[from the Medical Aid and Poor Relief Commission Report - 1879]

MEDICAL RELIEF AND HOSPITAL ACCOMMODATION.

Attached to the Hospital at Douglas is a Dispensary, and the House surgeon is expected to visit out-patients in the town, but in no country parish in the Island have we found any system of medical attendance on the poor, and in Castletown and Ramsey alone of the three remaining towns is there any attempt to make such provision on the part of the administrators of the charitable funds. What the provisions amount to in these towns is, as we have already seen, the supply—at Castletown—of necessary medicines and comforts for the sick poor by the Relief Committee. and the gratuitous attendance so liberally given by the two medical gentlemen practising in the town ; and—at Ramsey —the establishment of a dispensary, attached to which is a medical gentleman who "attends all cases in the town, where the poor people are too poor to be able to pay for medical advice." His prescriptions are made up, free of cost to the patient by any of the chemists in the town, at the same price as they would be to the medical man himself, and the chemists send in their accounts quarterly to the Dispensary Committee. by whom they are paid.

In Douglas alone is there anything in the nature of a hospital in active operation, though in Castletown there is, as we have seen, a small house rented by the Poor Relief Committee, and dignified by the name of "The Hospital," which was "originally taken for that purpose, and is still used for the reception of people who are sick." although it has "no appliances whatever for a hospital," Still, in this town, the necessity for a hospital has been recognised by charitable persons that,

"Some years ago a site was given by two gentlemen. and subscriptions were obtained for the purpose of erecting the hospital, and were applied in part, to taking down the old house in Queen-st. (the site in question)"

It was not, however built, and in addition to a balance of about £10 remaining from the subscriptions then raised, there has been a legacy of £100 left within the last five months towards providing a hospital for the town, subject to the condition that if the hospital is not established within five years the legacy lapses.

The site of the old house in Queen-street is much too confined for the purposes of a hospital, and it was suggested that application should be made to the Court of Chancery for power to sell the ground and apply the proceeds towards the erection of a hospital on a more eligible site.

"The absence of such an institution is,"(to quote Mr Gill again) "no doubt a somewhat serious defect in our system of poor relief." And, in reference to a suggestion that there should be a cottage hospital at Castletown for the town and adjoining parishes, the same gentleman sats - "We ought to have a proper nurse, if one could be got by any manner of means. Indeed, it would be a great boon to have have a trained nurse in Castletown. If there was a proper hospital in Douglas, a person might be sent from Castletown to be trained. There is great difficulty in procuring a nurse of any kind. It would very much depend on the size of the hospital whether sufficient subscriptions could be obtained, but I think that it would be a very good thing if there was a grant from the revenue for such a purpose as that. I have no doubt that if there was a public grant of, say, half the money, there would be no difficulty in raising the balance in the south of the Island. I think a small hospital would be quite sufficient. if it was managed. by the existing machinery, and brought into the working of the Poor Relief Society. No doubt if there was such an institution here it would be supported by the adjoining parishes of Malew, Arbory, Rushen, and Santon."

And Dr Clague, the principal medical practitioner in Castletown, says—

"From my knowledge of the rest of the Island, I think that if a good hospital was established at Douglas, and smaller ones at Castletown, Ramsey, and Peel, that would be amply sufficient for the requirements of the whole Island. It might be desirable to have a small hospital at Laxey, the population there being nearly as large as at Castletown, while there is greater liability to accidents on account of the mines."

The opinion thus expressed by Dr Clague, of Castletown, is confirmed - as regards the wants of the particular localities - by Drs H Higgens and J. Reynolds, at Peel; by Dr J. Wood, at Ramsey; and by the Rev J. Bellamy Mr W Kneale, and Mr John Killip, as to Laxey: and as regards the need of small hospitals generally at the places named, by Drs Ring, Nelson, Gray, and Dearden, of Douglas.

