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TWENTY-SECOND NATIONAL CONFERENCE OF CHARITIES

Poor-law Infirmaries and workhouses. Confining our comments to the latter, we would briefly say that there were in London twentyfour Poor-law Infirmaries, containing 12,445 beds. In nearly every case the infirmaries which contained what we call pauper sick were in buildings separate from the workhouse. This is worth remembering, it being the exception rather than the rule in the United States. The judgment of the committee was that the poorest class treated in these Poor-law Infirmaries is, in fact, much better provided for than the poor just above the pauper class, for whom, when they are suffering from chronic or incurable complaints, no hospital accommodation is provided except in charitable institutions. The committee criticised the general management of the workhouse infirmaries, because the professional care of the sick was left to a superintendent with two or three assistants, the infirmaries oftentimes having from five to six hundred patients. It was clearly pointed out that the responsibility of the medical superintendent for the general control of the whole establishment in all its branches was incompatible with the proper discharge of his duties as a doctor, and it was suggested that the professional care of the sick should be given to a medical staff. The committee further criticised the crowded condition of these infirmaries.

It would seem that the cost of these establishments was out of proportion to the professional and nursing care received by the patients. The committee reported that the average annual cost was £30 and 175., or about $3.56 per capita per week. The average weekly cost of all paupers treated at the Tewksbury Almshouse was $1.91 per week, and at the State Farm at Bridgewater $1.88 per week. These last two figures obviously count the cost of all classes of patients. The average weekly cost per capita of the six lunatic. hospitals in Massachusetts is $3.33, $3.48, $3.48, $3.37, $3.65, respectively, and for the chronic insane at the Worcester Asylum $3.04 per week.

I doubt if any one even casually familiar with the care of the insane in State hospitals in Massachusetts and the Poor-law Infirmaries in England could for a moment question the superiority of the former. The excessive cost is certainly a damaging evidence against the Poor-law Infirmaries.

Leaving out other interesting points for want of time, what can be said of the nursing? The Committee of the House of Lords said:

"Nursing reform has made great advances in the Poor-law Infirmaries, as well as elsewhere; and the employment of unskilled pauper nurses, which used to be the rule, has now become a rare exception, though they are to be found in the sick-wards of the workhouses, where a large proportion of the less severe cases are retained." Many of the infirmary nurses have gone through a regular hospital training. About one-half of the matrons, however, are women who are not regularly trained nurses; and the appointments are made by the guardians at their own discretion. High praise was paid to the efficiency of the nursing staff in some of the new infirmaries. Dr. Bridges, medical inspector of the Local Government Board, estimated that about one-fifth of the nurses employed were trained graduates. The whole number of nurses in infirmaries was said to be 888, or about one to every ten patients. This proportion is quite as large as it was in some of the general hospitals in the United States fifteen years ago. The wages paid to infirmary nurses was as high as 30 a year, or about $12.50 a month. Miss Louise Twining, who is favorably known even on this side of the water, is authority for the statement that there appeared to be no difficulty in getting a sufficient supply of good material for nurses. In 1891 the parish of Marylebone Infirmary gave its pupils a regular three years' course of training, and other infirmaries have since followed its example.

In the course of this inquiry it was shown through witnesses that the wards of the workhouses, as a rule, as well as the nursing, were of an inferior character, except in the small institutions, where the character of the nursing was in a general way equal to many of the general hospitals. I am informed on credible authority that by reason of this report of the Committee of the House of Lords great improvement has been made in the quality of the nursing, and that the criticisms and recommendations made by the Committee of the House of Lords have had much force and have worked great good among the pauper sick under charge of the various parish infirmaries in London. The same general advancement has been made in Birmingham, Manchester, Leeds, Liverpool, and other urban districts of England. Indeed, the history of almshouse nursing would be quite incomplete without mention of the pioneer work of Miss Agnes E. Jones, who instituted great reform in the workhouse at Liverpool, which is one of the largest in England. In 1863, only

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three years later than Florence Nightingale's inception of the school for the training of nurses, the medical world was stirred by a commission of the Lancet appointed to investigate the nursing of the sick poor in infirmaries. Without entering into the details, it is sufficient to say that the report of this commission led to many reforms, although slight in proportion to the crying need. It was at this time that Miss Agnes Jones entered the workhouse at Liverpool, and the result of her endeavor is well stated by another: In less than three years she had reduced one of the most disorderly hospital populations in the world to something like Christian discipline, such as the police themselves wondered at. She had led, so as to be of one mind and heart with her, upwards of fifty nurses and probationers. She had converted the Poor-law Board to her views, two of whom bore witness to this effect. She had disarmed all opposition and all sectarian zealotism, so that Roman Catholic, High Church, and Low Church, all literally rose up and called her blessed. Miss Jones, after a brief period of three years, died of typhus fever, a martyr to the cause to which she had given such distinguished work."

