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MEDICINE, ITS PRACTICE AND ITSPUBLIC RELATIONS.

CHAPTER XIL1 1

THE POOR-LAW AND MEDICAL SERVICE (Contineted).The Poor-law Medical Service in Ireland.-Death of Mr.

William Smyth of Dungloe.-1’he rievances of the

Dispensary Service.-The AbsoZ’utely Necessary Reforms.THE condition of the Poor-law medical service in Ireland

has for many years been a scandalous blot on the adminis-tration of the country. Politicians, journalists, and en-

lightened general opinion have condemned the system ; themedical press has called loudly and persistently for its im-provement ; the Irish Medical Association more than four

years ago published a statement of studied moderation everyword of which showed the necessity for immediate reform ;the leaders of medical opinion in Ireland, in the medicalschools of Dublin, Belfast, Galway, and Cork have advisedtheir pupils not to take office in the service-advice whichhas not been neglected ; and the Local Government Board ofIreland, under whose jurisdiction the dispensary districts lie,has admitted the necessity of ameliorating existing condi-tions. But nothing has been done that really counts whenthe magnitude of the evil is realised.

In the same way as the case of Mr. J. Lamont serves toillustrate by one lurid story the troubles of the ScottishPoor-law medical officer, so the infinitely sadder event ofMr. William Smyth’s heroic death may be regarded as asupreme example of the trials of the Poor-law medicalomcer in Ireland. Here the sacrifice of a noble lifeproved terribly dramatically and finally that the Poor-lawmedical service in Ireland must be reformed. Mr. Smyth’sdeath is too recent to need more than the briefestrecord for all its tragedy to recur to our mind. He was

dispensary medical officer of Dungloe No. 2 District,co. Donegal, and died on Nov. 22nd, 1901, from an

attack of typhus fever contracted in his efforts to fight thatdisease which had broken out in part of his district, theisland of Arranmore on the western seaboard of Donegal.Mr. Smyth was most anxious to remove his patients to theisolation hospital at Glenties on the mainland but met withsuch difficulties and opposition that Dr. B. McCarthy, LocalGovernment Board inspector, was sent to his assistance. Asthe fishermen would neither lend their boats nor row thefever patients across, an old and unseaworthy boat was pur-chased by the relieving officer and the two medical men, whowere novices at rowing, set off for the island. Here freshdifficulties arose, as the friends of the patients opposed allremoval which was only accomplished by the aid of thepolice. On the homeward journey the medical men haileda boat which was manned by six policemen and asked to betaken in tow to Burton Port, but these men refused torender any assistance, fearing infection. Tired out withtheir unaccustomed exertions the two intrepid rowers reachedBurton Port at last where an ambulance awaited theirarrival and the patients were removed to Glenties. Mr.Smyth caught typhus fever and died in a few days,a veritable martyr to his splendid sense of duty.This narrative epitomises the position of the Poor-

law medical officer in Ireland. Here we have a man

left single-handed amid a frightened, ignorant, callouspeasantry, to combat a dangerously infectious disease asbest he could. The sea must be passed before he canreach the hovels of the sick; he has no skilled assistanceand no lay assistance. The representative of the depart-ment under which he works gives strenuous help at thelast, but the dispensary medical officer dies at his post. Andhe dies for no purpose, for if similar circumstances aroseto-day there is no guarantee against similar issues.The manifest and manifold grievances of the medical officers

of the Poor-law or public dispensary service in Ireland havebeen set forth frequently and clearly. In the columns of the

1 Chapters I., II., III., IV., V., VI., VII., VIII., IX., X., and XI.were published in THE LANCET of Feb. 18th (p. 447), and 25th (p. 517),March 4th (p. 593), 18th (p. 736), and 25th (p. 817), April 1st (p. 877),15th (p. 1017), 22nd (p. 1089), and 29th (p. 1151), and May 6th (p. 1218)and 13th (p. 1287), 1905, respectively.

