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to us contrast very favourably with the large hospitals, both as regards curative efficiency and economy. The average death-rate in the general hospitals of the metropolis is stated to be 10.21, whereas the death-rate in cottage hospitals is only 5.4, less than half in favour of the latter, which are also said to contain a proportion of severe accidents above the average in general hospitals. Sir James Simpson states that 2098 amputations in the chief hospitals gave a mortality of 855, while an equal number, similar in nature and extent, in cottage life and in country districts only gave a mortality of 226, leaving a balance of 629 against the hospitals. It is true that Sir James Simpson's figures have been objected to, but they have never been refuted, and until they are by an equally eminent authority, we are justified in referring to them as proof that disease, and even severe surgical operations, can be more successfully treated under the natural and healthy conditions of home, or isolated treatment, than in the large hospitals, where the highest surgical skill, and the latest and most perfect appliances, are obtained, but where the fatal influence of aggregation is predominant.

As regards economy, the figures show a saving of £8 per bed in favour of the cottage hospitals. This, however, would be but a small proportion of the actual saving, as imposition would be almost impossible, when every patient could be received and treated in his own district, where his circumstances, and those of his family and friends, would be well known. On this subject a somewhat lengthy extract from Dr. Burdett's book will be valuable :

Patients' payments are a special feature of the cottage hospital system, as they are practically unknown to the managers of general hospitals in this country. It is true that there are one or two exceptions to the rule of gratuitous relief which prevails at most hospitals, but their number is so limited as to be unappreciable. Cottage hospital managers from the first have recognised the importance of encouraging feelings of self-help and independence amongst their patients. Hence, without exception, the system of patients' payments is to be found in force at all true cottage hospitals. We use the word “true," because in a few instances some have tried to abolish the system. In future no hospital so managed should be regarded as a cottage hospital, and for this reason. The original promoters of this system of relief desired to help the poor, and not to pauperise them. Any institution, therefore, which fails to carry out the plan of patients' payments, forfeits its right to be considered a cottage hospital. It may be a private charity of a few wealthy personages, or an almshouse, or a sort of private poorhouse, but as its principles of management are diametrically opposed to those which have made these small hospitals thrifty and popular, it certainly cannot claim the proud title of “Cottage Hospital.” If ever these small hospitals become free to any large extent, from the trouble which is caused by receiving or collecting the patients' payments, or because the committee have a considerable endowment, from that day they will prove a curse rather than a blessing to the labouring poor. This is one of the rocks ahead. Those then who really have the welfare of the cottage hospital at heart, will take care that the love of

patronage, which has so strong a hold upon some otherwise worthy people, shall not be allowed to ruin so beneficent a system of medical relief as that of patients' payments, which originated with the cottage hospital, and which forms the brightest jewel in its crown. The sums paid are very varied in amount, and they range from 2s. 6d. to 21s. per week, for ordinary patients; domestic servants, when admitted on the recommendation of their masters, being charged a higher sum, varying from 5s. upwards. It is clear that at a cottage hospital, where the patients come from the immediate neighbourhood, no difficulty can exist in assessing the ability of the applicant to pay for hospital relief. Where each person is known to the medical officer, or to the vicar of the parish, in which he or she may reside, a tolerably correct estimate of their means is easily arrived at. Under these circumstances, imposition, if attempted, is soon detected, and the would-be improvident are made to pay according to their means. We believe that the introduction of this system will eventually lead to important results. Experience, backed by the above figures, will, sooner or later, compel the managers of the large general hospitals to consider seriously, whether they are justified in continuing to administer so great an amount of eleemosynary charity as they do at present. Amongst the artisans and the working classes generally, at the present day, admission to the hospitals is looked upon as a right. Free medical relief is not regarded by these classes as in any sense a degradation.

Here, where the working class is in a state of affluence as compared with the mother-country, all this is of tenfold weight, and we must endeavour, at the cost of some personal inconvenience and loss of time, to draw the line between a merciful and brotherly charity to the afflicted, and that careless laxity of indiscriminate generosity, which culminates in the pauperisation of a community.

There is yet another benefit which would accrue from the adoption of the payment system: a large number of young men are employed throughout the colonies whose homes are in far distant lands; if they fall ill they have very little chance of being properly nursed and cared for in a boarding-house, where, in fact, the presence of sickness is a drawback to business, and the general arrangements of the house cannot be expected to be made subservient to it. But, under the payment system, the patient could be at once removed; the spread of sickness, if it be infectious, stayed; and good nursing, and medical attendance, be obtained at a moderate rate, without the sacrifice of independence.

