Encyclopaedia Britannica, 11th Edition, "Horticulture" to "Hudson Bay" / Volume 13, Slice 7

by Various

As to the relative merits and demerits of the systems of government of municipal hospitals and voluntary hospitals a few words may be useful. There can be no doubt that the voluntary hospital in Great Britain has had a remarkable effect for good upon all classes in the making of modern England. The management of these institutions is frequently representative of all classes of the people, while the voluntary system, as the Hospital Sunday collections all over the country, and all over the English-speaking world, prove, has united all creeds in the good work of caring and providing for the sick and injured members of each community. Again the voluntary system makes for efficiency in the administration of all hospitals. Each voluntary hospital is dependent upon its popularity and efficiency, in large measure, for the financial support it receives. In this way an ill-managed voluntary hospital, or one which has ceased to fulfil any useful public purpose, is sure to disappear in due course under the voluntary system. Voluntary hospitals are always open to, as well as supported by, the public, and, owing largely to the example so prominently set by King Edward VII. and members of the royal family, more people every year devote some time in some way to the cause of the hospitals. Attached to the voluntary hospitals are the principal medical and nursing schools upon which the public depend for the supply of doctors and nurses. The education of students and nurses in a clinical hospital makes that hospital the most desirable place for everybody when they are really ill. In such a hospital no patient can be overlooked, no wrong or imperfect diagnosis can long remain undiscovered and unrectified, and nowhere else have the patients so continuous a guarantee that the treatment they receive will be of the best, while the provision made for their comfort and welfare, owing to the unceasing and ever varying quality of the criticism to which the work of everybody, from the senior physician to the humblest official, is subjected in a clinical hospital, is unequalled anywhere else. At a great voluntary hospital, not only do hundreds of medical students and nurses work in the wards, but thousands of people, in the persons of the patients’ friends, and those members of the public who take an interest in hospitals, pass through the wards in the course of every year. Again, each voluntary hospital has to live by competition, a fact which guarantees that everything in the way of new treatment and scientific development shall in due course find its proper place within the walls of such an establishment. Open as they are to the full inspection of everybody whose knowledge and presence can promote efficiency, the voluntary hospitals have shown, especially since the last quarter of the 19th century, a continuous development and improvement. Here the patients are treated with invariable kindness and consideration, as human beings rather than cases, to the great benefit of the whole human family as represented by the officials, the patients and the students, with their relations and friends, the honorary medical officers, hundreds of medical practitioners and nurses, who receive their medical training in the hospitals, and the ever-increasing number of governors and supporters by whose contributions voluntary hospitals live. The great missionary and social value of the voluntary hospitals to the whole community cannot be questioned, and they have been of inestimable value to the churches by inculcating the higher principles of humanity, while removing the many acerbities which might otherwise prevail between rich and poor in large cities.