Of the absolute need of some reliable provision for bringing medical aid within reach of the poor at their own homes throughout the country parishes there is general concurrence of testimony ou the part alike of both the medical and non- professional witnesses. "What we are really in want of for the poor," says Mr W. Corris, one of the churchwardens of Patrick, "is medicine" ; and indeed the absence of facilities for obtaining this and medical attendance on the sick and dying is, really, the one principal want of the poor in the Island.

That many, especially children, die without having been visited by any medical man, we have in evidence from more than one witness.

The Rev J. Bellamy, speaking of the poor in Lonan and Laxey, says—

"I think that the medical attendance in the parish is in a most lamentable state. And I am sorry to say that it comes within my positive knowledge that the attendance of a medical practitioner in cases of even the most serious nature is quite exceptional. In fact most of the children in Lonan who die, die without a doctor having attended them."

So, too, Mr John Killip, the secretary to the Laxey Mines' Poor Relief Committee, says —

" There is no doubt about it that a very large proportion of the children of Lonan die without seeing medical aid. I agree generally with the Rev Mr Bellamy, that there is an absolute necessity for a better system of medical attendance for the poor in the parish, and I think that this want would be best met by means of a cottage hospital, with a dispensary attached, and that the medical officer attending to the hospital should visit poor people on the production of an order from the General Relief Committee."

In this parish there is a medical man who visits once a week from Douglas, and who receives a fixed salary from the Laxey Mining Company, to attend to the miners. His duty, however, does not extend to attending to their famiies. And although we have it in evidence everywhere that a great deal of advice is given to the poor gratuitously by the medical practitioners in the several towns of the Island, and indeed too much praise cannot be awarded to these gentlemen fo; their liberality and kindness, still it is impossible that they can give the requisite attention in the majority of non-paying patients ; nor is it, indeed, fair to expect it of them. Dr Dearden says— "I am strongly of opinion that there is an absolute necessity for better provision being made for medical attendance upon the poor in the country. I often, accidentally as it were, come across cases in out-of-the-way districts which require attendance. These people are too poor to pay for a medical practitioner."

The necessarily casual character of the attention which the medical men alone can bestow upon the very poor is nowhere, perhaps, more accurately described than by this witness— ,

"Three-fourths of the poor in the country districts are totally dependent for medical advice on the kindly feelings of the doctors. There is no doubt that in many cases they make an endeavour to pay the medical man, but in the great majority of cases they cannot do so, and it is simply impossible for doctors to be continually going out to attend them without remuneration. They may call the medical man in, and he prescribes for them, but as a rule the attendance he can give is only casual. If you are on the way to some person who can pay you, you, perhaps, give a call as you are passing ; but I have seen a number of sick persons who have died in the country for want of proper medical attendance; and I have no hesitation in saying that many have died for want of medical attendance who might have been saved. As an instance of the hardships which the poor have to undergo, I may mention the case of an old man who came down to see me from a distance of four miles in the country while suffering from distended bladder. He had walked all the way to Douglas, and must have been suffering the most intense agony. He came to me in very great pain. ... I may also state that great numbers of children die without medical attention. Perhaps you will be sent for just as the child is dying, and when, of course, it is too late for the medical man to render any service. I was informed the other day of a young girl in the country who had died of consumption, and who never had a doctor."

Again, our colleague the High-Bailiff of Peel, speaking of Peel and the surrounding districts, told us—

"The absence of a system of medical attendance is a great defect in this town and district."

And another member of the Commission, the Vicar of Rushen— :

"With regard to the sick poor, I must say that I would, if it were possible, like to see a medical whose duty it would be to look after the poor in our district, and the poor alone. My reason for this is that a medical man in ordinary practice may come now and then to look after the poor, but we cannot expect him to be regular in his attendance on such cases when he does not get paid for it... . There should be a medical man specially to attend on the poor in the southern district — that, in my opinion, is an absolute necessity."

These views were emphatically endorsed at the time by the Vicar of Malew, another of our colleagues, who had previously for 13 years vicar of Rushen. Again the Vicar of Marown another member of the Commission, thus gives his experience of his own parish -

"Having no system of medical attendance, I must say that we have at times found the want of medical relief very much ...It might be well if there were a medical officer who might visit the parish when necessary. I think such an arrangement as that would be very desirable."

