HOSPITAL ABUSE.

HOSPITAL ABUSE.

1564 "THE LIMITS OF PROFESSIONAL I therefore ask your correspondent whether all mixture. is not snobbism, and, if not, let him say what is. this . T...

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1564 "THE LIMITS OF PROFESSIONAL

I therefore ask your correspondent whether all mixture. is not snobbism, and, if not, let him say what is. this .

To the

SECRECY." Editors of THE LANCET.

I am. Sirs. yours faithfully. M.R.C.S., L.R.C.P. EDIN. London, May 28th, 1898.

lay employer a word on an aspect of this hardly, I think, received its due attention. I am an employer who, I venture to hope, take as HOSPITAL ABUSE. high a view as most of my duty towards those in my service, (BY OUR SPECIAL COMMIESIONER.) that duty including, as I conceive of it, the obligation of charity and kindliness. I also hold the strongest possible views on the question of professional confidence. But in XVI.-BRIQHTON.1 the case of the medical attendant of a servant, questioned an it seems to me that a situation to arises at the by employer, Reform lllaternity Hospital,-TrÌ/’ial Cases.-The which professional ethics can hardly be rightly applied in General Dispensary and its Abase.-The Sussex County their strictness, and this not by any means because a Great IrlC’I’ease of Hospital Hospital’s Investigation. servant has any less right to protection than his or her Patientl.-The Hospitals Refuse to Assist in the Work of master, but because that protection is more afforded by Reform.-Num6rous lllagrant Cases of Abuse. openness than by reticence. THE figures collected by Dr. F. J. A. Waring concerning For a master’s duty extends to all his servants-not only to the sick one; and not only to them, but to every member the distribution of tickets for treatment at the hospitals of of his household. And if the illness of any one of them is of a Brighton indicate most clearly that abuse prevails in that nature dangerous, or indicative of danger, to the rest or any town as in so many other places. In 1894 no less than of them, it is his duty to them to remove the peccant one. tickets were given to intending patients and 38,113 On the other hand, if no such danger exist it is equally his these as some of tickets were renewed they do not duty to consider or overlook the otherwise objectionable SIRS,-Permit

