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health. Another case was as follows. A woman developedmalignant diseases of the ovary and other organs in the

pelvic basin, any previous knowledge of such a disorder

being disavowed by her relatives. About two years afterher death her widower, who was a hearty man to all appear-ance, contracted epithelioma; he then admitted that hisfather had died from an abdominal tumour in another countryabout thirty years previously and that his sister had diedfrom " internal complaint." Almost contemporaneously theintimate lady friend of the lady and widower, who wasengaged to be married to the latter, developed scirrhus, and,as usual, denial was made of any historical taint. The aseo-ciate of husband and wife dwelt in a part situated miles awayfrom her fellow sufferers. The following is an additional in-stance. In the case of a female who had resided in this colonyfor fifteen years easily recognised malignant disease appearedafter certain dyspeptic symptoms, coupled with alternatediarrhoea and sickness, had prevailed for some days. She hadalways been strong, but her only son had been killed in a tragicfashion, and her illness dated from the crisis of the catas-trophe. As usual, denials were made of the pre-existence ofsimilar disease in the members of her family, but the coinci-dent was announced in the person of her husband’s sister,who was not a blood relative and who had never been to theantipodes, but had died from cancer at the other side of theglobe a few months previously.

* * * * * * *

To sum up. A definite material organism in every indivi-dual has a concomitant mind depending upon it, and inpathology, agreement or a law of similarity obtains, which,operating as the attraction of cohesion, governs the incidenceof mating. I am, Sirs, yours faithfully,

LAVINGTON G. THOMPSON, M.D.Aberd.Launceston, Tasmania, June, 1897.

* ’" On account of the great length of the original com-munication we have been compelled slightly to curtail theintroductory part and to omit several of the illustrativecases.-ED. L.

"MEDICAL GEOGRAPHY AS AN AID TOCLINICAL MEDICINE."

To the Editors of THE LANCET.

SIRS,-Will you kindly let the following corrections in myaddress on Medical Geography, published in THE LANCET ofJuly 31st, be made in your next issue. Read at p. 238, col. 2,third line from top : " but this is due to the fact that canceraffects the river-valley systems, which protect and shelterthe phthisical, whilst they harbour the materies mo,-bi ofrheumatism, and its too frequent sequel heart disease,"instead of what now stands; p. 239, col. 1, line 35, insteadof 92, read 92.3; and at line 37, instead of "a little over12" read 10.8. I am, Sirs, yours faithfully,Aug, llth, 1897. ALFRED HAVILAND.

MEDICAL MAGISTRATE.-Mr. Charles HarrisonM.D. St. And., M.R C.S. Eng., D.P.H. Camb., has beenplaced on the Commission of the Peace for the city ofLincoln.

CLAYTON HOSPITAL, WAKEFIELD. - The 110thannual meeting of the Clayton Hospital, Wakefield, was heldon the premises on July 28th, Mr. Tew, J.P., the President,being in the chair. The report showed that during the pastyear there had been 654 in-patients and 3960 out-patients.Both the income and the expenditure had been materiallyless than in the preceding year. Mr. J. W. Walker, one ofthe surgeons, read a letter from Mrs. Louisa Milnes-Gaskell,widow of Colonel Milnes-Gaskell, J.P., of Lupset Hall, nearWakefield, the purport of the letter being that on accountof the great interest which her late husband felt in theClayton Hospital she offered to enlarge the wing containingthe present Gaskell Ward so as to make an upper and alower ward, each with beds for sixteen patients. A portraitof the late Mr. Samuel Fozzard Harrison, who not long agobequeathed nearly R25 000 to the hospital, was subsequentlyunveiled by Dr. T. G. Wright, the senior physician. Theportrait has been presented to the hospital by Colonel W. W.Clapham, of Manchester, and will be hung in the board-room.

HOSPITAL ABUSE.(BY OUR SPECIAL COMMISSIONER.)