The fact that the various benefit provident Societies, which are, as we have seen, so largely supported by the working classes in the Island, having each a medical officer attached to them can scarely be said to militate against this view for the gentleman's duty is invariably confined to attending on the sick members of the club or froendly society, and not upon his wife and children.

"The wives and children of the 1,700 members of the benefit clubs whom I attend, says Dr Higgins, have no claim on me for medical aid."

At the same time, as suggested by Dr Wood at Ramsey, the system of having a medical man paid specially to attend upon the sick poor -

"Might be worked economically in connection vith the public vaccinators, or by the medical man attending the clubs."

"In connection with this subject, the memorandun addressed to your Excellency by the public vaccinators, on the 23rd of August, 1878, possesses so much interest that we have ventured to print it in the appendix to this report. (Appendix VI.) It will be there seen that these gentlemen deliberately given expression to their belief—

"That there are undoubtedly many cases in the country districts that require medical attendance, and who, through poverty and other causes, die without any medical relief."

While reference is being made to this document, it may be convenient to state how far the opinions then expressed by the public vaccinators are shared by us upon the various questions addressed to the Commission relative to the provision which should be made for bringing medical aid within the reach of the sick and infirm poor.

And first, as to the establishment of Medical Dispensaries.

The evidence at Castletown and Ramsey is entirely confirmatory of the view taken by the public vaccinators as, to the inexpendiency of establishing dispensaries 1m the country districts. In addition to the reasons assigned by them in the memorandum for dissenting from the proposal, we have it in evidence that, even in those towns where it may be readily supposed there would be less risk of drugs deteriorating than in country villages,the medical men prefer to have their prescriptions made up at the local chemist's.

Dr Clague says "As for a dispensary, I don't think it is necessary to have one at all. I think that the prescriptions could be obtained, as at present, at the druggist's, and that there is no necessity to go to the expense of providing a special room for a dispensary. Probably if there was a dispensary they would flock to it when it was not necessary. Medicines kept long in stock have a tendency to degenerate, and I am confident that it would be more advantageous to have the drugs dispensed from the shops than to have a special dispensary for the relief of the poor only. I never dispense; we have good chemist's shops here. . . . The poor people in Castletown get all the medicines they require from the Relief Society ; but I do not know how the poor people in the country manage to get medicine. Sometimes, I have given them orders necessary for medicines on the Castletown druggists, and marked them 'Poor Relief,' When they are so marked, the prescriptions are given at a low rate—almost at Cost price. I do not see why it could not be arranged that the chemist's shops should act as dispensaries for the whole district. Orders might be given on them for medicine, and an arrangement might be made to get the medicine from them at a cheap rate. Practically they would be the dispensaries of the district. In the country, the order might be signed by the vicar and wardens, and in the town by any member of the Poor Relief Committee."

And at Ramsey we find that this is the system upon which the Ramsey Medical Dispensary is worked. To that institution a salaried medical officer is attached (Dr F. S. Tellett), whose duty it is "to attend all cases in the town where the people are too poor to pay for medical advice." He attends to the case, and gives his prescription, and the patient is allowed to have it made up at any chemist he likes, and the several chemists in the town send in their accounts quarterly to the Dispensary Committee. It being understood that they ''make up the prescriptions on the same terms that they would to the medical man himself i,e., about cost price."

The salary of the medical man is £30 per annum, and this and the cost of medicines are the only expenses of the institution, there being no actual dispensary, nor any room provided for the attendance of patients. These are either seen by the doctor at his own house, or he visits them at their own homes. "The funds of the Dispensary Committee amount to about £60 a-year," and "the annual average cost of medicines for the last three years has been £32 17s 2d".