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the full amount of charitable work done. That these charities are largely abused is clearly demonstrated by the experience of the West-street Lying-in Hospital. In 1894 there were at Hove and Brighton 3704 births registered. No less than 1240 of these births were attended by one charity. But other births were attended at the Brighton and Steyning Infirmaries and by the Merciful Society for helping fallen women. Thus more than one-third of the mothers at Hove and Brighton were in receipt of charity. It is obvious that in so prosperous a locality the proportion of mothers who really needed charitable help was not so high. Dr. Waring states that one of the midwives in the service of the Lying-in Hospital expressed her opinion that half the cases which she attended could well afford to pay. Many of these patients were assured in benefit societies which allow 30s. at the birth of each child. As a further proof of abuse it is shown that some years ago the number of patients was not man’s position often so delicate. We adhere to our expressed so high, but a midwife was appointed who gained great opinion.—ED. L. popularity in consequence of her kindly manners and her skill. The number of applicants for admission to the hospital consequently increased rapidly. Now, however, " THE DIPLOMA OF THE APOTHECARIES’ this midwife has left the hospital and established a private SOCIETY." practice of her own. The result is that she is at the present time treating, and receiving fees from, the very same persons To the Editors of THE LANCET. who formerly were gratuitously delivered at the hospital. The fee charged by the midwife is 15s. and this is readily SIRs,-Your correspondent "G.P. and Physician" asks me 4.0 explain my letter. With your kind permission I will there- paid by the former patients of the hospital. These facts, it fore do so.stated that "an intolerable amount of must be explained, are not new; they were brought so snobbism"" was going on in the present day with regard to prominently forward in 1894 that action was taken and with the abuse of the designation " Physician and Surgeon," at good results. Calling at the West-street Lying-in Hospital I was inwhich " G.P. and Physician" retorts : " cannot for the life formed that a wage limit had been established. If the of me see whysuperior’ persons should call him a snob for so describing himself." Now, Sirs, as a matter of fact I husband had no children and was earning ;E1or more a have not called, nor do I intend to call, anybody a snob, and week an inquiry was made. On the other hand, if he had if your correspondent chooses to twist my phraseology so as several children then no inquiry was made. Patients, on to apply such an offensive epithet to himself it is no fault of applying, must bring a letter of recommendation from a mine, as one would have thought it scarcely necessary to subscriber. They are given a card in exchange for the letter and told to call again in a week. The details are entered point out to him that there is a vast difference between in a book and shown to the medical officer in attendance and a one of snobbism and of as calling speaking any system if he objects the secretary is informed and an inquiry is that it is obvious a because snob, many directly person instituted. It will be seen that this is a weak system. Its persons of good breeding and culture are guilty of some act of snobbism (in fact, probably everybody is) which success depends entirely on the accuracy with which the would not be sufficient per se to identify such person as a 1 The previous articles on this subject were published in THE LANCET All I can add, therefore, is that if any given snob. on the following dates: (1) Sept. 26th, 1896, Plymouth and Devonport ; practitioner chooses to inflate himself before the English (2) Oct. 10th, 1896, Exeter; concluded) Oct. 17th, 1896, Exeter; public with such a puff and pompous title as "Physician (3) Oct. 31st, 1896, St. Thomas’s(2Hospital, London ; (4) Nov. 14th, 1896, and Surgeon" he is undoubtedly, to my mind, guilty of an Liverpool; (4 continued) Nov. 21st, 1896, Liverpool; (4 concluded) act of snobbism, although in all other respects his environ- Dec. 12th, 1896, Liverpool; (5) Jan. 2nd, 1897, Manchester; (5 continued) 9th, 1897, Manchester; (5 concluded) Jan. 23rd, 1897, Manchester; ment, &c., may redeem him from being a snob. I could Jan. (6) Feb. 6th, 1897, Leeds; (6 concluded) Feb. 13th, 1897, Leeds; take your correspondent a rural stroll if so disposed and (7) April 17th, 1897, Coventry; (8) May 1st, 1897, The Royal London point out two graduates with "Physician and Surgeon" Ophthalmic Hospital; (9) May 8th, 1897, France, United Action and - embedded or incised in marble after a sepulchral fashion, Legislative Action; (10) May 15th, 1897, Leicester; (11) June 5th, 1897, Nottingham; (12) July 31st, 1897, Birmingham; (12 continued) and I can show him a medicine label-one of many sown Aug. 14th, 1897. Birmingham; (12 continued) Sept. 4th, 1897, broadcast amongst the general public-where the aspirant, Birmingham; (12 concluded) Sept. 18th, 1897, Birmingham; (13) Oct. 30th. 1897, Southampton; (14) March 5th, 1898, Glasgow; 14 - evidently preferring a title before his name to one after, has (concluded) March 19th, 1898, Glasgow; and (15) March 26th, 1898, in conspicuous letters "Physician" So-and-so on each Bradford. nature of the disease. But to do this he must know its mature. And if he is simply told that’’the complaint is one which the patient objects to my disclosing," what can he ,possibly do but assume that it is one which, if known, would - entail dismissal-and act accordingly2 Of course, I do not for a moment mean that if, after this has been pointed out, the servant-patient still insists on secrecy the medical man would be justified in violating it. But I cannot help thinking that, in his patient’s own interests, he should deprecate that insistance to the very uttermost. I am, Sirs, yours faithfully, AN EMPLOYER. Mav 25th. 1898. ** We print the above letter with pleasure, for it sets oat with particular force the layman’s side of a difficult .question. It is because there are such strong arguments .as these which "An Employer" uses that the limits of professional secrecy are so hard to define and the medical

1565 recommendation form is filled up. Under such circumstances it is not surprising that but few inquiries are instituted. I was informed at the hospital that not more than six or at most eight such inquiries had been made during the The very vagueness of this last two or three months. to that check is not very questions suggests my reply systematically applied. The medical officer in attendance on the day of my visit did not, however, think that there was much abuse. It was his impression that the husbands of the women usually earned only from 15s. to 18s. a week and that the greater number were cabdrivers or fishermen. Though this state of affairs can scarcely be considered as very satisfactory it is, with regard to the prevention of hospital abuse, the best that Brighton has to show and it has sufficed to bring about favourable results. In consequence of these measures, such as they are, to prevent abuse, and, above all, as a result of the departure of the popular midwife, the number of patients has considerably decreased. They amounted, as already stated, to 1240 in 1894. In 1895 there were 1172 patients ; in 1896 only 1024 patients ; and I am told that the figures for 1897, when published, will show a further reduction to 955. These figures are rendered more significant by the fact that the population has, at the same time, been steadily

