HC Deb 23 June 1869 vol 197 cc486-99

Order for Second Reading read.

MR. BRADY

, in rising to move that the Bill be now read a second time, said, he considered it a most useful measure, and one certain to be followed by beneficial results. At present the medical officers of the Poor Law in Ireland were as efficient as any similar class in Europe, but that state of efficiency could not be maintained unless a system of retiring pensions were established. He wished the medical officers of the poor to learn to look upon their appointments as permanent ones, and not merely as stepping-stones to something else. Under the Medical Charities Act of 1851, Ireland was portioned out into 716 dispensary districts, containing 1,038 dispensaries, and to those districts 785 medical men were appointed. These districts sometimes contained from forty to sixty square miles, so that the medical men had often to travel six or seven miles in order to see a patient. They were not eligible for appointment until twenty-three years of age, and they were not allowed to take any other public office, such as a coronership. In 1861 it was further ordered that no one should be entitled to hold such an office unless he had three qualifications—in surgery, midwifery, and medicine. The qualification had been continually increased, but there had not been any increase of salary. A few years ago a man could enter the Army if he were either a physician or a surgeon; and, in order to induce men of ability to enter the Army, they had to raise the status and remuneration, besides allowing the officers to practice, and enabling them after twenty years to retire on a pension of or over £300 a year. The Poor Law medical officers of England, who were paid 6s. 6½d. for each patient, were only required to have two qualifications; while the Irish Poor Law medical officers, who had three qualifications, got only 1s. 4d. for each patient. Their duties were of the most arduous nature. They were bound to attend to the poor either at the dispensary or at their own places, and attend any Bridewell or House of Correction in their districts. They had to attend at all times on the order of the red ticket sent by the guardians, irrespective of any practice of their own, on peril of being displaced. They were exposed to great risk of contagion in visiting the sick poor. In one epidemic 10 per cent of the medical men perished. Each Irish medical officer had 7,400 persons in his district, and in 1867 they attended more than 900,000 men and women, or one-sixth of the entire population. The whole rural population of Ireland was, indeed, dependent upon them for medical relief. In proof of the benefit which their services were to the community, and the fidelity and for- titude with which they discharged their duties, he need only allude to the figures given in the last Census Returns. It appeared that the number of deaths from fever in the ten years preceding 1841, was 112,072. In the decade ending in 1851, which was a calamitous period for Ireland, there were 222,029 deaths from fever; whilst in the ten years ending 1861, after the passing of the Medical Charities Act, the number of deaths from this cause was only 48,315. This marked decrease was unquestionably due, in a great measure, to the self-sacrificing efforts of the Poor Law medical officers. In 1841 the deaths from epidemic were 357,249; in 1863, the numbers had been reduced to a little more than 189,000. In the ten years, preceding 1841, there were 58,000 deaths from small-pox. In the ten years before 1861, 12,000 deaths only occurred from this cause; and in the year 1867 only twenty deaths. This was what had been done by the medical men of Ireland. Well, what was their remuneration? There were 867 of these medical men in Ireland, paid, on an average, £90 each per annum, which was about 1s. 8d. for each case attended in the rural districts, and only 4d. for each case attended in the towns; that was, supposing an ordinary disease to require four visits, the medical officer received 5d. for each visit in the former case, and 1d. in the latter. In fixing the rate of pay the guardians took into consideration what the medical men might obtain in other ways. In England the payment made by clubs for medical attendance was from 4s. to 5s. per head; in Ireland it was but 1s. 8d.; and, whereas in England the medical officer had only to attend heads of families, in Ireland the children had to be attended as well. The average number of persons attended by the medical men in Ireland was 1,212, which, at 4s., would amount to £250, showing a balance of £160, which either went to the guardians or to the Government, and the gross amount saved by under-paying these gentlemen in this way was £125,000. It was objected to this Bill that the poor rates were already too high. That he admitted; but there could be no better means of reducing rates than securing the health of the people. Dr. Wallace stated before a Committee of that House that 72 per cent of pauperism arose from illness. He must also complain that there was no such thing as a holiday allowed to the medical man. If he took a holiday he was compelled to find a substitute; and, even if he were laid up with illness, in many cases he was compelled to pay for his substitute. This was extremely hard, and he thought the Poor Law Board ought to take the medical men into their own hands, and rescue them from the Poor Law Guardians. It was of the utmost importance that the medical attendants of workhouses should be liberally dealt with; for, without the most skilled medical attendance in workhouses, the diseases of the poor might spread to the residences of the rich, and the wealthiest might thus suffer from the neglect of the poor. In looking at this question he admitted that he was interested in the profession to which this Bill referred, but he was still more interested in the welfare of the community at large. He proposed that the Poor Law Guardians should be empowered to tax the rate-payers with the view of providing for the medical officers a superannuation allowance, and the men who supported this measure were above all selfish considerations, and promoted it for the good of the country. The hon. Member concluded by moving that the Bill be now read a second time.

