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HOSPITAL ABUSE.
909 cases of suspicious death where a post-mortem ,examination has been considered necessary, is in the habit of HOSPITAL ABUSE. requesting the surgeon who has made the examination to (FROM OUR SPECIAL COMMISSIONER.) .give him a written statement as to the cause of death. Should this be ’’ natural causes " the surgeon is not required at the inquest and only receives a fee of .61 Is. for the postI.PLYMMUTTH AND DFVONPORT. mortem examination. This procedure is due to the action of IT cannot be said that the members of the medical profes’the County Council, who in such cases object to pay an additional guinea for the medical evidence. I need hardly sion engaged in practice have shown any particular energy point out that a guinea is a very inadequate fee for a or ability in organising for the defence of their economical thorough post-mortem examination, especially if it be not interests or so as to maintain a high ethical standard in the :supplemented by an additional guinea for the evidence. It exercise of their profession. Yet a medical society was also seems something of a farce that twelve men should be founded in Plymouth so far back as April llth, 1794. It is taken from their business occupations to inquire into the true that up to the year 1814 the membership was limited to cause of a death when this has been already settled by the statement of the surgeon. I believe there are many cases fifteen. Thus from the very first the society was a somewhat throughout the country where the cause of death is, to say the exclusive organisation. The funds of the society were used least, doubtful in which no inquest is held, and certainly no for the purchase of books and to assist bereaved and indigent necropsy made, on account of this question of expense. families of professional men. The principal object of the I have always advocated that each coroner should have a society was the maintenance of a medical library and the medical adviser, whose duty would be that of inquiring into occasional meeting of members for the discussion of subjects cases of uncertified death and then advising as to whether of professional interest." This rule, therefore, does not or not a more searching investigation should follow. Many exclude, but distinctly includes, ethics. All duly qualified .cases could be settled in this way, and the very fact that members of the profession may be elected to membership. in all cases an inquiry (however informal) was made would The entrance fee is £2 2s. and the annual fee .61Is., and, have a deterrent effect and would certainly help to prevent on the whole, the society has remained a somewhat select crime and criminal carelessness, especially in connexion with and exclusive body. The black sheep of the profession are But where a post-mortem exa- very rigorously blackballed if they present themselves for the deaths of young infants. mination has been made I hold that the medical man should election. The Plymouth Medical Society had thus remained attend and give evidence as to the cause of death at the for many years in a semi-dormant condition, and it is only subsequent inquest and that for this he should receive the recently that it has awakened to comparative activity. The usual fee. It is upon this point that I ask your opinion and publication in THE LANCET of reports of its proceedings has that I shall also be glad to hear the experience of your materially encouraged this revival. The meetings are now held I remain, Sirs, your obedient servant, readers. more frequently, are better attended, and the discussions are A FOLICB BURGEON. not always limited to merely scientific questions. There have 1:;ept. zzna, tuyti. been a few debates on ethical matters, though the interest displayed was somewhat lukewarm. Nevertheless it was prolast April to appoint an ethical committee composed posed " THE PRACTITIONER’S M.D." of seven members, which was to investigate the question of medical fees, club practice, and medical aid associations and To the Editors of THE LANCET. exercise discipline over the members of the medical society. with the "A of Practitioner SiBS,—I quite agree opinion One member suggested that a general meeting of the entire but still a Student" on the undesirability of the abolition of should be convoked to deal with these questions ; the St. Andrews M.D. examination for general practitioners. profession but in spite of all this nothing has yet been done. ConAs it is not likely that the State will provide a new M.D. siderable is felt because several of the examination, as suggested by your correspondent, I do think leaders ofdiscouragement the profession have taken no part in this some steps ought to be taken to preserve the present examinahave refrained from reading papers on the tion for practitioners at St. Andrews University. Having agitation, and remain in the enjoyment of their own prosubject, been debarred the opportunity of taking a degree in London without concerning themselves about the troubles perty the unfitness the London examinaof University by general and difficulties of the junior members of the profession. tions for the average London student I have looked for some the Medical Society decided that its members time to the chance of getting a degree at St. Andrews Nevertheless should refuse to administer chloroform to the patients of see and I feel to the doors shut do now, dentists who are not on the Dental aggrieved University, Register, or to consult and I would gladly join any movement to prevent the new with homceopaths or with men associated with medical aid ordinance being passed in its present form. Which are the associations. There is reason to fear, however, that the proper