414 SUPPLEMENTARY NOTES. of the poor would be transferred to this new body, that they would correspond with Boards of Guardians," [Boards of Health he should have said], "and that all these medical matters would be withdrawn from the cognizance of the Poor-Law Commissioners." C. See p. 259. PRINCIPLES ON WHICH MUTUAL ASSURANCE MIGHT BE APPLIED TO A SELF-PROVISION OF MEDICAL ATTENDANCE BY THE WORKING CLASSES. 1. No Insurance Fund of this nature should be sanctioned or protected by law, or promoted by benevolent persons, to which any labourers or artisans are permitted to contribute, who have not previously insured in a well-regulated Provident or Friendly Society (which does not hold its meetings in a public-house), for a reversionary payment at death, a reversionary annuity in old age, and a weekly allowance in sickness sufficient for the ordinary maintenance of themselves and those dependent upon them. 2. Every such person proposing to insure for the privilege of choosing his own medical attendant, should also be required to have previously provided, by mutual assurance or otherwise, for a supply of dietetic tonics, cordials, and medicines, and perhaps for the attendance of a nurse (the average cost of these requirements in illness being susceptible of calculation by way of average")—such arrangements to be effected, if possible, by means of legally-authorized local institutions. 3. Those who produce proofs of having made all the above-mentioned provisions, who are not members of public-house clubs, and whose wages, income, or means of living, are duly certified not to exceed a specified rate or amount, proportionate to the number of those dependent on them for support, and to the rate of medical remuneration agreed upon (see 10), might be admitted, with the consent of a fairly-constituted Board, as members of an Insurance Society for the provision of medical attendance, on the following terms: 4. That every member should be secured the privilege of selecting his medical adviser from among those who are ready to attend on the specified terms; and of changing such adviser as often as he may please. 5. That the contributions of the insurers should be calculated on the same principles as those for a pecuniary allowance during sickness. SUPPLEMENTARY NOTES. 415 The premiums should therefore vary according to the liability of each member to sickness, and be determined by the age, sex, condition of health, place of residence, and occupation of each candidate for admission. 6. That the working classes should be at liberty to insure for their wives and children on the same principles and regulations as for themselves. 7. That the fund so raised should constitute a permanent fund, and the surplus protected by law for future claims, as securely as those of Friendly Societies are at present. 8. That, out of this fund, all those resident practitioners who are appointed to the care of the members, should be remunerated, each according to the number of cases he may have attended during a given period. 9. That any legally-qualified and resident practitioner, who does not contract (or who engages not to renew any existing contract) with any Benefit or Medical Club, should be permitted to connect his name with the Society,-which, nevertheless, should be nowhere established, unless a majority of such practitioners, residing within the proposed district of its operations, should signify their assent to it. 10. That different tables of insurance contributions should be calculated, to meet different rates of medical remuneration; and that one or more of the latter having been selected by the medical practitioners and Dispensary Committee of a district, the contributions of the working classes would be determined accordingly. 11. Persons who are ill and desirous of joining the Society for the sake of obtaining immediate attendance, should be permitted to do so, on payment of an adequate fine and extra premium. D. See pp. 271, 272. CHARITABLE DISPENSARIES. Extracts from Evidence taken by Select Committee, in 1844. 9164. "The attendance on Dispensary patients at their own houses, is at present irregular and uncertain. In a few institutions, I am informed that they are regularly visited by the honorary physicians and surgeons. It cannot, however, be expected that any extensive or regular system of home-visiting will be kept up by unpaid officers. In the majority of instances, the ordinary visiting is performed by the 416 SUPPLEMENTARY NOTES. paid resident apothecary of the Dispensary; and the honorary officers either do not profess to visit, or they only go to serious cases when requested by the resident apothecary. I firmly believe, although it is difficult to obtain conclusive evidence on this point, that dispensary patients are by no means so thoroughly attended to, or so regularly visited, as the patients of the Union medical officers." "There are several serious defects in the present mode of dispensing relief. From the number of cases presented to the notice of the physician or surgeon on the morning of his attendance, they are necessarily hurried over, and imperfectly examined. Then the patients are often detained for an inconvenient and injurious length of time; and the regulations for their attendance at the dispensary preclude the possibility of prompt relief in many urgent cases, and often deprive them of the advantage of necessary changes in the treatment of their case. There is also an excessive and unnecessary consumption of drugs, which, however, are always of the best description, and are, in fact, a substitute for regular and frequent attendance." "Supply the latter, and the former will diminish." 9165.. "The fact is, that the present financial condition of these dispensaries is, in many towns, far from satisfactory. I find from most of the printed Reports that the funds have a steady tendency to diminish, and are only kept up by constant appeals to the benevolent, and an occasional grand effort by the friends of the institution to pay off the balance due to the Treasurer." 