365

THE LANCET.

LONDON: SATURDAY, MARCH 13, 1869.

THE HOSPITAL SYSTEM.

WE reported in the last number of THE LANCET, thedebate of the Metropolitan Counties Branch of the BritishMedical Association on the question of the abuse of medicalrelief at hospitals. We cannot but feel that the meetingwas not a distinguished success ; and that the speechesserved chiefly to show, what everybody knew before, thenecessity for an impartial inquiry, with a view to the recon-cilement of conflicting interests by a comprehensive projectof reform. We have already called attention to the factthat, although nearly every man throws his stone at thepresent arrangement, still nearly every stone is aimed atsome different defect. We may even go farther than this,and may say that there are people to whom some of thedefects appear only as merits in disguise. It is even pos-

sible that a few more meetings and debates would bringthe differences between the reformers into greater promi-nence than their points of concord. Such a result would

not only be a lamentable proof of professional incohesion,but it would afford a valid excuse to the public and to Par-liament for continued neglect of the question. They would

say, with some appearance of justice, When you are agreedamong yourselves, gentlemen, we shall be happy to hearfrom you again.For many reasons, and chiefly because we consider the Ipresent state of the hospitals to be in itself a prominent

cause of medical disunion and a chronic source of weak-

ness to our body, we are very desirous that we should notbe referred to the Greek Kalends as the probable date ofthe initiation of change. We purpose, therefore, to laybefore our readers certain general principles that should,we think, form the basis of improvement, and that may bemore profitably considered in the quiet of the library thanamidst the din of debate. We invite each one to hold a

private meeting with his own copy of THE LANCET, andto form a decision about principles before descending todetails. When some such decision has been generallyarrived at, the time will be ripe for the assembling, not ofthis or that Branch or Society, but of the profession throughits recognised heads and representatives.The discussion of the question must evidently be prefaced

by some account of the interests that are involved. These

are-

1st. The sick poor, for whose benefit hospitals are pre-sumed to exist.

2nd. The subscribers who maintain the hospitals, andwho often consider and use them as so much property.

3rd. Medical students and the managers of medical

schools, who desire to attract numerous patients, in orderto be secure of a superabundance of materials for instruc-tion.

4th. The hospital physicians and surgeons in their pri-

vate capacities, who desire to have patients so afflicted, andso socially circumstanced, that successful treatment mayenhance professional reputation in profitable directions.

5th. Medical practitioners not connected with hospitals,who desire to modify the existing hospital monopoly ofoperative surgery, and to obtain fees from multitudes ofpeople who are now treated gratuitously. " Gratuitously"is, after all, not the right word; for, as a rule, nobodyreceives even the gratice.

6th. The public, who have the highest possible concernthat a profession upon which they are so largely dependentshould be composed of cultivated, contented, respected, and

moderately prosperous men; removed by education fromthe snares that beset ignorance, and by position from thetemptations that beset poverty. It is almost equally amatter of public concern that the funds devoted to charit-able purposes should be administered with economy, and that

idleness and improvidence should be sternly discouraged.Having thus enumerated the interests that we seek to

reconcile, we have first to take the " sick poor."It may be conceded at once that it is sound policy for the

public to provide, in some way or another, and under someconditions, medical care and treatment for all who requireit, and who cannot provide it for themselves. It is mani-

fest that the cannot is a matter that will vary with circum-

stances. In the country, for example, a respectable artisan,by the aid of his club, and with the advantages of a com-

paratively spacious and airy dwelling, may provide himselfwith attendance, and may undergo treatment, which inLondon he could only obtain in an hospital. The past or

probable duration of illness has also to be taken into

account. We may say, as a general rule, that every manwho has fulfilled, with regard to self-help, the reasonablerequirements of the public opinion of respectable membersof his own class, and who then, at his place of abode, cannotobtain the attendance that his case requires, is a fittingrecipient of hospital relief. Very often the standard thus

appealed to will be a low one, and might be raised with

advantage; but we must not expect any individual to actin excess of it. In cases of illness of probably slow progressand fatal termination, the aid of the hospital should be

given early, and prior to the exhaustion of little savingsthat, if still husbanded, may preserve a widow and childrenfrom eventual destitution. The details based upon this