Journal of the Irish Medieal Association,2 the Medioal Pressand CiratÛar, and rrHE LANCET full particulars will befound of all the abuses under which the luckless officer ofthe Dispensary Medical Service abides. But no purview ofthe medical profession in its public relations can be completewhich does not deal with the matter in detail, however oftenit may have been dealt with before, for the dispensary medicalofficers are the Poor-law officers, sanitary officers, and generalpractitioners of Ireland, and a large proportion of the Irishpopulation comes into contact with no other medical men.Few people in England understand the hardships underwhich the Poor-law medical officers work in Scotland or

Ireland and some may even be content to believe that theattitude of the bureaucracy, which stigmatises the officers ofboth services as chronic malcontents, is justifiable.The main grievances of the medical officers of the Poor-

law system in Ireland are the hardship of their work, thescantiness of their pay, the absence of promotion, the diffi-culty of obtaining holidays, the absence of definite arrange-ment for superannuation pensions, and their anomalous posi-tion as servants of the Poor-law guardians. They can beconveniently considered in the order in which I have setthem down.The following are the duties appointed for the dispensary

medical officer by the Irish Local Government Board in

respect of the dispensary work. He must attend the

dispensaries on such days and hours as the Local GovernmentBoard may direct and afford outdoor medical relief to all

poor persons presenting the " black ticket " for dispensarytreatment. He must attend the patient’s residence when hereceives a " red ticket " and treat the case to its fortunate orunfortunate issue. He must keep a register of all patientsattended either at their homes or at the dispensary and sendthe book monthly for inspection by the guardians, and hemust also give a certificate, if needed, of the state of healthof any dispensary patient if called upon to do so by theguardians. He must keep stock of his drugs and appliancesand make quarterly application to the Local GovernmentBoard for new supplies. He must almost invariably dispensehis own medicine, for the last annual report of the LocalGovernment Board of Ireland shows that in 746 dispensarydistricts only 47 compounders or dispensers are kept. Hemust send samples out of each consignment of drugs to betested, he must pack up and return all empties. He must

report to the guardians monthly his hours of attendance andthe duration of his stay at the dispensaries. He must sendquarterly to the Local Government Board and to the board ofguardians a statement showing the number of tickets issued,the number of tickets cancelled, and the number of lunaticscertified, as well as the number of cases that have occurredof small-pox, typhus fever, diphtheria, typhoid fever, andscarlet fever. He must answer questions about dispensaryarrangements and anything else that either authority maywant to know.The tickets alluded to as red " or " black " are in the

gift of the guardians and are issued by them personally orthrough their relieving officers or wardens to the sick poor.The black ticket entitles its holder to medical advice andmedicine at the dispensary ; the red ticket is an order tothe medical officer to visit the patient at his home. Theguardians are supposed to be the sole judges of who is

"poor," but the wardens, as the official ticket issuers arecalled, can distribute the tickets as they like, and they fre-quently abuse the discretion vested in them. This does not

signify so much in the matter of the black ticket as themedical officer has to attend at the dispensary at certainhours and it does not make much difference to him when heis there if some of the patients to whom he has to administercharitable relief can really pay for his services. Every suchabuse of the system diminishes the medical man’s chance ofmaking money out of private practice, but in many districtsof Ireland this chance is so slight that the luckless medicalmen see it made slighter without particular resentment.But the matter is different when red tickets are abused. Thered ticket is an order, and some boards of guardians construeit as a peremptory order, to visit the sick at their ownhomes. These homes may lie widely apart from each otherand from the medical officer’s house, journeys in cars overvile roads or in boats over rough seas may be necessitated,so that anything like an abuse of the issue of red tickets

2 See especially an admirable "Report on the Poor-law MedicalSystem in Ireland, with special reference to the Dispensary MedicalService" by the Special Commissioner of the British Medical Journal—British Medical Journal, March 26th, 1904.

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leads to most serious consequences. The medical man’stime is occupied in long and unremunerative travel andhis shallow purse is drained by boat- and cart-hire. Butthese things do not prevent the wrongful issue and employ-ment of red tickets, while unfortunately it is not easy to

say in Ireland who is and who is not entitled to the benefitsof rate-paid medical attention.So much for the dispensary officer’s duties as a dispensary

officer pure and simple, and they would seem to account formuch of his time. The dispensary medical officer is, how-ever, medical officer of health for his district also, and thewhole sanitary administration of rural Ireland, such as it is,is in his hands. The larger cities, Dublin, Belfast,Londonderry, Limerick, and Cork, for example, have a

proper medical officer of health, but there is no provision ofcounty medical officers as obtains in Scotland. The dis-

pensary medical officer is the only person in the countrysidewith an elementary knowledge of sanitation, but he ispowerless to do anything. His additional salary as healthofficer amounts to only some fo20, his time is over-occupiedwith his dispensary duties, he may have a few privatepatients to whom he must give a certain amount of atten-tion, while he must feel that any efforts which he makestowards improving matters will be largely wasted. The

people will not understand his object and the majority ofhis uneducated masters, the guardians, will share their