The voluntary hospitals are attended, however, by certain disadvantages which do not attach to municipal institutions. A municipality which undertakes the provision of hospitals for the entire community is largely able to plan out the urban area, and to provide that each hospital site selected shall not only be suitable for the purpose, but that it shall be so chosen as to contribute to make the whole system of hospital provision easily accessible to all classes who may require its aid. The voluntary hospitals, on the contrary, have grown up without any comprehensive plan of the districts or any real regard to the convenience or necessities of their poorer inhabitants. Voluntary hospital sites were almost invariably selected to suit the convenience of the honorary medical staff and the general convenience of the hospital economy rather than to save the patients and their friends long journeys in search of medical aid. The best of the municipal systems too enables economy to be enforced in the administration by a plan which provides a central office in every town where the number of vacant beds in each hospital is known, so that the average of occupied beds in all the hospitals can be well maintained from an economical point of view. This speedy and ready inter-communication between all hospitals in a great city, which might perfectly well be secured under the voluntary system if the managers could only be brought into active co-operation, prevents delay in the admission of urgent cases, promotes the absence of waste by keeping the average of beds occupied in each establishment high and uniform, and has often proved a real gain to the poor by the diminution in cost to the patients and their friends, who under the best municipal systems can find a hospital within reasonable distance of their home in a large city wherever it may be placed. Another advantage of the municipal system should be that central control makes for economical administration. Unfortunately a close study of this question tends to prove that municipal hospitals for the most part have resulted in a dead monotony of relative inefficiency, often entailing great extravagance in buildings, and accompanied by much waste in many directions. Existing municipal hospital systems are attended by several grave disadvantages. The administration shows a tendency to lag and grow sleepy and inert. The absence of competition, and the freedom from continuous publicity and criticism such as the voluntary hospitals enjoy, make for inefficiency and indifferent work. Rate-supported hospitals, as a rule, are administered by permanent officials who reside in houses usually situated on the hospital sites, and who are paid salaries which attract the younger men, who, once appointed, tend to continue in office for a long period of years. This fixture of tenure is apt to cause a decline in the general interest in the work of the municipal hospital, due mainly to the absence of a continuous criticism from outside, and so the average of efficiency, both in regard to treatment and other important matters, may become lower and lower. Those who have habitually inspected great rate-supported hospitals must have met instances over and over again where a gentleman who has held office for twenty or thirty years has frankly stated that his income is fixed, that his habits have become crystallized, that he finds the work terribly monotonous, and yet, as he hopes ultimately to retire upon a pension, he has felt there was no course open to him but to continue in office, even though he may feel conscientiously that a change would be good for the patients, for the hospital and for himself. Under the voluntary system evils of this kind are seldom or never met with, nor have these latter establishments, within living memory, ever been so conducted as to exhibit the grave scandals which have marred the administration of rate-supported hospitals not only in Great Britain but in other parts of the world. We believe that the more thoroughly the advantages and disadvantages of rate-supported and voluntary hospitals for the care of the sick are weighed and considered, and the more accurate and full the knowledge which is added to the judgment upon which a decision can be based, the more certain will it be that every capable administrator will come to the conclusion that on the whole it is good for the sick and for the whole community that these establishments should, at any rate in Great Britain, be maintained upon the voluntary system. Of course it is essential to have rate-supported hospitals where cases of infectious disease and the poorest of the people who are dependent largely upon the poor-law for their maintenance can be cared for. It is satisfactory to be able to state that of late years the administration of both these types of rate-supported hospitals has greatly improved. The added importance now given all over the country to medical officers of health, and the disposition exhibited, both by parliament and government departments, to make the position of these officers more important and valuable than ever before, have tended largely to improve the administrative efficiency of hospitals for infectious diseases. No doubt the whole community would benefit if residents in every part of the country could be moved to take a personal interest in the infectious hospital in their immediate neighbourhood. Amongst the smaller of these establishments there has been so marked an inefficiency at times as to cause much avoidable suffering. The existence of such inefficiency casts a grave reflection upon the local authorities and others who are responsible for the evils which undoubtedly exist in various places at the present time. Unfortunately knowledge has not yet sufficiently spread to enable the public to overcome its fear and dread of infectious maladies. It is therefore very difficult to induce people to take an active interest in one of these hospitals, but we look forward to the time when, owing to the activity of the medical officers of health who have immediate charge of buildings of this kind, this difficulty may be overcome, when the avoidable dangers and risks and the appalling discomfort which a poor sufferer from a severe infectious disease in a rural district may suddenly have to encounter under existing circumstances, would be rendered impossible.

The poor-law infirmary in large cities, so far as the buildings and equipment are concerned, very often leaves little to desire. Poor-law infirmaries lack, however, the stimulus and the checks and advantages which impartial criticism continuously applied brings to a great voluntary hospital. Such disadvantages might be entirely removed if parliament would decide to throw open every poor-law infirmary for clinical purposes, and to have connected with each such establishment a responsible visiting medical staff, consisting of the best qualified men to be found in the community which each hospital serves. The old prejudice against hospital treatment has disappeared, for the least intelligent members of the population now understand that, when a citizen is sick, there is no place so good as the wards of a well-administered hospital. Looking at the question of hospital provision in Great Britain, and indeed in all countries at the present time, it may be said, that there is everywhere evidence of improvement and development upon the right lines, so that never before in the history of the world has the lot of the sick man or woman been so relatively fortunate and safe as it is in the present day. Probably it is not too much to say that to-day hospitals occupy the most important position in the social economy of nations.

Classification of Hospitals.—Having dealt with hospitals as a whole it may be well very briefly to classify them in groups, and explain as tersely as possible what they represent and how far it may be desirable to eliminate by consolidation or to increase by disintegration the number of special hospitals.