MR. PEEL DAWSON

seconded the Motion. The proposal of the hon. Gentleman appeared to him to be entitled to support on the double ground of generosity and justice, and he thought that little harm could be done by giving to Boards of Guardians a permissive power to superannuate their medical officers after twelve years' service. From what he knew of the Boards of Guardians in Ireland he was certain that it would not be attended with any risk of abuse. He had heard the late Secretary for Ireland (the Earl of Mayo) say that this was a question entirely for the Irish Members, and that if there was a majority of Members for it, that ought to be a guide for the action of Government. Now Lord Mayo was a valuable authority on Ireland, only equalled by that of the present Secretary, who was also a resident proprietor, and he trusted the Government would be guided by his opinion.

Motion made, and Question proposed, ''That the Bill be now read a second time."—(Mr. Brady.)

MR. W. H. GREGORY

said, this Bill was not framed upon the measure which was brought forward last year. He had been compelled to move that that Bill be read a second time that day six months; but he was glad to find that he was relieved from that unpleasant duty in the case of the present Bill. He grounded his support of the Bill not so much on justice as on public expediency; as he believed it would be for the benefit of the poor and of the public in general, that these superanuations should be given, because it would attract a higher class of medical practitioners to discharge the duties of these offices, and the poor themselves would be benefited by being attended by medical officers of the highest standing. But he hoped though this Bill were sanctioned it would not be drawn into a precedent, and that it would not be understood that any medical man in Ireland, no matter what the nature of his practice might be, should hereafter be quartered on the rates. Some alterations in the Bill would be required in Committee, but he gave his hearty support to the second reading.

MR. SYNAN

said, this matter ought to be discussed in three aspects; first in relation to the poor; second, to the guardians; and third, to the medical officers themselves. He might say there was a fourth aspect, namely, its relation to the Government; for he found that part of the salaries of the medical officers were paid out of the rates, and he supposed that part of the superannuation funds would be so too. With respect to that he was of opinion that there should be some limit on the standing of the medical officers before they were entitled to the superannuation, and his hon. Friend the Member for Leitrim (Mr. Brady) was, he believed, willing to make ten years' service a necessary condition. Now, with regard to the poor, it would not admit of question that the interests of the poor demanded that the best medical service should be provided for them. With respect to the interests of the rate-payers, it was their interest, by the employment of a good medical officer, to reduce the amount of disease. It was for the interest not only of the poor but of the middle and wealthy classes that an able medical man should be settled in the district, and no possible harm could arise from his having a private practice, as he was always ready and would have to obey the orders of the Poor Law Commissioners. To speak of his not devoting the whole of his time to the public was to quibble about words. The practice of the medical officers retaining their private practice might be defended on account of the smallness of their salaries, as well as because few medical officers were to be found in the country districts of Ireland, and it was desirable that medical men should obtain varied and full experience. On behalf of the medical men he must urge that they were fully entitled to the demand that was now made in their favour; and on all these grounds he hoped the Government would give their support to the Bill.