In the town of Douglas alone do we think it necessary or desirable to maintain or establish a dispensary. Here a dispensary has been always attached to the hospital, at which the out-patients attend, and medicines are dispensed by the resident medical officer. The town of Douglas has now, probably, a population of at least 15,000—it was returned as 13,846 at the census of 1871—and the parishes in which it is situate, viz., Braddan and Onchan, had at the same time, exclusive of the town, a country population respectively, of 2,115 and 1,620. If to thesebe added the population of Lonan 3740, and Marown, 1,121, we have a total population at the preasent time, of probably 24,000 within the district of the High-Bailiff of Douglas. The poor of this large district, who are more or less dependent on charitable relief, numbering about 700, might all well be supplied, in case of sickness, with medicine and drugs from the dispensary in connection with the hospital in Douglas. If however, as we hope, a cottage hospital be established at Laxey, and it be decided to have a resident medical officer in that locality to attend to the mining population, and to the poor of the parish of Lonan. it would probably be found expedient to maintain a small dispensary in connection with this hospital. This would reduce the number of poor who would, in case of sickness have to procure their medicines from Douglas by about 120.

That an income, sufficient to induce a competent medical man to reside in Laxey might be readily assured appears probable from the following statement made to us by the Rev J. Bellamy, the curate of Laxey—

"There would be, to start with, an income of £50 a year from the Mining Company. That sum is given every year by the Company to a medical man to attend on the miners themselves. [At present this gentleman is Dr. Elliott, a resident practitioner in Douglas.}] There would be a further source of income from the parish clubs. I daresay that £100 a year at all events, could be found to commence with in the parish as a basis for a salary for a medical man."

When it is borne in mind that the Oddfellows and the Rechabite societies, and the old Parish Club—who have, between them, some 750 members in the parish of Lonan on their books—each pay a medical man to attend on their members, and that the Miners' Club numbers 500 members more, it would seem tolerably clear that a very fair income to start with, irrespective of private practice, might be secured to any medical man whose qualifications might be such as to render him an acceptable candidate for the posts of club and parish doctor, and medical officer to the Laxey Mining Company.

We would suggest then, that in order to supply the absence of any existing provision for affording medical aid and hospital accomodation to the poor beyond the towns of Douglas, there be established in each of the towns of Castletown, Peel, and Ramsey, and in the village of Laxey, or some convenient situation in the parish of Lonan, a Cottage Hospital, the medical officer of which should be resident in the town or parish, though not necessarily in the hospital. To each hospital should be attached a district embracing at the three first named places, though with possibly, some modifications, the several parishes which form the High-Bailiff's district of these towns, and to that at Laxey, the parish of Lonan, and—if found more convenient—that part of the parish of Maughold most distant from Ramsey.

The medical officer of the Cottage Hospital should be also the district medical officer, whose duty it would be upon the receipt of an order from the vicar and wardens, or from the chairman or honary secretary of the Poor Relief Society in a town, to visit such of the poor as are dependant upon the Church funds or Relief Association for support, or who are ascertained to be deserv- ing objects for gratuitous medical advice.

This mendation has been to some extent anticipated by the memorandum addressed to your Excellency bY the public vaccinators, who are also medical officers to many of the clubs, and who might very probably be in their respective districts candidates for these appointments.

It has been suggested to us at Castletown subsequently elsewhere, as we have already noticed in this report, that a grant might be not unfairly made from the Insular Revenuo towards the establishment of these cottage hospitals, and if your Excellency should fall in with that suggestion, and would be further disposed to contribute there from half the salaries of these district medical officers, a very great advance would, we feel, be made towards the establishment of this very essential reform.

A precedent for this would be found in the English system of medical relief to the poor, half of the salaries of the poor law medical officers being there defrayed from the Consolidated Fund.