ignorance. The dispensary medical officer is also the

public vaccinator, factory surgeon, and very usually theregistrar for births, deaths, and marriages. For these

appointments he receives small fees which he is glad to earn.He also attends the men of the Royal Irish ConstabularyForce and the coastguard and lighthouse staff. Such is abrief enumeration of the work performed by the dispensarymedical officer.The average pay is a fraction above R100 per annum as

dispensary medical officer. To this pittance has to be addedfrom E10 to .625 received for the discharge of sanitaryduties but with this addition we find that out of 810dispensary medical officers 500 receive less than .6150 perannum, only 2 receive more than 200, and 32 receive under100. Fees of 2s. 6d., 2s., ls., and 6d., as registrar, vaccina-tion officer, certifying factory surgeon, and surgeon to theRoyal Constabulary and the coastguard and lighthouse staffhave also to be added, and like the English guardiansthe Irish guardians point to vaccination fees as an

excuse for starvation salaries. In the dispensary servicethere is virtually no promotion, so that a man cannotcomfort himself for taking a small salary while he isyoung with a feeling that as he grows older and the ex-penses of a family begin to fall upon him his income willincrease to meet his needs. Nor is there any certainty of apension. It is within the discretion of the board of guardiansto grant a pension to a retiring dispensary officer but theycan refuse it to anyone who has offended them. Then theunfortunate medical man, who cannot be expected to havemade any great provision for old age out of his income,must toil on in harness until he dies, being forced by penuryto continue the work, however unfit to do his duties.

Tables I. and II. show the superannuation allow-ances, some of them terminable at a certain date, of allmedical dispensary officers and workhouse medical officers

paid during the year ending March 31st, 1903, which Ihave extracted from the figures in the last report of theLocal Government Board of Ireland. The age, period ofservice in years, and salary are also given.These figures, taken as a whole, form an unanswerable

indictment of the system. We have only to look at thelong average length of service and the low averagesize of pension to come to this conclusion. I have placedan asterisk (*) against a few special cases. It will be seenthat out of 82 hard-working men 13, or nearly one-sixth, werecompelled to remain in harness until over 70 years of age,one working until his eighty-fourth year. The Local Govern-ment Board of Ireland acknowledges that this position existsbut seems unable to bring itself to take the initiative in

promoting any remedy. No one should be placed incircumstances like those of the Irish dispensary medicalofficer and be compelled to abide in them until old ageovertakes him, because he has been unable to makeprovision for the end of life and has no certainty ofobtaining a pension. Note the case of the dispensary Imedical officer numbered in the first table "63 "who was

Ifor 45 years in the service and who, when verging on80 years of age receives a pension of a little more than

TABLE I.-Medical Dispensary Offleers. _

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TABLE II.- Workhmlse Medical Officers.

30s. per week. From one such text a sermon of completeindictment of the whole system could be preached. Note,also, the number of retirements at an unusually early age.The cause assigned to most of these retirements is physicalbreakdown. The exacting nature of the life of the Irish

dispensary medical officer could not be shown in a more luridway, and a factor in producing this frequent breakdownis the monotonous persistency of the work. There is nodefinite regulation providing for any recreation or holidayleave for the medical officers. Until recently the medicalofficer got no holiday at all. The guardians refusedto make any grant towards the expenses or the fees of asubstitute, and the medical officer never had money enoughto pay a substitute and also to go away. And so

to the manifest detriment of his own interests and thoseof the community whom he served, he remained day in andday out on his dreary rounds. The position has been im-proved by a general order made in 1899 by the Local Govern-ment Board of Ireland for an annual vacation not exceedingfour weeks for each medical officer, while three years laterrecoupment was provided from the Board of one half of theamount paid by the guardians with the Local GovernmentBoard’s sanction. It will be seen that the unfortunatemedical officer has to get the acquiescence of the guardians,who in their turn have to get the sanction of the LocalGovernment Board. There ought not to be any necessity forall this routine. In every walk of life it is now recognisedthat a hard-working employe has a right to a holiday, thathe ought to be allowed to go as a matter of right in enjoy-ment of his salary, and ought not to be taxed by having topay a substitute. The fact that many, a majority, of theofficers of the Irish Medical Poor-law Service do now getthese fitting opportunities for a vacation shows that thelocal authorities who control the service are waking up to thesituation. Soon the officer’s right to a holiday will be takenby him as a right, at present it is yielded to him afterrequests, and perhaps bickering, as a concession.And over and above all these grievances there is the