SIR JOHN GRAY

said, he hoped the Government would not oppose the second reading of the Bill upon any technical ground, but allow it to go into Committee, and there receive such Amendments as might be thought necessary. The hon. Member for Limerick (Dr. Brady) was quite correct in stating that, if the Government opposed, it would be useless to press the Bill forward, for in form and structure it was in the nature of a Money Bill, and should technically have originated in Committee. The objects of the Bill were, however, so just and equitable, so universally approved by the Irish Members, and so advantageous to the best interests of the community, that he could not believe any advantage would be taken of the informality. If the Bill were merely to affect the financial status of the members of the medical Poor Law staff, he would hesitate to support it; though even, on that single ground, it was just and equitable. The results of the adoption of the measure would be, however, of far more importance to the country than to the medical staff, and of quite as much interest to the rich as to the poor. To the community at large it was important that the conditions of medical service should be such that men of a superior class would accept the positions of medical officers, and that the men engaged in the public service would not be at all times haunted with the apprehension of being overtaken by want in old age. The labours of the medical staff were so forcibly dwelt upon by his hon. Friend the Member for Leitrim that he (Sir John Gray) need not discuss them, but he would ask the House to remember that the service was one of peculiar risk, and that the duties were often performed at the hazard of life. He knew one case in which the medical staff of a town attacked by an epidemic consisted of twelve, and of these eight were struck down and died of disease caught during the discharge of their duties. It was the direct interest of the community to give proper encouragement to men of honour, of skill, and of humanity, to enter on the duties of a profession so encompassed with danger. But, above all, it was their interest that the medical officers of the district should be men of real skill as well as men of moral courage, for the Poor Law officer was, in many rural districts, the only medical practitioner in the district; and every resident in such a district, be he rich or be he poor, ought to feel anxious as to the competency and skill of the individual to whom was entrusted the health and lives of them all. He would go farther, and say it was the duty of the Government to assist in securing for the community the services of an able and competent medical adviser in every district in the country, and to the non-performance of that duty might be traced much of the pauperism that prevailed. If the medical practitioner were unskilled or incompetent, the result would be death in many cases, and impaired strength and vigour in many more If the bread-winner be struck down, and if an incompetent medical man be called in, the probable result would be that the bread-winner would succumb either to the doctor or to the disease. The widowed wife would be left destitute, the children would be pauperized, and wife and children would become permanent burdens on the rates. It was the interest of the rich, too, to secure the presence amongst them of an efficient practitioner, and this Bill tended, in a considerable degree, to secure such a man, by enabling the guardians to superannuate a medical officer when no longer equal to the work to be done, instead of retaining him when effete, as the only alternative to his becoming as destitute as the paupers he had under his care. He supported the measure, then, as much in the interest of the community as in that of the medical officers—as much in the interest of the rich as of the poor; for the medical officer who had official charge of the poor was, in all the country districts, the only man accessible to the wealthy who resided within the district. It was rumoured that Government would oppose the Bill, on the plea that the medical officer was not a civil servant, inasmuch as he did not, like other civil servants, give up his whole time to the public service. Now, the assertion that civil servants who gave up all their time to the service of the public were the only persons entitled to retiring allowance was not in accordance with the facts; and he saw no reason why one rule of civil service should be applied to the members of one learned profession and another rule to those of another equally learned profession. We had three professions called learned—the Church, the Law, and Physic. Compare the manner in which the members of these three professions were treated. The Church, though it had no retiring allowances, had its great prizes of £5,000, £10,000, and £15,000 a year, and which were held by the fortunate possessor up to the day of his death. The Law also had its prizes—its Chancellorships of £10,000 and £8,000 a year, which entitled those functionaries, though they might have held their offices only a month, to retiring pensions of £5,000 or £4,000 a year; there were Vice-Chancellors, Chief Justices, Judges, all of whom were entitled to retire on pensions after certain periods of service. But take especially the Chairmen of Counties in Ireland—they had salaries ranging from £600 to £1,300 a year; their duties consisted in acting as County Judges for a few weeks in each year, and for the rest of the year were free to seek private business, and each was entitled to a fixed retiring annuity. The medical officers worked 365 days a year on miserable pittances; surely they were entitled to the same consideration as the County Judges. Did not the medical man confer as much service as a civil servant on the community as did those petty Judges? Was he less learned, less charitable, less humane, less attentive to his duties? Yet, one was a civil servant, highly paid and entitled to a superannuation, though he devoted about 340 days in the year to himself and the remnant to the public; while the member of the other profession, equally called learned, was declared not a civil servant, because he did not give the entire of every day to the public, and, therefore, not entitled to a retiring allowance when old age, or sickness, or injury, received in the discharge of his duty, might disable him from earning his bread. The hon. Member for Limerick (Dr. Brady) had complained that Poor Law medical officers must have three diplomas or degrees, while two only were required in the medical service of the Army; and also that the Poor Law officer must be twenty-three years of age before he was permitted to hold an appointment. But the Army Board required the candidate to have two certificates as a necessity, but would not admit him to physic a corporal's guard until they had tested his acquaintance with disease and his knowledge how to deal with it. But, since this subject had been introduced, he (Sir John Gray) would take the opportunity of saying, and would say, without hesitation, that the Government—he did not mean the present Government—he meant all the Governments that existed in this country for the past thirty years—had most grievously, most grossly neglected their duty to the community in not securing a sufficient test of the fitness of a candidate for medical or surgical degrees, before the health and the lives of the community are handed