THE HOSPITAL SYSTEM.
"——Non h?c sine numine Divum
Eveniunt."
?neid, lib. ii, 1. 777.
If we would view any human institution dispassionately, we must distinguish the vices of System from the faults of those who administer it.
Trite as this remark may be, the caution it involves is just that which is too frequently overlooked or unobserved. By a careful attention to the distinction it implies, we may develop the elements of rational reform, as contrasted with Utopian schemes; which, whatever of abstract truth they may contain, are frequently useless, simply because they are impracticable. We cannot effect any material change in human nature by any summary legislation, nor prevent the obtrusive necessities of daily life from bringing down the soaring aspirations of mind, to the humble level of the practicabilities of matter. Whoever, therefore, expects that any body of men, invested with irresponsible power, will hesitate to exercise it so as to procure, as they believe, the maximum of advantage to themselves,—might just as hopefully quarrel with the negro on account of his complexion. Do what you may, Man is Man "for a\' that;" but whilst it is necessary to remember this, it is by no means so, to do it in a spirit of unkindness or hostility, nor in any sense opposed to brotherly love; but, on the contrary, in a tone of mind which, alike mild and uncompromising, desires to promote universal harmony and good feeling, by removing the285 temptations which experience has shown to be influential in disturbing such relations.
Neither should we quarrel with a man who endeavours to do the best he can for his family and friends. Should he, even in this pursuit, compromise his duty to the public, it is very possible that the objects which he had in view may have been in themselves praiseworthy, and therefore, instead of exasperating our blame, may readily extenuate faults which it may be impossible to excuse.
The truth is, that the interests of the public and of individuals are seldom, if ever, incompatible; the occasions on which they appear to be so are not unfrequent; those in which they really clash are extremely rare.
Wherever circumstances occur in which the temptation of a present fruition is found habitually to lead men to courses which, however apparently promotive of their own interests, are really detrimental to those of the public,—it becomes very necessary that the public should impose safeguards against such an injurious exercise of power.
The hospitals of London, as we formerly observed, are, in the main, very fine institutions. They are many of them very wealthy, which generally means powerful also.
The Governors, as they are termed, consist of certain noblemen and gentlemen; the latter being, for the most part, drawn from the more wealthy sections of the mercantile and trading classes.
The knowledge possessed by these gentlemen of the requisitions of a large public hospital, must (special instances excepted) be very measured; and be, in the main, derived from the medical officers with whom they are associated.
It thus happens that the administration of the hospital is in great part confided—as, with some restrictions, it ought to be—to the medical officers. The interests of these gentlemen, it may be assumed, would be best promoted by carrying out in the most efficient manner the benevolent objects of the institution: and we believe, looked at fairly and comprehensively, this would be really the case. The duties of a large hospital, however—if they are to286 be performed conscientiously—require much time, not a little labour, and some health to boot. Now all these, in a crowded community, are very costly articles; and which must, in justice—and, what is material, in fact too—be fairly remunerated. The public never really pay so dearly, as when they appear to get labour for nothing.
Here we come to the first defect in the "Hospital System."
It might be supposed that, with ample means, the Governors of Hospitals, by adopting such previous tests as were in their power, would have secured the most efficient officers, by paying them remunerative salaries; and, having retained them as long as their services were deemed efficient, or the duration of them justified, that they would have released them from the necessity of further exertion by a retiring pension. No such thing. The Hospital gives nothing: actually, there is a small nominal retaining fee, as it were, of about ￡60 to ￡100 a year, and the medical officer is left to obtain his remuneration for time, trouble, and health, by such private practice as his reputation or the prestige of being attached to an hospital may afford; from fees from pupils, or such other means as the position he occupies may place within his power.
He very naturally sets to work to do the best he can; and from this first budding, we very soon arrive at the full blossom of the System; one effect of which is, that, in hospitals, which have so large a care of public health—institutions which, whether correctly or incorrectly, give so much of the tone to the medical opinions of the day, which exert, either directly or indirectly, an influence on the claims of hundreds to public confidence—that in these hospitals there is not one single surgeoncy that is fairly and bona fide open to scientific competition.
Let us now examine a little into the machinery by which these results are brought out.
The experience afforded by the hospitals necessarily supplies abundant means for instructing students in surgery. They are accordingly admitted on paying certain fees to the surgeon; and this at once supplies a large revenue. This revenue is of course regulated by the number of pupils; and as there are in London287 many hospitals, so it follows that there is an active competition. Thus, some time before the season commences, the advertisements of the medical schools occupy a considerable space in the public journals, and circulars are also liberally distributed.
