aggrandisement, amusement, or scientific advancement of any class of specialists. In offering, then, any criticism of existing management, or considering any scheme for new management, we must examine into these questions: 1. How most economically to provide adequate treatment for the sick. 2. How best to provide for the greatest benefit and comfort of such of the public as would derive advantage from hospital treatment. 3. How most advantageously, without in the least involving the second question, to provide for the technical training of new generations of surgeons and physicians. THE EXTENT OF THE HOSPITAL SYSTEM. The treatment of the sick in modern England is a very much more organised and rational affair than the old Babylonian method of laying the sick in the public squares, on the chance that someone might pass who had formerly suffered from the same ailment and had discovered a cure for it. Nevertheless, so early as 4,000 years before Christ, the Egyptians seem to have had an extensive system of public hospitals in connection with the temples, with medical schools attached to the hospitals. But, in a later age, Egypt appears to have reckoned science above humanity, and Celsus says of them that "They procured criminals out of prison by Royal Commission, and dissecting them alive, contemplated, while they were yet breathing, what nature had before concealed." We find a marked contrast in the more humane customs of the followers of Buddha, as is seen from this extract from an edict of the Hindoo emperor Asoka, who was crowned about 270 B.C. and founded hospitals throughout India and Ceylon: "Everywhere within the conquered provinces of Raja Piyadasi, the beloved of the gods, as well as in the parts occupied by the faithful, such as Chola, Pida Satiyaputra, and Ketalaputra, and even as far as Tambapanni, and moreover within the dominion of Antiochus the Greek (of which Antiochus's generals are the rulers), everywhere the heaven-beloved Raja Piyadasi's double system of medical aid is hereby established; both medical aid for men and medical aid for animals, together with medicaments of all sorts which are suitable for men and suitable for animals." In England, to-day, the extent of the various instruments for the collective treatment of the sick poor is even more enormous than is usually supposed. Thus, in the Lancet for November 9th, 1889, Dr. Rentoul calculated that 4,000,000 persons receive free medical relief in England yearly. He said further: "I think if one said that one person in three was provided with practically free medical relief in this country a very near approach to accuracy would be made.” It is said that about 8,000 persons are employed throughout the year in tending the sick "paupers" of London. The infirmaries of London are provided with about 14,000 beds, whilst the thirteen London hospitals to which medical schools are attached have nearly 5,000 beds, and the Fever hospitals of the Metropolitan Asylums Board about 3,500. The number of beds gives but a small idea of the number of the patients attended. Thus the thirteen large London hospitals above alluded to provide treatment annually for over 51,000 in-patients, and over 660,000 out-patients, in addition to attending more than 15,000 maternity cases in the patients' homes. Moreover, the demand for hospital treatment is growing every year. Thus, whereas the number of out-patients treated in Birmingham in 1867 was 67,000; twenty years later it had grown to 166,000. The annual income of the various voluntary hospitals in Great Britain amounts to some one and a half millions, of which the London general hospitals absorb about one third. Of this half a million, something over £200,000 is derived from dividends, invested property and grants, about £80,000 from legacies, £46,000 from subscriptions, and £54,000 from donations. Surely such an extensive system is composed of mutually helpful and thoroughly inter-related parts; and is not left in the hands of a number of competing groups of almost irresponsible persons. Yet, as a matter of fact, so unrelated are the various hospitals that even in matters of finance we find no common ground. Thus, to give but one instance, whereas the annual cost per bed at St. George's Hospital is only £88, at St. Bartholomew's it is nearly £130; whilst in the Infirmaries it only amounts to some £30 or £40. Surely there must be either absurd extravagance or meanness somewhere. Even the Hospitals Committee was obliged to report its "regret that there does not seem to be any genuine wish for co-operation between the various kinds of medical institutions. They are of opinion that much more might be done than at present by the hearty co-operation between the special hospitals and general hospitals, between dispensaries of all kinds and general hospitals, and between general practitioners and general hospitals." PATIENTS OR "CLINICAL MATERIAL"? Concerning the inhumane treatment of hospital patients a great deal of unwise and exaggerated stuff has been written. To read some of these vague denunciatory outpourings one would imagine that every qualified medical man in the country was a sort of disease-spreading devil, whose whole mind was ever devoted to discovering some new pain to inflict on his fellow men. Anyone with his eyes open, who is at all acquainted on the one hand with hospital life and on the other with the home of the average hospital patient, must see that to hundreds of thousands of poor people the hospitals as at present worked have been a veritable godsend. In the very great majority of all serious cases the patients are well fed and well nursed, and receive the best skilled treatment obtainable. But, while we are glad to allow this much, we must not forget the other side of the matter. There is, beyond all doubt, a great deal of abuse consequent on the almost unlimited powers of the medical staff. This power is especially misplaced when we remember the motive which makes men anxious to get on the staff of any of the great hospitals. The London hospitals do not for the most part pay any salaries to their staffs, either visiting or resident. The resident staff of house surgeons, house physicians, and obstetric officers, consists as a rule of students of the particular hospital who have recently obtained qualifications, and are anxious to get some real experience before leaving their alma mater; whilst the visiting staff consists of men with high qualifications who are desirous of obtaining more experience on the one hand and of becoming known to the profession and outside world on the other. Thus, in the British Medical Journal Dr. Hickman is reported as saying in all candour that the large and increasing number of hospitals and dispensaries was not an evidence of the intense interest taken by the pro fession in the poor, nor was the large amount of time and labour gratuitously devoted to their service simply an index to the disinterested philanthropy of medical men. The object of this interest and these services was not the benefit of the poor, nor of the profession, but the particular benefit of the individual, who looked forward to be amply repaid in the future by increased experience, enhanced reputation, and the legitimate advertisement of himself, which was almost the only opening to high-class practice and high-class fees." The profession, moreover, is far too prone to regard the hospitals merely as departments of the medical schools. Thus we find Mr. Timothy Holmes, one of our most eminent surgeons, saying1 "that the chief use of hospitals was that they should teach practitioners of medicine and surgery. Firstly, a hospital should be a place for medical education; secondly, for the relief of suffering; and, thirdly, for the training of nurses; all of which objects should be considered in due proportion by those exercising the management." Again, Dr. Carter, the then President of the Medical Society, speaking at the Mansion House in 1886, said :"The greatest use of hospitals is to promote the advancement of medical science, and to afford us improved methods of recognising and treating disease." It is obvious that to delegate the control of our hospitals. to men holding these views is an absurdity beyond defence. No wonder the suspicion begins to show itself that the "human vivisection" of Vesalius and Fallopius, of Erasistratus and Herophilus is being, or about to be, revived. For this suspicion there is of course some foundation. We are getting familiar with proposals for vivisecting criminals, idots, and such; and the distance 1 British Medical Journal, April, 1884. |