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 greatest improvements in operative surgery. his discovery had all the elements of improvement that are possible in this branch of the profession.
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an operation which had been founded upon erroneous views of the nature and relations of the parts affected—which had been always tedious and painful in performance—which, whether successful or not, entailed much subsequent suffering, which in its results was highly dangerous, and which was very commonly followed by the loss of the limb or life,—was replaced by one founded on more correct views of the disease, easy and simple in its execution, occupying not more than a very few minutes, and which, so far as regards the purpose for which it was instituted, and to which it should be restricted, is almost invariably successful. if it be performed under circumstances implying conditions contrary to those on which mr. hunter's operation was founded, very different results have no doubt taken place; but, when properly applied, his operation for aneurism is no doubt one of the greatest improvements in operative surgery.
john hunter treats of operations in terms which show how low he rated that part of our duties. he speaks of them as humiliating examples of the imperfection of our science, and figures to himself an operator under the repulsive symbol of an armed savage. "no surgeon," said he, "should approach the victim of his operation without a sacred dread and reluctance, and should be superior to that popular éclat generally attending painful operations, often only because they are so, or because they are expensive to the patient"—p. 210. abernethy, whose keen observation saw the difficult web which various sophistries, to use no harsher term, had thrown around the subject, was very characteristic in the manner in which he dashed it aside, and pointed to the salient source of error.
"never perform an operation," he would say, "on another person, which, under similar circumstances, you would not have performed on yourself."
the truth is, that operations, to be performed properly, must be properly studied. they must be frequently performed on the dead, and afterwards carefully examined. there is a wide difference between neglecting a necessary study and making that the test of science which is the most emphatic proof of its imperfection. we have ourselves had no lack of experience in this291 branch of the profession, and have included not a few operations which are too commonly delivered over to men who are said to devote themselves to special objects. the result of our experience satisfies us in entertaining the views which the most distinguished men have held on this subject; whilst we are persuaded that few things have contributed more to impede the progress of science than the abuse of operations.
to return to the surgical appointments of the hospital.
the positions which had at first been left without any remuneration, become, by the machinery described, very lucrative; directly, by the fees paid by the pupils; and indirectly, in some cases, by keeping the surgeon constantly before the public. any prestige, therefore, in obtaining these appointments, is of great value; but, if that do not really involve professional excellence, it is as plain as possible that the public may be very badly served, and an evil generated equally opposed to the interests of science and humanity. it is obvious that the only legitimate grounds of eligibility are moral and professional superiority, as determined by the test adopted at public schools and universities—namely, public competition. now, what are the tests employed? without meaning to insinuate that moral or professional eligibility is wholly disregarded—no system in these days will support that—still the eligibility depends on a qualification which few would beforehand have imagined. it is certainly something better than mr. macaulay's joke in relation to the proposed franchise to the militia—namely, that the elector should be five feet two—but something not much more elevated; namely, that a bounty should have been paid to one of the hospital surgeons in the shape of an apprentice fee; thus making the holding one of the most responsible offices in the profession—a condition, which absolutely ignores relative eligibility of skill, steadiness, assiduity, and humanity; and which recognizes them only in such shape that the possession of office is practically made to depend on a point absolutely extrinsic to any one important requisition recognized by the public or the profession.
we need not insist on the tendency of this system to the protection of idleness and incapacity, or the injustice inseparable292 from it to the young gentlemen whose interests it is supposed to guard. one necessary consequence is obvious—namely, that the hospitals, instead of having to select from the general body of pupils, or from the more industrious or talented of them, is obliged to choose from a very small minority.
it is, in fact, just as if scholarships and fellowships at public schools and universities were conferred without any reference to the proofs which the candidates might have given of their talents or industry; but were distributed to those who had given a certain fee to a particular professor. would any man in his senses doubt as to the influence of such a plan on the interests of classical literature or mathematical science? it seems to us impossible that men should really differ on that point, or hesitate to admit that, mutatis mutandis, whatever the science might be, so far as the cultivation of it could be influenced by system, the result must be alike prejudicial in all cases. we are, however, far from arriving at the end of the system by this general statement.
the public and the government, uninformed or unmindful of this "system," wish to consult authorities on professional matters. they not unnaturally look to those who hold public appointments, because these afford the prestige of extensive opportunity, which is supposed to imply, and under a fair system would ensure, skill and experience. men are apt to look at a man's position, without stopping to inquire how it was obtained; and although position may cut both ways, and in particular instances "throw a cruel sunshine" over incapacity, still amongst gentlemen extreme cases are not to be expected; the rule is much more likely to be a respectable and protected mediocrity, which is just that tone which has rarely done anything to enlarge the boundaries of any kind of knowledge.
