INFIRMARY SURGEONS.

65

all so frequent, as the calls for private practice which a successful practitioner will be required to attend.

It appears from a recent case that a committee may dismiss an officer solely for intemperate language offered to one of them, and that the commissioners will sanction the removal of the officer. In the case alluded to, without any further offence, the officer was also called on to resign a separate office, that of physician to the fever hospital.

The appointment of surgeon to the county infirmaries throughout Ireland was highly prized some years ago, from the superior position it conferred, and from the emoluments it afforded, which, however, have been greatly reduced. The following are some statistical facts relative to them, published in 1857. Number of beds, 1,722; average number of patients received yearly, 18,529; average deaths, 459; total income, £33,366; salaries and wages, £8,326; average expense of each patient, £1 13s. 9d.; average expense of each bed, £18 3s. 9d.; average cost on each acre, Old. They have done good service in educating pupils before they come to schools of medicine, and attendance on them is in part recognised by the colleges. Similar institutions exist over other divisions of the empire. The Medical Charities Bill, as originally drawn, sought to absorb the county infirmaries into the poor law system; but this was successfully resisted by the surgeons, who, through the grand juries and county members, were able to make themselves heard in parliament. Many able and disinterested medical men urge against these infirmaries that they frequently receive the servants and dependents of the wealthy subscribers, for whose treatment on their respective estates they should pay. The commissioners were of opinion that artizans, small farmers, and servants might contribute to their own maintenance. By the 25 & 26 Vic., cap. 83, persons suffering from accident or acute disease are ad

66

ENGLISH WORKHOUSES.

missible into the workhouse infirmaries, and as the county infirmary may be many miles distant, this is an evident advantage.

The fever hospitals of the counties were placed under poor law administration, and all must allow that benefit has followed. Also a few fever hospitals are supported by county funds, the emoluments and regulations of which vary greatly.

The sanitary state of the English workhouses has created during the last year or two intense interest. That most eminent statist, Dr. Guy, said, "It is highly probable that for every life which the poor laws save by averting starvation, a hundred are sacrificed by the imprisonment they inflict." The Lancet, by special commissioners, the Pall Mall Gazette, and such distinguished members of our profession as Sir T. Watson, Sir J. Clark, Sir W. Ferguson, Mr. Paget, &c., drew attention to the subject. 800 cubic feet was assigned as the least space for each workhouse hospital patient. The Inspector, Dr. Smith, advised that " a re-arrangement of the mode in which the medical officer performs his duty is necessary, with a view to the devotion of more time to them. The medical officers should act more generally 'as sanitary officers, and their recommendations of every kind should be in writing." With regard to the deficiency of inspection, he reported: "More than one Inspector of the Poor Law Board should be appointed for the district, and after the example of the Lunacy Commissioners, they should have special and different professional qualifications." According to this recommendation the board secured the services of so distinguished a physician as Dr. Markham, but for vacancies which have since occurred they have not recognised the claims of medical men. Dr. Smith has, however, been constituted medical adviser to the board somewhat after the manner of the Irish Medical Commissioner.

In all public lunatic asylums there are at least two medical officers, a resident and a visiting. In some lunatic asylums, as the Richmond, there are three externs. In England there are 65 public asylums and 103 private ones, which engage the time of 195 medical men; 3 of the commissioners of lunacy belong to the profession. In Ireland there are 20 public asylums employing 42 medical officers and 16 apothecaries, and 20 private houses, 17 of them being directed by medical men. The two Inspectors-General are medical men. In Scotland there are 18 public hospitals, 18 poorhouses for pauper lunatics, and 9 licensed houses, 44 medical men being connected with them, including 3 commissioners. In the three kingdoms there are therefore 261 of the profession directly concerned in the treatment of insanity, and it is surprising that so little attention is paid to the subject in the schools. In Ireland no lectureship on the subject exists, but a few pupils attend some of the public asylums. The government have very properly announced that they will require from resident superintendents proofs of special knowledge of the treatment of mental disease. The number of inmates range from 740 in the Richmond to 130 in the Carlow; in the larger ones an assistant resident physician is much needed. The desirability of placing the management of lunatics wholly in the hands of public officers has been lately advocated by a high legal authority, mainly on the grounds that the average of recoveries is greater in public than in private asylums. But it must be remembered that the latter get a much more incurable class of cases-namely, patients whose higher mental training make mental malady proportionately more incurable, and the richer classes will usually keep and care at home the slighter cases, thus making the run of cases in private asylums more grave.

68

THE GENERAL PRACTITIONER.

THE GENERAL PRACTITIONER.

In Ireland, the general practitioner, after the model of the English one, scarcely exists. In Dublin, indeed, there are gentlemen who, besides keeping open compounding establishments, visit and supply the medicines; but through the country, practitioners do not sell medicine by retail. Few practising assistants are therefore required, and they are always qualified. The assistants of apothecaries are, however, frequently unqualified, which is much to be regretted. The custom of charging separately for the visit and the medicines supplied is peculiar to England. The most faithful description of that branch of our profession is to be found in Tom Taylor's inimitable play, "An Unequal Match." On the stage the doctor is usually sketched as the solemn, silly, and pedantic nostrum vendor. It would be hard indeed to satirize the high-minded disciple of the most noble of sciences. Indubitably this practice has retarded the profession of scientific medicine, and lowered medical men in public estimation more than any other cause. The great benefit of the Medical Act was to abolish the monopoly of the apothecaries under the Act of 1815, and to permit the compounding of drugs by the registered practitioners by whom they were prescribed; but it is most deeply to be regretted that the practice of charging separately for medicines was not suppressed.

The drawing up of a tariff of fees in general practice is very desirable, not that it should be enforced in every case, which would be to commercialise our profession, but that it should afford a standard for the guidance of the public and junior practitioners. It should be graduated into, at least, two or three scales according to circumstances of the district or town; and the house rental of the family, as suggested at Sydenham, is the least objectionable test. With the exceptions of accouch

THE GENERAL PRACTITIONER.

69

ments, important surgical operations, and night visits, no "job" charges should be named, but a fair sum should be received for each visit and the medicine supplied. The year just passed having been one of great commercial difficulty has been less profitable than usual to practitioners. If the system of general practitioners were established in Irish towns, the fees to persons of rental under £25 might fairly be 5s., and 10s. to those whose rental exceeded that. Iu rural districts an additional fee might be charged for every three miles travelled to the patient's house. In the case of fees for attending benefit societies among the humbler people, a large meeting of the profession of Birmingham lately resolved that 5s. per head per annum should be the lowest charge. Payment in proportion to the number of visits would be a better plan, and a certain number might be given for a subscription, all others to be paid for. The consultant's fee should be either one or two guineas according to his standing, with a proportional increase according to distances. It should be of course paid at once after the visit, for as the feelings of a sick man and a cured one are so different, the rule accipe dum dolet should never be forgotten. The maxim in ancient Rome was exceeded, so that the Emperor Valentinian decreed that no arrangement as to fees should be made while the person was ill. Quacks of the present day extort from the fears of the patient, as well as by threats of exposure, immense sums. The time and attention needed for a consultation have always been regarded as justly rewarded by a fee double that for the ordinary visit.

The position of a medical assistant is of a much more confidential nature, and one in which the interests of the principal can more easily suffer than that of the assistant of other professional or commercial men. The public do not appreciate degrees of qualification, and they will take fancies to assistants and transfer their