authorities to approach’! latter clause is not very strictly observed. I am, Sirs, yours truly, In regard to hospital abuse, the opinion of the proE. C. Sept.21st.l896. fession is fairly unanimous, and some medical men have displayed considerable foresight in seeking to exclude unsuitable patients. At the South Devon Hospital care OCCUPATIONS FOR WOMEN. is taken to observe the appearance and tone of language To the Editors of THE LANCET. of applicants. If these excite suspicion, the patient SiBS,—After forty years’ practice, with failing strength and is asked if he has previously consulted a private practibad health, I am still obliged to labour on to maintain my- tioner, and if so, the case is referred back to the self and bring up my family. Naturally I feel how precarious practitioner in question. If the patient has not yet our situation is and how desirable it is to put the young ones sought medical adviee, but is found to be in a position ’in a position to earn their own living. Probably some of my to pay for medical attendance he is given the address of a brethren would kindly give me some useful hints as to getting practitioner. The hospital physician or surgeon who detects situations for young women. The supply of governesses, this abuse does not take the patient for himself, so that in teachers of music, and public singers seems already greater detecting the abuse he cannot be accused of a selfish motive. than the demand, but there are I believe some clerkships According to one of the leading hospital physicians the under Government open to young ladies which offer a worst sinners are the small shopkeepers. There are also -comfortable living. May I ask any one who is able to tell many highly skilled artisans who are bachelors and who me to whom to apply for information respecting female earn E2 or .62 10s. a week, and yet they constantly attempt clerkships in the Post Office or other departments under to obtain gratuitous medical attendance at the hospital. Government ?2 I suppose all such appointments would be There is also a large influx of farmers from the surrounding obtained by competitive examination, and consequently be rural districts. Some time ago a young man went to the very difficult to obtain. My daughters are fairly well hospital with an injured finger. He belonged to a well-to-do educated and have been partlv educated abroad so that they family, lived at home free of expense, and was earning £30 a have some practical knowledge of French and German. On year. The surgeon in attendance suggested that on his way the other hand, they have not passed the usual English up to the hospital he had passed by the surgeries of several examinations now so very general. I enclose my card and ’I private practitioners where he might have had his wounded Sirs, yours obediently, am, finger dressed. The young man replied that his employers subscribed liberally to the hospital, and, therefore, he M. D., At. n. U. r. Sept. 23rd, 1896.
ceside, in
910 he had a right to the gratuitous services of that gave his patient a letter of introduction to a Plymouth institution. This affair was brought to the notice of the surgeon, but when the patient reached Plymouth he suphospital committee, and they then decided that the first pressed the letter of introduction and contrived to get treated aid should be given in all cases, but inquiries were to be gratuitously at the Eye Hospital. made before the attendance was continued. At the Royal Albert Hospital of Devonport the authorities, For admission as in-patients to the South Devon and East as far as possible, communicate with the medical advisers Cornwall Hospital, written details must be given on the who have attended the patients before they applied for application paper describing the occupation of the patient or admission as in-patients. The medical man thus consulted of the patient’s husband or father, the age of applicant, the can enter a protest if the proposed patient ought not to be number and age of the children at home, and the average admitted. Nearly all the cases here are surgical, and not weekly earnings of the family. The subscribers, in exer- medical or chronic cases. Many men go to the Royal cising their privilege of recommending patients are Albert Hospital suffering from varicose veins, varicocele, requested to send only those who are, strictly speaking, fit and hernia, and are anxious to be cured so as to obtain subjects for the receipt of charitable aid--that is to say, service in the navy. They seek to get operated upon " who are unable to afford adequate medical or surgical for nothing, although many of them are skilled shiprelief independently of the hospital." Patients living at a wrights or artificers in receipt of very good wages. In distance, before leaving home must ascertain by letter if these instances, when it is ascertained that the patients they can be admitted, and obtain and forward from their are earning high wages they are made to pay Is. 6d. local medical attendant a statement as to the nature of the per day while in the hospital. This only covers the cost of their food, for, as the hospital accounts set case. The necessity of such rules is very obvious. For instance, forth, the average cost of an occupied bed amounts to a short time ago four persons came from Torquay to be .61Is. 6d. per week. Also many artisans pay because they treated at the Plymouth Hospital. They were visitors from belong to benefit clubs, a fact which is generally and As Devonport is not a commercial London who had the means to go for their holidays to so promptly notified. expensive and fashionable a place as Torquay, where they centre and most persons living there work for Governlived in private apartments, yet they imagined that they ment