At the same time, we desire to express our conviction that, if provision is thus made for bringing the great boon of gratuitous medica] aid, always accessible, within the reach of the poorest class of the community, too great care and discrimination cannot be exercised to guard against its being unduly extended to those who are in a condition to provide such attendance at their own cost, and thus to prevent the abuses which are sure to follow from the lax administration of any system of gratuitous medical relief,

Admirable as is, in many respects, the system of medical to the outdoor poor in Ireland under the Dispensaries Act of 1851, abuses have crept in from the extreme facility with which tickets for medical relief are there obtainable from the members of the Dispensary Committee. These are noticed by Mr Lambert, C.B. The present Secretary of the Local Government Board(England) in his admirable report on this system in 1866, to the Right Honorable Gathorne Hardy, M.P., then President of the Poor Law Board.

Indeed, the indiscriminate character of the distribution of these dispensary tickets was, so lately as April, 1878, the subject of a letter of complaint from "the Irish Association" to the Chairman of the Poor Law Inquiry Commissioners, whose report has been just published.

One of the recommendations contained in that letter —'That persons able to provide for their medical attendance by provident dispensaries or sick clubs should be debarred from receiving gratuitous dispensary medical relief" — is, we consider, especially deserving of notice in this Island, where such a large number of the labouring classes are, to their great credit, members of such societies.

We think such a rule might have considerable influence in giving effect to a suggestion of the Rev G. Paton, one of the members of the Commission, that the various provident societies of the Island should, upon payment of a small additional sum—say a halfpenny per week per member—provide medical attendance to the wives and families of such members.

At present it appears clear, from all the evidence we have received, that, with scarcely an exception, no member of the "Oddfellows." "Rechabites," or other well-established provident societies in the Island, is at present in receipt of relief from the charitable funds at the disposal of the vicar and wardens of the country parishes,or from the funds of the Castletown or Ramssey Relief Associations. But if gratuitous medical aid were made accessible to such member, and their families it might not improbably result in lessening the provident habits of the com. munity, as it would certainly have a direct tendeney to diminish the inducement to subscribe to these benefit societies,

We would purposely limit to the vicars and wardens, and to the chairman and secretary of the Castletown and Ramsey and any similar relief associations that may be hereafter formed, the power to issue tickets for the attendance of the district medical officer. or for the gratuitous Supply of medicine; as one of the most fertile sources of the abuse of the Irish dispensary system has been found to arise from the number of persons empowered to grant tickets for medical] orders, and from the lax manner in which these were distributed. '' The dispenser at Limerick"— we quote from Mr Lambert's report to Mr Hardy—

Stated that the right conferred upon so many persons to grant medical orders is open to great abuse, and he thought it should be limited to relieving officers and ex-officio guardians.

And Mr Lambert further says -

"I was assured at one place that retail tradesmen have been known to sign a book of tickets, and leave them to be distributed by their shopmen among any customers willing to accept them. And in another the medical officer informed me that a member of the committee had sent oneof his children with a ticket under a fictious name and had obtained cod liver oil for a period of three months".

When such impositions can be practiced with impunity, we cannot wonder that the Irish Medical Association recommend — "That a person not entitled to gratuitous medical relief, who obtains a ticket by misrepresentation, should be punished for so doing."

The town of Douglas with the parishes of Braddan and Onchan, in which it is situate, and the neighbouring parish of Marown, might form the remaining district for the purposes of medical poor relief.

The population of this district may be roughly taken as 20,000, and it is doubtful whether it would be efficiently worked by a single medical man, but three-fourths of the population and the great bulk of the poverty lies within the town of Douglas, and would be thus readily accessible, while the outside area is considerably less than would be that attached to the suggested districts of either Castletown, Peel, or Ramsey.

It must be borne in mind that the hospital in Douglas is entirely supported by voluntary contributions, and that no part of the duty of attending to the sick in this hospital would fall on the proposed medical officer. At present it forms part of the House Surgeon's duty to visit the sick and infirm in the House of Industry, and this arrangement might possibly be continued with advantage, or the care of the latter might be transferred to the district medical officer.

