POWER OF ORDERING SICK DIET.

259

When that national benefit shall have been fully and fairly established, it may be advisable for the State to promote wellconsidered arrangements for mutual insurance,—in which, after adequate funds for the supply of all other necessaries in sickness are secured, some facilities may be offered to larger contributors for the free selection of their medical advisers.*

VI.—As to the power, exercised by the Medical Officers of Districts, to direct the supply of Necessaries (not being Medicines) in sickness, at the cost of the Rate-payers.

§ 22. The promoters of the late inquiry assented fully to that feature of the Irish system, which in a social point of view, constitutes its main difference with the English law.

The almost unlimited power possessed by the medical officers here, of recommending-or as some call it, ordering-articles of diet, vinous and alcoholic stimulants, even fuel, flannel, and other personal comforts, for the sick, was stated not only to be a source of constant altercation between these officers and Boards of Guardians, but to offer direct temptation to the poor to make use of the doctor as the key to the parochial reliefchest.

The notions of some medical officers, as to their duty in this matter, were rather extravagant. One gentleman thought that the relieving officer ought to obey the directions of any and every medical practitioner who might be willing to give them.†

Another admitted that, when he had an average of forty poor persons at his surgery in a morning, he usually wrote twenty or twenty-five orders for "medical comforts."

He avowed that he took upon himself to judge of the destitution of applicants, and that he considered it his duty to attend to their wants. So that on hearing the common complaint-"I have no means of support-I must have some relief

*Certain conditions or regulations considered essential to a sound system of mutual assurance for medical relief, are stated in Supplementary Note C.

+ Evidence, 2381. Ibid. 1285-1297. | Ibid. 1299-1301. Ibid. 1344.

260

ADMINISTRATIVE ANTAGONISM.

-some bread and meat," he, not doubting the truth of the statement, and without the right or possibility of making proper inquiry, at once gave them "orders" for food!*

No wonder that so complete an usurpation of the functions of the relieving officer kept the two officials in a constant state of antagonism. Whether the doctor might not have performed this duty better than the officer legally appointed for the purpose, is quite another question.

§ 23. The Boards of Guardians, however, are, and must continue to be the ultimate courts of appeal in the matter;† and after such unsatisfactory discussions with their officers, these Boards must be fully excused for their general impression, that the doctors order "dietetic tonics to save their own drugs.”‡

When the cost of these "extras" nearly amounted to the sum of the medical salaries,||—when the supply had "doubled within the last two or three years"¶-the local authorities cannot be justly blamed for their suspicions.

Mr. Kingsley might have been justified in saying that, "the notion with rural Guardians is, too often, that medicine is to cure everything, when, in fact, food is what is required ;"** but he also testified to the "continual jealousy and irritation" prevailing in most districts "about medical officers ordering too many necessaries;" "substituting them for medicines."++

Mr. Oxenden, whose disinterested position and knowledge of medicine entitle his opinion to much weight, stated that these recommendations are given "a great deal too often;" that a free provision of medical aid‡‡ ought to be wholly unconnected with power to interfere in the grant of other relief.

* Evidence, 1306-7. See also Rev. E. J. Howman's evidence :-"They (the medical officers) constitute themselves into irresponsible deputy relieving-officers.-1875. + Mr. Inspector Weale's evidence, 419. Ibid. 352. ** Ibid. 1560.

|| Ibid. 1783.

¶ Ibid. 2875.

++ Ibid. 1555. See also his story of a medical officer who was turned out for ordering too many of these good things, but being re-elected in three years, the Guardians found that they had not taught him the lesson they intended, for "he is as liberal as ever."-1558.

‡‡ Ibid. 1472.

DIETETIC TONICS AND DRUGS.

261

§ 24. The present practice is doubtless one of the main causes of the pauperizing effect of English medical relief.

It would, in itself, almost justify an entire change of system. And as has been shown, it might be superseded, to a great extent, and with great benefit to society, by a well-regulated mutual provision of those "comforts" by means of provident associations.

If drugs were supplied by local Boards, even though a reduction in the cost of dietetic adjuvants did not follow,-the district surgeons would no longer be liable to such diagreeable imputations. And this leads us to the next point.

VII. As to the parties by whom the Medicines for the Poor are, or ought to be, provided.

§ 25. Every one knows that, with few exceptions, drugs and other appliances are at present furnished by, and at the cost of, medical officers, under the Union contract. The reform pro

posed long ago, and still urged with increasing force, is, that articles of the materia medica, like nutriment and cordials, should, in general, be provided by local Boards.