2. Extract from Report of the Huddersfield Infirmary and "The governors are aware that the duty of administering medical assistance to such of the sick poor as are recipients of parochial relief, more immediately belongs to surgeons of unions, and not to the medical officers of infirmaries, whose resources are more appropriately directed to the prevention (not the relief) of pauperism. They are led to this remark in consequence of the frequent applications of out-patients to this charity who are at the time in receipt of parish relief. If this description of patients consisted merely of accidents and cases requiring operations, or attended with peculiar difficulty, it would be admitted on all hands, that for all such purposes the wards of an infirmary are best calculated; but, exclusive of these instances, there are many who become chargeable to the infirmary, who ought to be more properly placed under the care of the district surgeons, whose province it is to attend to such cases." SUPPLEMENTARY NOTES. 417 3. The Governors of the Gloucester Dispensary, at their Annual Meeting, in 1844, memorialized the Poor-Law Commissioners in the following terms: "That this meeting, feeling that the present system of supplying medicines to the poor materially affects the interests of this Institution, begs to suggest to the Poor-Law Commissioners, the propriety of directing that the medicines for the sick poor be not supplied by the medical officers, but provided by the guardians, at the cost of the Union; and that the Secretary be requested to communicate this to the Poor-Law Commissioners." E. See pp. 273, 289. FRENCH AND BELGIAN SYSTEMS OF OUT-DOOR MEDICAL ATTENDANCE ON THE POOR. 1. Reformed Administration of Medical Aid and Visitation in Paris. The Moniteur of Nov. 22, 1853, published an article of which the following is a translation in the Medical Press, Jan. 11, 1853:— "An important and salutary innovation in the administration of public aid has been introduced under the direction of the Emperor. The following is a very summary account of the new arrangement. The number of medical attendants at the Bureau de Bienfaisance is fixed at 159; they will be distributed among the twelve arrondissements in proportion to the indigent population. Their services will no longer be gratuitous; they will each receive a salary of 600 francs in the central quarters, and of 1000 francs [some now receive 1200] in those parts such as the Quartier Popincourt, the Invalides, Petit Pologne, &c., where the indigent circumstances of the population do not give an opportunity of making a practice, while the distance to be traversed increases the labour of visiting. There will also be in each arrondissement paid midwives. The medical attendants will be presented by the Bureau de Bienfaisance, and proposed by the Director of Public Aid; they will be elected for six years and will be capable of re-election. Stations will be appointed in the different quarters, at which patients may consult medical officers, who will be bound to attend at fixed days and hours, and to remain as long as they may be required to give advice. A member of the Bureau de Bienfaisance will be present on each occasion. The medical attendants will visit at their own houses those who may not be able to attend. A register will be E E 418 SUPPLEMENTARY NOTES. opened at the office of each bureau, in which will be inserted the names and residences of all the patients, the date of the commencement of their treatment, and all other necessary information. Patients with acute diseases will be visited at least once a week by an Administrator or Commissioner of Public Aid, who will enter on a schedule such observations as may occur to him, principally with regard to the medical attendance which the patients are receiving. A committee composed of the president or of a vice-president of the bureau, of a governor or commissioner, of the treasurer of the bureau, and one of the medical officers, will meet every week to debate on subjects regarding attendance on the patients, and especially on the visiting lists. They will determine what aid it may be proper to afford in medicine, food, linen, &c., or even in money. In urgent cases, the president may in the intervals advance such aid as is absolutely needed; and of this he shall render an account to the Committee. Persons not enrolled as paupers, such as needy workmen, persons with large families, or those who are in any way very destitute, will be attended at their own houses, either at their own request, or at the requisition of the Mayor or one of the administrators of the bureau in their district, or at the instance of the Director of Public Aid." 2. French Colonial Medical Aid. The Minister of War, Marshal Vaillant, published a report upon the condition of French Algeria, at the end of 1853. Amongst other matters, he noticed at length the efforts made by to Government for the establishment of institutions of charity and bienfaisance in that colony. Some of the details are interesting both statistically and as developing the system of French colonization, so widely different from our own, as regards what is left to individual exertion, chance or necessity supply, or is neglected altogether, and what the central government considers as falling within its peculiar province to provide. After describing the Banque du pauvre or Loan Institution, the Caisses de Secours Mutuelles or Mutual Aid Societies, and Asylums or Industrial Schools for orphans and deserted children, the Marshal proceeds: "I may mention, lastly, as worthy of notice, the system of medical aid established throughout all the remoter parts of the colony by the official assistance of the Government. Each district marked out for colonization has been divided into a number of medical circumscriptions. Every one of these has been provided with its medical attendant, who must be a person furnished with a regular diploma, |