60 IRISH POOR-LAW SERVICE. dispensaries in Ireland. The funds collected from the surrounding inhabitants, an equal sum being added by the grand jury, failed gradually, and the medical officer, to receive anything like adequate payment for his services, should beg it from the residents. The distance from the dispensary to the remote parts of the district made timely or frequent attendance impossible. For example, in 1836, the county Mayo, containing 2,100 square miles, had but one dispensary. Inspection to insure adequate medical attendance and appliances did not exist. During the disastrous years 1846-50, the income almost entirely failed. The new system, by which the medical charities were wholly placed under Poor Law administration, was objected to by many, and an amendment, proposing that yearly subscriptions should be also received, met with warm support. The Infirmaries Bill of 1854 proposed to confer privileges upon subscribers of twenty guineas to the Union hospitals, into which these institutions were to have been converted. In 1841, the medical charities of Ireland were investigated by Mr. Phelan and Dr. Corr, and the first Act to "extend the practice of vaccination," was put under Poor Law administration. A bill for the regulation of the medical charities was framed, but so powerful was the opposition offered by the medical profession, that it was never brought in. In 1851, the medical treatment of the poor was placed under the commissioners (one of whom was to be a medical man at a salary of £1,200), and they were given the power of appointing a sufficient number of medical inspectors. The funds under this Act were to be derived wholly from the rates; the guardians were to divide the unions into districts, governed by a committee of exofficio guardians and elected ratepayers. The medical officers of existing dispensaries were continued, and the committees had the election of their successors. The expenditure was estimated at £102,700 for the first year, IRISH POOR-LAW SERVICE. 61 but that for 1866 was £116,315, exclusive of £12,892 for registration expenses. Dr. Rumsey (State Medicine") objects to the system established in the place of the voluntary one, mainly because of its pauperizing tendency. The guardians, in arranging the districts, were much influenced by the desire of economy, and the commissioners in 1854 reported that the average population to each district was 9,060 (a number now reduced to 8,098), the acreage 28,000, and the average valuation £1,814. Many districts had 40,000 acres under the care of one medical officer. By the change the salaries of the officers, which averaged, in 1854, £75, were not increased, although attendance on the sick was more arduous and the keeping of books much increased. It now averages £89, and £8 for vaccination for each of the 786 medical officers to whom 716 districts are allotted. There also are 163 workhouse physicians, and 39 apothecaries to dispensaries. The construction of the committee from unintelligent ratepayers, and their very infrequent meetings, have been often complained of. Many of them in remote parts of the country cannot read or write, and with a majority the sole principle is to lessen expenditure. Such men are incompetent to direct steps for the prevention and cure of disease. The most galling complaint of the dispensary physician has been the enforced attendance on persons who, though clearly not poor, bring tickets from members of the committee. He is bound to attend, but at the next meeting of the committee, perhaps many weeks distant, the ticket may be cancelled. Then the attendance has probably ceased, and due payment cannot be had by legal process. During last year in the 716 districts only 828 tickets were cancelled. Dispensary officers are likewise often called on to see members of the constabulary force in sudden cases, if their paid attendant resides at a distance, or to give aid to persons who meet with sudden illness or accidental injuries, or who are drowned. In such cases remuneration is scarcely ever obtained. The midwifery branch of the profession entailed a most harassing amount of duty, but it has been lessened by the appointment of midwives in seventy dispensaries. Dangerous lunatics must be also examined, even in a neighbouring district," without fee or reward," according to an Act passed last session. It must, however, be allowed that under the old dispensary system abuse of charitable relief existed to an even greater degree. Payment from the Consolidated Fund, as medical officers of the army and navy are paid, and superannuation, have been often advocated, and very forcibly by that valuable union of the profession, the Irish Medical Association. The civil service estimates for the year 1867 for the first time contained an item (£59,300) for defraying part of the medical salaries and expenses, and which, by recommendation of the commissioners, will be mainly appropriated to impoverished