If your Excellency should be willing to recommend the Tynwald Court to give the site in the Buck's-road, known as the Hill's Estate, for the erection of a hospital, upon some such conditions as those indicated by your Excellency's Minute of October 31, 1877 (vide Appendix VII), and if the Legislature should fall in with such recommendation, and the subscribers to the present hospital should be willing to remove it and rebuild on this site, upon the conditions attached, we entertain no doubt that the resident medical officer of the hospital might be able, in that case, to give the requisite attention to the House of Industry, to which the hospital would then be in close proximity. Another incidental advantage of this would be the facility with which any case of sickness or disease arising in the House of Industry which might requie constant attendence, might be removed to the hospital - cases of chronic infirmity, or mental imbecility, being alone such as it is desirable to retain for medical observation in the House of industry.

It being no longer intended to erect upon the site in Buck's Road the legislative or other public building, for which it was purchased in 1871, and that site being, in the opinions of the members of the Commission who have visited it, and in the opinion of every medical witness to whom it has been mentioned in all respects a most eligible and admirable site for a new hospital, we venture to express our hope that no difficulties may be interposed to its adoption for that purpose, nor to the erection thereon of a hospital sufficient for the growing wants of the town of Douglas and its vicinity, and for the reception, in case of need, of patients from other parts of the Island.

In connection therewith and within the same grounds, though quite detached therefrom, we consider there should be infectious wards. for the reception of from four to six patients of each sex.

The extent of ground available will admit of this and, although such limited accomodation will not meet the requirements of a severe epidemic, it would be probably sufficient to meet any ordinary emergency, and would greatly dimish the risk of smallpox or epidemic fever spreading for want of means of early isolation, as was the case during the epidemic of 1877.

The evidence given before the Commission by all the witnesses who have the greatest experience of the homes and habits of the poor, appears quite conclusive on this point. As Dr Nelson, for instance, told us—

'In many places in the town whole families sleep in one room, and it has sometimes happened that there has been a case of infectious disease in that room. . . . . I have seen an instance of a man and three or four children lying ill of an infectious disease in one bed, with the children's legs stuck up here and the arms there, and the heads nowhere visible. I do not think that if a person suffered from smallpox it would be sufficient, as has been said, simply to vaccinate the others residing in the same house to prevent the spread of the disease. I have seen a corpse in one room, occupied by several people, who still slept in the same room ; and have seen a man lying ill of an infectious disease, in a room occupied by several others. I have also seen a woman being confined surrounded by grown-up persons, who are in the same room."

Entirely corroborative of this is the evidence of Dr Gray, the late resident house surgeon of the Douglas Hospital, who thus gives the dimensions of some of the rooms he visited during the late epidemic of smallpox in the town, and the number of their occupants— "I have frequently to visit the dwellings of the patients. I find them, in many instances, not at all clean. They are very frequently much overcrowded. I have seen places with whole families residing in one room. Of Course, these were people who were, more or less, in receipt of charitable relief. In order to give the Commission an idea of the crowded state of some of the rooms Iwill give you their measurements, and other particulars. During the recent epidemic I came across a room 11 feet 10 inches long, by 10 feet 11 inches broad, with the ceiling 8 feet high, and a window 4ft. 4¼in. by 2 feet 7 inches. There were five persons in the room, and in the midst of them Was a case of confluent smallpox. Other persons who had not smallpox were going into the room, and out into the town indiscriminately, and we had no power to stop them. Another room on the same floor was 14 feet 9 inches long, by 9 feet 7 inches broad. The ceiling was 7 feet high. In this room 7 persons ate and slept. There was no case of smallpox in that room, but there was one in the room adjoining. I have here also the particulars of a very bad case, in a room in Heywood-place. The room was 10 feet 6 inches long by 9 feet 6 inches broad; the ceiling was 7 feet from the ground. The window 3 feet 2 inches by 3 feet 3inches. Six persons slept, ate, and drank in this one room. Amongst them were three suffering from smallpox. The only ventilation was a small door which opened into the passage ; the window did not open, and the floor was of stone. I think that this Island is decidedly the place where there should be an infectious hospital, and I am of opinion that we would have these epidemics much oftener if it were not for the winds which sweep through the towns."