Time does not warrant further elaboration of this subject. The splendid progress made in the care of the sick in our general hospitals, and the work of the training schools in sending out women well equipped for the various branches of philanthropy, need no eulogy before this Conference. The advance is sounded that can never know retreat. The next development is to put the medical care and nursing of the sick poor in our almshouses on the same rational, wholesome basis that obtains in general hospitals. There is many an American Agnes Jones whose love of humanity will gladly impel her devoted service among the afflicted, unfortunate dependants in our almshouses.

What of the result? The condition of the sick poor will be ameliorated, a larger number restored to wage-earning, the mortality reduced, and the tendency to pauperism lessened.

Medical Charity.

PROVIDENT MEDICAL ASSOCIATIONS.

BY W. H. PRESCOTT, M.D.

The whole question of the administration of the medical charities of a large city is one for which a solution has long been sought. For years most physicians and many philanthropists have viewed with alarm the rapid growth of hospitals and dispensaries, feeling that the tendency was toward a medical pauperization of the people. Each large dispensary or out-patient department has felt the competition, and has put forward all its energies to increase its clientèle without paying any regard to the kind of people attracted. It is, however, easier to see the faults of the system than to suggest a remedy at all satisfactory.

In what may be called the regular charity work of a city a great advance was made when the Associated Charities was started, with its system and means; but the application of this principle to the medical charities does not seem practicable or advisable. Undoubtedly, some good might be done if each out-patient department or dispensary could keep a person at the entrance to inquire into the civil condition of each applicant for relief; but wrong addresses and lies as to the financial condition render most work of this kind unsatisfactory. It has been tried many times, but usually has been abandoned as of little use. The attempt has also been made to influence the patients to give a little something for their treatment by establishing boxes in the different rooms, but it was never a success. So it is with most of the attempts to provide a remedy.

The applicants for relief may be divided into three classes, the "rounders," those able to pay, and the needy poor.

No one who has had any experience in different hospitals and dispensaries can have failed to notice the large number who go from one clinic to another, seemingly always needing and of course always

receiving treatment.

A black list should be kept of these medical vagrants, and no treatment should be furnished.

There are two objections to this: first, the objection already made, that it is so difficult to keep track of such cases, when disguises, wrong addresses, and false names are so common; and, second, it may happen that a rounder may be really sick and need treatment. This danger was well illustrated in the following case which occurred when I was assistant superintendent of the Boston City Hospital. A man was brought to the hospital in the police ambulance, having been found in a doorway, who complained of severe pain in the abdomen. Pulse and temperature normal. He proved to be a man whom I had admitted many times for what turned out to be alcoholism. The symptoms were always the same. I should have sent him to the almshouse which is on an island in the harbor

to sober off, had it not been that it was too late for the ambulance to catch the boat. I agreed to keep him. In thirty-six hours he was dead of acute hemorrhagic pancreatitis. Although a trip to the island would not have influenced his case in any way, I was glad the boat had gone.

Many of those well able to pay give wrong addresses or feel that free medical treatment is their right at any of the dispensaries, especially if it be a city institution. Many instances are on record where patients with hundreds and even thousands of dollars on their person have come for treatment to a free hospital.

Another source of danger is to be found in the rapid increase of rooms for specialists. Each specialist naturally wants to see as many cases as he can, and therefore does not pay much attention to the class of patients who come to see him; and, if he were particular, it is quite a delicate question for him to solve how best to find out whether a patient can afford to pay or not. Clothes are of little help in this respect, for sometimes good clothes are a relic of former wealth or a gift from rich relations.

Of all the means for limiting the amount of free medical attendance, and one which has been exciting a good deal of interest of late, the provident medical associations have been the most successful.

These also have their weakness; but it seems to me that the weakness is not inherent in the associations, but come from a misconception of their needs and the causes which have led to their establishment.