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THE HOSPITAL REFORM ASSOCIATION.REPORT OF THE COMMITTEE APPOINTED TO INQUIRE

INTO THE WORKING OF THE SPECIAL HOSPITALSOF LONDON.

To the Council of the Hospital Reform Association.GENTLEMEN,-In pursuance of your instructions to inquire 0

into the working of the special hospitals of London we have bpersonally visited forty-one institutions, which has necessi- o

tated about eighty separate visits, besides numerous letters. f

We herewith append in tabular form the specific details

required of these institutions. In the following remarks we c

abstain as far as possible from mentioning individual institu- tions. Unless otherwise specified, all the details in the ttable are taken from the published hospital reports for the e

year 1895. With few exceptions we were well received and a

the information for which we asked was readily given. Wehave nearly always interviewed the secretaries, and in some s

cases we have also seen members of the visiting staff or e

officials in charge of the out-patient departments. In many tcases the secretaries recognise the possibility of abuse ; in pvery few instances was its existence absolutely denied. It s

should be borne in mind that in all cases our information has n

been obtained from interested parties. There are several a

points to which we wish to draw attention in detail.1. Subscribers’ letters.-Out of the forty-one hospitals ten c

do not issue letters, and of the remaining thirty-one only six t

rigidly enforce their use. Some of the smaller institutions b

appear to use letters to enable them to obtain a grant from v

the Hospital Saturday Fund. r

2. Payment by patients.--Thirty-two hospitals receive s

payment from their patients, collecting a large sum annually d

(&24,085 in 1895). We would point out that this amount v

is earned entirely by the work of the medical staff, who ireceive no portion in return. More than half (eighteen) of these institutions obtain more money from their patients than tfrom their annual subscribers ; in some cases as many as from c

ten to twenty-five times as much. On comparing the t

patients’ payments and annual subscriptions for these tnirty- r

two hospitals we find that these received Z7000 more in c

patients’ payments than in annual subscriptions in 1895. We c

cannot refrain from drawing attention to the fact that 1at one institution the average sum received for treatment from each paying out-patient is lls. 9d. The payments are s

often made to subordinate officials, and no register or check fis kept. c

3. Inquiry as to the means of patients.--At fifteen of these s

institutions there is practically no inquiry at all, patients s

being admitted unquestioned, so that anybody may apply for, and will as a matter of course receive, treatment. Where (

an inquiry exists it is for the most part inefficient and wrongly directed. It partakes, as a rule, of one of two characters, either (a) How much can the patient pay the 1hospital ? or (b) Can the patient pay a specialist’s fee of one tor two guineas ? In neither instance is the patient asked if I

he or she could afford to pay the fees of a general practi- ttioner. The inquiry is usually of a most cursory nature ; the word of the patient is accepted, and no steps are taken to verify the statements. In other cases 1we found that although the letters contained spaces for the insertion of wages, means of livelihood, rent, &c , these

particulars were neither filled in nor the questions asked. At some hospitals it appeared to ba the custom to put upon the medical staff the duty of deciding the eligibility of the patients. We consider this to be unfair and unadvisable. This work is obviously outside the duty of thevisiting staff, who as a rule have much more to get throughthan tney can conscientiously da in the time at their disposal.Besides, it involves a personal element. If a medical mantells a patient he can afford to pay a practitioner it is ;

equivalent to saying to the patient, "You can consult meat my own house." Even at those hospitals which professsome form of inquiry it is unusual to ask any questions ofpatients bringing a subscriber’s letter for fear of offendingthe subscriber, and still rarer of those patients bringingletters from the Hospital Saturday Fund. We had re-

peated statements from the hospital secretaries as to theunsuitability of many of these latter patients for hospitaltreatment.

4. Limitation to the speciality for which the hospital

nominally exists.-This limitation is fairly well enforced.However, at some chest hospitals large numbers of cases ofanæmia and dyspepsia are treated; the Cancer Hospitaltreats abscesses, syphilis, and piles ; and at women’s hospitalsgenerally the cases are by no means all obstetric incharacter.