it happens, however, from the "system," and the position thus given to those who are supposed to profit by it, that the interests of the poor, and, in a considerable degree, those of the rich also, are, in a very large sense, confided to their care.
it thus follows that positions, in themselves highly desirable, and which enable men to exert considerable influence on the progress293 of a science, on the sound condition of which the physical comforts, and in no small degree the moral condition, of mankind depend, are occupied by men who have undergone none of those tests which public competition alone affords, and which the summi honores of almost every other profession either directly or indirectly imply.
so far for one mode in which the interests of the public are compromised; but there are many other channels. the government, ignoring the evils of this system, have placed the regulation of the surgical branch of the profession in the hands of a body of men whom, when we examine, we find to be no other than the apprentices we had recognized at the hospital, grown into the full bloom of a legislative body—whence again are chosen presidents, vice-presidents, examiners, &c., of the royal college of surgeons of london!
if, fatigued with this machinery, we walk to the royal medical and chirurgical society—a chartered body for the especial cultivation of science—we meet, as its name would imply, a number of our honoured brothers, the physicians; but here we find that, whether we observe presidents or any other officers, the influence exerted by the apprentice system continues; and that, in almost everything surgical, the best possible individual is an apprentice who has attained his first position without any public competition. can any one be surprised that the published transactions of this society are not of a higher character. we hope and believe that the point of the wedge is already inserted, which will, at no distant period, rend asunder this system, which we shall not trust ourselves by attempting to characterize farther. but there are points in connection with the interests of science and of abernethy which require yet to be noticed.
we need scarcely observe that it would be very desirable that the interests of science should be entrusted to those who had shown most assiduity or talent in the cultivation of them; that if operative surgery be really, as a whole, a series of facts exemplifying the defects of a science—that whilst every pains should be taken that what is necessary should be done thoroughly well—all294 factitious inducement to multiply their number should be avoided, and especially any which tended to increase emolument commensurately with their multiplication.
that as operations (with some few exceptions) merely minister to effects, their real bearings on disease can only be estimated by knowing the ultimate result; and that, in order to this effect, returns of all operations should be kept, with full accounts of the cases; the addresses of the patients should also be taken, and such means as were obvious and practicable employed to obtain the ultimate result of the case.
another point which should be attended to in hospitals, is an accurate notation and return of all cases whatever; so that we might obtain from statistical records whatever light they might be capable of affording in aid of the prosecution of a definite science. in this return, a full history, and all the phenomena of the case, which are known to have an influence on the body, should be accurately noted, and in tabular forms convenient for reference.
the defects of the hospitals in this respect are too well known to require comment; and we think the profession indebted to dr. webster for the exertions he has made to draw attention to this subject. in no respect are the hospitals more defective than as regards the division of labour75. to supply the requisitions of a yet dawning science, there is too much confided to one surgeon; for, at present, the practical administration and the scientific investigation should be confided to the same hand. if more be entrusted to one man than can be performed without great labour, and the greater labour be voluntary, we shall have little chance of obtaining that full and accurate notation of facts which all cases furnish more or less the means of obtaining, and without which the evolution of the maximum of human ability is absolutely impossible. it seems to us also an imperative duty to avail ourselves of the experience afforded by the history of other sciences, in the cultivation of our own.
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all sciences have been in as bad a condition as medicine and surgery, or worse. all sciences have progressed immediately that they were investigated on a rational plan—a plan, which, simply stated, is little more than the bringing together all the facts that can be perceived to bear any relation to the inquiry, and reasoning on them according to well-established and necessary conditions. if this be the case, and this plan have never been applied to the investigation of medical science, we know not how those who are placed in positions which supply the necessary means can be excused; or how we can halt in condemning the system under which such a flagitious neglect of the claims of science and mankind is exemplified. it is true, when we arrive at the acmé of our convictions of the effects of such a system, our reflections remind us that such things are "permitted," and that ultimately they will work for good; that man is not destined to interfere with the ultimate plan and designs of providence, however he may be allowed to place his intellect under the direction of a responsible volition, and to discover the path to the temple of truth, only after having fruitlessly threaded the mazes of error.