at the report for 1896 of the I find that there were 63 and during the same year cases of impaction of wax, there were 44 cases of circumcision at the Sussex County Hospital. In 1895 Dr. Waring brought to the notice of the profession a certain number of incidents as examples of the sort of abuse which was prevalent. He said that a county cricketer was at that time sending his daughter to be gratuitously treated at the dispensary. A male patient of the same institution was renting a shop of at least C40 a year. He was a foreman at some works and his wife was also earning a livelihood. Another man in constant employment, earning from 35s. to &:2 a week, with his son assisting in a shop and his wife letting apartments, sent his infant for treatment. A gentleman living in one of the best parts of Brighton subscribes 10s. a year to the dispensary; he sent a young lady relative who was living in his house to be treated for varicose veins and she took away with her elastic stockings, and the gentleman had still remaining after this tickets for four months’ more attendance. A man who keeps a shop for which he pays 50 rent, ar d whose wife lets apartments, sent his children to the Sussex County Hospital. One of Dr. Waring’s patients was suffering from cataract ; he lived on a pension and had some savings. Dr. Waring offered increasing. As an example of the sort of abuse which has been to procure a surgeon to remove the cataract for the checked a case was mentioned to me of a woman reduced fee of five guineas. The patient replied that who applied to the Lying-in Hospital though her husband he could well afford to pay that sum. Nevertheless, subscribed to the Hearts of Oak, which allows 30s. at he went to the Eye Hospital, where the operation each accouchement. Many members of this benefit society was performed gratuitously by the very same surgeon. strive to be admitted to the hospital for nothing and in The result of this state of things-and several other this they are often encouraged by people who ought to similar examples were given-was described by Dr. Waring know better. Thus a man employed by a large dairy paid in the following words: "I have seen no end of young a fee of .&20 for the operation of abdominal section performed medical men, gentlemanly in manner, well skilled and conon his wife. His employer reproached him for having ex- scientious in the performance of their professional duties, so pended large a sum and told him that he should have sent come into the town with the just expectation of earning a his wife to the hospital, where the operation would have living and leave after a few years’ struggle utterly ruined. been done for nothing. Of the cases of abuse which have Some years ago a few doctors in Brighton and Hove together not been prevented that of a well-to-do shopkeeper was with one or two other philanthropists started a Medical and mentioned to me. It was necessary to induce premature Surgical Home in Ellen-street and they advertised for labour for his wife and this was done at the hospital. resident patients and got some from different parts of the Another case related to a patient who offered his usual country. There was also a dispensary attached to it where medical adviser four guineas to attend his wife during the sick and injured could resort and by purchasing a ticket her confinement. As, however, the patient in question for one penny receive advice and treatment. Of course a lived a long way off the medical man refused to take large number flocked to it. A little prior to this a medical the case and recommended a local practitioner whose man came to Hove whom I knew slightly. I met him once in house was close at hand. Subsequently, and on making the street, and from what he told me and from my knowinquiries, he found that the woman had been taken to the ledge of him I knew that he was doing well and was able to Lying-in Hospital in West-street, and yet her husband had support his wife and family ; but some time afterwards I offered to pay four guineas. In a paper read by Dr. Waring met him again and he was shabby in appearance and looked at a special meeting of the Brighton Medico-Chirurgical depressed. I asked him what was the matter and received Society in November, 1895, there occurs the following the reply that the Medical and Surgical Home in Ellen-street, passage: "Dr. A. H. Dodd and I have written to the follow- together with the General Dispensary, had ruined him." Calling on a member of the honorary staff of this dising large towns for information-viz., Portsmouth and its adjoining towns, worthing, Hastings, Eastbourne, Tunbridge pensary he informed me that undoubtedly many of the Wells, Lewes, Maidstone, Ramsgate, Margate, Dover, patients appeared to be in a good position. If inquiries were Rochester, Red Hill, and Folkestone, covering a population made it would often be found that the husband was an of a little over half a million-and we find that they have no ergine-driver; but the patients would argue that they had a lying-in institutions among their charities. The married right to come because they put a penny a week into one of people in those towns study the principles of thrift. I firmly the boxes which are known at Brighton as the workmen’s maintain that it is not right that a woman should be boxes." This is an old-standing practice. An employer sends attended gratuitously in her first accouchement. People the box round and with the pennies collected from-his should certainly not be encouraged to marry who have not workmen he buys tickets which he gives to the workmen saved sufficient to pay for the expenses of the first little or their families. Of course the employer does not make any stranger’s arrival. I am in possession of the names of men close inquiry into the position of his workmen, whose wives employed in large business firms and receiving wages of are often lodging-house keepers and thus make a good over ;E2 a week and adding to their income by letting income. At the railway works there are many labourers apartments who have received from the lying-in charity that and others who receive very low wages and are geneassistance for their wives which is only intended for the rally fit persons for a charity. But the skilled artisan whose poor." But, as already remarked, the abuse of the Lying-in I wife lets lodgings can well afford to pay a few small fees for Hospital has been greatly reduced since these words were ordinary illnesses or he can join a provident club; and spoken ; and as such reform can be achieved with regard to I am told that there are ten or twelve fully-qualified practhe maternity institution it makes it all the more pertinent to titioners in Brighton who will take sixpenny fees. Indeed, inquire why similar measures are not enforced at the other the situation of the profession at Brighton is at present so hospitals. deplorable that I was told that it would be inexpedient to The Lying-in Hospital was not the only institution attempt to raise the club fees. There are too many starving criticised and publicly denounced. It was pointed out that medical men ready to take the place of anyone who should in 1894 there were at the Throat and Ear Hospital 55 complain. Another general practitioner, however, urged that cases of impacted wax and 14 of simple tonsillitis, and at the competition of the provident dispensaries was more the Sussex County Hospital 33 cases of circumcision. Such disastrous than that of the hospitals. A medical man cases do not require long or special attention. Two or on the staff of the General Dispensary admitted to three visits from a local practitioner would have sufficed and me that there certainly was some abuse, but not circumcision could in most cases be deferred till the parents much. The medical officers had to report cases of abuse; He were in a position to pay a small fee to their ordinary but, of course, they could not do this very often. medical attendant. Throat and Ear

