THE MANUFACTURE OF PAUPERS.* VIL — THE HOSPITALS.

IT would be a pleasure to dwell with emphasis upon all the undoubtedly good and valuable work which is done by our hospitals,—how they have not only relieved the sick, but have advanced medical science in this country. But it is necessary, unfortunately, to point out also the errors that they are making, and to show how they are, by the maladministration of their out-patient departments, sapping the independence of the people, and helping to manufacture paupers.

These institutions are managed by men of great ability. Some of the managers are trained business men ; others have been, or still are, in one or another of the professions. Clergymen of all denominations, soldiers, sailors, and lawyers all meet to assist in the deliberations of the board of their pet charity. As it would be supposed, men such as these, assisted as they are by secretaries who are for the most part extremely able men, imbued with boundless energy, and loyally devoted to their own institution, do regulate the affairs of their own charities in a very satis- factory and enlightened manner ; but it is much to be wondered at that they have not long before this evolved some scheme whereby the present disorganisation in the administration of our Metropolitan medical relief could be changed, and order and system produced out of chaos,-- some well-thought-out method that might bring about [4. The articles in this series are contributed by different writers,—each an expert in his own subject. Hence, though the general aim and purpose are the same, a difference in point of view may occasionally be visible, and there may also be occasional overlapping. It has been thought better not to suppress the individualism thus apparent in the articles, nor to attempt the production of a rigid uniformity by editorial omissions, alterations, and additions. An essential harmony produced by the adoption of common principles, and by the desire to awaken the public to the evils caused by the manufacture of paupers, is, however, visible throughout the series. Next week's article, which will deal with "The Lessons of the Old Poor Law," will complete the serlea—Es. Spectator.] co-operation between the charities themselves, and between them and the infirmaries and dispensaries under the Poor Law.

It will, no doubt, be a painful surprise to many people to learn that there is a large body of thoughtful and experienced people who think that medical relief as it is now administered in London, more particularly through the out-patient and casualty departments of our voluntary hospitals, and through the 'free and part-pay dispensaries, is a frightful source of evil, inasmuch as it is to a large extent a waste of energy and material, and is a means of pauperising the recipients.

Much has been written upon this subject of the out- patient and casualty departments of our hospitals. As long ago as the year 1870 a meeting of one hundred and fifty-six medical men (Sir William Ferguson in the chair) passed resolutions, amongst which were the following, viz. :— "That this meeting is of opinion that there exists a great and increasing abuse of outdoor relief at the various hospitals and dispensaries of the Metropolis which urgently requires a remedy."

"That, in order to encourage a feeling of self-respect among the working classes, and that they may secure for themselves during health the necessary medical attendance in sickness, it is desirable that the system of provident dispensaries should be largely extended, both by the conversion of the present free dis- pensaries and by the foundation of others."

And again :— " That the practice of receiving payments for medicine or medical advice from the out-patients of hospitals Is undesirable."

In a letter addressed to the editor of the Times in the year 1874 the late Rev. J. F. Kitto, at that time perpetual curate at St. Matthias, Poplar, and better known latterly as the rector of St. Martin's-in-the-Fields, wrote:— " Two or three years ago a very important discussion was raised in your columns, and the eyes of the public were opened to the many abuses connected with the present administration of medical relief at the out-patient departments of the great London hospitals. Since that time very little has been done to improve the management; the system in its main features remains unaltered, and its abuses entirely unchecked."

After pointing out many of the abuses, he added :— " Surely there can be no legitimate reason why deserving local practitioners should be deprived of their proper patients, the energies of the hospital staff unfairly and unreasonably taxed, the resources of the hospital itself diminished, and the self-respect of the patients be impaired, in order that the Committee may be able to parade before the eyes of the public the number of thousands of patients whom they have treated during the year? If any other kind of relief were to be given in the same way the danger and folly of it would be at once noticed. I write in the true interest of the hospitals and with an earnest desira to advance the interests of the poorer classes when I say that such wholesale relief, from whatever source it comes, tends to uproot the independence of the recipient, and is the first step in the too easy road which leads to a hopeless and degrading pauperism."

About this time Sir Charles Trevelyan wrote to the Times upon the hospital out-relief system. After referring to Mr. Kitto's letter, he said:— " Those who best know the London poor speak of many painful consequences of these unlimited medical dispensations. Instead • of having their attention directed to regular employment, Cleanli- ness, and wholesome air and food as the true remedy for the depression caused by idleness, excess, and squalor, the poor are encouraged to seek delusive temporary relief from the habitual use of tonics and cordials, which are often obtained by the same person from more than one place of gratuitous distribution."

