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"THE LIMITS OF PROFESSIONALSECRECY."

To the Editors of THE LANCET.

SIRS,-Permit a lay employer a word on an aspect of thisquestion which has hardly, I think, received its due atten-tion. I am an employer who, I venture to hope, take ashigh a view as most of my duty towards those in my service,that duty including, as I conceive of it, the obligation ofcharity and kindliness. I also hold the strongest possibleviews on the question of professional confidence. But inthe case of the medical attendant of a servant, questionedby an employer, it seems to me that a situation arises towhich professional ethics can hardly be rightly applied intheir strictness, and this not by any means because aservant has any less right to protection than his or hermaster, but because that protection is more afforded byopenness than by reticence.

For a master’s duty extends to all his servants-not onlyto the sick one; and not only to them, but to every memberof his household. And if the illness of any one of them is of anature dangerous, or indicative of danger, to the rest or anyof them, it is his duty to them to remove the peccant one.On the other hand, if no such danger exist it is equally hisduty to consider or overlook the otherwise objectionablenature of the disease. But to do this he must know itsmature. And if he is simply told that’’ the complaint is onewhich 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 accordingly 2 Of course, I do notfor a moment mean that if, after this has been pointed out,the servant-patient still insists on secrecy the medical manwould be justified in violating it. But I cannot help thinkingthat, in his patient’s own interests, he should deprecate thatinsistance to the very uttermost.

I am, Sirs, yours faithfully,Mav 25th. 1898. AN EMPLOYER.

** We print the above letter with pleasure, for it setsoat 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 pro-fessional secrecy are so hard to define and the medicalman’s position often so delicate. We adhere to our expressedopinion.—ED. L.

" THE DIPLOMA OF THE APOTHECARIES’SOCIETY."

To the Editors of THE LANCET.

SIRs,-Your correspondent "G.P. and Physician " asks me4.0 explain my letter. With your kind permission I will there-fore do so. stated that "an intolerable amount ofsnobbism" " was going on in the present day with regard tothe abuse of the designation " Physician and Surgeon," atwhich " G.P. and Physician " retorts : " cannot for the lifeof me see why superior’ persons should call him a snob forso describing himself." Now, Sirs, as a matter of fact Ihave not called, nor do I intend to call, anybody a snob, andif your correspondent chooses to twist my phraseology so asto apply such an offensive epithet to himself it is no fault ofmine, as one would have thought it scarcely necessary topoint out to him that there is a vast difference between

speaking of any system as one of snobbism and calling aperson directly a snob, because it is obvious that manypersons of good breeding and culture are guilty of someact of snobbism (in fact, probably everybody is) whichwould not be sufficient per se to identify such person as asnob. All I can add, therefore, is that if any givenpractitioner chooses to inflate himself before the Englishpublic with such a puff and pompous title as "Physicianand Surgeon" he is undoubtedly, to my mind, guilty of anact of snobbism, although in all other respects his environ-ment, &c., may redeem him from being a snob. I couldtake your correspondent a rural stroll if so disposed andpoint out two graduates with "Physician and Surgeon"- embedded or incised in marble after a sepulchral fashion,and I can show him a medicine label-one of many sownbroadcast amongst the general public-where the aspirant,- evidently preferring a title before his name to one after, hasin conspicuous letters "Physician" So-and-so on each

mixture. I therefore ask your correspondent whether all

this is not snobbism, and, if not, let him say what is..

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

HOSPITAL ABUSE.

(BY OUR SPECIAL COMMIESIONER.)

XVI.-BRIQHTON.1

Reform at the lllaternity Hospital,-TrÌ/’ial Cases.-TheGeneral Dispensary and its Abase.-The Sussex CountyHospital’s Investigation. - Great IrlC’I’ease of HospitalPatientl.-The Hospitals Refuse to Assist in the Work ofReform.-Num6rous lllagrant Cases of Abuse.

