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IN a former paper upon this subject (April 1872) I showed how large is the number of persons who annually apply for gratuitous medical relief at our hospitals and dispensaries, and at what an alarıning rate this number is increasing, and I indicated what appears to me to be one remedy for this unsatisfactory state of things, and recommended the estab. lishment on a large scale of provident medical institutions. I propose now to follow the subject up a little further, to adduce a few more statistics, and to enter somewhat more at length into the other remedies that I would venture to suggest.

The number of free hospitals and dispensaries in the metropolis is just over 100, and the applicants who annually apply to them for relief cannot be esti. mated at less than 800,000; in all probability they are nearer 1,000,000. I have lately gone carefully through the returns of the expenditure of these numerous institutions, and I find that it amounts to about 440,0001. per annum. This is exclusive of the numerous homes and convalescent establishments, some of which approach very closely in their character to the hospitals. Many of these homes are of a private or semiprivate character, and publish no report of their disbursements. If we could include all these in our statistics, we should not be far wrong in saying that the amount of money annually expended upon the sick and the suffering in London alone, as the result of private benevolence and voluntary charity, is little short of 500,0001.

But these figures do not represent the total number of the sick poor, or the whole amount of the money which is spent upon them within the metropolitan area, for it takes no account of

those who are assisted from the rates. In the form in which the Poor Law Reports are presented to us it is not easy to ascertain the exact number of indi. viduals relieved in the metropolis during the course of the year. But after a careful analysis of the figures given, we arrive at the following conclusions : In 1870 about 150,000 persons were so assisted. In August of that year over 16,000, or more than one-tenth of the whole number, were receiving medical relief, either as in or out-patients. In the same year we find that over 830,0001. was expended on the in-maintenance and out-relief of paupers in the metropolis. This is exclusive of the sum spent on salaries and the support of lunatics. If we take one-tenth of this amount, i.e. 83,0001., we shall certainly be under-rating, rather than overrating the sun expended annually upon the sick paupers.

This represents the rate-supported medical charity of the metropolis, and so much has been done of late years to improve and extend the accommodation made for sick paupers that the most exacting could hardly expect the ratepayers to do more for them.

If now we recapitulate in a single sentence the statistics already given, we obtain a startling view of the number of sick poor within the metropolitan district, and of the money which is annually spent upon them. The population of London, as ascertained by the last Census, being 3,250,000, the pumber of the sick poor cannot be less than 816,000, and the cost of their medical relief amounts to at least 523,0001. per annum. And this, be it remembered, without including lunatic asylums, convalescent honies, and many other minor and private medical charities.

In all these calculations I have been

careful not to overstate my case, and yet the resulting figures present us with a state of things which cannot be deemed satisfactory.

When the country is prosperous, when work is abundant, when wages are high, it is surely very serious, if not alarming, to find so large a proportion of the lower and lower middle class making no provision for themselves in anticipation of the time of sickness, which sooner or later is almost certain to come; but rely ing entirely upon the assistance which they hope to obtain from their neighbours when the exigency arrives. In plain words, about one-fourth of the population depends upon the charity of the other three-fourths in a matter which is as much their own care and concern as the education of their children, although the latter may perhaps be allowed to have a prior claim.

This evil might, I believe, be remedied to a very great extent by the establishment of institutions based upon the principle of mutual assurance, whether they are called provident dispensaries, sick clubs, or by any other name. Such institutions would not merely remove a source of danger, but they would create a positive good. They would give to all those who enrolled themselves as members an inducement for regular work and continuous thrift, and they would help to interest the working classes in the permanence of existing social institutions. If the opportunities for the wellto-do poor to insure themselves against sickness were one-tenth port as numerous as the facilities at present afforded them to ruin their health at the ginshop, the most zealous advocate of medical reform could scarcely ask for more, and my wishes on this point would be fully realized.

But there are difficulties in the way of these alterations. Let us now consider what they are ; and this will give me an opportunity of explaining how, as I think, the Poor Law Service, the hospitals, and the provident sick societies might all work together with much mutual benefit, and greatly to the advantage of the commonwealth.

There is an obstacle which meets us at the outset, whenever we propose any change in the existing arrangements of the hospitals, and it is this, that it requires some self-denial on the part of both the managers and the medical officers to sanction an alteration whereby the number of applicants would be diminished to any considerable extent. It is only natural that those benevolent gentlemen who give largely, both of their money and of their time, to support and to manage a hospital, should wish to see the institution prosper; and we have got into the way of thinking that the chief test of prosperity is the number of applicants for admission. Thus it is almost thought necessary to offer some explanation if the number of patients one year is smaller than it was the year before ; and an ever-increasing muster-roll is taken as a subject of congratulation. Surely, if this be so, it is allowing a mistaken charity to over-ride our patriotism-it is to congratulate ourselves upon what is in fact a mark of social decay, and of the unsatisfactory relation in which different classes stand towards one another. Strange as it may seem to some, it is clear to all thoughtful men that, if any amelioration is going on in the social condition of the lower orders, the dole-giving charities--whether their doles are bread, or blankets, or medical advice-ought to be diminishing the circle of their gifts, and not enlarging it. Thus the managers of the hospitals, when called upon to initiate a reform, are asked to impose a self-denying ordinance upon themselves. They are asked to allow their numbers to be diminished, and some of their applicants draughted off to other institutions. And a similar self-denial is required of the medical men. At present the great majority of hospitals either give them no salary at all, or else a most inadequate one. The return which they obtain for their services is the experience which they acquire. The more patients that present themselves the larger is their field of observation, and the more likelihood is there that something will turn