Well, the points here, as in all other cases, are the advantages offered, and the price paid—the maximum and minimum respectively. Here we arrive at the elements of numerous evils.
Students are not always—and before they try, hardly ever—judges of a school. The general reputation of a man (as he is never subjected to open competition) is no test whatever of his comparative power in teaching students; but they are accustomed to ascribe great importance to operations; and, c?teris paribus, they incline to prefer that hospital where the greatest number are supposed to be performed.
This arises from various causes; in some of which the public play no unimportant part. The student has perhaps seen, in the country, a good deal of medical and surgical practice; but very few operations. His stay in London is comparatively short, averaging, perhaps, not more than the better part of two years. Unnecessary length of time is generally inconvenient, always expensive, and the student is naturally anxious to see most of that which he will have least opportunity of observing elsewhere. Moreover, he knows that when he returns to the country he may save twenty limbs, before he obtains the same amount of reputation that he may possibly get by one amputation—the ignorance of the public, here, not appreciating results which very probably involved the exercise of the highest talent, whilst they are ready to confer a very profitable distinction on that which does not necessarily involve any talent at all.
We have no wish whatever, and certainly there is no necessity, for straining any point in reference to this very serious matter; but these two facts are indisputable—that the surgeons obtain their remuneration from the hospitals by the fees they obtain from the pupils; and, c?teris paribus, the pupils will flock the thickest where they expect to see most operations.
The next thing that we would submit, is that the prestige in favour of operations is both directly and indirectly opposed to the288 progress of scientific surgery. Almost all operations, commonly so termed, are examples of defective science. To practical common sense, therefore, it would appear a very infelicitous mode of obtaining the maximum of a man\'s genius in aid of the diminution of operations, to open to him a prospect of enriching himself by the multiplication of them. We desire to consider the subject with reference to its scientific bearings only, and would avoid entirely, were that possible, any appeal merely to the feelings. Such impulses, however right, are apt to be paroxysmal and uncertain, unless supported by the intellect. But, on such a subject, the feelings must necessarily become more or less interested. Wherever a system takes a wrong direction, a great many minor evils insensibly grow out of it.
The erection of a theatre for the purpose of operating, though founded on a feasible pretext, is a very questionable measure; and, unless of clear advantage to the profession or the public, is surely not without some character of repulsion. As regards art and science, it is certain that not more than twenty or thirty can be near enough in the theatre to see anything that can be really instructive in the performance of operations. In the absence of actual advantage, therefore, an exhibition of this kind is more calculated to give publicity to the surgeon operating, than it is to raise the tone or chasten the feelings of men about to enter a profession which almost daily establishes requisitions for our highest faculties. Operations without opportunities of real instruction, are merely unprofitable expenditure of valuable time. That which is viewed as a sort of exhibition to-day, may be with difficulty regarded in the light of a serious duty to-morrow. Were the object to tax the sensibility of a student, and blind him to any higher association with pain and suffering than that afforded by custom and chloroform, and to substitute for a dignified self-possession and sympathy with suffering, which each kept the other in due control, an indifference to everything save adroitness of manipulation and mechanical display,—no machinery could be better calculated to effect such objects; but science and humanity require very different qualifications, and experience has shown that they are neither incompatible nor beyond our power.
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The humanity and science that beholds, in operative surgery, the lowest of our employments, and which would thence be impelled to seek, and as experience has taught us to seek successfully, to diminish the number of such exhibitions, and to lessen the suffering of those which are still retained, is perfectly compatible with coolness and skill in the performance of them.
When we speak of lessening pain, we must not be understood as alluding to chloroform, or agencies of that kind. We have, on the contrary, the greatest distrust of their utility; we do not hesitate to admit the propriety of their use in certain cases; but we are satisfied that, as at present employed, a very few years will make a great change. Many a so-called incurable case has been shown to be curable by the hesitation of the patient to submit to an operation. We have published some ourselves, wherein we joined in recommending the measure which the patient declined. Many deaths that we do know have already occurred from the use of chloroform; and a significant remark was made by a man who had considerable reputation in this way. He said: "Chloroform is a good thing for operating surgeons."
To return from this digression. The most distinguished surgeons ever known in this country have shown us how to combine, in the highest degree, dexterity and skill, with science and humanity; together with a just estimate of the low position occupied by operations in the scale of our important studies. I may allude to two more particularly, Cheselden and John Hunter; the former, the most expert and successful operator of his day, in the European sense of the word, has left us a satisfactory declaration on this subject. Cheselden acknowledges that he seldom slept much the night previous to the day on which he had any important operation; but that, once engaged in operating, he was always firm, and his hand never trembled. John Hunter was not only a good operator himself, but he deduced from observation one of the gre............