1513

THE LANCET.

LONDON: SATURDAY, DECEMBER 14, 1895.

MEDICAL MEN AND THE DEPENDENT CLASSES.

THE limits of a medical man’s duty to the dependentclasses form a subject of great interest and importance, andthis has been well handled in an able article by Dr. JAMESWALK in a paper read before the American Academy ofMedicine at Baltimore on May 4th of this year. It is

obvious that our American confreres suffer as severelyas we do from over-competition and crowding of pro-fessional men, and especially from unjust imposition of

gratuitous work. The medical student of to-day has the

greater part of his training devoted to the physical sciences.In former times the tyro engaged in professional visits withhis preceptor and acquired not only remedial science but themethods of dealing with men and women in their moral,social, and business aspects. The ordinary medical charities,crowded with patients, are not the only outlets for the super-abundant philanthropy of the young physician or surgeon.It is a growing notion that the medical man should treatfree of charge all the dependents of his neighbourhood.Upwards of 20 per cent. of the population of Philadelphiareceive free medical treatment. In the crowded out-

patient departments of dispensaries and hospitals what

opportunity is there for that careful and systematic investi-

gation of cases which alone is of true clinical value ? The

wholesale system of gratuitous medical relief pauperises the

community. The younger medical men are defrauded of theirshare in practice, and the whole profession is injured and

degraded. The enormity of the evil may lead to a powerfulrevulsion of feeling, within and without the profession. The

article, written in a moderate tone, certainly does not showan encouraging aspect of affairs in America. Any candidobserver must assert that in our own country, especially inthe large towns and centres of civilisation, matters are little

better, though we have good reason to believe that in thiscountry the " special hospitals " are perhaps the most

abused.

It is a lamentable fact that the training of manya modern scientific student does little to fit him for the

practical duties of his profession, especially in its business

aspects. The advice not uncommonly given by senior

members of the profession to juniors just emerged as fullyfledged practitioners is somewhat as follows: "Now youhave passed your examinations, go and learn your pro-fession by acting as assistant." Be this as it may, many

young consultants and practitioners are strangely deficientin even that rudimentary business capacity which wouldbe essential towards the successful conduct of any other

occupation or profession. The enthusiastic physician or

surgeon who occupies years of his life in crowded out-

patient departments will assuredly waste his time unless heturns his opportunities for the investigation of disease to

account. The crowds of patients, as well as the deficientaccommodation, not uncommonly quite prevent this. Of

the scores of individuals who occupy his time, and who

dub him by the suggestive epithet of the "free doctor,"not a few, if closely questioned, would be found to be wellable to pay the customary fee for consultation. We do not

believe that matters are quite as bad in this country as in

America ; anyone, however, who perused the addresses of

representative practitioners in the ethical section at the

recent meeting of the British Medical Association could notfail to be struck with the serious tone which pervaded manyof the sentiments uttered regarding such matters as hospitalabuse and club practice. The evil is already" sufficientlyenormous " in this country to call for the most serious

attention on the part of all the younger members of the

profession. As regards the matter of hospital abuse, thislies almost entirely in the hands of the profession itself.In this connexion we may recall to our readers the valuable

paper of Messrs. GRIFFITHS and HoRDER, published in ourissue of Nov. 30th. The paper embodied the results

of an elaborate inquiry undertaken by these gentle-men into the matter of abuse of medical charities and

contains a number of most practical suggestions. 111’e

cannot commend the wisdom or savoirfaire of any con-sultant who gratuitously gives away his services at a hospitalto a patient who can pay him a fee. We do not altogetherthink well of the medical or business capacity of any familypractitioner who allows his patient to drift to a hospitalthrough his tardiness in suggesting a consultation ; still less

do we approve of the custom, which is alleged to be gainingground in London, of practitioners sending their patients to

hospitals to ootain gratuitous opinions. It is almost an

established fact that three-fourths of the accident practicein London is done gratuitously at the hospitals. While

no one can be refused first aid at a hospital, be he peer orbe he pauper, we would most earnestly urge the surgeons of

hospitals situated in fashionable localities of large townsto exercise very close supervision in this matter. So soon as

a simple fracture has united, or is safely placed in retentiveapparatus, the patient should be dismissed to his own houseunder the care of his own medical man, or to one of the

many excellent private institutions which exist for care and

nursing. There is little reason why such cases as woundsof the radial artery or fractures of the bones of the upperextremity, after receiving the immediate aid which theydemand, should not at once be consigned to the care

of the patient’s own medical man, who in his turn mayask the consultative advice of any surgeon he chooses.