districts. An Act was obtained in 1866 to superannuate union officers, physicians excepted, as it was averred they did not give their whole time. A dispensary officer lately resigned after fifty-three years' service in the county Down. It must be acknowledged that his committee appreciated his services, for they presented to him a very flattering testimonial, and appointed his son as his successor. But surely there ought to be some other rule than "do or die" to meet the case of the dispensary officer. By a recent act the ratepayers are relieved from one-half of the medical salaries, and it would be only just that medical officers should be included in the benefits of the Local Officers Superannuation Bill now before parliament. It is unjust to the poor to have an attendant incapacitated by age, and who, from the salary being his main support, cannot resign. The salary is so small that he can make IRISH POOR-LAW SERVICE. 63 no provision by saving or insurance for old age or infirmity. Assistant-barristers, who devote some two or three weeks yearly for an average stipend of £800, are nevertheless pensioned. They have many friends in parliament; the doctors few. If ultimately refused by government, the officers should allow two and a-half per cent. to be deducted from their salaries, so as to make a widow and orphan fund, as in the constabulary. By far the greatest grievance under which the Irish dispensary attendant suffers is the inadequacy of his payment. It seems to be forgotten that the impoverished state of the country affords in many places no private practice, and that therefore his poor-law salary is his whole supporta wretched one when the expenses of horse and servants are deducted. The salary varies from about £60 to £100 per annum, and it should be uniformly raised to at least the latter sum. Mr. Morris, M.P., Galway, has just moved in that union that the minimum salary be £100, as the large contribution from the Consolidated Fund fully justifies the increase. In poor and thinly populated districts, as it must be the doctor's whole support, the salary ought to be more, and might be calculated by the radius of the district or the number of houses under £2 valuation in his district, or both by compound schedule. If consultants are called in, or if other physicians give help on emergencies like the invasion of epidemics, such services will not be recompensed. That guardians are capable of actually reducing salaries, the case of the Kenmare union some years ago demonstrated. It was comforting to see how warmly the manly resistance of the late Dr. M'Carthy to this step was approved of by his professional brethren, many hundreds of whom subscribed to a testimonial. The average number of patients in fever hospitals daily during 1864, 1865, and 1866, were respectively 1,654, 1,824, and 1,357. The total number of persons relieved by dispensary attendants last year was 760,797, of which over one-fourth were at their homes. 64 IRISH POOR-LAW SERVICE. The rules for the regulation of dispensaries direct that the officers shall be qualified in medicine (by having the degree of a university, licence of a college of physicians, or apothecaries' diploma), in surgery, and midwifery, and that he shall be twenty-three years of age, a restriction which is much complained of, for many candidates, on having passed all the required examinations, are compelled to wait perhaps idly at home for two years if they are anxious to be employed in the service. In the army and navy medical department the age is fixed at twenty-one, as well as in most colleges. The selection by the committees is too often made on party and sectarian considerations, not on qualifications; and there have been lately instances of such electioneering tactics as increase and decrease of the numbers of the committees just before the poll. In France and in Prussia such officers are appointed by central boards above such despicable motives. The Poor Law Commissioners have lately decided that they will not sanction as dispensary attendants medical men already holding the office of coroner in rural districts. Whatever may be said of the expediency of this determination, it is very generally felt that it was scarcely just to set aside an appointment which had been made by the committee many weeks before the abovenamed order, but which appointment they had not sanctioned. There are very many coroners in Ireland who are likewise dispensary physicians, and no complaints have been made as to the way in which both duties have been performed. A few months before the commissioners' refusal to sanction the appointment of one of the coroners of Kildare, they had sanctioned the appointment of his colleague to a similar office; and in December they refused to interfere with a dispensary officer who had been elected coroner, six of his committee having addressed them. The calls to perform coroners' duties are not from a greater distance, nor at |