over to a man, as is often the case, who is an ignorant and incompetent pretender. It was the duty of Government to protect the public against the possibility of a man, who knew nothing of disease, being licensed to practice. That duty had been grossly neglected, and he now asserted, without fear of contradiction, that a man who never felt a human pulse, who never opened a vein, bandaged a limb, or prescribed for a patient, might, and often did, receive a medical and surgical degree authorizing him to practise the medical profession. He knew hon. Members would be startled by the statement, and that they would probably conclude that, inasmuch as there are Colleges of Physicians and Colleges of Surgeons to regulate the granting of licenses, and a great Medical Council to regulate the education, and examination of candidates for the medical degrees—the statement he had just made, that a man utterly unacquainted with disease could obtain a license to practise, and be registered under the Medical Council—was one that could be made only by a man just escaped from Bedlam. Yet it was true—it was no exaggeration even of the truth. The late Sir James Graham attempted to grapple with the evil; but he had to succumb to the chartered bodies whose privileges he attempted, needlessly, to invade. A noble Lord, now a Member of the House (Lord Elcho), tried to effect a change in 1856; and another hon. Member, who held the Office of Chief Commissioner of Works under Lord Palmerston (Mr. Cowper), carried, in 1858, the Act referred to by the Introducer of this Bill. These several attempts to legislate were based mainly on the evidence and on the opinions of eminent medical men, some of whom stated before a Committee of this House that neither the course of study nor the mode of examination was sufficient to secure practical knowledge. The object of the appointment of the Medical Council of 1848 was to secure a high standard of education; and to ensure that the candidates were taught up to the highest point of modern science and practice, by ensuring the efficiency of teaching and examination. He regretted to say that the Council had not fulfilled these duties, and that the examinations as to the candidate's knowledge of disease—his acquaintance with disease—was as much a sham and a delusion as it was the day the Council was first formed. When a man was sick he did not want a doctor who could give him a first-rate lecture on botany—he wanted the aid of a man familiar with disease—a man to whom all the features of ordinary disease were so familiar that he would not fail to recognize them, and who would be as prompt to combat the symptoms and beat them back as he was to recognize the peculiar malady which afflicted his patient. That was the medical practitioner whom the sick man required, and no matter what the scientific attainments of a candidate for a license to practise might be, he ought not to be licensed to tamper with the health or with the life of the poor or of the rich—of any human being—till he had been so tested by his examiners as to satisfy them that he was intimately acquainted with all ordinary forms of disease, and capable of recognizing them when presented to him. Every man of ordinary intelligence will see that committing to memory the names of diseases and the description given of them in the books, and making the acquaintance of the symptoms in the hospital ward or in the dispensary are two very different things. But a man might walk the hospitals for years and not know the features of disease as he would those of a friend or of any enemy He had recently accompanied Sir William Jenner through the hospital in which he practised, and afterwards asked Sir William to explain the small degree of attention which the students paid to his able and careful explanations. The reply was—"A man does not want hospital practice in order to pass;" and at a meeting of the Medical Teachers' Association, held in Dublin, presided over by Sir William Jenner, the inefficiency of the present examination was prominently dwelt upon, and the fact noted that the only test consisted of mere certificates of hospital attendance, and mere answers from memory to certain questions, without any practical bedside examination. But it might be asked—"Are not the present examinations very severe, and are not many men rejected? No doubt they were, in some respects, very severe, but those respects were chiefly as to knowledge of the accessory sciences—they were not examinations as to a man's knowledge of disease, and many men who were not able to distinguish one disease from another were passed these examinations with éclat. But a good "grinder" would post him up in all the necessary knowledge in six or eight months. Students were now taught by grinders in their snug studies to answer questions like parrots; and the fees paid for these services ranged from twenty to ten guineas, according to the difficulty of the examinations as to the memory of words and names. The grinder's fee for passing a man through the Dublin College was, he understood, twenty guineas, for London fifteen, and for some of the Scotch degrees ten. But as regards London, the London degree, for which fifteen guineas only was charged, it was but just to observe that it was for the license to kill and not for the license to cure that this fee was charged. He would give an illustration of the practical effect of the present system of examination. A man seeking a Poor Law appointment had a surgical and medical degree, but not an obstetric degree, and was therefore not qualified. He attended an obstetric hospital, "crammed" the subject, and in about three weeks presented himself for examination. His answers were so much to the point that the examiners perceived that he had been "ground," and therefore tried him on new grounds. He was asked what he would do in a certain difficulty. He said at once that he would bleed. "But," said the examiner, "if there were constitutional or other causes to contra-indicate bleeding, what would you do?" "I would give her tartar emetic," was the reply. "How much?" "Sixty grains," was the answer. "Just think," said the examiner; '' you know what tartar emetic is?" "Oh, yes—tartarized antimony of the Pharmacopoeia." "Well, then, what dose would you give now?" The answer was—"Perhaps sixty grains would be too much to give at once; I would put sixty grains in a six-ounce mixture, and give an ounce of that occasionally." Now the dose is about the eighth of a grain, and if this medical man with his two degrees—a registered practitioner under the Medical Council—a man entitled to write ten medical letters after his name—met in practice the very ordinary and frequently arising difficulty indicated—if the patient were rich or poor—the inmate of a poorhouse or the wife of the most exalted—she would assuredly die. If a lawyer made a great mistake in the conducting of a case, there was a Court of Appeal which might rectify the error; but if a licensed practitioner, who was as utterly ignorant of disease as was this ten-lettered doctor, gave eighty or ninety doses at once, death carried away the victim of his ignorance, and there was no Court of Appeal to restore the patient to the circle of friends who mourn over the dead, but know not the hand that gave the fatal blow. To this he wanted to call public attention, this he wanted to force on the Government, and in this he hoped the House would aid him.