general principle would vary in different localities, accord-

ing to the industries, the habits, and the earnings of the

people ; but the application of the rule can never, underany circumstances, be made a medical function. It is, andmust remain, a function proper to lay managers, to secre-taries, and committees; and, unless discharged by them, it

can never be discharged at all. No physician or surgeoncan preface his investigation of symptoms by preliminaryinquiries into circumstances and position. The task would

be foreign to his habits, distracting to his thoughts, andaltogether beneath the dignity of his calling.For the idle or vagabond poor, for the utterly improvi-

dent, and even for those whose best efforts still leave pro-

vidence an unattainable virtue, so that they live from handto mouth, and, with their families, come immediately tothe parish in case of illness, any hospitals that are needed

366 .THE ETHICS OF PROGNOSIS.

should be provided by the State; and would be better pro-vided, we think, by subsidies to general hospitals than as

separate institutions. To the idle and the utterly impro-vident we would apply the simple scriptural rule-that ifa man will not work, neither shall he eat. When in need

of hospital treatment, such men should obtain it by applica-tion to the relieving officer; and, when discharged cured,they should contribute to the cost of it by a period of forcedlabour, which would, at all events, serve to establish a prin-ciple in their minds. As far as they are concerned, no kindof almsgiving can be properly called charity. For those

whose honest labour is barely sufficient for their dailybread, the same provision should be made, with the ex-ception of the task work; and, in both sets of cases, theguardians of the poor would be the proper persons to ad-minister and to decide. The function of the hospital shouldbe to treat the State patient under a definite agreementwith regard to remuneration. In very many cases, we

think, some officials might receive from the intermediateclass of honest poor-from those whose claim to a medicalorder would not at once be incontestable-small weeklypayments, like those made to a provident dispensary, butof even less amount. Such payments might give a claimto medical relief on a basis that would not involve pau-

perism ; and the money received would serve to augmentthe stipends of parochial medical officers.

In our next number we propose to carry the subject a

step further; and we reserve the general consideration ofdifficulties and objections to be dealt with in a concludingarticle.

THE primary object of a patient in going to a physician isthe cure or the mitigation of his disease; the saving, or, ifthis may not be, the extension of his life. It is a secondaryduty of the physician to give, and a secondary object of thepatient to receive, general instructions about other bearingsof his symptoms. We wish to say a few words about this

secondary duty of the physician, in the discharge of which,it seems to us, there is room for a very conscientious phy-sician to feel embarrassed, and for a heartless physician todo more harm than all his advice will do good. This ethical

point is one which arises daily in practice. There are greatdifferences amongst medical men in this matter of prognosis.Some physicians are sanguine and hopeful even in regard tocases they know must sooner or later succumb; others are

grave and gloomy on the slightest indication of bad symp-toms or degenerative appearances; and both have a certainsuccess out of their opposite habits of prognosis. The one

cheers and pleases patients by his hopefulness ; the otherimpresses them with his prescience, and if all his prognos-tications are not realised, it is often set down to the skill

with which foreseen evil has been averted. The difference I

between the physician who takes the gloomy side of a caseand the one who takes the bright side for the foundation ofhis prognosis is often one of temperament. Sometimes-

not often let us hope-it is a designed and studied one.We wish to say a word in advocacy of favourable pro-

gnosis, as far as this can be given consistently with thefacts. Of course there are cases to which our remarks can-

not be applicable--cases in which plain and almost abrupt

expression of truth, however unpalatable, is the clear dutyof the physician. In advocating a favourable prognosis,we would urge two considerations. First, as we have said,the principal duty of the physician is, to do his patientgood, to give him comfort, and to prolong his life. To

magnify the bad features of his case, and so give a gloomyprognostication, is to do the patient palpable harm, probablyeven to shorten his life. On the other hand, to put "thebest construction" on even bad symptoms is to give thepatient an additional chance of life, and certainly an addi-tional chance of extending life.