THE figures collected by Dr. F. J. A. Waring concerningthe distribution of tickets for treatment at the hospitals of

Brighton indicate most clearly that abuse prevails in thattown as in so many other places. In 1894 no less than

38,113 tickets were given to intending patients andas some of these tickets were renewed they do not

represent the full amount of charitable work done.That these charities are largely abused is clearlydemonstrated by the experience of the West-street

Lying-in Hospital. In 1894 there were at Hove andBrighton 3704 births registered. No less than 1240 ofthese births were attended by one charity. But other birthswere attended at the Brighton and Steyning Infirmaries andby the Merciful Society for helping fallen women. Thusmore than one-third of the mothers at Hove and Brightonwere in receipt of charity. It is obvious that in so pros-perous a locality the proportion of mothers who really neededcharitable help was not so high. Dr. Waring states thatone of the midwives in the service of the Lying-in Hospitalexpressed her opinion that half the cases which she attendedcould well afford to pay. Many of these patients wereassured in benefit societies which allow 30s. at the birthof each child. As a further proof of abuse it is shownthat some years ago the number of patients was notso high, but a midwife was appointed who gained greatpopularity in consequence of her kindly manners and herskill. The number of applicants for admission to the

hospital consequently increased rapidly. Now, however,this midwife has left the hospital and established a privatepractice of her own. The result is that she is at the presenttime treating, and receiving fees from, the very same personswho formerly were gratuitously delivered at the hospital.The fee charged by the midwife is 15s. and this is readilypaid by the former patients of the hospital. These facts, itmust be explained, are not new; they were brought soprominently forward in 1894 that action was taken and withgood results.

Calling at the West-street Lying-in Hospital I was in-formed that a wage limit had been established. If thehusband had no children and was earning ;E1 or more aweek an inquiry was made. On the other hand, if he hadseveral children then no inquiry was made. Patients, onapplying, must bring a letter of recommendation from asubscriber. They are given a card in exchange for the letterand told to call again in a week. The details are enteredin a book and shown to the medical officer in attendance andif he objects the secretary is informed and an inquiry isinstituted. It will be seen that this is a weak system. Itssuccess depends entirely on the accuracy with which the

1 The previous articles on this subject were published in THE LANCETon the following dates: (1) Sept. 26th, 1896, Plymouth and Devonport ;(2) Oct. 10th, 1896, Exeter; (2 concluded) Oct. 17th, 1896, Exeter;(3) Oct. 31st, 1896, St. Thomas’s Hospital, London ; (4) Nov. 14th, 1896,Liverpool; (4 continued) Nov. 21st, 1896, Liverpool; (4 concluded)Dec. 12th, 1896, Liverpool; (5) Jan. 2nd, 1897, Manchester; (5 continued)Jan. 9th, 1897, Manchester; (5 concluded) Jan. 23rd, 1897, Manchester;(6) Feb. 6th, 1897, Leeds; (6 concluded) Feb. 13th, 1897, Leeds;(7) April 17th, 1897, Coventry; (8) May 1st, 1897, The Royal LondonOphthalmic Hospital; (9) May 8th, 1897, France, United Action andLegislative Action; (10) May 15th, 1897, Leicester; (11) June 5th, 1897,Nottingham; (12) July 31st, 1897, Birmingham; (12 continued)Aug. 14th, 1897. Birmingham; (12 continued) Sept. 4th, 1897,Birmingham; (12 concluded) Sept. 18th, 1897, Birmingham; (13)Oct. 30th. 1897, Southampton; (14) March 5th, 1898, Glasgow; 14(concluded) March 19th, 1898, Glasgow; and (15) March 26th, 1898,Bradford.

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recommendation form is filled up. Under such circum-stances it is not surprising that but few inquiries are insti-tuted. I was informed at the hospital that not more thansix or at most eight such inquiries had been made during thelast two or three months. The very vagueness of thisreply to my questions suggests that check is not verysystematically applied. The medical officer in atten-dance on the day of my visit did not, however,think that there was much abuse. It was his impressionthat the husbands of the women usually earned onlyfrom 15s. to 18s. a week and that the greater number werecabdrivers or fishermen. Though this state of affairs canscarcely be considered as very satisfactory it is, with regardto the prevention of hospital abuse, the best that Brightonhas to show and it has sufficed to bring about favourableresults. In consequence of these measures, such as theyare, to prevent abuse, and, above all, as a result of thedeparture of the popular midwife, the number of patients hasconsiderably decreased. They amounted, as already stated,to 1240 in 1894. In 1895 there were 1172 patients ; in 1896only 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 thatthe population has, at the same time, been steadilyincreasing.As an example of the sort of abuse which has been