up of unusual interest or importance. ledgment. They ought to be relieved It might be said of them, as Sydney from anything like a personal interest Smith said of the clergy, that they are in the mere number of the patients paid by lottery tickets. They toil resorting to the hospital. They should through the drudgery of numberless be freed from the excessive recurrence ordinary cases for the sake of the com- of ordinary and trivial cases that now paratively small number of interesting occupy so much of their time, and yet and important ones which present they should have a guarantee that the themselves; for it is by these latter more important cases, which are necesthat their experience is really enlarged, sary for educational purposes, as well as and that they obtain the means of to extend their own professional knowmaking themselves known through the ledge, will find their way into their medium of medical literature. To ask hands. the medical men, therefore, to support The way having thus been cleared by any reform which would curtail the an act of justice to the medical men, we number of their patients, is to ask them should be able to consider what would to forego one of the main advantages be the best mode of dealing with the which they derive from their connection 800,000 who now apply every year to with those institutions.

the hospitals and dispensaries. In the These are the initial difficulties to first place, we must look the fact in the which we have alluded. The first steps face that such splendid charities are towards reform appear to be retrogres- quite certain to be abused unless some sive, and to impose some self-denial on check is imposed. It is idle to suppose all parties connected with the hospital, that when half-a-million of money is to But I hope to show that under the alte- be distributed yearly, there will not be rations which I propose all the really many hands held out to receive it who critical and difficult cases would find have no claim to the gift. The experience their way to the hospital, and that from derived from other dole-giving charities a larger area and upon a better organized corroborates this statement. And, besides system than at present. My profes- those who knowingly impose upon the sional brethren need not fear that I am charity, there are others who apply to. unmindful of their interests ; while to the hospital in sheer ignorance, having the managers of hospitals, whose aim it no idea of the proper scope of such inis to do the greatest amount of good and stitutions, but with a vague notion that the least amount of harm with the everyone has the right to resort to them money placed at their disposal, I would for the best advice. venture to say that the suggestions I am The proper clients for the hospitals about to offer would rid the hospitals of may be easily defined in general terms. many of their present evils and would They are those who are raised above the enhance their real value. There might, level of pauperisin on the one hand, but no doubt, be a considerable diminution who on the other hand are not able to in the numbers attending the out-patient pay even the lowest scale of medical department, but there would be no charges, and who cannot reasonably be diminution in the charity exercised. expected to provide for themselves in The gifts would be of the same money time of sickness. But though the secvalue as heretofore, but they would be tion of society whom the hospitals are distributed over a smaller area and with intended to assist may be thus readily a more discriminating hand.

defined, I admit that it is not always Having thus pointed out the hin easy to say in the case of a particular drances to hospital reform, I venture individual whether he does, or does not, now to indicate the direction which, in belong to this section. Even now, in my opinion, such reforms ought to take. theory, every one who is relieved is

First of all, the services of the medical supposed to do so, but in fact it is men ought to receive proper acknow far otherwise. How, then, are we to

discriminate between those who are and perfected. He also is passed as a matter those who are not proper subjects for of course. The third is a middle-aged gratuitous medical charity ? Surely such widow. She is asked where she lives, an important duty ought not to be en- what rent she pays, what family she trusted to the hall-porters. Nor is it has, and how she earns her livelihood. reasonable to expect that the out-patient Her answers are deemed satisfactory, and physicians and surgeons, whose attention she is permitted to enter. The fourth is is occupied by the medical details of the a gentleman's footman. He is told that cases that pass rapidly before them, should the hospital is not intended for such as have leisure to inquire into the social con- he is, and that, if he spoke to his master, dition of the applicants. Here and there he would probably send him to bis own they may weed out a glaring instance of medical attendant. The fifth is a skilled abuse, but more than this is quite be- mechanic in regular work, earning forty yond their power. What is needed is shillings a week, and with no one to that, with the exception of accidents and provide for but himself. He is asked cases of emergency, all applicants should whether he belongs to a Sick Club or have to pass before a competent officer Provident dispensary. No-he never specially charged with the duty of ascer heard of such societies. Accordingly a taining that their position and circum- printed paper is given to him, containstances are such as to entitle them to ing information respecting the Provident hospital treatment. Such an officer medical institutions of the neighbourshould be altogether raised above the hood, and he is recommended to apply class of the applicants themselves. He to one of them. The sixth is a retail should be a man of some education and tradesman. He is asked whether he could refinement, of a kind and forbearing dis not afford to pay a general practitioner. position, but at the same time possessed He admits that he could, but says he has of firmness, discernment of character, come to the hospital because he wishes to and tact. He should be thoroughly get the best advice. He is referred to a acquainted with the neighbourhood, and competent medical man in his locality, with all the charitable agencies in the with the assurance that, if he should surrounding parishes. Perhaps this ultimately require it, a note from the officer might occupy the position of general practitioner will secure him hosunder-secretary to the hospital, with such pital treatment. The seventh is an old assistants under him as might be found man, who is evidently so destitute that necessary: or the duty might be relegated he requires the necessaries of life more to a special department of the secretary's than medicine, and he is accordingly office. I cannot imagine that there referred to the relieving officer and to the would be any great difficulty in carrying parochial medical man. The eighth is out such a system of inquiry if the a well-to-do woman with a glib tongue managing committee and the medical and a plausible story, who comes from staff were bent upon it.

