . . The State has never very earnestly sought the co-operation of the medical profession on a big scale in the campaign against disease. . The salaries paid to its own whole time medical officers of health are wholly inadequate and unattractive in comparison to the highly important functions which the officials are called upon to fulfil. They compare very unfavourably, > with salaries paid to other State officials, especially in the higher ranks, whosa duties are not of such economic value to the nation. The remuneration paid to the practising profession for the performance of statutory duties is absurdly small and ■ out of. date and needs revising. Fees of ono shilling and sixpence for notification! and two shillings and sixpence for certification, offer no_ practical inducement to take* an interest in preventive medicine. The ■ establishment Of free and complete supplies in local depots of throat swabs, sterilized containers for pathological material, certificate forms and similar detailed conveni« ences has never been adequately attempted.. The establishment of accessible diagnostic! laboratories has been very slowly proceeded! with. In these and many other ways the StaFe Has failed to interest the general practitioner- in the preventive side of hi* work. A genuine request made to the! medical profession to formulate a detailed scheme of prevention would be most loyally; and sympathetically received. Every pronouncement on the prevention of disease! > made by the British Medical Association

bj representing the practising profession, has insisted on the prime importance of the subject. The Congress and its predecessor placed prevention in the forefront of the discussions. The founders of the British MediCal Association in' 1832 remembered it in laying down the objects of association; and before a recent Royal Commission on National Insurance in England it was officially stated by the British Medical Association that “it is of paramount importance that regard should be had primarily and constantly to the maintenance of health and the prevention of disease and not merely to the provision for the alleviation or cure of morbid, conditions when once they have arisen.” That is the creed of every well-trained and conscientious medical practitioner. f He is willing to do his valuable part in the work of prevention and to regard his duty to the State in the same light as his duty to himself.

NON-MEDICAL POINT OF VIEW.

Mr R. J. Love, Inspector of Hospitals and Charities, of Victoria, gave an address on the relationaship of medical practitioners to hospitals, particularly in regard to the prevention of disease. He considered the guestions involved in connection with hospitals from the non-medicai point of view. He pointed out the a uniform settlement of these questions had been an imperative necessity for many years, and it was therefore difficult to understand why a practical scheme had not been brought into effect. He Iqoked to the British Medical Association for a uniform expression of

opinion. In summing up the position as it existed he stated that there should be ample hospital accommodation and facilities for treatment for the indigent sick. People who were able to pay full charges for hospital accommodation and for medical attendance should do so without interference provided that there was full value for money in the matter of service. Between the extremes there should be an arrangement under which every patient could obtain essential service without financial hardship or an undermining of his independence and without imposition on the medical practitioner. Hospital policies in Australasia varied somewhat. In some hospitals charges were made for accommodation and maintenance, but the practitioners received no fee or remuneration. A condition of the government subsidies to Victorian hospitals was as follows: —No medical or other officer attached to any institution shall be allowed to accept from patients either directly or indirectly any fee for his own use or services rendered at the institution. This must be made clear to patients who receive treatment or re-

lief. This free service brought with it a reward to medical officials in the shape of the feeling of having performed a kindly action as well as what the man in the street regarded as a wonderful opportunity to acquire proficiency, experience, and enhanced professional status. Mr Love also, dealt with the important function of teaching at public hospitals. The cost of buildings and maintenance is provided out of contributions to charities, Government, subsidies, and municipal grants. He questioned whether the intentions of the charitable public were being faithfully observed in view of the fact that others than the indigent sick were admitted to these institutions. He assumed that the figures for Victoria could be accepted as an index of the position in other States, and in the Dominion. In ?901 the population of Victoria was 1,490,000. There were 25,351 in-patients and 74,036 out-patients treated during the year, and these people contributed £14,885. In 1926 the population was 1,700,000; there were 54,003 in-patients, and 193,325 outpatients ; the total amount contributed by these patients was £123,655. It therefore followed than in 26 years the population of Victoria had increased by 21.4 per cent., while the total amount paid by patients had increased by 730.7 per cent. The public should not he held wholly to blame for this state of affairs; the tendency towards the improper use of hospitals would increase unless facilities for treatment were widened and grades of hospitals established. He suggested that a financial classification was the first essential for hospital purposes the community could be divided into four groups: private, intermediate, third and public or free. Private patients called for no detailed comment. Intermediate patients were those who,

