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THE LANCET.

LONDON: SATURDAY, MAY 20, 1905.

The Financial Relations of theLondon Hospitals and their

Medical Schools.WE publish this week an address dealing with the

financial relations that exist between the London hospitalsand their associated medical schools by Mr. HENRY MORRIS,the representative of the Royal College of Surgeons of

England upon the General Medical Council and senior

surgeon to the Middlesex Hospital, B7ho has studied the

bearing of these relations with particular closeness.

Mr. MORRIS fairly and forcibly puts his views upona situation which is so familiar to our readers

that it needs only the briefest rcs7ome here. It is

sufficient to say that the greater number of the medical

schools of the metropolis are no longer self-supporting andthat as a result they are, or have been, in greater or less ’,

measure subsidised by the hospitals. Into this matter a ’

committee was appointed by King Edward’s Hospital Fundto inquire, with the result that it reported that at least

eight metropolitan medical schools have received pecuniarysupport from funds which should strictly have been devotedto the maintenance of the hospitals although at most or allof the schools the teachers have during the last decade

done their work for practically no salaries, thus reducingexpenditure to the utmost. This position-one, we wouldpoint out, entailing upon the medical teachers of the

metropolis an amount of self-sacrifice which is very

inadequately recognised-has been brought about, withoutentering into details, by two circumstances. The first

is the increased cost of medical education and the second

is the increased popularity of the provincial medical

schools which are supported by students who until

recently came as a matter of course to walk "

one of the London hospitals. The committee of the

King’s Fund, in making clear the unfortunate financial

position, in no sense regarded the assistance given by the

hospitals to the medical schools as constituting a viciousdiversion of funds or an immoral breach of trust but it

came strongly to the conclusion that for the future the

moneys received for medical education and those received

for the maintenance of the hospital must be kept separate.As a comment upon the bad economy of the arrangementsfor medical education which necessitated the keeping of 12

separate foci for instruction in the elementary and ancillaryscientific branches Sir EDWARD FRY’S committee warmlyendorsed the plan of the University of London for startinga Medical Institute for the centralised teaching of such

subjects. Such is, in brief, the admitted position and Mr.MORRIS’S oration amounts to a distinct opposition to the

views of Sir EDWARD FRY’S committee. Mr. MORRIS

recognises the plight of the schools perfectly but he doesnot agree that a central school would have the result of

relieving or improving it.In the first place, Mr. MORRIS considers that medical

education resulting in exact knowledge, and hence in

scientific treatment, was, or should have been, one of

the objects of the benefactors of hospitals, so that the

question of immoral diversion of funds he does not con-

sider to arise. But we must all see the necessity for

medical charity to be above suspicion. We must be able

to close the mouth of criticism whether honest or whether

merely poking as care for the public weal, and the onlyway in which this can be effected is by rigidly keepingthe hospital moneys for the support of the hospital. Mr.

MORRIS points out that the hospitals owe more to the

medical schools than the medical schools owe to the hos.

pitals ; and in a sense this ij undoubtedly true, but if it

is not absolutely sure that the hospitals have the powerto pay the debt they must not be allowed to make the

attempt. Nor is it any excuse for irregular finance to

plead that the irregularity is only a little one. The amount

paid by the hospitals to the medical schools is relativelyvery small when the huge outgoings of the big generalhospitals are considered, and even the handsome contribu-tions made to hospital expenses by the King’s Fund onlymeet a small percentage of the absolutely unavoidable

expenses. Still, it is clear that no hospital should run

counter to the wishes of the King’s Fund, for this Fundand the Metropolitan Hospital Sunday Fund represent orderand organisation in medical charity, and as such are

regarded as public safeguards. So that for the future the

medical schools of the metropolis, with a continuallydropping list of entries, will receive nothing save the

students’ fees for their support unless they can promptlyinstitute special school funds. This is the course which

Mr. MORRIS recommends should be taken rather than the

adoption of the centralisation scheme of the tniversity ofLondon, for that scheme he find" absolutely uneconomical, un-

scientific, and impracticable. He points out that the centralinstitute is not yet built, that it will cost an enormous sumto build it and another to endow it, and the result must be,he thinks, that in the end the medical student would requireconsiderably more money per head to educate him than henow costs. Mr. MORRIS argues with conviction that anatomyand physiology should never be divorced from the generalstudy of disease, as a knowledge of these subjects remains,and must always remain, an integral part of the practice ofmedicine, he dwells on the vast size of London as an obstacleto the utility of a central medic il institution to be placed inSouth Kensington, and he pertinently asks what is to be

done now, as it is evident that the central institution, what-ever its success may be when it is a going concern, will notbe ) eady to do its work for some time.Our readers know that we favour strongly the idea of a

central institution and although Mr. MORRIS’S position is inmany respects a strong one-and everyone should read hisaddress and learn for himself how forcibly the situation

can be described from the other side-he has not been

able to alter our view. It seems to us that there

will let a most valuable economy of labour by teaching

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all the preliminary medical studies at a central in-

stitute, in time there will, we believe, be a100 a

saving of money, and medical education will be im-

proved much in all its later stages by the more orderlyand satisfactory grounding that the students will receive.