checked a case was mentioned to me of a woman

who applied to the Lying-in Hospital though her husbandsubscribed to the Hearts of Oak, which allows 30s. ateach accouchement. Many members of this benefit societystrive to be admitted to the hospital for nothing and inthis they are often encouraged by people who ought toknow better. Thus a man employed by a large dairy paida fee of .&20 for the operation of abdominal section performedon his wife. His employer reproached him for having ex-pended so large a sum and told him that he should have senthis wife to the hospital, where the operation would havebeen done for nothing. Of the cases of abuse which havenot been prevented that of a well-to-do shopkeeper wasmentioned to me. It was necessary to induce prematurelabour for his wife and this was done at the hospital.Another case related to a patient who offered his usualmedical adviser four guineas to attend his wife duringher confinement. As, however, the patient in questionlived a long way off the medical man refused to takethe case and recommended a local practitioner whosehouse was close at hand. Subsequently, and on makinginquiries, he found that the woman had been taken to theLying-in Hospital in West-street, and yet her husband hadoffered to pay four guineas. In a paper read by Dr. Waringat a special meeting of the Brighton Medico-ChirurgicalSociety in November, 1895, there occurs the followingpassage: "Dr. A. H. Dodd and I have written to the follow-ing large towns for information-viz., Portsmouth and itsadjoining towns, worthing, Hastings, Eastbourne, TunbridgeWells, Lewes, Maidstone, Ramsgate, Margate, Dover,Rochester, Red Hill, and Folkestone, covering a populationof a little over half a million-and we find that they have nolying-in institutions among their charities. The marriedpeople in those towns study the principles of thrift. I firmlymaintain that it is not right that a woman should beattended gratuitously in her first accouchement. Peopleshould certainly not be encouraged to marry who have notsaved sufficient to pay for the expenses of the first littlestranger’s arrival. I am in possession of the names of menemployed in large business firms and receiving wages ofover ;E2 a week and adding to their income by lettingapartments who have received from the lying-in charity thatassistance for their wives which is only intended for the Ipoor." But, as already remarked, the abuse of the Lying-in IHospital has been greatly reduced since these words werespoken ; and as such reform can be achieved with regard tothe maternity institution it makes it all the more pertinent toinquire why similar measures are not enforced at the otherhospitals.The Lying-in Hospital was not the only institution

criticised and publicly denounced. It was pointed out thatin 1894 there were at the Throat and Ear Hospital 55cases of impacted wax and 14 of simple tonsillitis, and atthe Sussex County Hospital 33 cases of circumcision. Suchcases do not require long or special attention. Two orthree visits from a local practitioner would have sufficed andcircumcision could in most cases be deferred till the parentswere in a position to pay a small fee to their ordinary

medical attendant. Looking at the report for 1896 of theThroat and Ear Hospital I find that there were 63cases of impaction of wax, and during the same yearthere were 44 cases of circumcision at the Sussex CountyHospital. In 1895 Dr. Waring brought to the notice of theprofession a certain number of incidents as examples ofthe sort of abuse which was prevalent. He said thata county cricketer was at that time sending hisdaughter to be gratuitously treated at the dispensary. Amale patient of the same institution was renting a shopof at least C40 a year. He was a foreman atsome 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 hiswife letting apartments, sent his infant for treatment. A

gentleman living in one of the best parts of Brighton sub-scribes 10s. a year to the dispensary; he sent a young ladyrelative who was living in his house to be treated forvaricose veins and she took away with her elastic stockings,and the gentleman had still remaining after this tickets forfour months’ more attendance. A man who keeps a shopfor which he pays 50 rent, ar d whose wife lets apartments,sent his children to the Sussex County Hospital. One ofDr. Waring’s patients was suffering from cataract ; he livedon a pension and had some savings. Dr. Waring offeredto procure a surgeon to remove the cataract for thereduced fee of five guineas. The patient replied thathe could well afford to pay that sum. Nevertheless,he went to the Eye Hospital, where the operationwas performed gratuitously by the very same surgeon.The result of this state of things-and several othersimilar examples were given-was described by Dr. Waringin the following words: "I have seen no end of youngmedical men, gentlemanly in manner, well skilled and con-scientious in the performance of their professional duties,come into the town with the just expectation of earning aliving and leave after a few years’ struggle utterly ruined.Some years ago a few doctors in Brighton and Hove togetherwith one or two other philanthropists started a Medical andSurgical Home in Ellen-street and they advertised forresident patients and got some from different parts of thecountry. There was also a dispensary attached to it wherethe sick and injured could resort and by purchasing a ticketfor one penny receive advice and treatment. Of course alarge number flocked to it. A little prior to this a medicalman came to Hove whom I knew slightly. I met him once inthe street, and from what he told me and from my know-ledge of him I knew that he was doing well and was able tosupport his wife and family ; but some time afterwards Imet him again and he was shabby in appearance and lookeddepressed. I asked him what was the matter and receivedthe reply that the Medical and Surgical Home in Ellen-street,together with the General Dispensary, had ruined him."