5. Limit to the number of new cases in the out-patientdepartment.-Only two have a fixed limit. In the majoritythe attendance is small, but there are undoubtedly cases ofovercrowding. The new patients on one day at the followinghospitals are: No. 11, occasionally fifty ; No. 22 an averageof from thirty to forty ; No. 3, from thirty to fifty ; No. 10,from twenty-five to thirty ; and No. 6, from twenty to thirty.Many of the cases treated at these special hospitals are of acommon nature, could be suitably treated by a generalpractitioner, and do not require the skill of a specialist.For example, at ophthalmic hospitals a large proportion ofthe cases are ophthalmia and common diseases of theeyelids ; at skin hospitals, pediculi, scabies, and ringworm ;at chest hospitals, anasmia and dyspapsia ; and so on.We are of opinion that considerable abuse exists among these

special hospitals in the following ways: (1) by the treatment,either free or for a small sum, of patients who could affordto pay a reasonable fee outside; (2) by the admission ofpatients who do not actually require treatment by aspecialist; and (3) by the treatment in some instances ofmore patients in a given time than can be considered eitheradvisable or defensible.

Recommendations.--In attempting to recommend whatcourse should be adopted by the association as a remedy forthe present state of things we are confronted at the outsetby a very serious difficulty. The majority of these hospitalswould cease to exist were it not for the payments theyreceive from their patients. A rigid inquiry and the con-sequent rejection of many patients would so seriouslydiminish the receipts that some at least of these institutionswould be unable to keep open. It is, therefore, primâ facieimprobable that we shall receive much support in thisdirection from the hospitals themselves. We recommendthat each of these hospitals be asked to appoint an inquiryofficer. We recognise the importance of this post being heldby a reliable and suitably paid individual. In view of the

necessary cost we recommend that hospitals in one locality-or, better still, the hospitals with the same speciality-shouldcombine to support a joint inquiry officer, who shall devotehis or her whole time to the work. We recommend that a

wage limit be fixed for out-patients, say, 30s. a week for asingle person and 50s. for married people. Some deviationfrom this rule might be allowed at the discretionof the inquiry officer in cases of a lingering charactersuch as phthisis, or in cases requiring a long course ofspecial treatment. In no instance should an able-bodiedperson living on his or her private means be admitted as anout-patient to any hospital. We recommend that an appealbe made to the management of the Hospital Saturday Fundasking them to exercise more care in the bestowal of theirletters and to exclude as far as possible persons in a positionto pay fees. We consider that much might be done if themedical staffs could be induced to take an active interest inthe subject of abuse. It is probable no hospital committeewould continue to act in opposition to the unanimous viewsof the staff, provided such views were strongly and

persistently laid before them. We therefore recommendthat a letter be sent to every member on the staffs of thesehospitals asking them to take an interest in this question,and pointing out (a) the pauperisation of the patientsthrough the present abuse, (b) the serious injury they aredoing to their fellow practitioners, and (e) the large amountof money they are earning of which they receive nothing.

Subscribers’ letters.-We have pointed out that out of theforty-one hospitals ten do not have letters. These do not

appear in consequence to suffer any loss in public support,for the average amount of their annual subscriptions is £743,as contrasted with £758, the average annual income from sub-scriptions returned by the others. At most institutions patientsbringing subscribers’ letters are admitted unquestioned, andit is certain that large numbers of undeserving cases gainadmission in this way. As only six out of the remainingthirty-two hospitals rigidly enforce the use of their lettersit is probable that no very serious objection would be raisedto the total abolition of the letter system. At any rate, wetrace the worst instances of abuse to this system, and wewould therefore strongly recommend its total abolition.Many hospital secretaries have expressed the opinion to

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us that the amount of the specialist’s fee for private con-sultation often conduces to instances of abuse of the specialhospitals. Thus numbers of patients who pay the hospitalsas much as from 5s. to 10s. are unable to pay 1 or 2 guineasto the medical man at his own house. With reference to thiswe fail to see any very strong objection to institutions acknow-ledged to be on a business and not on a charitable basis. Insuch institutions patients bringing an introduction from theirgeneral practitioner (this we regard as essential) might obtaina specialist’s advice on the payment of a small sum, say,from 5s to 10s., a portion of which would go to the specialisthimself,-We are, Gentlemen, your obedient servants,

W. KNowSLEY SiBLEY, M.D.Cantab., M.R.C.P. Lond.,ERNEST A. SNAPE, M.D. Brux., L.R.C.P. Lond.

HISTORICAL NOTES ON MEDICINE,SURGERY, AND QUACKERY.

