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for a few weeks, it permits a number of cases oflate tetanus and there is the added risk of re-

injecting horse serum into a person within a fewmonths of a previous dose. Active immunisationwould therefore have distinct advantagesespecially for those likely to be repeatedly exposedto the risk of bomb splinters, falling masonry andthe like-fire brigades, A.R.P. workers, policeofficers, ambulance men, and perhaps medical andnursing staff. Local authorities in towns which

might be particularly subject to air attack shouldalso consider offering free immunisation to econo-mically important groups in their community.Tetanus spores are present wherever there are

domestic animals, and the risk of infection, if lessthan on the battlefield, is probably as great forthe town-dweller as the countryman.On the wider issue of immunity to infectious

diseases, evacuation and dispersal of our child

population has resulted in a remarkable reductionin the incidence of childhood infections, butprobably to the detriment of the process ofnatural immunisation which constantly goes on incrowded urban areas. Every effort should there-fore be made now to encourage active immunisa-tion of school and pre-school children againstdiphtheria and pertussis and to collect convales-cent or adult serum for the control of measles.Too often the day of reckoning comes and we arenot prepared for it.

THE MUNICIPAL HOSPITALDr. ARTHUR MORRIS, in his lecture to the

Harveian Society on June 5, spoke as one fullyconvinced that the administrative head of a hos-pital should be a medical man. Business capacityhas been urged on the other side but a talent forbusiness management is not unknown amongdoctors and he did not think that important deci-sions concerning the patient and the medicalor nursing staffs should be made by a layman-if a hospital is to be progressive it must beadministered by one who knows how the medicalwork ought to be done and how to provide facili-ties for doing it. The Society of MedicalSuperintendents now has some 150 members, so

there is no question of the principle not beingtried out on a large scale. It was, he said, thelast war that revolutionised the type of cases

admitted to municipal hospitals; many of the

voluntary hospitals being then filled with woundedsoldiers their civilian cases had to be diverted tothe poor-law infirmaries. These hospitals cannow offer almost the same advantages as the

voluntary hospitals. Their patients are no longerhumble; they demand the best. In the old daysif a medical superintendent was economical in hispurchase and use of supplies, if he kept his hos-pital clean and bugs out of the beds, if he gavehis patients fairly decent food to eat and kept hisstaff in order, he was considered exemplary. Nowhe is expected to keep abreast of every modernmethod of treatment, and his knowledge mustextend from cookery to practical epidemiology.Many-sided and versatile as he has to be, and agood mixer into the bargain, he should not bea specialist except in his own branch. But in this

some special qualties are required. For example,he needs wisdom and tact if his heart-to-hearttalk with each patient before he leaves the hos-pital precincts is to prevent complaints later.Under the poor-law guardians the infirmary wasan ideal training ground for the general prac-titioner, for it offered a wide and varied experi-ence, though many of the acute cases were

filtered off by voluntary hospitals. Now undercouncil control the majority of the patients comestraight from their doctors and are classified sothat it has become possible for residents to beemployed exclusively on this or that work-medical, surgical, obstetrical or gynaecological—and the resident assistant physicians or surgeonsare young, ambitious men in the heyday of theircareer. In this formative stage not the leastfactor is the human element in their work. Byinterviewing relatives and friends they learn torealise practical possibilities and how to conductthemselves in their future practices. These maybe the most profitable lessons of their training.About the scope of outpatient departments at

municipal hospitals Dr. MoRRIs had somethinginteresting to say. While it was proper to avoidinvading the province of the general practitioner,actually many of them were sending up cases fora second opinion and were encouraged to do so.Should a further attendance be suggested thepatient is very properly referred to the almoner todetermine whether he should not return to his owndoctor. At St. Leonard’s a district medical officerresides in the hospital and attends the relief dis-pensary which is a part of the outpatient depart-ment. Making treatment available for outpatientseffects a major saving in hospital beds. Thusscores of ulcerated legs are now treated ambulant.Some 90 per cent. of medical outpatients at St.Leonard’s are diabetics and 2 per cent. are suffer-ing from pernicious anæmia. For these laboratoryfacilities are essential. On the surgical side theoutpatient department is almost solely a fractureclinic. The antenatal clinic is the only placewhere the work of the private doctor has beenmuch encroached upon.

Finally, Dr. MORRIS dealt briefly with one ofthe ticklish problems of hospitals which cannotrefuse admission to needy cases. A large propor-tion of the patients are suffering from incurableor chronic diseases and occupy beds for longperiods. They should, he felt sure, be nursed inchronic-sick hospitals where the cost of mainten-ance is much lower. This is the greatest muni-cipal hospital problem awaiting solution at thepresent time.

SPECIAL surgical centres have been set up by theEmergency Medical Service to which orthopaedic casesand patients suffering from maxillo-facial, head or

chest injuries may be sent for treatment. Thesecentres are open to both service and civilian casualties.Now that a considerable number of war casualties havebeen admitted to E.M.S. hospitals the removal of suit-able patients to these centres should be undertakenas soon as it can be done without risk to the patient.It is specially desirable that maxillo-facial cases forwhom plastic surgery may be needed should be trans-ferred without delay.