This criticism is just characteristic of the medical mind .sx It is coincident with the general hospital policy of the 19th century .sx Indeed it reflects the whole of the modern hospital practice to this day .sx This practice is rigidly selective of the cases desired to retain within its walls .sx Its responsibility is necessarily restricted to its interests and its capacities .sx Let it be admitted that it is constantly driven to the limits of its resources .sx Nevertheless , its policy is none the less selective .sx And in this it casts the responsibility upon other agencies of treatment .sx And these agencies have been chiefly State agencies , which have compulsorily grown pari passu with the general hospital policy .sx They have been compelled to provide for the large residues of undesirable and undiscriminating applicants at the voluntary institutions .sx In a word , the development of State aid and State institutions is largely due to the medical profession and hospital methods .sx " As a matter of fact , " says another medical authority , " the out-patient department is so crowded that the work has to be done in a slipshod fashion , and unless the case happens to be an interesting one , the patient is put off with the stereotyped , ` How are you to-day ?sx ' 'Put out your tongue .sx ' 'Go on with your medicine .sx ' " .sx It is undeniable that the endowed and voluntary hospitals confront burdens and difficulties which have been and still are very great ; and their medical and nursing staffs are chronically overworked .sx Their well-known merits of administration are , fortunately , equally undeniable .sx They are freely used by the poor , and the Boards of Guardians everywhere avail themselves of them , handing over suitable cases from their infirmariesfor treatment , usually with a contribution to the maintenance of the particular patient or the institution generally .sx Nevertheless , during the 19th century , and to this day , they have proved inadequate to the great demands of the poor .sx They are largely concentrated in London and some 60 or 70 of the more important provincial towns where physicians , surgeons and students for the most part gravitate .sx Their geographical distribution is unequal , and they by no means cover either the needs or the convenience of the population generally .sx According to Sidney and Beatrice Webb , " they appear to provide in the aggregate little more than 25,000 beds , which is about one-fourth of the number of sick beds actually occupied in the workhouses and the workhouse infirmaries .sx " With regard to the out-patients' department the policy of selection , like that of the in-patients' for preventive medicine , is equally arbitrary , and , compared with all other institutional treatment , is similarly inadequate .sx In orthopaedic cases , where the handling of the crippled and other deformities involves prolonged treatment , cure is hardly ever the object aimed at , even in the general hospitals for children .sx The universal policy or system is of necessity the " quickly-in " and the " quickly-out " method .sx It may be more or less compulsory , but it corresponds with the selective policy of " interesting " cases .sx Hence the rise of the comparatively new and special orthopaedic institutions , like the Lord Mayor Treloar Hospital and College of Alton in Hampshire , where the aim is cure , no matter how prolonged the treatment .sx The State hospitals for zymotic and tuberculous diseases are a godsend to the endowed and voluntary hospitals , to which places , on the slightest suspicion , such cases are at once generally transferred , except where an isolation block is erected for the purpose .sx It was because the voluntary institutions refused to provide for zymotic cases , of which the chief are small-pox , diphtheria , scarlet fever , whooping-cough , measles , croup and erysipelas , that municipal hospitals were established .sx It was because .sx cases of chronic disablement or delirium tremens were also refused that the hospital departments of workhouses were instituted under the Poor Law .sx Similarly with venereal diseases , which now in general have their place elsewhere .sx Even to-day private philanthropy is quite unequal and incompetent to provide institutional treatment for the three most serious and widespread diseases , tuberculosis , cancer and syphilis .sx These facts go to show that the voluntary hospitals have in the past manifested marked preference for the acute case rather than the chronic ; the " rare or interesting " case rather than the commonplace .sx It is a matter of common knowledge , at least amongst certain informed classes , that the voluntary hospital does not regard itself as primarily concerned with the treatment of disease , but rather with the treatment of the " collapse " stage of disease .sx And " urgent " cases it never turns away .sx The patient generally is in extremis from disease .sx Being unable to follow his employment he , perforce , seeks admission to the hospital , probably by the advice of his doctor .sx As soon as he is well over the collapse stage he follows the general tendency of the institution to pass out patients as quickly as possible when the acute stage is over .sx And if the disease is chronic or incurable there is prompt transfer to the workhouse or Poor Law Infirmary .sx Otherwise , he is returned home and the institution loses sight of him .sx All these matters were part and parcel of the evidence taken by the Government Commissioners of Inquiry at the close of the 19th century and the early years of the 20th century .sx In conclusion , these facts are not given in any spirit of hypercriticism .sx There is no desire to depreciate the great , the important work of voluntary hospitals .sx It is accepted as an axiom .sx We all admire their courageous and magnificent efforts to cope with the cumulative pressures and burdens which have been yearly thrust upon them ; the increase of the population , the multiplicity of diseases , the necessity for new equipments wherewith to combat them .sx We all know their dire need of financial assistance , their difficulties of staff administration , the embarrassments of medical and nursing administration,all constantly increasing in volume and seriousness .sx Nevertheless , these immense and important labours do but constitute one-sixth of the total range and intensity of such labours on behalf of the diseased poor .sx This most important remainder