it is comparatively easy to know what means the were entitled to gratuitous treatment at the hospital. Again applicants for admission to the hospital possess. Neverthea medical practitioner at Kingsbridge sent one of his patients less, impositions are often attempted. For instance, a little to consult a Plymouth surgeon. When the patient reached while ago a tradesman who met with an accident went to Plymouth some friend told him that he could obtain the the Royal Albert Hospital. He asked the surgeon who necessary advice gratuitously at the hospital, where he dressed his wound to sign a certificate so that he presented himself at the out-patients’ department. Here, might claim an allowance from an insurance company. however, it was ascertained that he was a farmer ; the assist- Naturally this was refused. The opinion expressed by ance was refused, and he was sent to the surgeon his both the secretary and the steward of the Royal Albert local practitioner had advised him to consult. On Hospital was that there always would be some abuses, and another occasion a man who had a wounded foot went to the that rules were of comparatively little service. It was easy hospital. In answer to questions he explained that he had enough for a committee of gentlemen to sit round a table and hurt his foot while yachting in the Clyde. Rather than draw up a most admirable set of rules. The whole secret consult and pay some Scotch practitioner he preferred to lay in their application. Now, it often happened that these wait till he got back to Plymouth where he imagined his rules were applied by different persons and therefore diffoot would be treated gratuitously at the hospital. Thus ferently interpreted. A man, for instance, might be in this patient could afford to go all the way from Plymouth to receipt of Pllox. sick allowance. One medical man might Scotland so as to participate in a yachting expedition on the think that the whole of this sum should go to the family Clyde, and yet felt loth to pay for medical attendance. Of while the patient was being treated at the hospital. Another medical man would think that £1was quite enough for the course the case was refused at the hospital and the his consult a at told to practitioner private family and that the patient could be made to pay 10s. patient own expense. With regard to yachts there are sail- towards his maintenance at the hospital. If such questions makers at Plymouth who earn very good incomes, yet were decided by one single authority there would be much they often go to the hospital for medical attendance. less abuse. This is what is done at the provident dispensary When a patient writes from the country asking for admit- attached to the Royal Albert Hospital; nevertheless, a-case tance he must, according to the rule mentioned above, send or aouse occurrea 1Ine ocner aay. A man aliuenaea ana aeciarea that he was a pensioner in receipt of .f:40 a year ; he therea statement of the case drawn up by his local practitioner. This gives the latter an opportunity of writing privately to fore received all the attention and relief that his case the hospital to explain that it is not a suitable case for a required. It was only ascertained afterwards that though hospital. As another example of the tendency of country a pensioner he was also a shipwright and earning wages to, farmers to seek hospital aid, a farmer who was suffering the extent of 34s. a week. from an ulcer in the cheek went to Plymouth, took private For this provident dispensary attached to the hospital a lodgings, and was operated on by a private practitioner. wage limit has been established. Single persons must not Later, finding that he was not cured, he visited Plymouth be in receipt of more than 18s. a week ; man and wife with and went to the hospital. Here he was told that, as he had no children, 20s. ; with two or more children, 24s. ; with been operated upon by a private practitioner and could afford four or five children, 27s. ; and with six or more children, to pay, he had better return to his usual medical adviser. 30s. All children are counted as such if under fourteen years The farmer, however, did not do this. He waited for a of age. Single persons pay 5d. per month ; man, wife, and month and then went again to the hospital. Fortunately for two children 9d. ; and larger families Is. ld. per month. him the surgeon who had refused to attend to this case was This is a hard-and-fast line, and the same rules will be absent, and the surgeon then on duty failing to notice that applied in October to the ophthalmic department, where this was an unsuitable case the patient was taken in and abuses more frequently occur. The patients will then have the necessary operation was performed. This case illustrates to make their application first and supply all the details the persistence with which some persons seek to avail them- concerning their income before they are allowed to see the selves of public charities, although they are in nowise entitled surgeons. As some of the physicians and surgeons attached to receive charitable relief. to this hospital are also club or parish medical officers they At the Eye Hospital, Plymouth, abuses also occasionally are well acquainted with the inhabitants of the town, soSome effort is made to establish a wage limit here, that there is a good prospect of detecting any imposition. occur. but the, great difficulty rests with the patients who come At Plymouth there is also a public dispensary with a from the country bearing a ticket of admission. It is not provident department. Here the scale of payment is 5d. easy to tell their status and it is necessary to trust to per month for every person above fourteen years of age. the discretion of the person who gives the