MR. CHICHESTER FORTESCUE

said, the hon. Member (Sir John Gray) had made a statement of a very formidable character, containing facts which were enough to make us all tremble when we called in a member of the medical profession. The House would not expect him to follow the hon. Gentleman into the various statements which he had made, which, no doubt, would one day demand the attention of Parliament. With respect to the Bill before the House, his main objection to it related to the manner in which it was drawn. In his view, it should be a simple extension to the medical officers of unions of the Irish Poor Law Superannuation Act of 1865. He admitted that the ease of these officers was one of a peculiar character, and in its bearing on the well-being of the poor, was deserving the consideration of that House. No doubt cases arose in which the guardians found themselves unable to make up their minds to discharge an old public servant without some adequate provision, and the consequence was that the poor were sometimes left in the hands of infirm and inefficient persons. Upon the whole he had come to the conclusion that there were sufficient reasons for giving a discretionary power to the Boards of Guardians, enabling them to superannuate the medical officers upon the same conditions as those upon which they superannuated other public servants. According to the Act of 1865, no officer was entitled to superannuation allowance on the ground of retirement who was under sixty years of age, and who had not served as a union officer for twenty years. It was only on the understanding that that course would be taken in Committee that the Government could assent to the second reading of the Bill. As to any contribution on the part of Government, no grant for superannuation was made in the case of England; and until the general law was changed in that respect, the same rule should prevail in Ireland.

MR. DOWNING

said, he was glad that the Government had accepted a measure which would enable Boards of Guardians to discharge a duty which they had long felt was one due to the medical profession.

LORD CLAUD HAMILTON

also expressed gratification at the general tone of the observations of the right hon. Gentleman the Secretary for Ireland.

MR. AYRTON

said, that so far as the Treasury was concerned the question stood thus—The principle of the superannuation of local officers was first introduced in reference to England. The medical officers were excluded. A similar measure was afterwards introduced with respect to Ireland, and the law was exactly the same with regard to the two countries. The House under that law had been in the habit of voting one-half the expense of medical officers. That Vote, however, did not include any charge on account of superannuation. It would be necessary to confine the Bill exclusively to the action of the local authorities on local rates, which were the funds at their disposal, and he did not think there would be any difficulty in settling it in that form.

MR. BEADY

said, he was satisfied with the explanation of the Chief Secretary for Ireland.

Motion agreed to.

Bill read a second time, and committed for Tuesday next.