medical position to be remembered. Always the razor isused to cut the firewood. The scientific man is never spared,if the guardians or the Local Government Board of Irelandcan help it, by a proper supply of assistants to take the loweradministrative details off his hands. Imagine 746 dis-

pensary districts with but 47 compounders, and 119 dispensaryassistants among them, so that the great majority of thedispensary medical officers have to dispense their ownmedicine. Again, there is a dearth of midwives who mightact as assistants to the medical officers and spare themmuch arduous waiting and watching, for 551 women do notgo far when it is remembered how much of the countrythe poor relief system of Ireland has to serve. Theunpacking of medicines, the despatching of samples, and thereturning of empties, clearly the work of a boy or porter ata few shillings a week, have to be done in most cases by themedical officer himself Then his clerical work has to beconsidered. He has to keep records of his work to be shownto the guardians, he has to supply statistics for the con-sideration of the Local Government Board, and no amount ofoverwork is allowed to excuse a default.Reform is urgently needed and everyone knows it. There

should be better pay, there should be more assistance, thedual control of the dispensary medical officers by central andlocal authority should be less vexatiously in evidence, the

elections of the medical officers should be managed on properprinciples, and the Local Government Board should supportthe medical officers where the local authorities try to oppressthem. Everyone knows the crying need of these things butnothing is done.

- (To be continued.)

ROYAL COLLEGE OF SURGEONS OFENGLAND.

AN ordinary meeting of the Council was held on May 13th,Mr. JOHN TWEEDY, the President, being in the chair.

Mr. Herbert J. Paterson was introduced and the PRESI-DENT handed to him a cheque for the amount of theJacksonian prize, together with a document declaratory ofthe award.

It was resolved that diplomas of Membership should beissued to 108 successful candidates.A report was circulated, which had been drawn up by Dr.

P. H. Pye-Smith, chairman of the Laboratories Committee,on the history and work of the Laboratories since their open-ing in 1890. The report was received and entered on theminutes and the best thanks of the Council were given toDr. Pye-Smith for his interesting and valuable account.The PRESIDENT reported that the solicitor of the College

had made inquiries regarding the person calling himselfwrongfully F.R.C.S. and stated that he had instructed thesolicitor to take steps with a view to prosecuting this personfor his false assumption of the title F.R.C.S.-The proceed-ings of the President were approved and confirmed.The Council resolved to give a reception at the College to

the members and visitors of the Atlantic Union on a date tobe settled later.The Council elected a Fellows Dinner committee.A letter was read from the registrar of University College,

Sheffield, stating that in the Charter for incorporating aUniversity of Sheffield which the Privy Council has recom-mended His Majesty the King to grant, provision has beenmade for the Royal College of Surgeons of England to havea representative on the University Court and asking thatsteps may be taken for the appointment of such a repre-sentative. The Council appointed the President as theirrepresentative.The PRESIDENT reported that he had received a letter from

Mr. Thomas Bryant presenting to the College some lettersand a photograph of historic interest.-The best thanks ofthe Council were given to Mr. Bryant for his gift.The PRESIDENT reported that he had approved of a pro-

posal by the executors of the late Mrs. Jane Begley topurchase £ 800 2 per cent. Consols in the name of the RoyalCollege in satisfaction of Mrs. Begley’s bequest to theCollege.-The President and the Vice-Presidents were re-

quested to draw up regulations for the award of the Begleyscholarship.The Council resolved-That it be referred to the committee of management to consider and

report as to the desirability of treating chemistry, physics, and biologyas subjects of preliminary education and of requiring that an examina-tion in them should be passed before the recognition of the commence-ment of medical studies, and further to report as to the desirabilityof the two Colleges approaching the universities and other examiningbodies with a view to adopting a five years’ curriculum of professionalstudy from the date of passing the preliminary science examination.

ASYLUM REPORTS.

City of London Asyl1lm (Ann1lal Report for 1904).-During the year under review there were admitted intothis asylum 178 patients; the discharges amounted to 142,of whom 57 had recovered, and the deaths to 34. Onlyone of the deaths was due to pulmonary tuberculosis, avery satisfactory record. The resident population at theclose of 1904 was 565, 257 being private patients. The

visiting committee reports the resignation of the medicalsuperintendent, Dr. Ernest W. White, who retires upon aliberal pension, and expresses its high appreciation of hisservices. He is succeeded by Dr. R. H. Steen. The privatedepartment continues to be an important feature of thisasylum ; a table is given showing its steady growth since itsinitiation in 1892. During 1904 86 private patients werereceived. The profits arising from the maintenance of this