The vastness of London can be got over by having morethan one amalgamated school and the’difficulties owing tothe delay that must occur before the central institute, as

devised by the University of London, is in working ordercan probably also be met by the use of temporary sub-centres. But these are matters on which the medical

profession ought now to be receiving more information

from those actually interested in the promotion of

the central institute. The arrangements by which

sub-centres could do the work of the central insti-

tute for the time being ought to be arrived at soon

and the medical schools of the metropolis ought to knowtheir individual chances under such a temporary scheme.The sub-centres would have their quarters at existing medicalschools and the other medical schools ought to know as soonas possible what steps will be taken to safeguard their

property in their pupils. The movement for concentration

has actually commenced with the transfer by Westminster

Hospital Medical School of their students to King’s CollegeMedical School for instruction in the subjects of the pre-

liminary and intermediate examinations. An arrangementhas been made by which the students will remain students of

Westminster, which is satisfactory hearing. The unrivalled

clinical teaching in the wards of the London hospitals mustnot be jeopardised by the retention as permanent students attwo or three centres of all the attendants at the scientific

classes.

The Relation of Milk Depôts to thePublic Health.

IT is a strange satire upon preventive medicine to haveto admit that although our general death-rate has under-

gone, and is still undergoing, a steady decline our infantile

mortality should show not only no substantial fall but evenin some instances a tendency to rise. It is difficult to

believe that none of the forces which have been associated

with the reduction of the general mortality should havebeen without influence upon our infantile mortality, to

admit, in fact, that the improved well-being of the poorerclasses,’ their better housing, their higher wages, their im-

proved water- and air-supply, and the better regulationof refuse collection, should, in so far as the infants are

concerned, be without effect, more especially when to

these considerations we have to add over a quarter of

a century of compulsory education. Still, if we claim

such good results we are apparently compelled to concludethat this increased well-being has brought with it fresh

forces which entirely, and in some cases more than, counter-balance the good, in so far at least as the infants of the

working classes are concerned. Probably, however, this isa sound conclusion, and in a measure the increased pre-valence of urban conditions, the disinclination and, at times,inability of mothers to suckle their young, female labour,and the diffusion of cheap brands of skimmed milk and ofartificial foods are counteracting the improvements which

obtain in other respects. In short, the high infantile

mortality of the present day is an exceedingly complexmatter and is the result of many forces. Those, therefore,who seek to attribute it entirely to an unwholesome

milk-supply are eminently unscientific persons who must beclassed with those who seek "to stamp out" pumona-rytuberculosis by the use of sanatoriums alone. But, this

notwithstanding, there can be no reasonable doubt that avery substantial share in the causation of infantile mortality,more especially during the hot months of the year, must beclaimed for the unwholesome milk which is supplied to thechildren of the poor, and it is this knowledge which is

inducing some of our large towns to embark on the esta.b.lishment and the maintenance of milk depots, a name whickat the present time is largely synonymous with the supply ofsterilised or at least pasteurised milk. We are anxious,however, in this article to point out that the supplyof sterilised or pasteurised milk is, or should be, but

a very small portion of a municipal milk-supply, and

it is that portion of it which could perhaps be most

easily dispensed with. We are, indeed, very glad t6

see that Dr. G. F. MCCLEARY, whose milk dep6t ix

Battersea is known to a large section of the medical

profession as well as of the public, has lately drawnattention to this aspect of the question both in his workon " Infantile Mortality and Milk Depots" and in am

admirable paper which he read in February last before

the Society of Medical Officers of Health. In that paperDr. McCLEARY expresses the opinion that ’’ any methods

having for their object the purification or quasi.purificati&bgr;&in the city of milk already polluted in the country-suchmethods as sterilisation, pasteurisation, centrifugalisation,or filtration-must be regarded merely as makeshifts to beabandoned when better methods become practicable." This

is in our view a thoroughly sound and statesmanlike positM&and it is one with which apparently Dr. GEORGE NEWMAMthe medical officer of health of Finsbury, who has latelytaken part in the organisation of a depot in Finsbury onthe lines of some of the French depots, entirely agrees.

It can, of course, hardly be seriously urged that nature hasintended the young of one species to be nourished by themodified milk of another species and, assuming that the

mother be healthy and able to suckle her young, she shouldbe strongly urged, more particularly by her medical

adviser, to do so rather than to shirk her responsibilitiesby procuring modified cows’ milk at the municipal depot, andthe promoters of such depots should use every legitimatemeans of bringing home to the mother her responsibilities ’6eher child and to the State. In fact, this education of themothers of newly born infants should be one of the most

important functions of every sanitary authority and themilk of the depot should only be employed, as a Mias a pis aller. This is in no sense equivalent to an

argument that such institutions are unnecessary ; indeed,in our view there should be such an institution in connexionwith every urban district, as also well-trained female

inspectors to control the use, and to prevent the abuse, of themilk. But such a dep6t should not only supply sterilisedor pasteurised milk but also fresh, pure, whole milk drawn.and kept under the most wholesome conditions. There are,

too, obvious advantages in supplying such milk in sealed