ticket. This is For a father, mother, and one child the subscription is lOd. very much like resting on a broken reed, but it is now pro- per week. If the family exceed three 2d. per week is posed that patients for treatment at the Eye Hospital charged for every additional child. Where there are three should, like the patients recommended for the South Devon children the charge is ls. 3d., and for every additional child Hospital, also fill up a paper giving details as to the wages above that number 2d. per week. The applicants must give How far this is necessary is shown by a full details as to their joint family earnings, and there is an they earn, &c. recent case. A man living at Penzance consulted a local investigation committee to inquire as to the accuracy of the practitioner, to whom he paid guinea fees. This practitioner information given. The medical aid given does not include
thought
911 confinements. The Plymouth Public Dispensary is divided into two departments-the provident department and the charity department. This institution was founded in 1798, .at first purely as a charity, but more recently it has evolvad a provident side. The patients first appear before the medical attendant, the case is then entered in the books and referred to the investigation committee, so that one consultation can, in any case, be obtained without any check being exercised. The investigation committee having gone into the matter decides whether the patient can be admitted to the charitable department or whether he should join the provident department, or whether he is well enough -off to consult a private practitioner. This committee meets every week and is said to do its work well. Several complaints were made against the ticket system. .Subscribers to hospitals gave their tickets away too freely and without first considering whether the recipients were fit subjects for a public charity. When a person comes with a ticket it is somewhat dangerous for the house surgeon to .refuse admittance. By so doing offence might be given to a It would be much better to. relieve valued subscriber. medical men of this responsibility, which might be borne by a committee especially appointed to deal with such matters. But the giving of tickets to persons who can afford to pay for medical attendance is complicated with the big question of medical attendance for persons of limited means. Thus, at Plymouth there are the hospital, the workhouse infirmary, and the provident and free dispensary for poor people. Then there is a " Home"" for rich people. At this Home the charges vary from three to five guineas per week, but the patient has also to pay his medical attendant’s fees, the cost of his medicines, and of his washing. With all these extras, representing uncertain figures, it will easily be seen that persons of limited means who are too well off to go to the hospital may not be .able to go to the Home. A fund was therefore started for the purpose of admitting some persons to the Home on the payment of a guinea a week, and anything more which was required was to be paid out of this fund. While the fund lasted governesses, clerks, and a similar class of patients were taken in, but this system does not seem to have prospered. Yet something has to be done to meet the .needs of this large class of persons. This is a question that the Plymouth Medical Society might well take up and discuss. I have said enough about the hospital abuse prevalent at Plymouth and Devonport to show that, though it might be much worse, there is still room for action and improvement. As for the friendly societies and the medical aid speculative insurance companies they are a thorn in the side of the medical profession at Plymouth as in most large towns of England. For all these reasons not only should the Medical Society take a more active interest in ethical questions, but as many of its members are the local leaders of the medical i, profession it should take the initiative and seek to form a ’, medical union embracing every member of the profession practising at Plymouth, Devonport, and the neighbourhood, which would have for its mission the defence of the material interests of the profession. Plymouth, Sept. 22nd.
BIRMINGHAM. (FROM
OUR OWN
CORRESPONDENT.)
Marston Green Cottage Homes. committee of these homes have just presented the sixteenth annual report to the Birmingham board of guardians. Some interesting details are brought out in connexion with the policy pursued in this undertaking. No corporal punishment is under any circumstances allowed to be administered by any of the officers save the superintendent. The supervision which is directly and indirectly continued over the children after they leave the home practically ends with boys at eighteen years and with girls at twenty years. The Act ot 1889 for the protection of children was a considerable advance, and the committee state that they have given a generous interpretation to its clauses. Where the benefit to children calls for it they desire a further eKtension of powers that adequate control may be exercised over children, THE
management
of vagrant, destitute, or disorderly parents. During the year ended March last 192 children were admitted to the homes and 254 discharged, and there remained in the homes at the close of the year 359, against 421 twelve months before. As to the sanitary arrangements of the homes and the medical attendance which the inmates enjoy the committee say that they are confirmed in the opinion that under no conceivable conditions can such children be better placed for the eradication or amelioration of hereditary disease, and there are cases in their experience where healthy, well-formed children have been developed from an apparently hopeless
infancy.