This best construction of bad symptoms is justified byconsidering that we are sometimes wrong in regard tothe gravity of symptoms, that even degenerative changesare often very slow, and that organic diseases are moreamenable to treatment than they used to be. It is surpris-ing when we think of the number of men that are figuringmost conspicuously and creditably in the world, or have so

figured, after showing symptoms of the gravest disease. A

very prominent member of the present Cabinet was, ten ortwelve years ago, so prostrated as to be incapable of writinga note. One of the ablest members of the late House of

Commons had, years ago, an attack of paralysis. And mostmedical practitioners could point to men filling highly im-portant posts, over a great series of years, in commerciallife, whom few insurance offices would consider good livesIn fact, most such men are not absolutely healthy, andmany of them might be positively spoiled for their work bya melancholy view of symptoms which they occasionallypresent.Perhaps the disease which most aptly illustrates the

difficulties of the ethics of prognosis, and the differencebetween one practitioner and another, is the case of

phthisis. Given the occurrence of haemoptysis and a fewphysical indications of phthisical disease, the practitioneris apt to be excessively serious. The symptoms aredis-

agreeable, and the chances are against his patient. He is

tempted to be gloomy, and to give directions about life ’and

duty which the future may falsify, or which are calculatedto seriously depress the patient. A very eminent livingphysician has recorded a case that should operate as a

warning against a too decidedly gloomy prognosis. A gen-tleman came in from the country to consult him and another

distinguished practitioner of the metropolitan city in whichthey lived. He was labouring under advanced phthisis.H The patient was a perfect picture of consumption. He

had a rapid pulse, hectic sweating, purulent expectoration,and all the usual physical signs of t]aberculax deposit andof a cavity under the right clavicle." The physician inquestion, a deservedly great authority on diseases of thechest, thinking the case hopeless and that nothing couldbe done, advised the gentleman to get home soon. The

patient accepted the verdict. He was a sportsman, andthe particular sport to which he was addicted was that ofduck-shooting. As he had only a short time to live, he

thought he might as well enjoy himself in shooting ducks.In pursuit of this sport, he used to stand up to the hips inthe Shannon for four or five hours of a winter’s day, follow-ing the birds. In the matter of food he was equally lawless.He took whatever was going. His favourite drink was

367A ROYAL ACADEMY OF MEDICINE.

punch, and he rarely went to bed with less than seventumblers of punch. In eighteen months he presented him-self to Dr. STORES—the physician to whom we are indebtedfor the above intensely important history-recovered fromphthisis and quite well. Since this case was recorded, wehave become more familiar with the idea of curing or arrest-ing phthisis. Dr. WiLLiAMS’s valuable communications

on the subject in our columns of last year make the ques-tion of prognosis in phthisis more important than ever, andmake gloominess of prognosis positively wrong.

It would be a good bit of medical work if someone wouldcollect a history of cases presenting grave symptoms, eitherextending over a number of years during which useful and

good work has been done by the patient, or in which thesymptoms after presenting themselves have been followedby recovery. Cases of vertigo, of epileptic attacks, of in-

sanity, of haemorrhage, of hemiplegia, of diabetes, of albu-minuria, of cancer, or of phthisis might be reported with aview to this question of prognosis, so as to be at once in-teresting and instructive. We are just now in a diagnostichumour. New methods of diagnosis are making it easyfor us to diagnose disease very accurately. The dangeris that we become too physical in our view of disease ; thatwe content ourselves with detecting it, with associating itwith some degeneration of structure, and acquiescing in itas something inevitable. When physicians had less helpfrom. physical means of research, they were more dependenton close observation of physiological and clinical facts. It

is gravely to be doubted whether, with all our improvedmethods and skill in physical diagnosis, we are exercisingthose faculties which made HIPPOCRATES, SYDENHAM, andCULLEN great physicians, and which make their writingsbooks for all times. How little we know of the -history ofcases other than those which happen to die in hospitals.

’

On this question of prognosis some physicians seem to beof opinion that it is their duty to tell their patients all theyknow and all they think about their diseases. We entirelydemur.to this view of the physician’s duty. It is right inthe physician to be guided in giving truth to his patient byone or two considerations. First, he should consider howfar his patient is capable of understanding the exact valueof pathological truth. He will soon perceive that the patientis quite unable to go far in this direction, and thereforeshould not be troubled with too much information that is

only likely to mislead him. Secondly, he should considerhow far the cure of his patient will be hindered by thecommunication of opinions as to the most probable termina-tion.of his case. We have already excepted cases in whichthe tendency to death is obvious and certain. In these it is

alike -unkind and immoral to be otherwise than candid. In

all cases it is proper for patients and physicians to considerthe possibility of a bad termination of diseases; and thegreat duties of men, social or religious, do not depend merelyupon the probable duration of life. On every ground wemaintain that, in the interest of the patient, and in accord-ance with the growing resources of medical art, prognosisshould be as cheerful and favourable as possible, and thatunduly or prematurely hopeless prognosis is a violation ofthe first duty of the physician.