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Looking Hospital

1566 ’himself had reported a case of gonorrhoea, on the ground father earned as a gardener 27s. a week, owned a house that if a man could afford dissipation he could afford to pay worth £25 a year, and did a good business in letting aparta medical practitioner’s fee. Besides there were medical ments. It is generally felt that far too many letters of men who undertook to attend a patient at his house for a recommendation are given in exchange for small subwhole week for only one shilling. In the face of such com- scriptions. (To be continued.) petition it was very difficult to act and he felt that if he attempted to prove cases of abuse he would become unpopular. One of his patients, a lady in receipt of an income of £500 a year, said that she was absolutely unable to pay LIVERPOOL. £40 for a very serious operation, therefore she went up to (FROM OUR OWN CORRESPONDENT.) London to get it performed at a cheaper rate. Many persons to the in houses came in but living very good dispensary, spite of appearances they were sometimes in very precarious Asylum Accommodation in Lancashire for Pauper Lunatics. AT the recent quarterly meeting of the Lancashire Asylums positions. Lodging-house keeping is very hazardous and it often happened that all the furniture of persons so engaged Board, held in the County Hall, Preston, Mr. Shelmerdine He did not think that the well-to-do (Liverpool), on behalf of the Lord Mayor of Liverpool, drew was seized and sold. tradesmen of Brighton were particularly prone to attend the the attention of the board to the delay in the completion of hospitals ; but nevertheless there was a widespread feeling the extra wards at Whittingham Asylum. The Lord Mayor that medical men were defrauded, but it was difficult to had received a letter from Dr. Raw (the medical officer of the obtain positive proofs of the fact. Then the medical men Mill-road Infirmary, Everton) complaining of the congested had a great amount of gratuitous work to do for curates, state of the insane wards in that institution, which were so crowded that it was impossible for him to give adequate governesses, and domestic servants. The General Dispensary was founded in 1809, therefore it supervision to dangerous lunatics. Eight lunatic cases were is a very old-established institution, and has so grown in im- sleeping (at the time Dr. Raw wrote) in the ordinary wards, portance that there are now a western branch and a northern a state of things to be greatly deplored. The chairman of branch besides the parent institution. At each of these there the Whittingham Asylum Committee said the work had been is a house surgeon attached who receives a salary of £140 a greatly hampered by strikes and other causes, but they were year but is debarred from private practice. Then there are making every effort to hasten the completion of the necessary four district medical officers who receive between them L280 wards. The Lord Mayor of Liverpool takes an active interest a year. But apart from the paid staff there is an honorary in the matter, being a member of the West Derby Board of an Guardians. consulting - physician, an honorary consulting surgeon, and honorary visiting staff’ of twelve physicians and surgeons Hospital Saturday Workshops’ Collection. two dental surgeons. This staff attended during the year 1896 On Saturday, May 21st, the twenty-eighth annual no less than 15,078 patients and this was a decrease of 700 on collection in the workshops, warehouses, and other inthe previous year. At the western branch there are wards dustrial establishments in the city on behalf of the medical and here 125 in-patients were treated in 1896. The number charities took the past twenty-seven years place. During for the previous year was 113. There are fifteen beds at the the sum of has been raised by means of this .680,172 western branch so that this constitutes yet another hospital. The collection in the streets called the "ladies’ Patients are accepted at the General Dispensary on pre- agency. are fixed for June llth, after which date the comday" senting a letter of recommendation and on paying a regis- bined amounts will be advertised. tration fee of 6d., but free letters are distributed in return Hospital for Women, Shaw-street. for contributions from friendly societies