The large administrative staff, which it is necessary to keep up in the general hospitals, is another disadvantage. The chief officials are, for the most part, very earnest and diligent in the discharge of their arduous duties, but the cumbrous nature of the institution renders the management one of extreme difficulty; and the fact is obvious that all this costly system of administration does not even succeed in perfecting existing arrangements.

Without making an attack upon the hospitals, the recent cases, which have been brought before the public, may fairly be cited as

proof of the breakdown of the system. In cottage hospitals such scandals could hardly take place, as we see glimpses of from time to time, in the general hospitals; the simplicity of the arrangements renders supervision comparatively easy; and in case of any neglect, the offence could be sheeted home at once, instead of one official taking shelter behind another, as is now too often the case.

The fundamental difference between the large hospital ward, and the home-like cottage hospital, cannot be too seriously considered. On the one hand, there is a huge barrack-like cheerless ward, on admission to which a patient may almost be said to lose his individuality, and to be only a certain disease which has to be treated according to a certain routine. Everything bears the impress of cold formality, and the hired nurses can scarcely be expected to take even a passing interest in individual cases; it is wholesale sickness on a scale of magnitude which accustoms the attendants to regard it with almost unfeeling monotony. Lady nurses are seldom employed, and ministrations from the outside world are not only discountenanced, but from the very nature of the arrangements, it is difficult for personal benevolence to find a place for its exercise. The regular stereotyped nurse only is relied upon, and her probationary course, to fit her for the gentle duties of nursing, is, in the Melbourne Hospital, to scrub the floors of the large wards.

Contrast this sad and cheerless scene with a cottage hospital in a country district, or in the suburbs of a large town, where it could be a centre of interest to all kindly-disposed people, and where the gentlewomen of the neighbourhood could arrange among themselves to assist and supplement the nurses' labours at stated times, always, of course, conforming to the discipline laid down, and under the rule of the head nurse. They could bring with them books, flowers, and cheery words, to brighten the slow, dull hours of pain, and perhaps when the severe malady was cured, would assist the convalescent while yet unable to work. What an elevating tendency such a nucleus of kindly sympathy would exercise! Many, doubtless, would come forward eagerly to assist in such a labour of love, and a new and more honourable occupation would be opened to many who are now wasting their hours in idleness, and longing for some worthy work upon which to expend their energies.

We might go so far as to hope that the close and personal interest which these district hospitals would create might result in such a flow of practical sympathy as would render them independent of State aid. But should the patients' payments not be

sufficiently supplemented by private benevolence, a local rate would be preferable to a Government grant, as the expenditure would then be more rigidly looked into, and a keener local interest would be called forth.

In conclusion, may we not say that in cottage hospitals we have a remedy of proved efficiency for the formidable indictment which has been preferred against the large hospital system, of costliness, indiscriminating and demoralising relief, and maladministration; as hot-beds of disease in the midst of a teeming population they are as much opposed to modern sanitary theory as city graveyards, and they are in their constitution alike contrary to the true principles of healing and of charity.

Of all these important considerations the greatest is charity. Life, health, and money, are barren possessions, if we are not bound by ties of gentleness and kindness, to those around us. We must have some common bond of union to prevent classes falling apart, to stay that process of disentegration which seems to be going on apace. In the hard struggle for existence, in the hurry for wealth, we clash both individually and collectively until class is arrayed against class, and every man's hand is against his neighbour. Politically, this is carried out to the verge of revolution; socially, we are as a house divided against itself. How is oil to be poured on these troubled waters? What is to unite us in the common bonds of humanity, and to make us feel practically that the good of one is the good of all ? How can we link poverty and riches together in any brotherhood ?

It is not sufficient that the poor should be allowed to eat the crumbs which fall from the rich man's table; nor is the relief which the State affords to the indigent, by means of the poor-house, and the machine-like hospital, calculated to allay that sense of wrong which rankles in the hearts of those who see all the ease, enjoyments, and culture of life monopolised by a class who regard them as their heaven-born right to possess, for their own personal gratification, instead of regarding them as a trust held for the benefit of mankind. Where the duty is in part recognised, the obligation is sought to be performed by means of subscriptions to charities into the working of which no one takes the trouble to inquire.

But what is there in these so-called charitable institutions, which is worthy of the sacred name of charity? A cold and formal relief without personal beneficence, which is devoid of every senti

ment, which is received as a right and evokes no gratitude, cannot be called charity.

Those who aspire to the name of Christians, should learn the definition of that “most excellent gift of charity, the very bond of peace and of all virtues, without which whatsoever liveth is counted dead,”—and should ask themselves in what measure those institutions, by means of which they offer help to the poor and needy, come up to that description, and whether they are not, in very truth, the dry bones of charity, instead of that living spirit which should shed a light as from heaven upon the desolate and afflicted.

F.J. CARTER.

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