XII.-BIRMINGHAM (continued).1Abuse at the General Hospital.-The Measures taken at the

Queen’s Hospital-The General Dispensary as the ChiefOffender.-The Committee Captured by the Workmen.THE attempt at hospital reform which was initiated under

the most favourable auspices some seven years ago having,nevertheless, and as described, utterly collapsed, it is now

necessary to describe the present state of affairs. My first,care was to call on one of the visiting staff of the GeneralHospital, at which hospital the ticket system is in force

except for urgency cases and accidents. If, however, anymember of the staff thinks that a patient can afford to payfor medical attendance the patient can be referred to theoffice for inquiry. But this is not done often. There are-too many patients for the members of the staff to thinkabout such questions. It takes less time to prescribe than toinquire into the social position of the patient. That themajority of the applicants are poor people is proved by the-fact that their numbers fluctuate according to the conditionof trade. At the present moment trade is more prosperous,,so the number of patients in the out-door department hasconsiderably decreased, thus suggesting that many of theworking classes do pay for private medical advice when theyare in full employment. As for the proposal made with a.view to reduce the number of out-patients, it was franklyadmitted that the hospital visiting staff, but more especiallythe surgeons, liked to have a large number of out-patients.That cases of abuse existed at the General Hospital was.

not denied, and tickets were often very injudiciously dis-tributed. Thus an in-patient, on being told that he wouldsoon have to leave as the time generally allowed was almostterminated, replied that he bad ’’ instructed his solicitor toprocure him a second ticket." In the out-patients’ depart--ment a young girl was receiving explanations as to the streetwhere she should go so as to obtain an elastic stocking whenshe replied, "Oh, do not bother; the cabman will know I"But whatever fault might be found with the General Hos-pital for treating patients who could afford to pay myinformant was of opinion that far greater abuse of this

description prevailed among the frequenters of the Bir-

mingham General Dispensary. Further, he complained thatthe word charity" had been left out of the recommendation tickets, and the words "a proper subject for relief "substituted. This spread the idea that hospitals were notcharitable institutions and accounted for much of the abuse>This conception was still further accentuated by those hoE-pitals which compelled the patients to pay registration fees.On account of subscribing to the Hospital Saturday Fund-and the registration fees there were not a few workingpeople who imagined that they only received from the hos-pitals that for which they had made a full and sufficientpayment.

Calling on one of the leading surgeons who has taken a,

prominent part in the agitation for hospital reform, but who-is not on the staff of the General Hospital, I found that hewas disposed to criticise severely this institution. A newbuilding for the General Hospital was now almost completed,and it was said that the cost would amount to about £ 600per bed. How could the medical staff ask for economy inthe face of such conditions? If they objected to this luxuriousdisplay it might hurt the feelings of the wealthy and eminent.laymen who sat on the hospital committee. It was a sourceof personal satisfaction to these committee men to be con-cerned in the building of a palatial and model hospital,and they were not likely to study and understand whatmight be the economic consequences on the interests of the

1 The previous articles on this subject were published in THE LANCETon the following dates: (1) Sept. 26th, 1896, Plymouth and Devonport;(2) Oct. 10th, 1896, Exeter; (2 concluded) Oct. 17th, 1896, Exeter;(3) Oct. 31st, 1896, St. Thomas’s Hospital, London ; (4) Nov. 14th, 1896,Liverpool; (4 continued) Nov. 21st, 1896, Liverpool; (4 concluded)Dec. 12th, 1896, Liverpool; (5) Jan. 2nd, 1897, Manchester; (5 continued)Jan. 9th, 1897, Manchester; (5 concluded) Jan. 23rd, 1897, Manchester ;(6) Feb. 6th, 1897, Leeds; (6 concluded) Feb. 13th, 1897, Leeds ;(7) April 17th, 1897, Coventry; (8) May 1st, 1897, The Royal LondonOphthalmic Hospital; (9) May 8th, 1897, France, United Action andLegislative Action; (10) May 15th. 1897, Leicester; (11) June 5th, 1897.Nottingham; and (12) July 31st, 1897, Birmingham.

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profession as a whole. The principal abase arose in the out-patients’ department. At the Queen’s Hospital a superin-tendent registered the applicants and made inquiries as totheir social condition. But if this prevented some well-to-dopeople from coming to the hospital it did not prevent anynumber of trivial cases from among the poorer classes. Thiswas the worse abuse. Because a workman paid a penny aweek to the Hospital Saturday Fund he imagined he had theright to the services of an expert for the treatment of a slightboil. Every slight accident-even the case of a child whoruns a pin into his finger-is at once brought to the hospital.That this is not a necessity is proved by the fact that-these trivial cases all come from the immediate neigh-bourhood of the hospital. If the trivial ailment or