To treat cases of this nature in well-to-do persons

gratuitously is the worst form of hospital abuse. All

the junior officers of large hospitals, especially the hoasesurgeons, should be instructed to see into each case

and report on it in writing to the secretary of the

hospital or other responsible officer. Practitioners in the

neighbourhood of a hospital would confer a great boon uponthe profession if they reported to the secretaries any casescoming under their cognisance where their patients are

abusing the purposes of charitable institutions. We

hope that consultants at the hospitals will take these

remarks, wliich are offered in no captious spirit, seriouslyto heart. We trust also that practitioners will cooperatewith them in the duties of self-protection. The hour

has aniv ed when members of our profession should ceaseto give their time and labour to those who, although they

1514 THE QUALITIES OF CIDER.

can Slid money for the theatre or a trip to the sea-

side, go to t hospital when they are ill. Such persons, who

are numerous enough in London as well as Philadelphia,’!lsually take a professional man at his own value and, on onepretence or another, are constantly emulating the daughtersof the horse-leech and crying, "Give, givc ! " So far as

reaching opportunities go, benefit would certainly be

<Bonferred upon the hospitals by limiting the number of out-patients, and at certain well-known institutions this has

already been done. Sufficient material can readily be found

among the ranks of the really poor, who alone should

share the benefits of charitable funds.

We note with satisfaction that one of our large London’hospitals has recently increased its teaching staff - an

example which may be well followed by others. If, in

addition to increasing the care and facilities in teaching,the medical officers of our hospitals would once and forall set their faces against gratuitous relief to those who

have means, they would be helping a reform which couldnot fail to meet with all support from the rank and file

at the profession, and with the approbation of the right-:minded section of the public, who would recognisethat their charitable bequests were not wrongly used. The

growing generation of students would learn a useful

and lasting lesson-viz., that, though kindness and

philanthropy should ever be practised by every medical man,.he should most jealously guard against abuse in these

particulars and exemplify throughout his life the adagethat every man has a right to expect and receive adequateyecumary reward for his labours.

.

To the question what shall we drink, to discuss which atthis season of the year seems a little odd, Mr. RADCLIFFECOOKB in the Times of the 9th inst., backed by a

leading article in the same issue, would reply, cider. With

the economic and industrial aspect of the question, which}s a very important consideration, we have little to do

beyond expressing our entire approval of any movement thatis calculated to warm into life and vigour a well-nigh extincthome industry. We turn, then, to consider what are the Iqualities and special characteristics of cider upon which itsrecommendation as a popular drink could be based. In this

eonnexion there is little doubt that cider has not been very

favourably regarded, because no special care or attention

has been paid by cider makers to the exact conditions

which would ensure the production from the apple of auniform and palatable drink. The use of materials that

are chosen with little regard to their quality-as, for

example, damaged fruit, or fruit looked upon as of

no good for any other purpose than cider making-has operated largely against its taking rank on any

extensive scale with other better-known beverages. The

process of fermentation has hitherto been conducted in a

slipshod, rule-of-thumb way, without regard being givenbo the minutise of the process. What wonder, then, that

eider has not been popular except amongst a few countrypeople in those counties where it is chiefly produced. Yet

there is no reason at all why there should be any uncer-tainty as to the ultimate condition of cider, any more

han there should be of beer or claret. The composition

of good cider is not widely different from light claret,except that instead of tartrates and tartaric acid it

contains malates and malic acid, the characteristic acid ofmost fruits, and the proportion of spirit is less.The average composition of still cider is as follows:

4’88 per cent. alcohol, 0’33 per cent. malic acid, 1 per cent.acetic acid, 4 per cent. sugar ; of champagne and effervescin gcider, 3’5 per cent. alcohol, 0’35 malic acid, 0’05 acetic acid,6 per cent. sugar; of bottled Hereford cider, 5 per cent.