and to the collectors Dr. John E. Gemmell, the junior assistant medical officer, -of workmen’s boxes. Subscribers of only half a guinea annually are entitled to recommend six patients, and of has been promoted to the post of acting medical officer, course a much larger number of recommendations are I rendered vacant by the resignation of Dr. T. B. Grimsdale. given in exchange for larger sums. The government of Dr. David Smart has retired from the honorary staff of the the institution is vested in benefactors of JE10 10s. and hospital after eleven years’ of devoted service. Much regret upwards and in subscribers of ;E1ls. or more annually, is felt both by the medical staff and committee at the and they are entitled to attend the general annual severance of Dr. Smart’s connexion with the hospital, for meeting so as to elect the committee of management and with all of them he was deservedly popular. all officers. For these meetings Masonic lodges, friendly The Robert Gee Medical Scholarship. societies and other institutions of a similar character which Mr. Hubert Gordon Thompson, a former student of the subscribe E3 3s. annually may nominate a representative. has been the successful candidate in the The house surgeons and the district medical officers have to Liverpool College, for the Robert Gee Medical Scholarship at Unicompetition visit at their homes such patients as are unable to attend at Mr. Thompson had previously the surgery. Then there is a Samaritan fund for the purpose versity College, Liverpool. at the University of London, having been matriculated The in-patients of providing patients with extra diet, &c. in the first division. are received at the western branch on the recommendation placed Sir Henry Tate, Bart. of the house surgeon or one of the branch honorary medical staff. But domestic servants or other workpeople employed Mr. Henry Tate, formerly resident in Liverpool, who has by governors living in the district may be received as in- been the recipient of a baronetcy on the occasion of the patients on the payment of not less than 12s. weekly. The Queen’s birthday, has been a generous benefactor to the city income from all sources during the year amounted to £3800, of Liverpool. He contributed £8000 to the funds of the Liverof which L691 consisted of dividends on investments; the pool Royal Infirmary and generously assisted other local patients’ 6d. registration fees amounted to ëE253 and the medical charities, besides contributing largely to the Royal - contents of the workmen’s boxes to £309. The annual Jubilee Nursing Fund. The spacious library in University subscriptions amounted to £820. Then there were donations College, Liverpool, was also one of Mr. Tate’s numerous and life subscriptions to the amount of JM95 ; congrega- benefactions. His eldest son and heir to the baronetcy tional collections, £206; and legacies, £1022. I have also takes an active interest in hospital work, being a omitted the shillings and pence. These figures show the member of several committees, notably of that of the Liverimportance of this institution and the population of pool Royal Infirmary. May 31st. Brighton is estimated for the year 1896 at 120,000. As an example of abuse a case was related to me concerning a man who is employed by the town and receives SCOTLAND. a salary of 30s. a week. Two or three of his children are in regular employment and his wife does a good business in (FROM OUR OWN CORRESPONDENT.) letting apartments. Nevertheless she took her child to the dispensary to be treated for a fractured arm and when the The Perils of the Medical Profession. surgeon in attendance expressed his surprise she replied : ANOTHER name has been added in Glasgow to the long "Is not the dispensary a place for all accidents?"" On another occasion a tradesman who pays .E35 rent for his roll of those who have fallen in the performance of duty. house and lets apartments obtained a dispensary ticket and Mr. Thomas Henderson, son of Dr. T. Brown Henderson of took his child there to be treated for a slight injury to that city, a student of medicine of much promise, has at the ’the forehead. Then another case was mentioned to me of early age of twenty-two fallen a victim to blood-poisoning a child who was a patient at the dispensary though the contracted in the pursuit of his hospital work as the result