III.1

SOME time between 1780 and 1785 an extraordinary exhibition took place in a garden in the upper part of Fleet- oj

street, Liverpool, when that street, though laid out, was not S

a thoroughfare. A person professing to be a medical prac- Atitioner, called Dr. Graham, arrived in the town and recom- mended the use of earth baths as a cure for various f(complaints. His plan was to have the patient buried up to aithe neck in earth, and in order to set the example he and a 0

woman who was said to be his wife were buried up to theirnecks in the garden with their faces towards each other. They had their heads dressed with hair powder, as was the fashion iaat that period, and the public were admitted on payment of a a

small sum. There is not any reason, however, to believe uthat they induced any patient to follow their example. d

The following advertisement appeared in Williamson’s I

Liverpool Advertiser of Feb. 18th, 1757: "To prevent the Unwary from being drawn in by ignorant Pretenders to Midwifery in this town (as I have been lately), I think it my pduty to acquaint the public that my late beloved wife, MaryReily, was taken suddenly in labour on Saturday, the 5th instant, upon which the Surgeon we had formerly on the rlike occasion employed was sent for, but not then being at j.home, were under the Necessity of immediately applying to

t

some other. Mr. John Wareing, a young Surgeon in Preeson’s- orow (unfortunately for me), was the person brought, who rpretended to be acquainted with such like cases, & took uponhim the remainder of the business of a Midwife (the child (being born before his arrival) ; and tho’ Contrary to the advice rof an experienced Woman Midwife, who was called in, in

the Hurry, & told him he was doing wrong, has occasioned(thro’ ignorance) the Loss of my dear Wife and Child, ]who are since dead. This I am ready to attest upon foath, & can bring several experienced Persons to

verify.--THOMAS REILY, Hatter, in Redcross-street." r

Something of the proverbial madness which clings to the r

calling of a hatter must have moved Mr. Reily in this affair. iIn the next number but one of the paper appeared a replycouched as follows : 11 Whereas an Advertisement was 1inserted in this paper of the 18th ult., signed by one Thomas

l

Reily, a Hatter, in Redcross-street, addressed to the public, ereatly aspersing the Character of Mr. John Wareing, a Surgeon, in Preeson’s-row, in Liverpool, thereby charginghim with being the instrument, thro’ Ignorance, of the r

Death of said Reily’s Wife and Child; which upon strictEnquiry is found to be altogether unjust and untrue ; as itwill be proved such Advertisement was inserted therein atthe Instigation and by the Dictating of a Person in Townwhose Character is too well known to want an Eclaircisse-

ment ; and can assure the public that such Advertisementis utterly false and scandalous, and without the leastFoundation, and was intended, thro’ Malice, to injure theCharacter of Mr. Wareing, and no other Motive ; as

Mrs. Reily for many months before laboured under a

Consumption ; the Birth untimely, being but in theseventh [? month] of pregnancy, and the Child bornbefore Mr. Wareing was sent for, and she was attended

1 Nos. I. and II. were published in THE LANCET of March 6th andMarch 27th, 1897, respectively.

by another surgeon (whose rrescnptions only she took)both before such Delivery and afterwards, till the Time ofher Death, which was on the 10th Day after her Delivery,and not before; for which an Action at Law is, or soonwill be, brought against the Writer and Composer of thesame.-N.B, The publisher of this Paper assures the Publicthat the Advertisement inserted in the Manchester Advertiserof last Tuesday, relative to the above affair, is entirelyFalse, notwithstanding what is there asserted, and the samewas refused on that Account to be inserted in our lastPaper. "On July 29th, 1757, the following announcement (for

which the printer received 12s., according to tbe filecopy) appeared in the Advertiser: : "To the Public :Whereas an Advertisement was inserted on Friday,the 18th of February, 1757, in this paper, Signed by me theunderwritten Thomas Reily, a Hatter in Redcross-street inLiverpool, adressed (as therein is mentioned) to the public,to prevent the Uhzwary from being drawn in by ignorantPretenders to Midwifery, whereby the Character and