a distant part of the metropolis. She Let us picture to ourselves how the is allowed to pass for this time only, scrutiny would be conducted. Given and is told that inquiries will be made such an officer as I have suggested, we will respecting her, on the result of which suppose the applicants to be passing into will depend her admission the next time his office one by one. The first is a car- she presents herself. Such inquiries penter, who has just cut himself severely are made through the Charity Organizaat his work, hard by the hospital; the tion Society, and it is found that her case is regarded as urgent, and he is story is wholly untrue, and that she is passed at once. The second has been dis- well able to pay a general practitioner. charged from the hospital, where he has The ninth is a looking girl, spent some weeks as an in-patient, and neatly dressed, and expressing herself he has been directed to attend the out like a person of education and refinepatient department that his cure may be ment. At first sight she seems above

the level of hospital patients ; but on inquiry she describes herself as an orphan whom adverse circumstances have reduced to penury. She gives a reference to a neighbouring clergyman. Her story is found to be true. She is passed and welcomed. The tenth is a boy in a shoeblack's uniform, whose badge is well known to the inquiry officer. He is allowed to enter without hesitation. The eleventh is a potman, the twelfth a labourer, neither of whom earns so much as twenty shillings a week; some inquiry having been made, they are admitted. The thirteenth gives an address in a very poor court, and is passed on the faith of his statements ; but subsequent investigation proves that he has given a false address, and that he is unknown in the neighbourhood.

Such examples might easily be multiplied. These may be taken as types, and they are sufficient to indicate what would be the working of the system I venture to propose. In this way the applicants might be sifted with all needful rapidity. Anyone who knows how long patients are now detained in the waiting rooms, in consequence of the vast numbers who apply, will not see any cause to fear that the delay would be greater than it now is.

After the officer had passed the applicants he would have to write notes of inquiry, or to go out and make some investigations in person ; or, if the hospital were a large one, he would have to direct his assistants to make these inquiries. His time would thus be fully occupied. Correspondence, personal investigation, and receiving the applicants would fill the working hours of the day.

But it may be objected that such a system would create fresh machinery, and impose additional expenditure upon the hospitals. Unquestionably it would. But I maintain that the abuse of hos pitals has reached such a point that some remedy ought to be devised, and I hold that the money thus expended would be well spent-spent in the interests of true charity-in establishing such an organized system of inquiry.

A charge of about 2 per cent upon the income of the hospital would probably be amply sufficient to carry out the system effectually; and if the number of those admitted to out-patient treatment was curtailed, a great part of this sum would be saved in the diminution of the drug-bill. Probably if some such system of organized inquiry became general, and hospitals were willing to co-operato with one another in putting down the evils under which they all more or less suffer, the expense might be considerably diminished. The preliminary steps would be very much facilitated by the existence of such an association as the Charity Organization Society, with its numerous district branches ready to assist in the work; and in process of time experience would show how it could be most efficiently and most ecopomically carried out. And more than this, I believe there are many persons who would support the hospitals with still greater liberality if they felt sure that their money would be distributed with a discerning hand.

If such discrimination as this were exercised, if the circumstances of the applicants were in some degree ascertained, more might perhaps be done for them than is at present possible. Their fitness for hospital treatment being certified, they might sometimes be supplied with what are technically called medical comforts, which are often much more needed than medicine. At Charing Cross Hospital, thanks to the benevolence of a society of gentlemen, who style themselves the Order of St. John of Jerusalem, we have it in our power to order for a limited number of the most destitute of our out-patients a substantial dinner or a diet suited to their case. The advantage of such a resource is often very great, and the boon to the patient incalculable. At the National Hospital for the Paralysed, a committee of ladies distribute clothing, meat, grocery, coal-tickets, &c., among the outpatients, and lend blankets during the winter. When I say that hospitals, after discriminating their cases, might supply some of them with medical com

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