Sanitary Progress. in theHomewas the subject of the opening lecture at the Midland Institute class in the Laws of Health. Dr. W. H. Line, in aia interesting lecture illustrated by lantern diagrams and experiments, pointed out the influence of the condition of the soil on health in reference to the diseases associated with damp, pollution of soil, refuse disposal, &3., and the precautions to be taken in avoiding such influences. There was a large attendance at the lecture, which was presided over by Alderman Cook, the chairman of the Health Committee of the town council. The chairman referred to the origin of the lectures, and said that a friend of the institute-a Birmingham manufacturer-handed over the sum of R2500 in order to promote the study of sanitary science in the city-a laudable example which bad been productive of successful results by classes and lectures since their foundation in 1873.
Dangers
The Policeman’s Truncheon. At the
there are seen occasionally wounds on the heads of the roughs caused by the policeman’s truncheon. Outside philanthropists fail to recognise the difficulties and dangers which attend the suppression of the frequent disturbances occasioned by this turbulent element in large cities. The disregard of all law and order which makes the rough rampant and allows the brutal and ferocious attacks upon his fellow creatures to be a favourite pastime cannot be suppressed by gentle handling. In defence of personal safety an officer of the police is surely justified in protecting himself by means of the weapon placed at his disposal. To suggest that the truncheon should not be used upon the heads of the aggressors is sound advice in the abstract, but to respect the choice of any particular portions of therough’s body in the heat of a mêlée with a gang of ruffians is hardly a correct appreciation of human nature. All law-abiding citizens will give credit to the police for the tact and patience which they exhibit, as a rule, in the conduct of peace, and if occasionally the rough gets the worst of it in the encounter it must still be borne in mind that more valuable members of the community are sometimes maimed and disabled by the reckless residuum whom no sense of wrong can rouse to justice. some
hospital receiving rooms
severe
Adulteration of Milk. The difficulties of dealing adequately and even justly with adulteration of milk are well known. A recent case tried before the magistrates is an example of the doubts which arise in finding the actual source of the evil. Some farmers made an agreement through an agent to supply milk to a dealer who insists upon a written guarantee that the milk shall be delivered to him pure. The milk is forwarded from the country by rail, carriage paid, at the risk of the vendors. On Aug. 6t.h a churn of twelve gallons was sent off in the usual way ; both the defendants had assisted in milking the cows, and one of them had conveyed the milk to the station. They protested strongly that it bad been despatched as drawn from the cows. As soon as it came to the dealer it was tested and found to contain 12 per cent. of added water, and the dealer was able to prove that he had not tampered with it at the station where it was received. The question arises, Was the milk adulterated or was its quality at fault? The bench held that the guarantee made the defendants liable and therefore imposed a fine. Some more satisfactory method of inspection is evidently required by examination at the stations The frequency of such cases demands an or on the route. additional safeguard to the means ordinarily employed for the detection of the real wrongdoers. Farmers and dealers should combine for their own protection, as well as in the interests of the public, to have these cases placed upon a sounder basis of prevention as well as cure.
Sept.22nd.