Reputation of Mr. John Wareing, Surgeon, in Preeson’s-row, Liverpool, is greatly aspersed and injured byattributing the Death of my late Wife, Mary Reily,and the Child which she had then lately been deliveredof, to the Ignorance of said Mr. Wareing in the Practice ofSurgery and Midwifery; to which false and scandalous

Aspersion, I, the said Thomas Reily, was irritated by Mr.Ralph Holt, of Liverpool, Surgeon, the person to whomMr. Wareing faithfully served a legal apprenticeship ; andfor which Injury Mr. Wareing has had Recourse to the Lawagainst me and Mr. Holt for Satisfaction, but upon a Meetingof Mr. Wareing, Mr. Holt, and myself (at the Request ofMr. Holt), I find that Mr. Wareing did faithfully performhis Duty to my said late Wife, and that such Aspersion andthe whole of the said Advertisement is utterly false, and wasintended to injure the Character Mr. Wareing, for which Iam extremely sorry and sincerely ask his Pardon. And I theunderwritten Ralph Holt, of Liverpool, Surgeon, do herebydeclare that the said Mr. Wareing did faithfully perform hisDuty as Man Midwife to Mrs. Reily, that the whole Contentsof this Advertisement are strictly true, and that the saidAdvertisement of the 18th of Feby. last is without the leastFoundation ; that said Mr. Wareing faithfully served mea legal Apprenticeship in the Practice of Surgery andMidwifery, and after that studied the same and was

regularly educated therein at one of the best Schoolsin Great Britain, and that I believe the said Mr. Wareingto be in every Respect duly qualified in these Profes-sions ; and am sorry that I was in any wise the Occasionof so false and scandalous an Aspersion, as I was

misinformed relating to the subject matter of the saidAdvertisement, for which I have not only payed all Cost &

Charges incurr’d by the said Prosecution commenced againstme & the said Thomas Reily, but have asked Pardon of thesaid Mr Wareing in Public. Witness our Hands the 27th ofJuly, 1757.-THOMAS REILY, Hatter; RA HOLT, Surgeon."Even at this distance of time one cannot but rejoice at thefailure of this dastardly attempt to ruin the young surgeonon the very threshold of his career.

In consequence of the ravages of the small-pox it wasresolved, in the month of March, 1783, that a generalinoculation of the inhabitants of Liverpool should takeplace. The following medical men were formed into anInoculation Society for that purpose: Dr. Houlston, Dr.Brandreth, Dr. Binns, Dr. Worthington, Dr Camplin, Dr.Currie, Dr. Lyon, Mr. Alanson, Mr. Blundell, Mr. Buddicumb,Mr. R. Gerard, Mr. J. Gerard, Mr. Goldie, Mr. Hughes, Mr.Moss, Mr. Parke, Mr. Renwick, Mr. Shortcliffe, and Mr.Tetlow.

Dr. Currie, the biographer of Burns, was born on May 31st,1756, at Kirkpatrick Fleming, near Gretna, his father beingthe parish minister. He settled in Liverpool as a physicianin 1780, and filled for twenty-five years a most honourableposition. Dr. Currie published, under the pseudonym ofJasper Wilson," a letter to Mr. Pitt strongly condemnatory

,

of the war with France, which caused an extraordinarysensation. Three large editions were sold in two months,

besides reprints in Scotland, Ireland, and in the country., It was reprinted in America and translated into French and

German. Dr. Currie died on Aug. 31st, 1805. His life waspublished by his son, William Wallace Currie, the first

,

Mayor of Liverpool under the Reform Act. Dr. Curriewas a staunch opponent of the slave trade. In 1788he wrote: "The general discussion of the slavery of the