Calling on a member of the honorary staff of this dis-pensary he informed me that undoubtedly many of the

patients appeared to be in a good position. If inquiries weremade it would often be found that the husband was anergine-driver; but the patients would argue that they had aright to come because they put a penny a week into one ofthe boxes which are known at Brighton as the workmen’sboxes." This is an old-standing practice. An employer sendsthe box round and with the pennies collected from-hisworkmen he buys tickets which he gives to the workmenor their families. Of course the employer does not make anyclose inquiry into the position of his workmen, whose wivesare often lodging-house keepers and thus make a goodincome. At the railway works there are many labourersand others who receive very low wages and are gene-rally fit persons for a charity. But the skilled artisan whosewife lets lodgings can well afford to pay a few small fees forordinary illnesses or he can join a provident club; andI am told that there are ten or twelve fully-qualified prac-titioners in Brighton who will take sixpenny fees. Indeed,the situation of the profession at Brighton is at present sodeplorable that I was told that it would be inexpedient toattempt to raise the club fees. There are too many starvingmedical men ready to take the place of anyone who shouldcomplain. Another general practitioner, however, urged thatthe competition of the provident dispensaries was moredisastrous than that of the hospitals. A medical manon the staff of the General Dispensary admitted tome that there certainly was some abuse, but notmuch. The medical officers had to report cases of abuse;but, of course, they could not do this very often. He

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’himself had reported a case of gonorrhoea, on the groundthat if a man could afford dissipation he could afford to paya medical practitioner’s fee. Besides there were medicalmen who undertook to attend a patient at his house for awhole week for only one shilling. In the face of such com-petition it was very difficult to act and he felt that if he

attempted to prove cases of abuse he would become un-popular. One of his patients, a lady in receipt of an income of £500 a year, said that she was absolutely unable to pay£40 for a very serious operation, therefore she went up toLondon to get it performed at a cheaper rate. Many personsliving in very good houses came to the dispensary, but inspite of appearances they were sometimes in very precariouspositions. Lodging-house keeping is very hazardous and itoften happened that all the furniture of persons so engagedwas seized and sold. He did not think that the well-to-dotradesmen of Brighton were particularly prone to attend thehospitals ; but nevertheless there was a widespread feelingthat medical men were defrauded, but it was difficult toobtain positive proofs of the fact. Then the medical menhad a great amount of gratuitous work to do for curates,governesses, and domestic servants.

The General Dispensary was founded in 1809, therefore itis a very old-established institution, and has so grown in im-portance that there are now a western branch and a northernbranch besides the parent institution. At each of these thereis a house surgeon attached who receives a salary of £140 ayear but is debarred from private practice. Then there arefour district medical officers who receive between them L280a year. But apart from the paid staff there is an honoraryconsulting - physician, an honorary consulting surgeon, anhonorary visiting staff’ of twelve physicians and surgeons andtwo dental surgeons. This staff attended during the year 1896no less than 15,078 patients and this was a decrease of 700 onthe previous year. At the western branch there are wardsand here 125 in-patients were treated in 1896. The numberfor the previous year was 113. There are fifteen beds at thewestern branch so that this constitutes yet another hospital.Patients are accepted at the General Dispensary on pre-senting a letter of recommendation and on paying a regis-tration fee of 6d., but free letters are distributed in returnfor contributions from friendly societies and to the collectors-of workmen’s boxes. Subscribers of only half a guineaannually are entitled to recommend six patients, and ofcourse a much larger number of recommendations are Igiven in exchange for larger sums. The government ofthe institution is vested in benefactors of JE10 10s. andupwards and in subscribers of ;E1 ls. or more annually,and they are entitled to attend the general annualmeeting so as to elect the committee of management andall officers. For these meetings Masonic lodges, friendlysocieties and other institutions of a similar character whichsubscribe E3 3s. annually may nominate a representative.The house surgeons and the district medical officers have tovisit at their homes such patients as are unable to attend atthe surgery. Then there is a Samaritan fund for the purposeof providing patients with extra diet, &c. The in-patientsare received at the western branch on the recommendationof the house surgeon or one of the branch honorary medicalstaff. But domestic servants or other workpeople employedby governors living in the district may be received as in-patients on the payment of not less than 12s. weekly. Theincome from all sources during the year amounted to £3800,of which L691 consisted of dividends on investments; thepatients’ 6d. registration fees amounted to ëE253 and the- contents of the workmen’s boxes to £309. The annual