ceside, in
910 he had a right to the gratuitous services of that gave his patient a letter of introduction to a Plymouth institution. This affair was brought to the notice of the surgeon, but when the patient reached Plymouth he suphospital committee, and they then decided that the first pressed the letter of introduction and contrived to get treated aid should be given in all cases, but inquiries were to be gratuitously at the Eye Hospital. made before the attendance was continued. At the Royal Albert Hospital of Devonport the authorities, For admission as in-patients to the South Devon and East as far as possible, communicate with the medical advisers Cornwall Hospital, written details must be given on the who have attended the patients before they applied for application paper describing the occupation of the patient or admission as in-patients. The medical man thus consulted of the patient’s husband or father, the age of applicant, the can enter a protest if the proposed patient ought not to be number and age of the children at home, and the average admitted. Nearly all the cases here are surgical, and not weekly earnings of the family. The subscribers, in exer- medical or chronic cases. Many men go to the Royal cising their privilege of recommending patients are Albert Hospital suffering from varicose veins, varicocele, requested to send only those who are, strictly speaking, fit and hernia, and are anxious to be cured so as to obtain subjects for the receipt of charitable aid--that is to say, service in the navy. They seek to get operated upon " who are unable to afford adequate medical or surgical for nothing, although many of them are skilled shiprelief independently of the hospital." Patients living at a wrights or artificers in receipt of very good wages. In distance, before leaving home must ascertain by letter if these instances, when it is ascertained that the patients they can be admitted, and obtain and forward from their are earning high wages they are made to pay Is. 6d. local medical attendant a statement as to the nature of the per day while in the hospital. This only covers the cost of their food, for, as the hospital accounts set case. The necessity of such rules is very obvious. For instance, forth, the average cost of an occupied bed amounts to a short time ago four persons came from Torquay to be .61Is. 6d. per week. Also many artisans pay because they treated at the Plymouth Hospital. They were visitors from belong to benefit clubs, a fact which is generally and As Devonport is not a commercial London who had the means to go for their holidays to so promptly notified. expensive and fashionable a place as Torquay, where they centre and most persons living there work for Governlived in private apartments, yet they imagined that they ment it is comparatively easy to know what means the were entitled to gratuitous treatment at the hospital. Again applicants for admission to the hospital possess. Neverthea medical practitioner at Kingsbridge sent one of his patients less, impositions are often attempted. For instance, a little to consult a Plymouth surgeon. When the patient reached while ago a tradesman who met with an accident went to Plymouth some friend told him that he could obtain the the Royal Albert Hospital. He asked the surgeon who necessary advice gratuitously at the hospital, where he dressed his wound to sign a certificate so that he presented himself at the out-patients’ department. Here, might claim an allowance from an insurance company. however, it was ascertained that he was a farmer ; the assist- Naturally this was refused. The opinion expressed by ance was refused, and he was sent to the surgeon his both the secretary and the steward of the Royal Albert local practitioner had advised him to consult. On Hospital was that there always would be some abuses, and another occasion a man who had a wounded foot went to the that rules were of comparatively little service. It was easy hospital. In answer to questions he explained that he had enough for a committee of gentlemen to sit round a table and hurt his foot while yachting in the Clyde. Rather than draw up a most admirable set of rules. The whole secret consult and pay some Scotch practitioner he preferred to lay in their application. Now, it often happened that these wait till he got back to Plymouth where he imagined his rules were applied by different persons and therefore diffoot would be treated gratuitously at the hospital. Thus ferently interpreted. A man, for instance, might be in this patient could afford to go all the way from Plymouth to receipt of Pllox. sick allowance. One medical man might Scotland so as to participate in a yachting expedition on the think that the whole of this sum should go to the family Clyde, and yet felt loth to pay for medical attendance. Of while the patient was being treated at the hospital. Another medical man would think that £1was quite enough for the course the case was refused at the hospital and the his consult a at told to practitioner private family and that the patient could be made to pay 10s. patient own expense. With regard to yachts there are sail- towards his maintenance at the hospital. If such questions makers at Plymouth who earn very good incomes, yet were decided by one single authority there would be much they often go to the hospital for medical attendance. less abuse. This is what is done at the provident dispensary When a patient writes from the country asking for admit- attached to the Royal Albert Hospital; nevertheless, a-case tance he must, according to the rule mentioned above, send or aouse occurrea 1Ine ocner aay. A man aliuenaea ana aeciarea that he was a pensioner in receipt of .f:40 a year ; he therea statement of the case drawn up by his local practitioner. This gives the latter an opportunity of writing privately to fore received all the attention and relief that his case the hospital to explain that it is not a suitable case for a required. It was only ascertained afterwards that though hospital. As another example of the tendency of country a pensioner he was also a shipwright and earning wages to, farmers to seek hospital aid, a farmer who was suffering the extent of 34s. a week. from an ulcer in the cheek went to Plymouth, took private For this provident dispensary attached to the hospital a lodgings, and was operated on by a private practitioner. wage limit has been established. Single persons must not Later, finding that he was not cured, he visited Plymouth be in receipt of more than 18s. a week ; man and wife with and went to the hospital. Here he was told that, as he had no children, 20s. ; with two or more children, 24s. ; with been operated upon by a private practitioner and could afford four or five children, 27s. ; and with six or more children, to pay, he had better return to his usual medical adviser. 