alcohol, 0-3 per cent. malic acid, 0’1 per cent. acetic acid,1 per cent. sugar. The latter may be described, like some

champagnes, as dry. Success in the making of cider is

favoured also by carrying on the process of fermenta-

tion like that of lager beer at a moderately low tempera-ture, when the sugar is rapidly converted into alcohol

and carbonic acid. Otherwise, if the alcohol be slowly pro-duced, organisms rapidly make their appearance, producingacetous and possibly also lactous fermentation. These are

the enemies of the cider-maker, and of course fatal to

the production of a palatable drink. It is worthy of

remark that the alcohol of well-made cider is, owingprobably to the low temperature employed, particu-larly pure, and on distillation yields a spirit of excellent

character and from which very good brandy may be made.It is free from other alcohols and allied products, whichdoubtless contribute to the stupefying and heavy qualitiesof strong English beers brewed at comparatively high tem-

peratures. This alone is a fact in favour of cider as a

beverage. The fruit acid of cider, however, is not thrownout of solution as the alcohol increases, as is the case withcertain wines. The delicate flavour and agreeable fruityaroma of unsophisticated cider are due to the extraction

of the essential oils of the pips and skins of the

fruit by the alcohol produced, the alcohol itself beingrich in compound ethers. It is to malic acid that cider

owes its pleasant acidity, and the presence as well of

alkaline salts and malates (which produce alkaline salts)gives cider its diuretic and slightly aperient properties.On this account cider would seem to be a useful beveragefor the gouty and those who suffer from uric acid deposits,the expulsion of which it is said to favour. But for

this purpose, as, indeed, for general purposes, the

cider must be sound. If sound and genuine cider be

placed upon the market with a guarantee we make nodoubt that the demand for it will rapidly-increase, and whenthe public once find out for themselves the really wholesome

, and refreshing qualities of genuine cider the nasty pre-, paration purporting to be cider will be banished, a home, industry will be restored to the position it ought never to, have lost, and an agreeable and mildly stimulating beverage. will be available which, if consumed rationally, will be found. free from the objectionable qualities of many beverages thati unfortunately are only too highly held in popular esteem.c Sound cider, on the other hand, should possess to an equalL degree the refreshing and harmlessly exhilarating properties of genuine light grape wines, the consumption of whichr abroad, to the exclusion of ardent spirits, has had a distinctlyb healthy and moral effect upon the people.

; WE are sorry for the managers of the Metropolitan1 Asylums Board. A task at once impossible and ungracious

1515THE PLIGHT OF THE METROPOLITAN ASYLUMS BOARD.

has been assigned to them, and they are getting that

plentiful blame which awaits gentlemen in our happycountry who undertake such tasks without fee or reward.

All sorts of faults are attributed to them. They do

not supply an amount of accommodation for infec-

tious cases equal to the demand ; they dismiss,or their medical officers dismiss, cases before they arefree from infection, and thus give rise to fresh cases of the

very diseases for the restriction of which they were elected.

They spend money like water to the figure perhaps of

half a million a year, and one of their own number

has been unkind enough to suggest that some membersof the Board, or of its committees, pay ridiculously largeprices for sites, and that there is a suspicion of

personal profit and advantage in the transactions.

We may say at the outset that we have little belief in the

truth of these suggestions. It is undoubtedly tempting tomen dealing with such large sums of public money and withcontracts of such magnitude-and knowing also the diffi-

culty which the Board has in finding a local habitation for itsunpopular hospitals-to turn to personal advantage circum-stances of which they have early or exclusive knowledge.But, fortunately, in both Imperial and Local administrationthere has always been amongst us an abundant supplyof men of ability and standing who were " above

suspicion." And until the contrary is shown by very muchmore evidence than Mr. ELLIOTT has produced, we shall z,have implicit confidence in the integrity of the managers of ’,the Metropolitan Asylums Board. Sir EDWIN GALSWORTHY ’’,dealt admirably with Mr. ELLIOTT’S suggestions and hisdemand for an inquiry. He refused to be content with any

inquiry by a committee of the Board, and moved an

amendment for investigation by the Local Government

Board. This was a dignified course, and one that will be

entirely satisfactory to the public.This was by far the least interesting part of the