while unable to pay full fees were not in. such a position as to warrant their accepting any form of public relief.. He did not think that it would be practicable to determine any limit for this and suggested that the responsibility for the ctassificatic.is- must be accepted by the private practitioners. The intermediate h*.»su‘tals have passed through the experimental stage and were working satisfactorily, the chief need being for greatly increased facilities and accommodation. The third class was placed between the intermediate and the public or free. ,It included wage earners and small salaried peqple who at present ware contributing from 10s to 50s a week as maintenance fees in public hospitals. In the 'public or free class corresponded to the indigent patients who were unable to contribute anything for maintenance or treatment.

All the hospital needs could be met in a community hospital system such as has been adopted with success in America. He thought that there were so many factors to be. dealt with and so many vested interests to be considered that many years would elapse before such a system could be introduced into Australasia. He therefore suggested a modified form. The suggestion for immediate application were enumerated. Private accommodation should be extended.. The capital cost should be borne by private individuals and the units maintained by patients’ fees. He recommended the registration and standardisation of private as well as public hospitals. In regard to the intermediate hospitals independent institutions managed and controlled by church organisations, insurance companies or other corporate bodies could be established in large cities. In smaller centres the intermediate accommodation could be attached to the public hospitals. He thought that the intermediate hospitals could be financed more or less by private individuals in groups although.it might be necessary to obtain some assistance from the. Government n the nature of long loans on a basis such as the credit foncier. In the third place he suggested that some proprietors of private hospitals might set aside accommodation for the intermediate class of patient. He did not anticipate

that it would be feasible to establish a third class of patient in the immediate future. If a national health insurance scheme were introduced and provision for institutional treatment were included the insured would constitute a third class group. In dealing with the staffs of the various hospitals he pointed out that there need be no limitation of attendance by any reputable practitioner in private hospitals. The arrangements in intermediate hospitals would be the same as in private hospitals. Should comniuity hospitals be provided the medical staff arrangements would be the same as those obtaining at present in private and independent intermediary hospitals. He advocated the introduction of a system of hospital control and of hospital grading similar to that adopted by the American College of Surgeons. When the third class group of patients was created the treatment should be undertaken by the members of elected staffs.. These. doctors would be available for the teaching and training of students. The same arrangement would obtain in the public or free hospitals. Mr Love then turned his attention to the preventive aspect of medicine and pointed out- that preventive medicine was largely education. The education of the public however, had to be carried out by the medical profession. In this work the medical officers of public health departments, the teachers in medical schools and the private practitioners all had their place.

CONGRESS DINNER. The official congress dinner, for which special invitations were issued, was held in the Fernhill Club on Friday evening. The toast list was as follows:— “The King,” proposed by the chairman (Dr L. E. Barnett). “The British Medical Association,” proposed by the Hon. W. Downie Ste*art. and responded to by Dr H. Cooper Pattin, Dr Antill Pockley, and Dr Stanley Batchelor. “The Health Services,” proposed by the Mayor of Dunedin (Mr" H. L. Taplev), and responded to by the Hon. J. A. Young. Sir George Syme, and Dr Peter Buck. “The Visitors,” proposed bv Dr J. S. Elliott and responded to by Dr George Piness and Dr A. L. Kenny. “The Australasian Medical Congress (second session).” proposed by the Hon. Sir Charles Statham and responded to by the president.

DISCUSSION ON GOITRE.