General Hospitals.—These establishments consist of two kinds, (a) clinical and (b) non-clinical, each of which, under the modern system, should include every department of medicine and surgery, and every appliance and means for the alleviation of suffering, the healing of wounds, the reduction of fractures, the removal of mal-formations and foreign growths, the surgical restoration of damaged and diseased organs and bones, and everything of every kind which experience and knowledge prove to be necessary to the rapid cure of disease. The clinical hospital means an institution to which a medical school is attached, where technical instruction is given by able and qualified teachers to medical students and others. A non-clinical hospital is one which is not attached to a medical school, and where no medical instruction is organized.

Special Hospitals.—Up to about 1840 the general hospital was, speaking generally, the only hospital in existence. Twenty years later, as the population increased and medical science became more and more active, some of the more ardent members of the medical profession, especially amongst the younger men, pressed continuously for opportunities to develop the methods of treatment in regard to special diseases for which neither accommodation nor appliances were at that time forthcoming in general hospitals. In a few cases, where the managers of the great general hospitals were men of action and initiative special departments were introduced, and an attempt was made to make them efficient. The conservative spirit which, on the whole, represents the British character for the most part, resulted, however, in a steady resistance being offered by the older members of the medical staffs and existing committees to the advocates of special departments. In the result, especially as such special departments as there were in connexion with general hospitals were too often starved for want of means and men for their development and improvement, the younger spirits called their friends together and began to start special hospitals. To-day every really efficient clinical general hospital has within its walls special departments of almost every description, which have been made as efficient and up-to-date as money and knowledge can make them. Unfortunately the causes already referred to led to the establishment of hundreds of the smaller special hospitals, many of which were started in unsuitable buildings, and some of which have ever since maintained a struggling existence. Others, on the contrary, through the energy of their original promoters and the excellence of the work they have done, have obtained a position of authority and reputation which has had a very important bearing for good upon the development of medical science in the treatment of disease. If the world had to-day to organize the very best system of hospital accommodation which could be evolved, there is no doubt that few or none of the special hospitals would find any place in that system. As matters stand, however, the special hospital has had to be accepted, and nothing which King Edward’s Hospital Fund has done in London has met with greater popularity and professional approval than the labours which its council have undertaken in promoting the amalgamation of the smaller special hospitals of certain kinds, so as to secure the provision of one really efficient special hospital for each speciality. No doubt this policy of amalgamation will be steadily pursued, and in the course of years every great city will gradually reorganize its hospital methods so as to secure that, whether the patients are treated in a general hospital or in a special hospital, the average efficiency in every institution shall be as high and as good as possible.

We will take now the special hospitals in detail.

Cancer Hospitals.—The justification for efficient cancer hospitals must be found in the circumstance that most scientific men of experience believe that, if adequate resources were placed at the disposal of the medical profession, the origin of cancer might be discovered, and so the human race would be freed from one of the most awful diseases which affect humanity. Pending such a discovery the experience of the cancer department connected with the Middlesex Hospital in London proves to demonstration that the provision of adequate and special accommodation for the exclusive treatment of cases of cancer is not only desirable but necessary on humanitarian grounds alone.

Hospitals for Consumption.—For many years it was held that this group of hospitals was not a necessity, and the patients were treated in the ordinary medical wards of the general hospitals. Since the contagious character of tuberculosis became known, and improved methods of treatment have been developed, every one agrees that this type of special hospital is desirable, though it is believed by the more advanced school of scientists that before long it may be happily rendered obsolete owing to the discovery of methods of treatment which will stay the disease at its commencement and restore the patient to health.

Children’s Hospitals.—These hospitals were very much opposed at the outset. There can be no doubt that the children’s ward or wards in a big voluntary hospital is a most valuable asset to the managers, so long as the children are treated in separate wards. There is no reason of course why a hospital should confine its work to the treatment of children, exclusively. Still this special hospital is popular with the public; it has led to many discoveries and developments in the treatment of children’s diseases; on the whole the administration of these establishments has been good; and we believe they will continue to flourish, however many children’s wards may be provided in general hospitals. Children’s hospitals with country branches for the treatment of chronic ailments, such as hip disease, are a valuable addition to the relief of suffering in cities.