30s. All children are counted as such if under fourteen years The farmer, however, did not do this. He waited for a of age. Single persons pay 5d. per month ; man, wife, and month and then went again to the hospital. Fortunately for two children 9d. ; and larger families Is. ld. per month. him the surgeon who had refused to attend to this case was This is a hard-and-fast line, and the same rules will be absent, and the surgeon then on duty failing to notice that applied in October to the ophthalmic department, where this was an unsuitable case the patient was taken in and abuses more frequently occur. The patients will then have the necessary operation was performed. This case illustrates to make their application first and supply all the details the persistence with which some persons seek to avail them- concerning their income before they are allowed to see the selves of public charities, although they are in nowise entitled surgeons. As some of the physicians and surgeons attached to receive charitable relief. to this hospital are also club or parish medical officers they At the Eye Hospital, Plymouth, abuses also occasionally are well acquainted with the inhabitants of the town, soSome effort is made to establish a wage limit here, that there is a good prospect of detecting any imposition. occur. but the, great difficulty rests with the patients who come At Plymouth there is also a public dispensary with a from the country bearing a ticket of admission. It is not provident department. Here the scale of payment is 5d. easy to tell their status and it is necessary to trust to per month for every person above fourteen years of age. the discretion of the person who gives the ticket. This is For a father, mother, and one child the subscription is lOd. very much like resting on a broken reed, but it is now pro- per week. If the family exceed three 2d. per week is posed that patients for treatment at the Eye Hospital charged for every additional child. Where there are three should, like the patients recommended for the South Devon children the charge is ls. 3d., and for every additional child Hospital, also fill up a paper giving details as to the wages above that number 2d. per week. The applicants must give How far this is necessary is shown by a full details as to their joint family earnings, and there is an they earn, &c. recent case. A man living at Penzance consulted a local investigation committee to inquire as to the accuracy of the practitioner, to whom he paid guinea fees. This practitioner information given. The medical aid given does not include
thought
911 confinements. The Plymouth Public Dispensary is divided into two departments-the provident department and the charity department. This institution was founded in 1798, .at first purely as a charity, but more recently it has evolvad a provident side. The patients first appear before the medical attendant, the case is then entered in the books and referred to the investigation committee, so that one consultation can, in any case, be obtained without any check being exercised. The investigation committee having gone into the matter decides whether the patient can be admitted to the charitable department or whether he should join the provident department, or whether he is well enough -off to consult a private practitioner. This committee meets every week and is said to do its work well. Several complaints were made against the ticket system. .Subscribers to hospitals gave their tickets away too freely and without first considering whether the recipients were fit subjects for a public charity. When a person comes with a ticket it is somewhat dangerous for the house surgeon to .refuse admittance. By so doing offence might be given to a It would be much better to. relieve valued subscriber. medical men of this responsibility, which might be borne by a committee especially appointed to deal with such matters. But the giving of tickets to persons who can afford to pay for medical attendance is complicated with the big question of medical attendance for persons of limited means. Thus, at Plymouth there are the hospital, the workhouse infirmary, and the provident and free dispensary for poor people. Then there is a " Home"" for rich people. At this Home the charges vary from three to five guineas per week, but the patient has also to pay his medical attendant’s fees, the cost of his medicines, and of his washing. With all these extras, representing uncertain figures, it will easily be seen that persons of limited means who are too well off to go to the hospital may not be .able to go to the Home. A fund was therefore started for the purpose of admitting some persons to the Home on the payment of a guinea a week, and anything more which was required was to be paid out of this fund. While the fund lasted governesses, clerks, and a similar class of patients were taken in, but this system does not seem to have prospered. Yet something has to be done to meet the .needs of this large class of persons. This is a question that the Plymouth Medical Society might well take up and discuss. I have said enough about the hospital abuse prevalent at Plymouth and Devonport to show that, though it might be much worse, there is still room for action and improvement. As for the friendly societies and the medical aid speculative insurance companies they are a thorn in the side of the medical profession at Plymouth as in most large towns of England. For all these reasons not only should the Medical Society take a more active interest in ethical questions, but as many of its members are the local leaders of the medical i, profession it should take the initiative and seek to form a ’, medical union embracing every member of the profession practising at Plymouth, Devonport, and the neighbourhood, which would have for its mission the defence of the material interests of the profession. Plymouth, Sept. 22nd.