of the work is somehow compassed by the Poor Law Authority which has been termed the Destitution Authority and the Municipal Authority .sx And the vast pressure and momentum of the destitution , general poverty and disease of the 19th century has been the compelling force in the attempt to straighten out the tangle by setting up government machinery for the treatment of diseases for which the modern voluntary system is still inadequate , and do not pretend , nor ever did pretend , to handle .sx The failures of the 19th century are found to be continuous in the 20th .sx These failures have been the subject of criticism by both medical and general public authorities .sx They must ultimately compel more and more contributions of State intervention and assistance .sx The threefold system of hospital administration Voluntary , Municipal and Poor Law have only assumed a compound mechanism which the circumstances of a complex society have necessarily demanded , until the Doctor has become involved in a machine which is preponderantly a State machine .sx In this complex machine for dealing with multitudinous diseases Voluntaryism has accomplished what it could .sx But if the State had never been moved to ease its burden , and had never discharged what is now universally conceded to be its bounden duty , and its natural function , we should have remained bogged as a nation in the horrors of the Middle Ages , or in the filthy garishness and impotence of the 18th century .sx This may have been no reproach to private philanthropy , nor to Voluntaryism as its custodian ; but it would have been a disgrace to the nation .sx We have seen that the reason why the philanthropist as individual has played so prominent a role in the past is because citizens had not yet risen to the summit of their citizenship as reformers .sx In doing this they would have been but exercising the spirit of charity in the larger and completely humanitarian sense .sx They would have all been constructive philanthropists .sx CHAPTER XII .sx THE TWENTIETH CENTURY .sx THOSE who to-day would resist to the uttermost the long historical process , which , from the Dark Ages , has evolved a State Medical Service , little realise how deeply embedded we are in a system which must now inevitably develop towards its epiphany .sx This historical process has advanced more or less consciously with the actual assistance of the medical profession .sx Some doctors have perceived the full purport of the process .sx Some approve and some disapprove of it .sx Some condemn it as opposed to the best interests of the profession ; and a hard-grained self-regarding motive is apparent .sx Some , with their eyes wide open , accept office at different points of the State machine and become participants in its working .sx Under the auspices of Town , County , and District Councils , under Boards of Guardians , in the varied activities under the Public Health Acts , the Local Education Authority , the National Health Insurance Acts , the Poor Law , and so forth , the State has rapidly absorbed and utilised medical services .sx If these developments are wrong , if such Acts of Parliament have created an unclean thing , then it becomes clear that the profession is particeps criminis .sx Now and then a controversy is raised and an outcry is heard .sx But the mills of God grind slowly .sx In a recent discussion upon what was described as the insidious inroads continually being made upon private medical practice , Dr. E. B. Turner , of Kensington , said :sx " The medical profession is skidding on a very slippery slope , and at the bottom of the slope is nothing but a cemeteryfor all that the older type of men regard as worth having .sx The only thing likely to be resurrected from that cemetery is a State Medical Service .sx " It has mattered not one iota what political principles have been professed in any age , ancient or modern , laissez faire , or State regulation , the social necessities of the time have always imperatively demanded that practical remedies and practical progress must be applied to the problem in hand .sx I may cite , for instance , the words of Mr. Neville Chamberlain in his speech delivered at Birmingham in April , 1927 .sx The occasion was that of the inauguration of hospital extension in a town famous for its application of the collectivist principle .sx The words were spoken by the son of a statesman famous for his advocacy of the principle in Local Government .sx It was the late Joseph Chamberlain , who was an ardent advocate in his day of County Councils and the promoter of collectivist ideas in his own town .sx " ` There are three features which distinguish an enlightened hospital policy,' said Mr. Neville Chamberlain .sx `These are combination , concentration , and co-operation .sx ' These features , he claimed , were all illustrated in the amalgamation between the Birmingham Cripples' Union and the Royal Orthopaedic and Spinal Hospital , whose new out-patients' and demonstration centre he declared open .sx " 'What was the hospital position in the country to-day ?sx ' he continued .sx ` We had about one hundred and thirty thousand beds in hospitals administered by town , county , and district councils .sx There were about two hundred thousand beds in the hands of the Guardians of the poor , and an additional fifty thousand beds administered by the boards of voluntary hospitals .sx Many of them , however , were set aside for cases of infectious disease , and others were reserved for persons who were technically destitute .sx " 'It is true,' he added , 'that rumours go about that in certain cases the Guardians stretch the meaning of the word " destitute " or " destitution " to a pitch which is dangerously near the limits of what the law allows , but as you know I have a blind eye to which I have hitherto applied my telescope when I have been looking in that direction .sx " 'I do so with the more complacency because I am contemplating certain changes which may have the effect of doing away with this test of destitution altogether .sx If the two hundred .sx thousand beds now in the hands of the Guardians were transferred to the authorities which possess the hundred and thirty thousand beds , there would be no distinction between the treatment of those who are destitute and those who are not destitute , and the whole of these three hundred and thirty thousand beds could be applied as it may seem best to the local authorities in question .sx ' "