If medical officers are subjected to accusations, by interested parties, on the last head-i. e., sick diet,—their contracts (to furnish medicines) lead no less to unwelcome calculations, by other parties totally disinterested, as to the possibility of their fulfilling such engagements, without loss to themselves, yet with full justice to their patients.†

For instance, Mr. Kingsley, after an extensive inquiry, came to the conclusion that costly medicines, such as cod liver oil,

Evidence, 1378-9, 1445.

+ One of the medical officers examined in 1844 was too communicative on this point. He acknowledged that instead of supplying leeches and expensive drugs, which he could not afford, he got rid of the cases as soon as possible, by sending them to hospitals and dispensaries. (Ans. 2317.) Or if he had a doubt whether to order medicine or food, he should prefer ordering food to ordering medicine which he could not afford to provide.-2348.

262

OFFICIAL DISCREPANCIES.

quinine, and sarsaparilla, "cannot be given except in charity," at the average salary of the medical officers.* One surgeon, it was reported, feeling his inability to incur the expense, applied to the Board of Guardians for a grant of cod-liver oil, in a case where it was much needed.

The Guardians referred the application to the Poor-Law Commissioners, who replied that, if the oil were given as a medicine, the medical officer was bound to pay for it; if as food, it would be a different case. They might as well have asked the patient, after swallowing it, which he considered it. Of course, the Guardians gave themselves the benefit of the doubt, and at once refused to grant the request.†

It appears however that the Poor-Law Board has decided that cod-liver oil is a drug. A medical commissioner was not needed to enable them to arrive at this remarkable verdict. They, however, left the special supply of this remedy to the discretion of the local Boards. The liberal Guardians of Kingston (and they alone) actually agreed to include it among medical "comforts," at their own cost! O si sic omnes !

§ 26. It was the opinion of Mr. Cane, of the Central Office, that a supply of drugs from dispensaries, to be established by the local authorities, would be advantageous in places where the population is not widely scattered, and where economical arrangements could be made for dispensing.‡

The Inspectors however differed with their official colleague. They advised leaving the matter as it is, in the hands of the medical officer, on the ground that he has a pecuniary interest in supplying good drugs, since by so doing he economizes time; || a view of the case in which the medical staff generally concur.¶

On this subject Mr. Cane was at issue, also, with a former Commissioner, who assured Lord Ashley's Committee** that they had never been able to find a single instance in which a Union dispensary had succeeded; while Mr. Cane in 1854 "did not re| Ibid. 287. ** Report (1844), 9803.

* Evidence, 1562. Ibid. 2446.

+ Ibid. 1563.

Ibid. 142.

PROFESSIONAL OPINIONS.

263

member an instance where Boards of Guardians having agreed to provide drugs, had abandoned it, after a trial."*

This pleasing variety-may it not be called, discrepancy ?—in official statements, relieves the monotony of a public inquiry; and, as coming from gentlemen high in the civil service, who belong to the same department, is quite refreshing to ordinary blunderers.

The fact appears to be,-that, before recent changes in the local administration of the large towns of Birmingham, Bristol, Exeter, Leeds, Nottingham, and Norwich, these could all boast of parochial dispensaries in active and successful operation.† not three, of them can still do the same.

Two, if

We also learn from Mr. Cane's evidence that one metropolitanț and four country Unions had adopted this measure.

If, in any earlier or more recent instance, the separate provision of drugs has worked unsatisfactorily;-it would be only fair to ascertain whether such want of success might not be attributable to defects in other parts of the system, and especially to the absence of that scientific inspection, which has proved so beneficial in the dispensary organization of Ireland.

§ 27. The most eminent medical authorities have ever supported this reform.

The late Dr. Yelloly was probably the first and ablest public advocate of a separate provision of remedies, under medical supervision.||

Sir B. C. Brodie also gave the following opinion before Lord Ashley's Committee :-"I think it very desirable that the fur

* Evidence, 140.

+ Health and Sickness of Town Populations, pp. 63, 64.

The Stepney Union deserves notice, because the intelligent Chairman and another Guardian of that Union, gave valuable evidence on this subject before Lord Ashley's Committee (see Evid. 622, 715); and this accounts for their adoption of the reformed system.

To him the public are indebted for collecting evidence on the subject from the heads of the medical departments of the Army, Navy, and Hon. East India Company's Service. Their statements are contained in his admirable Letter to Lord John Russell. Second Edition. London: Longman. 1837. pp. 19-20.