The evidence of Mr Callow, inspector of nuisances is, as before stated, very much to the same effect, and most unfavourable as to the sanitary condition of the dwellings of the poor; as is, we have seen,that of the Rev James Fettes, minister of the Presbyterian Church of St. Andrew's; and the incumbents of St. George's and St. Thomas's, and other witnesses, all certify to the overcrowding in many parts of the town.

Some improvements have apparently, from the evidence of Mr Boyd, the chief-constable of the town, been manifested since the passing of the Amended Common Lodging House Act, and if the dens and rookeries which have been referred to in Quilliam's Court, in parts of Barrack-street, Hanover-street, and other localities, could be swept away, and some model lodging-houses substituted for these wretched tenements, the risk of the spread of epidemic disease might be reduced almost to a minimum in a place which has such natural advantages as the town of Douglas.

We are not of opinion that it is requisite to provide separate hospitals for those suffering from infectious diseases, either at Castletown, Peel, Ramsey, or elsewhere in the Island.

Cases of this character are of rare occurrence, and it is the opinion of all the local medical men that if the cottage hospitals we have recommended be there provided all ordinary requirements will be satisfied, and, in the event of any outbreak of infectious disease of an epidemic character, resource should be had to temporary iron hospitals or other premises, which, at Ramsey, at all events, might be readily improvised.

Each of these cottage hospitals should be under the charge of a resident trained nurse, who would act as housekeeper, and when there were no patients in the hospital, as might not unfrequently prove the case, her services would be available for out patients. The general want of trained nurses not only in the towns of Castletown, Peel and Ramsey, but also in Douglas, has been im. pressed upon us by almost every witness we have examined on this point,

If the Douglas Hospital be removed, and re-modelled for some forty patients, exclusive of infectious cases. a trained matron, with at least two trained nurses, would be then required, and it would be a great advantage to the town and Island generally if the matron were allowed, as at the Liverpool Workhouse Hospital, and in many of the London Hospitals, to take a certain number of probationers, who might be thus educated to supply the widely felt want of trained nurses. to which we have just adverted.

The committee appointed by the Tynwald Court November 22, 1877, to inquire into the subject of hospital accomodation, and whose report will be found in the Appendix to this report, after expressing their disapproval of the site of the present hospital in Fort-street, as unhealthy and unsuitable, recommended that "accommodation for forty patients should be provided, this to be exclusive of accomodation to from 40 to 60 patients of non-infectious diseases."

It is noteworthy in connection with some of the medical evidence given before the present commission with reference to the hospital in Fort-st., that the medical profession of the town were very strongly represented on the committee who came to this conclusion, and that among those present were Dr Fleming and Dr Ring.

Our present recommendation as to the number of patients for whom provision ought to be made in any new hospital for Douglas, will be thus seen to be within the requirements laid down by the foregoing resolutions. It has been, however, our great aim to avoid making recommendations which would lead to extravagant or unnecessary expen- diture of any kind; and we believe that, with small cottage hospitals at the places already in- dicated, accommodation need not be at present provided for more than forty cases of a non- infectious character, and for from eight to twelve infectious cases. The former to include two lock wards for three patients of each sex, and the latter to be supplemented, in case of need, by the erection of a temporary iron hospital to meet any future emergency.

The present Hospital is not only, as reported by the Tynwald Court hospital committee, "in an unhealthy and unsuitable site," but its maximum accommodation, if a proper allowance of floor and cubic space be given to each patient, is not suffici- ent for more than 14 patients.* There is no oper- ating room, and operations are at present per- formed in the male ward. which is, indeed, the only tolerable ward for surgical cases, or cases of acute disease, in the whole hospital. We need not comment on the cruelty of performing amputations other operations in a ward occupied by other patients. It is sufficient to remark that the ab- sence of an operating room—which could only be afforded in the present building by appropriating for that purpose the house-surgeon's room—dis- poses at once of the suggestion offered by Dr oe and Dr Woods, and one or two other witnesses, that sufficient additional accommodation might be here provided by removing the house- surgeon and matron into the adjoining cottages.