He concluded :- "If a great deal of what goes by the name of medical relief were discontinued, our lapsed London population would have a better chance of recovering their physical and moral stamina."

In the year 1889 a largely signed petition which was presented to the House of Lords prayed that a Select Committee of that House might be appointed to inquire into the financial and general management and the common organisation of medical institutions, endowed and voluntary, and into the administration of Poor Law institutions for the aid of the sick in the Metropolis, and to make recommendations. The Select Committee was appointed, and among the defects in the administration of medical relief in London which were set out before it were the following :— " (1) The promiscuous congregation in out-patient departments of large crowds of persons who in most instances are suffering from slight ailments for which skilled hospital treatment is quite unnecessary, is a constant hindrance to medical instruction in- creases the discomfort and pain of those who are suffering instruction, severe maladies, and occasions much vexatious and needless waiting.

(2) The indiscriminate admission to the benefits of hospitals and dispensaries tempts many who could pay for medical relief to become occasional recipients of charity, and by degrees habitual paupers. (3) The provision of gratuitous medical relief to large numbers of persons both as in- and out-patients, without inquiry or any sufficient regulation, is, as investigation shows, a serious obstacle to the promotion of provident institutions at which medical treat- went can be secured by small periodical payments.

(4) Hospitals and free dispensaries, as at present administered, usually offer no special advantages to those artisans and labourers who have combined to make provision against times of sickness, and there is no recognised relation between these hospitals and dispensaries and provident institutions."

It must be stated with regret that these defects are still existent, and remain as blots upon our hospital administra- tion.

The Select Committee reported in 1892, and their chief recommendation was that there should be a Central Hospital Board for London upon which all who had an interest in our medical charities should be represented. In the year 1896, as no Board had been created, the Charity Organisation Society formed a large General Committee with a view to the establishment of a Central Hospital Board. The objects of the Board were drawn as follows

(1) To maintain the voluntary system.

(2) To induce co-operation among medical institutions.

(3) To act as an advisory body to the public.

(4) To advise medical institutions, and to assist them in carrying out largo improvements, if desirable, by reports to the public, and by grants of money as far as the means of the Board will admit.

(5) To promote the consideration of the hospital and medical needs of London as a whole. ,The Board shall be representative of all interests.

It shall not interfere with the management of individual institutions.

It will act by advice and report only.

It will not attempt to absorb any of the ordinary monetary resources of the medical institutions, but will rely chiefly upon bequests or foundation grants."

On February 6th, 1897, the King, then H.R.H. the Prince of Wales, announced his intention of inaugurating a Hospital Fund for London to commemorate the sixtieth anniversary of the reign of Queen Victoria. The Prince concluded his letter thus :—" Finally, I venture to offer a word -in general commendation of the scheme. Public opinion has shown itself upon more than one occasion, and I think wisely, in favour of the maintenance of the voluntary system for support of our hospitals, combined with an adequate system of representation of the body of subscribers in their control and management. It is obvious, however, that if these institutions are to be saved from State or parochial aid, their financial condition must be secured. We must recall the fact that, apart from the purely philanthropic work carried on in relief of our sick poor, we look to the voluntary hospitals for the means of medical education and the advancement of medical science. Our hope is that, by the aid of this Commemoration Fund, we may be enabled to secure for these necessary institutions sufficient and permanent Support."

The Fund, which is now called King Edward's Hospital Fund for London, has done very much for the hospitals. It has been the means of opening for the use of the sick poor of the Metropolis four hundred and forty-three beds which were closed owing to want of money ; it has caused the hospitals to be visited annually, and their condition has been reported upon; advice has been offered on various points of administration ; some of the large hospitals have been helped by the subscriptions of the Fund to make extensive necessary alterations and additions.

The amalgamation of some of the small special hospitals is another very difficult problem which the Fund has set itself to solve. The money collected by the Fund since its inauguration nine years ago amounts to a very large sum,—viz., £1,207,474. Notwithstanding all this splendid work, the defects mentioned above still continue. The crowds attending the external departments of our hospitals are greater than ever. No real endeavour is made, except at a few hospitals, to persuade the thriftless to belong to clubs or provident dispensaries; nor is any appreciation shown or preference given to those who can prove that they have been thrifty. In 1887 the number of out-patients and. casualties attending at eighty-six hospitals was 1,056,852; in 1904 the number in the same hospitals was 1,775,422, and in ninety-seven hospitals 1,858,800.

It is to be hoped that H.R.H. the Prince of Wales and the Council of King Edward's Hospital Fund for London will before long turn their attention to the out-patient departments, and so ameliorate their administration that the accusation made at present that our hospitals assist in the manufacture of paupers may be removed.