BIRMINGHAM. (FROM
OUR OWN
CORRESPONDENT.)
Marston Green Cottage Homes. committee of these homes have just presented the sixteenth annual report to the Birmingham board of guardians. Some interesting details are brought out in connexion with the policy pursued in this undertaking. No corporal punishment is under any circumstances allowed to be administered by any of the officers save the superintendent. The supervision which is directly and indirectly continued over the children after they leave the home practically ends with boys at eighteen years and with girls at twenty years. The Act ot 1889 for the protection of children was a considerable advance, and the committee state that they have given a generous interpretation to its clauses. Where the benefit to children calls for it they desire a further eKtension of powers that adequate control may be exercised over children, THE
management
of vagrant, destitute, or disorderly parents. During the year ended March last 192 children were admitted to the homes and 254 discharged, and there remained in the homes at the close of the year 359, against 421 twelve months before. As to the sanitary arrangements of the homes and the medical attendance which the inmates enjoy the committee say that they are confirmed in the opinion that under no conceivable conditions can such children be better placed for the eradication or amelioration of hereditary disease, and there are cases in their experience where healthy, well-formed children have been developed from an apparently hopeless
infancy.
Sanitary Progress. in theHomewas the subject of the opening lecture at the Midland Institute class in the Laws of Health. Dr. W. H. Line, in aia interesting lecture illustrated by lantern diagrams and experiments, pointed out the influence of the condition of the soil on health in reference to the diseases associated with damp, pollution of soil, refuse disposal, &3., and the precautions to be taken in avoiding such influences. There was a large attendance at the lecture, which was presided over by Alderman Cook, the chairman of the Health Committee of the town council. The chairman referred to the origin of the lectures, and said that a friend of the institute-a Birmingham manufacturer-handed over the sum of R2500 in order to promote the study of sanitary science in the city-a laudable example which bad been productive of successful results by classes and lectures since their foundation in 1873.
Dangers
The Policeman’s Truncheon. At the
there are seen occasionally wounds on the heads of the roughs caused by the policeman’s truncheon. Outside philanthropists fail to recognise the difficulties and dangers which attend the suppression of the frequent disturbances occasioned by this turbulent element in large cities. The disregard of all law and order which makes the rough rampant and allows the brutal and ferocious attacks upon his fellow creatures to be a favourite pastime cannot be suppressed by gentle handling. In defence of personal safety an officer of the police is surely justified in protecting himself by means of the weapon placed at his disposal. To suggest that the truncheon should not be used upon the heads of the aggressors is sound advice in the abstract, but to respect the choice of any particular portions of therough’s body in the heat of a mêlée with a gang of ruffians is hardly a correct appreciation of human nature. All law-abiding citizens will give credit to the police for the tact and patience which they exhibit, as a rule, in the conduct of peace, and if occasionally the rough gets the worst of it in the encounter it must still be borne in mind that more valuable members of the community are sometimes maimed and disabled by the reckless residuum whom no sense of wrong can rouse to justice. some
hospital receiving rooms
severe
Adulteration of Milk. The difficulties of dealing adequately and even justly with adulteration of milk are well known. A recent case tried before the magistrates is an example of the doubts which arise in finding the actual source of the evil. Some farmers made an agreement through an agent to supply milk to a dealer who insists upon a written guarantee that the milk shall be delivered to him pure. The milk is forwarded from the country by rail, carriage paid, at the risk of the vendors. On Aug. 6t.h a churn of twelve gallons was sent off in the usual way ; both the defendants had assisted in milking the cows, and one of them had conveyed the milk to the station. They protested strongly that it bad been despatched as drawn from the cows. As soon as it came to the dealer it was tested and found to contain 12 per cent. of added water, and the dealer was able to prove that he had not tampered with it at the station where it was received. The question arises, Was the milk adulterated or was its quality at fault? The bench held that the guarantee made the defendants liable and therefore imposed a fine. Some more satisfactory method of inspection is evidently required by examination at the stations The frequency of such cases demands an or on the route. additional safeguard to the means ordinarily employed for the detection of the real wrongdoers. Farmers and dealers should combine for their own protection, as well as in the interests of the public, to have these cases placed upon a sounder basis of prevention as well as cure.
Sept.22nd.