*see Appendix for table showing the cubical and floor space of the several rooms of this hospital.

Dr Nelson, adverting to this suggestion, said— "I am not of opinion that it could be made imto a good hospital, even if the two cottages alongside of it were taken in. Even then it would not be large enough, to say nothing of the situation. And again—there are really none of the require- ments of a good hospital attached to the present Hospital. I do not think it advisable to spend any money whatever in extending the building in Fort Street."

And Dr Dearden says - "I do not think it would be possible to make the present site a satisfasctory hospital;" and he adds - "I have often seen cases in Douglas which should really be treated in the Hospital. I did the Hospital work for six months, and am quite convinced, from what I saw that I could have filled the Hospital several times over."

The Tynwald Court Hospital Committee, while considering the site for the present Hospital suggest—

"The retention of the Hospital garden premises for the purpose of a dispensary and accident ward."

And there is, no doubt, much to be said in favour of the position of this yard for these purposes. Should it be hereafter decided to move the Hospital out of the town, we should readily support the suggestion ; but if the site in Buck's- road be adopted, we have the medical authority for our belief that no practical inconvenience could arise from removing the Dispensary also to that site. Indeed, for the poor of Braddan and Onchan, and the upper parts of the town, it would be more convenient; and it undoubtedly must be an advantage to the house-surgeon to be able to see and dispense medicines to the out patients on the hospital premises.

There is, moreover, another purpose for which this yard in Fort-street is singularly well adapted, to which we now desire to call your Excellency's attention. We have already commented at some length on the intolerable nuisance, alike to the towns of Douglas and Peel and to the country districts, which arises from the systematic habit of begging and vagrancy, upon which at present no check is imposed; and we venture, therefore, to recommend—though it is perhaps not directly within the scope of our commission—that some legislative effort be at once made to cope with this growing evil.

A summary of the law as to beggars and vag- rants, whether Insular or foreign, is contained in the learned Attorney-General's letter to your Excellency of the 8th of January last, which, by your Excellency's permission, we print in the Appendix to this Report. From this it will appear that a bye-law passed in 1846 for the repression of foreign vagrants was considered to be in excess of the powers conferred by the Act of 1836, under which it was framed, and has consequently not been put in force, whilst no bye-law has been ever made under that statute with respect. to beggars belonging to the Island. An Act passed in 1665 to restrain the poor from ranging and begging out of their own parish is quoted by the Attorney-General, but with the significant remark that he has "never heard of its enforcement in modern times."*

We would therefore suggest for your Excellency's consideration whether it is not advisable that either bye-laws should be now framed and put in force under the 6th section of the Act of 1836 for "put- ting in force the law respecting beggars and vagrants," or that a simple act should be passed by the Legislature rendering it penal to be found begging in the streets or public highway either in or out of the parish to which such person belongs.

A tramp ward, under the charge of the police, should be at the same time established, with baths, and with cells on the separate system, for stone- breaking, corn-grinding, or other enforced labour, as now adopted with excellent effect in several English poor-law unions, for admission to which all persons should be recommended to give tickets to beggars or tramps, in lieu of the money or food now so recklessly be stowed on them. Into this tramp ward the person presenting the ticket would be admitted for a night's lodging, and would be assured of sufficient food to keep him from starv- ing, subject to compliance with certain rules and conditions, two of which should undoubtedly be the enforcement of a bath on admission, and the performance of a fixed task of work, as under the regulations now in force in English workhouses. No better situation for such a tramp ward could, be believe, be found than the yard opposite to the Hospital in Fort-street, of which mention has been already made.

The Hospital itself would admit of being converted into a model lodging-house, for which the site is well adapted, and to the great need for which we have already adverted.

* Attention should be called to the fact that, while the Poor Law Authorities in Great Britain and Ireland have power to remove to the Isle of Man natives of the Island who have not acquired a status of irremovability in those countries, no similar power is vested in the authorities here.

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