accident occurs at a, distance of more than half a mile,then the persons concerned have no trouble in getting out ofthe difficulty without resorting to a hospital. Thus peoplego to the hospital, not because they cannot do otherwise, butsimply because it is convenient and inexpensive. The middle’classes also think that they have a right to the servicesof the hospitals for any accident, even if it is but a simplesprain. Many people who possess ample means believe whenthey are hurt that they have a sacred right to go to thenearest hospital, and not only have their wounds dressed,but carry off with them bandages and dressing without everpausing to think that these things cost money. Yet only a’lamentably small proportion of the well-to-do classes sub-scribe to the hospitals. On analysing the subscription-liststo the various medical charities the same names will oftenoccur on three, and even five, different lists, and generallythese are the names of persons who are not very rich.It is those whose means are limited who have the highestsense of their public duties. The wealthier classes show fargreater selfishness. The number who could subscribe and donot subscribe constitute a large majority. The public alsodoes not sufficiently understand that a hospital is not merelya building ; what constitutes the value of a hospital is thequality, not the quantity, of the work done. Cases werementioned of boys who were on the out-patients’ list for fiveweeks and yet they only suffered from boils. To swell outthe list of cases treated by the record of such petty ailmentswas no real credit to a hospital ; but the public does not enterinto details, and being deceived by such figures concludes,-on the contrary, that the hospital is doing an immenseamount of work and therefore that larger subscriptionsshould be given. These evils would never be overcome tillthe members of the profession formed themselves into a

union, and this must be a fighting union. There had been

quite enough talk and discussion as to the grievances, it wasTMW only necessary to study what means of action wereavailable.On going to the Queen’s Hospital I found that the super-

intendent, Mr. Hulme, had taken his task of preventing.abuse seriously to heart. Nevertheless, he was obliged toacknowledge that being alone in the work, and having nomachinery for following up the inquiries made at the hos-pital by inquiries made at the dwellings of the applicants,he occasionally let through persons who were not fit

recipients of charity. When a patient goes to the Queen’sHospital he has to enter Mr. Hulme’s office and must theregive his name, age, address, describe the nature of hisemployment, and the name and address of his employer. Thenhe must state the number of his family and what isthe available income of his family as a whole. Fromthe address given and the nature of the employmentthe superintendent can generally form a rough estimate of ofwhat the income is likely to be. Thus, on the day of myvisit, a young woman, who stated that she was twenty-threeyears old, and yet had not been out to work anywhere, was ’,refused admittance. Her father earned two guineas a week,and some of his sons were at work, and also contributed tothe family income. Such a patient could well be treatedthrough the agency of a provident society or by a privatepractitioner, particularly if it was a slight case involving nogreat expense.My next visit was to a general practitioner who had been

for some considerable time on the staff of the BirminghamGeneral Dispensary. He expressed himself energeticallyagainst this institution as inflicting great injury on themedical profession. Persons who could well afford to

pay medical fees were constantly resorting to this charity.There was often a handsome sprinkling of seal-skinjackets in the patients’ waiting room. Taking the Ladywood’Branch, for which he had worked, he pointed out how the

immense increase of patients was quite out of proportionwith the increase of the population. Thus in 1888 therewere about 4000 patients attending at the Ladywood Branch.At the end of the year there were about 4800. The

population of the district has not increased 10 per cent. inten years, yet in 1890 there were some 6000 patients, and in1891 about 6900. At that time some of the outlyingdistricts were taken off the relief lists and the numbersfell, but nevertheless they soon rose again to about7000. The dispensary is much abused by a class justabove the working class-men who earn £2 and morea week. On one occasion some inquiries were made,and during the course of a week 25 per cent. of the

patients attending the Ladywood Branch stated that

they had more than .&bgr;100 a year. One case was mentionedof a father who earned £ 2 a week and his childrenearned 12s., 7s., and 4s. respectively. He argued that hischildren were too poor to pay medical fees, and he did notsee why he should pay them. Some 7000 tickets bad beengiven away in a year, and so great was the crush of patientsthat one of the medical officers attached to this branchdeclared that he had seen as many as 120 patients in a coupleof hours. Such hurried work, it cannot be repeated toooften, especially by the press the general public read, is notonly degrading to the medical profession, but dangerous tothe patients. No medical man, however competent, canavoid making mistakes when he has so little time to devoteto each patient. This is the side of the questionwhich most affects the general public, and therefore shouldbe specially insisted upon by all who are seeking to reformthe present abuses. There are now two medical officersat the Ladywood Branch, so the crush of patients is not sogreat, but the abuse continued a long time before thisimprovement was effected. When this branch was firstopened a local practitioner declared that it had reduced hisincome to the extent of £ 100 a year ; and two other practi-tioners, who have both been in the service of this branch,declared to me that, in their opinion, there was far moreabuse at the General Dispensary than among the members ofbenefit societies and other clubs. Then the fact that thedispensary medical officers visit the patients at their ownhomes causes a great injury to the general practitioner. Underthese circumstances a person with limited means, but stillable to pay medical fees for ordinary cases of illness, is