THE proposed amalgamation of the leading medical

societies of London into one body, to be termed the RoyalAcademy of Medicine, will commend itself to the membersof, these societies on many grounds. In the first place,there will be a saving of expense to the societies, and henceto individuals also; since the cost of rent, management, &c.,must naturally be less when the same building and officialsare employed by all, than when half-a-dozen staffs are ofnecessity employed. The scheme, which we published in

I extenso last week, appears to meet most of the requirementsof the case ; but there are one or two practical difficultiesthat will have to be overcome. Supposing the Fellows ofthe Royal Medical and Chirurgical Society to be willing toshare their glory with other societies (which some of theolder Fellows, and notably Dr. ROBERT LEE, are by nomeans certain to do), it remains to be seen whether the

other societies will be equally willing to embrace the oppor-tunity. The Pathological Society, which already meets inBerners-street, and the Clinical Society, neither of which

possesses any library, will no doubt be willing to amalga-mate ; but the Obstetrical Society, the most flourishing ofthe young societies, although it holds its meetings inBerners-street, is already in possession of a very consider-able library of works of reference, and enjoys a separatereading-room in Regent-street, and may therefore be morereticent. It possesses, too, a thousand pounds in consols;and consequently may, like other heiresses, require somewooing. The Epidemiological and Psychological Societieswould gain so decidedly in numbers and medical support bythe change that there would probably be no difficulty ontheir part.

It remains, then, to be seen whether the present pre-mises of the Medico-Chirurgical Society are sufficientlycapacious to take in other libraries, and to accommodate alarge accession of new members. Unfortunately for somereasons, the Society a little time back bought their lease,which has many years yet to run. Still it may be possibleto enlarge the room used for meeting, and, by occupyingthe entire house, to accommodate the extra libraries for a

time at least. We fear the time is gone by for putting in

any claim to a local habitation in Burlington House ; butwe throw out the suggestion that the examination-halls ofthe University of London are never used after 6 P.M., and

might possibly offer a more commodious and central placeof meeting than could be readily found elsewhere. It

appears to us that, according to the scheme, the pro-

posed Academy would be burdened with an unnecessarynumber of sections which have no corresponding societiesat the present time. State Medicine will surely be suf-

ficiently cultivated by the Epidemiological section, to

say nothing of the Statistical Society; physiology andanatomy betake themselves pretty much to the RoyalSociety, to whose Fellowship they are the great medicalpassport; materia medica and pharmacy may be safelyleft to the Pharmaceutical and the Chemical Societies;and comparative pathology, thanks to Dr. CRISP, alreadynot unfrequently enters an appearance at the PathologicalSociety, and scarcely deserves more at medical hands.

It may become a question whether the Royal Academyof Medicine shall imitate its Parisian prototype in re-

368 THE CONTAGIOUS DISEASES EXTENSION ACT.

porting officially, and by short-hand writers, the discus-

sions which take place at its meetings. It is undeniable

that the Transactions of all medical societies lose much

of their value from giving merely the papers read, andnone of the discussion which they provoked. We endea-

vour as far as possible to report the discussions at the

principal societies, though the demands on our space

necessitate great brevity in our reports. An authorised

verbatim report- of the speeches, condensed for immediatepublication, and given in extenso in the Transactions of

the Academy, would be valuable as treasuring up the

words of wisdom of men who seldom, if ever, find time towrite a paper.