THEORY OF lODINE DEFICIENCY. One of the meetings was devoted to a discussion on the pathological side of the goitre question—a subject which is of great importance to the community in New Zealand and to those residing in certain parts of Victoria and New South Wales. Dr S. V. _ Sewell (Melbourne) read a paper in which he recounted in a very clear manner the difference between the normal thyroid' <dand and the thyroid gland as enlarged to form a goitre. He pointed out that the manufacture within the gland of a minute quantity of chemical substance, called thyroxin, was necessary for the normal functioning of the gland. Various stresses in life, including those of puberty, pregnancy, and so forth, led to slight changes under physiological conditions, and to gross changes under abnormal conditions. If the gland were unhealthy all the signs of what is spoken of as toxic goitre developed. The speaker gave an account of recent research work which was being carried out in various parts of the world, and which had led to a better understanding of the functions of this curious gland. Dr A. H. Tebbutt (Sydnew said that Drs Woodhill and Hansman (also of Sydney) and himself had been working on the microscopical appearances of the gland in people suffering from goitre as well as in people who had died without signs of goitre. He gave an account of the changes dis-

covered in a series of glands collected from various sources, and traced the relationship of the various types of goitre from a simple replacement of the normal tissue by inflammatory products up to the condition spoken of as Riedel’s struma. From the pathological point of view’ this work was of considerable importance. Dr F. T. Bowerbank (Wellington) recounted the history of some work that had been started in 1907 in Europe in connection with the nutrition of the body in its relation to the function of glands like the thyroid gland. The nutrition was measured by estimating the amount of oxygen and carbon dioxide consumed and excreted respectively while the person was at complete rest. It had been found that what was known as the basal metabolic rate, or, in other words, the minimum amount of oxygen consumed while the person remained healthy was greatly influenced in such diseases as goitre, and these measurements were now regarded as indications, not only of the changes taking place within the body in the various forms of goitre,

but also as an indication of the correct “form of treatment that should be adopted. D r Walter Summons (Melbourne) gave an account of the extent of goitre in Gippsland (Victoria). He pointed out that examinations had been carried out with the aid of the school medical officers of the Education Department at the Bairnsdale State and high schools and the Lucknow State School. Among the boys the goitre was present in over one-third of those attending the Bairnsdale State School, and just under one-fifth of thdse attending the Lucknow State School. On the other hand, at the Lucknow State School under one-third of the girls were affected, and at the Bairnsdale State School just over one-third of the girls. At the Bairnsdale High School nearly one-half had goitres. Children between five and eight years of age had relatively little goitre, while those between eight and 14 had considerably more. In Traralgon. the girls were more frequently affected than the boys. 4 per cent, of the boys and 13 per cent, of the girls having very obvious goitres. At Moe, the extent of severe goitre was much smaller. On the other hand the school medical officers when examining 2000 girls between the ages of. nine and 14 years in the schools of Bendigo, Ararat. Ballarat, Warrnambool, and Melbourne, had found enlarged thyroid glands in only J per cent. It had been recognised that goitre had been endemic in Gippsland since the occupation by white people. Inquiries had elicited the information from the Department of Agriculture that goitre was not prevalent to any appreciable extent in animals such as horses, cattle, and - sheep. Dr Summons pointed out that the type of goitre was simple, that the physical development of the cnil-

dren was up -to standard, and that no defects were found that separated them in any way from children of other localities. Dr F. V. Bevan-Brown (Christchurch) spoke of the transition or metamorphosis of the simple form of goitre to that form which was associated with severe. symptoms. He dealt in the first place with the role of iodine in the economy of the human body and its relation particularly to the thyroid gland. The iodine molecule acted as an oxidising agent and accelerated all the functions of the body. It also stimulated the defences of the body by producing anti-bodies to counteract toxic substances derived from bacteria or absorbed from the food. When there was a considerable amount of bacterial action arising from a diet containing too much protein the iodine available was reduced, and y this would lead to a depression of the functions of the body and a reduction of the defensive powers. He pointed out that it was not necessary to acquire goitre if a person lived in a goitrous district where iodine in the soil was scanty. He accepted the theory of iodine deficiency as a cause for goitre, but he did not think that this was the only factor concerned. Professor A. M. Drennan (Dunedin) dealt with certain technical aspects in connection with the changes in the thyroid gland in 3°Dr e ’F. Fitchett (Dunedin) spoke cf the two endemic forms of goitre, and distinguished them from the exophthalmic which is usually known as Grave’s disease. He also accepted the iodine deficiency theory. Under certain circumstances the administration of iodine in the treatment would do harm rather than good.