strongly tempted to go to the General Dispensary. He willgo there, not as the recipient of a charity, but as the purchaserof a recommendation ticket. He will therefore think thathe has paid for what he gets. He will not pause to considerif the pay is sufficient; that is the business of those who sellthe tickets, and care has been taken to efface the word"charity" from these tickets.Some years ago the Birmingham General Dispensary

published the following announcement: "Notice to work-men’s clubs, schools, mothers’ meetings, &c. The attentionof the committee having been called to the objection felt byworkmen’s and other societies to the words object ofcharity’ appearing in the tickets available for the use oftheir own members, and paid for by their own contributions,they have decided in future to omit such words from thesetickets, retaining them on those issued to subscribers for

purely charitable objects. Six tickets will be given for eachannual guinea subscription as heretofore, but all extra super-numerary tickets will be charged 4s. each."

This simply meant that for certain persons the dispensarywas to cease to be a charitable institution and become a pro-vident dispensary without, however, inculcating any true

principle of providence. The theory of a provident dispen-sary is the same as that of insurances against death oraccidents. When a person is in sound health he paysgenerally a penny a week so as to secure medical aid whenhe is ill. But here it is not necessary to make any provisionagainst a rainy day. It suffices to have 4s. at the time ofillness to buy a ticket and thus secure the medical aid.Therefore, an institution which was founded as a charitabledispensary, and as such generously supported by the dona-tions and the legacies of the benevolent, degenerated into theposition of a sick club, which enables persons devoid ofscruple to obtain relief on terms that compete disastrouslywith the general practitioner. Instead of substituting thewords " deserving of medical relief " for the old words "realobjects of charity" these latter should not only have beenmaintained, but printed in big, bold, red letters. How thetrade in tickets increased was shown by the committee ofthe General Dispensary. In their report of January, 1888,

417

- the following passage occurs : 14 Having regard to these

,figures [an analysis of the subscriptions made by their ownsecretary] and to other information which has reached themthey [the committee] are led to believe that from one-fourthto one-third of the dispensary tickets issued are used by thepersons (or by the families of persons) who have contributedto the cost of the tickets, and who cannot, therefore, fairlybe described as ’objects of charity,’ or as the class of

persons for whose benefit charitable subscriptions and dona-tions are usually intended. There is reason to believe thatthis irregular practice is especially prevalent with the extratickets, and the tendency to increase in this class of ticketsis very marked. Thus in 1865 these extra tickets were but.5 per cent. of the whole, in 1875’23 per cent., and at presentthey are 36 per cent."

,.

Since that time the management of the General Dis-

,pensary has to a large extent fallen into the handsof the working - men subscribers. In 1873 the Bir-mingham Hospital Saturday Fund gave the GeneralDispensary a donation of £ 281; in 1896 this sum was

increased to R600. As donors, the representatives of theworkmen had votes for the election of the members of thecommittee of management. At the annual meeting held inthe commencement of 1893 the representatives of the work-people assembled in force. There were two vacancies on thecommittee, the Rev. Canon Gregory and the Rev. H. Bonnorbeing ineligible for re-election because they had attended,the fewest number of meetings since the last election.As a result two workmen representatives were electedin their stead. Speaking of the General Dispensary annual’meeting of 1894, Forward, a small paper which serves as theorgan of the Hospital Saturday Fund, says : "Thesummaryof receipts and expenditure shows another fact worthy ofnotice. For the first time for many years past the receiptsfrom subscriptions, interest on funded property, anddonations, have been expended on the general work of theinstitution. That is to say, that for the first time we believesince the Hospital Saturday Fund has been in existence thedonation from it has been applied to the purpose for whichit was given. So long as there is scope for additional workin the town we do not think any institution has a right tosave money out of its ordinary income. Whether the altera-tion in the policy of the dispensary is to be attributed to theworking-men representatives on the committee or not wecannot say ; but whatever the cause may be, the dispensaryis to be congratulated on the wise policy which has beenpursued during the year."This passage meets an objection made to me by some of