business before the Board at its meeting on Saturdaylast. The great interest of the meeting was in the com-

plaints from all quarters of the inadequacy of the accommo-dation provided by the Board, and the pressure put on it to

open Gore Farm-now used for small-pox cases-for fever

patients. The feeling of dissatisfaction on this subject willscarcely be allayed by the hopeful view of the chairman,founded chiefly on one day’s experience, that the decline

of the epidemic had set in. Though every applicationfor admission that day -the day of meeting - hadbeen met, the number of cases of fever and diph-theria treated in the hospitals in the last fortnighthad been 3562, against 3551 in the previous fort-

night. We have no doubt that the complaints from all

quarters-from Lewisham, St. Pancras, Bethnal - green,Limehouse, and other boards-are well founded, and we seelittle reason to hope for any immediate relief or remedy ifthe present absurd facilities for entering these hospitals bythe public are allowed to continue. It is one thing to

provide isolation hospitals for the poor or for those who hadno adequate accommodation in their homes. It is quiteanother to invite the public into such hospitals as Parliamenthas done. We have the greatest misgiving as to the justiceor the wisdom of this policy. But it was passed with a

light mind by Parliament in 1890, and it is the chief

cause of the insuperable difficulties into which the Board

has been brought. The representative of the /?..7’

6’aseMe satisfied himself, on statistical evidence furnished.

him at Norfolk House, that prior to the new legislationwhich admitted the public-as distinguished from the poor-to the hospitals of the Board the accommodation was

ample, and that this legislation led to a sudden and over-

whelming increase in the applications for admission. This

is what we have always suspected. The Hon. SYDNEY

HOLLAND says, in a letter to the same journalthat " if the Board did what it ought to do -provideaccommodation for every case of scarlet fever or other

infectious disease of like moment in London-it would pro-

bably mean the expenditure of a million of money. And

what would the ratepayers say to that ?" We should say thatit would probably mean the expenditure of many millions.

That might be a superable objection, for the poor ratepayer issoon silenced. But the wisdom of the policy seems se

doubtful that it should not be persisted in till a full inves-

tigation of the working of the present system of admissionhas taken place. Let the public realise that there are

hundreds, if not thousands, of cases which can be isolatedand treated at home, and which ought to be so treated.

The causes of the prevalence of infectious disease need.

immediate and close investigation.It is a little disappointing to see a man in Mr. Holland

position, as chairman of a charitable hospital, say, evem

with some qualification, "that the Board ought to provideaccommodation for every scarlet fever case and other in-

fectious diseases of like moment in London." We should

have expected some clearer exposition of the enormotie

difficulties and cost of such a policy, and some insistenceon the duty of all people who can treat their infectious casesat home to do so. We do not blame the hospitals of theBoard for the spread of infectious disease. The authorities

have shown that the "return" cases which arise from

patients prematurely dismissed are not many, and that

they keep scarlet fever cases on an average ten weeks and.

diphtheria cases seven weeks. All the same, it is obvious

that there is no obligation on the State to provide isolationfor those who can have it in their own homes, and that the

loose legislation of 1890 has excluded those for whom isolartion hospitals are urgently demanded on every ground of &pound;

humanity and policy. This matter is urgent, but the most

urgent matter of all, and the shortest way to find accom-modation for the really proper cases in the hospitals of theBoard, is to create safeguards against the use of the

hospitals by those who do not need them.

SURGICAL AID SOCIETY.-The annual meetingof the Surgical Aid Society was held at the Cannon-streetHotel on Dec. 9th, the Lord Mayor presiding. The reportwhich was read by the secretary, Mr. R. C. Tresidder, showedthat during the year 13,345 patients had been relieved, in-cluding 4842 men, 6961 women, and 1542 children. There

had been a considerable increase both in the amount of reliefafforded and in the number of surgical appliances granted topoor applicants, no fewer than 20,046 such articles havingbeen supplied. The income during the last twelve monthshad been f.lO,599 as against f.l0,256 in the preceding year.The Lord Mayor said that the society had been establishedthirty-three years, and during that period had supplied220,600 surgical appliances to needy sufferers.