THERE is probably no subject in the world more justlywithin the province of Government supervision than that ofthe national health. If we were to say that of all contagiousdiseases there are none which produce more injury andmisery to the human race than those which recently formedthe subject of a Committee of the House of Lords, weshould be within the limits of truth. There is no otheranimal virus with which we are acquainted which has thesame subtle property of protracting its morbid action overlong periods of time, which exhibits greater variety as re-gards its manifestations, or affects in the same way theinnocent and the unborn. That this is not the language of

exaggeration will be evident to anyone who will rememberthe number of disorders due to this cause over and above

the well known and ordinarily recognised manifestations.Take the organs of special sense-the eye, the ear, the skin,&c. The special departments of our large hospitals, as wellas special hospitals themselves, receive their chief supplyof patients from the source in question. The more we

study it, and the better we are enabled to trace the severalthreads in the great web of diseases to their origin, themore clearly we discover the paramount importance of

arresting its progress and averting its consequences. The

strength of a nation is not to be measured by the record ofits births, deaths, and marriages. It is to the adult popu-lation that we must turn for the workers and bread-winners ;and we must see what is its physical condition in the pre-sent, and what will be the physical condition of its suc-cessors-their children, and their children’s children. What

GOLDSMITH declared of the land-

"To hast’ning ills a prey,Where wealth accumulates and men decay,"-

might be applied with more sternness and truth to this

subject.There seems, fortunately, no doubt about the sincerity of

the determination which has been manifested, that the

time has come for us skilfully to devise a scheme and ener-

getically apply it, with the view of doing all we can tolimit, if we cannot entirely arrest, the sources of con-

tagion. And this can be done, we believe, if set about

properly; and we propose to state our opinion as to themethod. A Bill is soon to be brought into Parliament

by the Government for extending the Contagious DiseasesAct to the civil population; and the draft of it, if not

already completed, is in process of being drawn up. TheBill will be mainly based upon the recommendations of the

Lords’ Committee ; but we earnestly hope it will go farther.The Committee recommended the extension of the Act to

all naval and military stations, and to any place the inha-bitants of which apply to be included, and can give proofthat they have adequate hospital accommodation, and suffi-cient means of providing for the religious and moral super-vision of the inmates. With respect to the first we have

nothing to add; and we are glad to perceive that Mr.GUILDERS,, in moving the Navy Estimates, alluded to therather large additional charge which it was proposed shouldbe borne by the country in connexion with the ContagiousDiseases Act. We believe that, as regards a great centreof population like London and its suburbs, the legislationmust be of a compulsory and not of a voluntary character.Middlesex and parts of Kent and Surrey-the metropolitanpolice district, say-must be included within the operationof the Act; and it would be advisable not to wait for anyformal application from the inhabitants to the Government,but for the Government to legislate at once for the inha-bitants. We shall of course be met with the financial

objection, and asked how we propose to get the money.We answer, from two sources. From a local rate, supple-mented, in the case of the metropolis, by a Governmentgrant. It is better at once to look the difficulties

in the face. Everybody is interested- governors and

governed. It is cheaper to cure disease in individuals,than to allow it to sap their constitution and lodge them

finally and for life in a workhouse or hospital at the publicexpense ; but it is infinitely cheaper to prevent the spreadof the disease by affording timely succour to those who can-not be at large without certain risk of extending the sphereof our difficulty by spreading infection to others. The

public wants to diminish its poor-rates ; it must do so byremoving the sources of disease and poverty. Here is one

of them. The Government requires physical energy in itsrecruits for the public services, and it desires to diminishthe cost of these services by maintaining the health andefficiency of the men in them. Here is a cause for the’

rejection of recruits on the one hand, and of waste of

money in the loss of health and invaliding of soldiers

and sailors on the other. If London were divided into

districts, and a staff of medical men appointed as examin-ing surgeons and distributed in those districts, and womenof known character compelled to attend when required,we should soon get at the sources of contagion, and, inproviding for them until cured, arrest the spread of

these diseases. At first the amount of hospital accommo-dation required would be large, and the expense commen-surately so; but as soon as we had broken its back, as it.were, the outlay would rapidly diminish, and the diseasecome perfectly within control. As the case of London is

exceptional, we propose that Government should subsidisethe municipal and parochial authorities by a grant. Exist-

ing hospitals and workhouse infirmaries might be utilised asfar as practicable. New hospitals, as required, should be ofthe cheapest possible character, and not of permanent con-struction-such as huts or hired buildings; while Govern-ment hulks might be appropriated for the purpose on theThames, and placed conveniently near to given localities.