the former medical officers of the General Dispensary. Theycomplained that the dispensary made profits out of the sub.scriptions, which they employed to build branches at greatcost, provided even with bedrooms in the upper part of thebuilding. The fact that the workmen had obtained a strongrepresentation on the committee of the General Dispensarymaturally gave rise to many objections, particularly when itwas found that the workmen were very regular in theirattendance, and, by showing greater devotion to the businessat hand, soon obtained a preponderating influence. Thefact that they came in an organised body and carried theelection caused them to be described as " daylight robbers."They were accused of initiating a "subtle predatory policy,"and the gentlemen who gave guineas instead of pennies werewarned that they must follow similar tactics to save thecharities from being misappropriated by the working classes.Nevertheless, and in spite of the fact that the workmen arenow in a majority on bhe committee, the subscriptions have notfallen off, there is no complaint as to mismanagement, andthe average attendance at committee or business meetingshas never been so regular and numerous. But all this, how-ever favourable it may be from one point of view, does notmeet the question of abuse. It is still the opinion of a greatnumber of general practitioners and others that an enormousamount of abuse prevails at the General Dispensary. It hasbecome less and less a charity, more and more a providentdispensary. Mr. Smelley, the principal organiser of theHospital Saturday Fund, expressed the opinion that whatabuse exists arises out of the patronage of subscribers, whoare apt indiscriminately to give away tickets. But, headded, the workmen are interested in preventing abuse, andhe invited any medical man connected with the dispensaryto signalise any case of abuse, guaranteeing that the name ofthe person in question would at once be struck off the books.

This, however, is not so easy to do. In the absence ofsystematic inquiry, the fact that the patient is able to pay

proper medical fees is generally only ascertained after he hasobtained medical relief. The medical officers also are toobusy to make inquiries ; this constitutes no part of theirwork, and it is only accidentally that they discover a few ofthe many cases of abuse. It is undoubtedly more pleasant toattend a better class of patients and to visit the sick wholive in houses that are fairly clean and well kept. Also,many general practitioners now established in Birming-ham have commenced their careers as medical officersof the dispensary, and they would not have acquiredtheir present popularity if they had made enemies byinquisitorial proceedings against their dispensary patients.A young practitioner who is seeking to acquire a reputationnaturally prefers that his skill should be appreciated bywell-to-do people. It is not very probable, therefore, thatwhen he has the good fortune to meet with a better classpatient he will at once take measures to have his name struckoff the books. In such a case the interests of the present andof the individual clash with those of the future and of the

profession. It is only when the young practitioner leaves thedispensary and suffers from the deeds of his successors thathe fully realises how his own conduct was lacking inforesight.

(To be continued.)

BIRMINGHAM.

(FROM OUR OWN CORRESPONDENT.)

Druggists’ Prescriptions.AT a recent meeting of the Health Committee a report

was read on a number of samples of medicine prepared fromprescriptions by druggists in different parts of the town. Intwenty-four instances irregularities were found, but theseappeared to be due more to careless or unskilful dispensingthan to intention to defraud. For example, in one casethe principal drug, though far more expensive than the otheritems of the prescription, was found to be the one in excess.This, the report pointed out, was a matter of at least asgreat importance as was the protection of the customer fromfraud, as the action of a medicine often depends upon thecare with which the proportion of the various drugsmentioned in the prescription is dispensed. After considera-tion the committee ordered that a prosecution should takeplace in one case, and that in about a dozen others thedruggists should receive a written caution.

Death under an Anœsthetic.A sad fatality lately occurred in the rooms of a

dentist, when a man, aged twenty-seven years, met his deathon the administration of A.C.E. mixture taken for the extrac-tion of teeth. There was evidence to show that it wasskilfully given by a medical man.

Boxing Contests.

, In the recent case of the young man who lost his life at

a boxing contest held at the Olympic Club the grand juryat the assizes found no true bill. The case was thereforethrown out. Still, many are of opinion that such contestsare brutal and degrading. Some belief exists that the law issufficient to prohibit such exhibitions, and that in theinterests of humanity and social order they should bestopped.

Foul Air in Sewers.The above subject forms matter of complaint in the local

press. A veteran Fellow of the Royal College of Surgeonsleads the charge and formulates grave accusations againstthe system which admits of the escape of foul air from thesewers into the streets and houses. Much is to be said onthe subject, which in the future must command theattention of the authorities, though involving great outlayand much consideration.Aug. 8th.

MANCHESTER.(FROM OUB OWN CORRESPONDENT.)

Manchester Port Sanitary Authority.DR. F. W. BARRY, one of the inspectors of the Local

Government Board. held a formal inquiry at the ManchesterTown-hall on the 28th ult., with regard to the regulatiors