subscriptions amounted to £820. Then there were donationsand life subscriptions to the amount of JM95 ; congrega-tional collections, £206; and legacies, £1022. I haveomitted the shillings and pence. These figures show theimportance of this institution and the population ofBrighton 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 receivesa salary of 30s. a week. Two or three of his children are in

regular employment and his wife does a good business inletting apartments. Nevertheless she took her child to thedispensary to be treated for a fractured arm and when thesurgeon in attendance expressed his surprise she replied :"Is not the dispensary a place for all accidents?" " Onanother occasion a tradesman who pays .E35 rent for hishouse and lets apartments obtained a dispensary ticket andtook his child there to be treated for a slight injury to’the forehead. Then another case was mentioned to me ofa child who was a patient at the dispensary though the

father earned as a gardener 27s. a week, owned a houseworth £25 a year, and did a good business in letting apart-ments. It is generally felt that far too many letters ofrecommendation are given in exchange for small sub-

scriptions.(To be continued.)

LIVERPOOL.

(FROM OUR OWN CORRESPONDENT.)

Asylum Accommodation in Lancashire for Pauper Lunatics.AT the recent quarterly meeting of the Lancashire Asylums

Board, held in the County Hall, Preston, Mr. Shelmerdine(Liverpool), on behalf of the Lord Mayor of Liverpool, drewthe attention of the board to the delay in the completion ofthe extra wards at Whittingham Asylum. The Lord Mayorhad received a letter from Dr. Raw (the medical officer of theMill-road Infirmary, Everton) complaining of the congestedstate of the insane wards in that institution, which were socrowded that it was impossible for him to give adequatesupervision to dangerous lunatics. Eight lunatic cases weresleeping (at the time Dr. Raw wrote) in the ordinary wards,a state of things to be greatly deplored. The chairman ofthe Whittingham Asylum Committee said the work had beengreatly hampered by strikes and other causes, but they weremaking every effort to hasten the completion of the necessarywards. The Lord Mayor of Liverpool takes an active interestin the matter, being a member of the West Derby Board ofGuardians.

Hospital Saturday Workshops’ Collection.On Saturday, May 21st, the twenty-eighth annual

collection in the workshops, warehouses, and other in-dustrial establishments in the city on behalf of the medicalcharities took place. During the past twenty-seven yearsthe sum of .680,172 has been raised by means of thisagency. The collection in the streets called the "ladies’day" are fixed for June llth, after which date the com-bined amounts will be advertised.

Hospital for Women, Shaw-street.Dr. John E. Gemmell, the junior assistant medical officer,

has been promoted to the post of acting medical officer,rendered vacant by the resignation of Dr. T. B. Grimsdale.Dr. David Smart has retired from the honorary staff of thehospital after eleven years’ of devoted service. Much regretis felt both by the medical staff and committee at theseverance of Dr. Smart’s connexion with the hospital, forwith all of them he was deservedly popular.

The Robert Gee Medical Scholarship.Mr. Hubert Gordon Thompson, a former student of the

Liverpool College, has been the successful candidate in thecompetition for the Robert Gee Medical Scholarship at Uni-versity College, Liverpool. Mr. Thompson had previouslymatriculated at the University of London, having been

placed in the first division.Sir Henry Tate, Bart.

Mr. Henry Tate, formerly resident in Liverpool, who hasbeen the recipient of a baronetcy on the occasion of theQueen’s birthday, has been a generous benefactor to the cityof Liverpool. He contributed £8000 to the funds of the Liver-pool Royal Infirmary and generously assisted other localmedical charities, besides contributing largely to the RoyalJubilee Nursing Fund. The spacious library in UniversityCollege, Liverpool, was also one of Mr. Tate’s numerousbenefactions. His eldest son and heir to the baronetcyalso takes an active interest in hospital work, being a

member of several committees, notably of that of the Liver-pool Royal Infirmary.May 31st.

SCOTLAND.(FROM OUR OWN CORRESPONDENT.)

The Perils of the Medical Profession.ANOTHER name has been added in Glasgow to the long

roll of those who have fallen in the performance of duty.Mr. Thomas Henderson, son of Dr. T. Brown Henderson ofthat city, a student of medicine of much promise, has at theearly age of twenty-two fallen a victim to blood-poisoningcontracted in the pursuit of his hospital work as the result