OBSTETRICS AND GYNECOLOGY.

Dr J. W. Dunbar Hooper (Melbourne) delivered an address on the subject of the present position of obstetrics and gynecology. He recalled the ’ conditions obtaining in his student days, when obstetrics were known as midwifery, when antiseptics were little used, when asepsis was unknown, and when meddlesome midwifery was very common. The blessings of choloroform were well known, but the more modern means of relieving -. pain were unheard of. He also referred to the struggle between the pioneers in obstetrics and the surgeons, which led to much bitterness, because the surgeons in those days insisted on the carrying out of operative interference, while the obstetric physician stood by and looked on. Ail this had been changed in Australia, New Zealand, and the Old Country to-day, and the trend of obstetrics had advanced to the position that the dangers of meddlesome midwifery tended to be lost sight of. Dr Hooper deplored the too frequent use of severe abdominal operations. On the other hand, the result of ante-natal care had been the elimination of about 95 per cent, of the cases of eclampsia, which was a very fatal complication of child birth. Dr Hooper stated that when he was in charge of the women’s hospital in Melbourne in 1885 and 1880 about 1000 confinements were handled by his ordinary staff. At the present time the work had increased to such an extent that 2600 confinements took place within the hispital. They had a staff of four honorary obstetric surgeons constantly <n duty, and these men were carrying >ut ante-natal work in addition. The medical superintendent, two resident obstetric surgeons, and three resident gynecological surgeons supported them in their work. Dr Hooper claimed that the science of obstetrics had advanced sufficiently to justify the removal of the obsolete term •of midwifery. He pointed out that Sydney was fortunate in that a professor of obstetrics had been appointed at the university, and that he had expert assistants and a teaching staff to add honour to their work. He referred to the heavy physical toil involved by broken sleep,

weary night drives in the country over very rough roads, and the loss of other practice, which handicapped the general practitioner in rural disticts, and spoke in terms of high praise of the manner in which the majority of the general I practitioners safeguarded the lives and health of the mothers of Australia I and New Zealand. The highest death rate of mothers per 1000 births in New Zealand was 7.3 in"~1885, and the lowest was 3.58 in 1913. The death rate in New Zealand was 4.65 per 1000 births. In Holland the death rate between 1916 and 1920 was 2.6 per 1000 births, and it had remained at approximately this low figure in subsequent years. In Victoria the death rate was 4.37 per 1000 births in 1925, and over the whole of Australia in the same year it was 5.47. The figures for England and Wales fox* the same year were 5.04, for Scotland

6.16, and for Canada 4.70. In the United States in 1924 there were 6.5 deaths pex' 1000 births. Dr Hooper referred to the world-wide movement throughout civilised countries to attempt to diminish these

mortality rates. It had been ascertained that in England about 60 per cent, of the women were attended in their confinements by midwives. In Australia 91 per cent, of them were attended by doctors The sparsity of the population in Australia demanded the very best obstetrics, yet in the last two years 1504 women out of 270,719 had lost their lives. Recently the Edward Wilson (Argus) trust fund had provided money for the appointment of a director of obstetric research in Victoria. Dr Marshall Allan filled this position, and had attacked the difficult problems of his task with great energy. By means of this campaign the medical practitioners throughout Victoria were taking their responsibilities more seriously, and the result was already making itself felt. Dr Hooper stated that he was convinced that a careful practitionex* could conduct a larger private family practice and deliver some 3060 women within his lifetime with an extremely low mortality, and an exceedingly low morbidity. In his own experience, extending over 40 years, per cent, of the confinements had been either normal or only slightly abnormal. He had found that only six times had it been necessary to remove an infant by means of an abdominal operation. He thought that the most important changes that had taken place so far as obstetrics was concerned were the introduction of ante-natal observation, the habitual use of sterile rubber gloves, the employment of surgical asepsis, and a few other technical innovations. Dr Hooper also traversed the advances that had takeß place in recent years in the

practice of gynecology, which had resulted in an immense saving of life and suffering.