THE HUMANITARIAN LEAGUE’S PUBLICATIONS. 1. Saas No. 16. a a a 62.11 541p : a | PUBLIC. CONTROL OF HOSPITALS. BY HARRY ROBERTS. LONDON : WILLIAM REEVES, 185, FLEET STREET, EOC. 1895. These Publications are issued under the auspices and with the general approval of the Humanitarian League; but for all particular views expressed on matters of detail the indivieucl writers are alone responsible. UNIVERSITY OF ILLINOIS LIBRARY «f URBANA-CHAMPAIGN OAK STREET IBRARY FACILITY 3G 4,1] J RE4/p PUBLIC CONTROL OF HOSPITALS. THE ProsiEM STATED. ‘THE poorer the guest, the better pleased he ever is with being treated,’ philosophised the Vicar of Wakefield ; and the aphorism which he applied to his poor relations is equally true of those who come under medical care. Thus is explained, or at any rate partly explained, the long silence concerning hospital management on the part of those who have been inmates of these refuges for the sick. Concerning these, however, like so many other previously uncriticised institutions, the public voice is at last beginning to demand, and in somewhat querulous tones, that more information be given, that more light be thrown on their inner working. In this paper I propose to state, as briefly as may be, the facts which, from the point of view of the layman, demonstrate the advisability, or rather the necessity, of taking the control of the hospitals out of the hands of the present governing bodies and placing it directly in the hands of the people’s representatives. And here I would lay stress on what may appear a truism to any but those interested, namely, that the /ay point of view is the only one to be considered. There cannot be any rational discussion of ‘‘the professional point of view” of which we have heard so much. Hospitals should exist solely for the good of the people, and not in the least for the 4 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 treat- ment for the sick. 2. How best to provide for the greatest benefit and comfort of such of the public as would derive ad- vantage 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. Tue Extent oF THe Hosprrat 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 dis- covered 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 5 an edict of the Hindoo emperor Asoka, who was crowned about 2708.c. and founded hospitals throughout India and Ceylon :— ‘“‘ Everywhere within the conquered provinces of Raja Piya- dasi, the beloved of the gods, as well asin the parts occupied by the faithful, such as Chola, Pida Satiyaputra, and Ketala- putra, and even as far as Tambapanni, and moreover within the dominion of Antiochus the Greek (of whirh 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 instru- ments 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 Eng- land 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 Asy- lums 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. 6 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 Hos- pitals Committee was obliged to report its ‘regret that there does not seem to be any genuine wish for co-opera- tion 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 ‘ CrinicAL MATERIAL” ? Concerning the inhumane treatment of hospital patients: a great deal of unwise and exaggerated stuff has been: 7 written. To read some of these vague denunciatory out- pourings 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 obtain- able. 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- 8 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 indi- vidual, who looked forward to be amply repaid in the future by increased experience, enhanced reputation, and the legiti- mate 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, saying’ ‘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 advance- ment 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. * Lancet, June 26, 1886. (P. 1250). 9 between a criminal and a pauper is usually easily traversed by the wishful. Of course, anything which could be legitimately described as dangerous or painful experimen- tation on hospital patients must be far from common in this country. Probably a majority of surgeons and physicians would discountenance anything approaching it. But at the same time there is no excuse for the super-critical air which Mr. Havelock Ellis assumes in his book on “The Nationalisation of Health,’”’ where he says :— ‘¢T doubt whether many people realise the suspicion with which a certain section of the more ignorant classes regard hospitals. Indeed, even among the more intellectual classes, the critics of medicine are in England, as a distinguished French surgeon has recently said they are in France, frequently conspicuous for their enormous incompetence. Charges of gross neglect, charges of treating patients as subjects for experiment, are freely and fiercely expressed, and occasionally they gain a prominent position in the newspapers and novels. On investigation these charges usually turn out to be ridiculously devoid of foundation; and anyone who is familiar with the working cf our large hospitals knows that such accusations are so absurd that it is difficult to consider them seriously.”’ Tur MerpicaL PROFESSION AND VIVISECTION. But one finds it far less difficult to consider them seriously when it is borne in mind what is the practice and doctrine of the men against whom these charges are made, and their colleagues, in the allied matter of animal vivisection. I say allied, because both animal vivisection and experiments on human beings are based on the same scientific fetish of misunderstood utilitarianism, namely, that the few and the weaker may wisely be used for the greater benefit of the many and the strong. We know 10 that those whose time is largely occupied with the slaughtering of cattle in the primitive and brutal manner which is still the almost universal one in this country are more prone than their neighbours to commit assaults on their fellow men. In the same way, it is fair to expect that men accustomed to subject animals to pain, primarily, it may be, in order that their fellow men may ultimately profit, but subsequently and more usually in order that some new scientific fact may be discovered, and consequent honour and glory be their’s—it is fair to expect that such men will be somewhat apt to use the sick pauper who chances to be suitable for the purpose to further the progress of science, even if such use is detri- mental to the individual thus treated. Such an inference implies no suggestion that doctors are naturally any worse or less humane than other people, for such a suggestion would be absurd, but is simply based on the ordinary well-established laws of training and habitude. In order to give an idea of the way in which animal vivisection is regarded by men who are reckoned at the head of the profession, the following extracts may serve. In answer to a question from the Chairman of the Royal Commission of 1876, ‘‘ What is your own practice with regard to the use of anesthetics in experiments that are otherwise painful?” Dr. Klein, F.R.S. (Lecturer on Physiology at St. Bartholomew’s Hospital), said :— ‘‘ Except for teaching purposes, for demonstration, I never use anesthetics where it is not necessary for convenience. If J demonstrate, I use anesthetics. If I do experiments for my inquiries in pathological research, except for convenience sake, as for instance on dogs and cats, I do not use them. as ‘* Chairman: When you say that you only use them for con- venience sake, do you mean that you have no regard at all to the sufferings of the animals? 11 ‘No regard at all. I think that with regard to an experi- menter, a man who conducts special research, and performs an experiment, he has no time, so to speak, for thinking what will the animal feel or suffer. His only purpose is to perform the experiment, to learn as much from it as possible, and to do it as quickly as possible. For my own purposes I disregard entirely this question of the suffering of the animal in per- forming a painful experiment. I regard it for demonstration because I know that there is a great deal of feeling against it in this country, and when it is not necessary one should not perhaps act against the opinion or the belief of certain in- dividuals of the auditorium. One must take regard of the feelings and opinions of those people before whom one does: the experiment.” How the more cautious and time-serving experimenters must regard such candid statements as the following by Dr. Charles Richet in the Revue des deux Mondes (Feb. 15th, 1883) may perhaps be imagined. Thus Dr. Richet :— **T do not believe that a single experimenter says to himself when he gives curare to a rabbit, or cuts the spinal marrow of a dog, or poisons a frog: ‘ Here is an experiment which will relieve or will cure the disease of some man.’ No, in truth, he does not think of that! He says to himself, ‘I shall clear up an obscure point, I will seek out a new fact.’ And this ‘scientific curiosity, which alone animates him, is explained by the high idea he has formed of Science. This is why we pass our days in fcetid laboratories, surrounded by groaning creatures, in the midst of blood and ee bent over palpitating entrails.” As showing how the ordinary prejudices of mankind against ruthlessly causing pain to sentient creatures may be overcome, and how the pain or disgust which most people experience in the presence of mangled budies of living animals may be converted into exuberant joy, the following extract from the ‘‘ Methodik”’ of Professor 12 Cyon (Lecturer on Physiology at the University of St. Petersburg) may be of melancholy interest :— “The true vivisector must approach a difficult vivisection with the same joyful excitement, with the same delight, with which a surgeon undertakes a difficult operation, from which he expects extraordinary consequences. He who shrinks from cutting into a living animal, he who approaches a vivisection as a disagreeable necessity, may very likely be able to repeat one or two vivisections, but will never become an artist in vivisection. He who cannot follow some fine nerve-thread, scarcely visible to the naked eye, into the depths, if possible sometimes tracing it to a new branching, with joyful alertness for hours at a time, he who feels no enjoyment when at last, parted from its surroundings and isolated, he can subject that nerve to electrical stimulation ; or when, in some deep cavity, guided only by the sense of touch of his finger-ends, he ligatures and divides an invisible vessel—to such a one there is wanting that which is most necessary for a_ successful vivisector. The pleasure of triumphing over difficulties held hitherto insuperable is always one of the highest delights of the vivisector. And the sensation of the physiologist when from a gruesome wound, full of blood and mangled tissue, he draws forth some delicate nerve-branch, and calls back to life a function which was already extinguished, this sensation has much in common with that which inspires a sculptor, when he shapes forth fair living forms from a shapeless mass of marble.” ‘¢ Corpora VILIA.’’ We need not now be surprised to hear that a tendency towards experimentation on human beings is not such an impossibility as Mr. Ellis would have us believe. The recent exposure of the Chelsea Hospital for Women by Dr. Louis Parkes should open our eyes a little, and the following extracts from the semi-official organs of the » profession and standard medical text-books may prevent 13 them from closing quite so tightly again. But first of all let us clear the way by reading the following letter from Dr. Armand de Watteville, M.A., M.D., B.Sc. (until recently on the staff of St. Mary’s Hospital), which ap- peared in the Standard of November 24th, 1883 :— To the Editor of ‘‘ Tok STANDARD” ‘‘Sir,—a few days ago an anonymous letter appeared in your columns which, emanating (as the signature, ‘‘M.D.,’’ appeared to show) from a medical practitioner, ought not to be allowed to pass without an energetic protest. As far as I can see, the writer intends to bring a charge against a distinguished member of his own profession, a physician who by his labours in the field of therapeutics, has done eminent service to medicine, and has been instrumental to the relief of much human suffering—a serious charge, I say, viz., that of having used patients in a hospital for other purposes than those tend- ing to their own direct benefit. ‘‘ Now I should like to ask ‘M.D.,’ whether his whole career as a medical student, from the day he handled his first bone to that on which he passed his last clinical examination, did not involve abuses very similar to those for which he now joins the unfortunately ever growing pseudo-humanitarian outcry against the methods of rational medicine ? ‘‘ What right had he to trample upon the feelings of others in dissecting the bodies of people whose sole crime was to have been poor, and, still more, to acquire his clinical experience at the expense of, perhaps, much human shame and suffering ? ‘‘T think we, as medical men, should not attempt to conceal from the public the debt of gratitude they owe to the corpora vilia—for such there are, and will be, as long as the healing art exists and progresses. So far from there being a reason why moral and pecuniary support should be refused to hospitals on the ground that their inmates are made use of otherwise than for treatment, there is every ground why more and more should be given to them, in order to compensate by every possible comfort for the dis-comforts necessarily entailed by the education of succeeding generations of medical men, 14 and the improvements in our methods of coping with disease. ‘“No amount of hysterical agitation and so called humani- tarian agitation will alter the laws of nature, one of the plainest of which is that the few must suffer for the many. Sentimentalists who think they know better, who uphold the abstract ‘Rights of Man,’ and want to push them to their logical consequences, have no other alternative in the question now before us than to condemn the modern course of medical studies, and trust themselves into the hands of bookmen whose tactus eruditus will have to be formed at their expense. The fundamental question at issue is not whether in this or that instance improper use was made of a hospital patient, but whether the manipulations and observations indispensable for the acquisition and extension of medical knowledge are to be made in a connected and enlightened manner in public insti- tutions and under the eyes of experienced men, or to be left to the isolated haphazard and groping efforts of necessarily ignorant men upon the persons of any who may be. found to pay them in the hope of benefiting by their medical skill. ‘* Whilst defending the moral grounds upon which experi- mental medicine rests, I allow that there are limits, narrow limits, beyond which it would be imprudent or criminal to go. But I most emphatically protest against the tendency of men nowadays—and I am ashamed to observe that a few are to be found within the medical profession itself—who act upon the supposition that the public at large form a proper tribunal to decide upon what constitutes a transgression of those limits. Those alone are competent judges who are able to form a correct opinion on the one hand of the ultimate utility, on the other of the proximate consequences of any investigations in corpore vili,”” We will next consider a few extracts from an exceed- ingly well-known and highly respected text-book, the ‘“‘Handbook of Therapeutics,”” by Dr. Sydney Ringer, Physician to University College Hospital. The edition of | this book which I possess is the eleventh, published in 1886. 16 On page 490 we read :— ‘In conjunction with Mr. E. A. Horshead, I have made some investigations concerning the action of muscarin on the human body. Our observations were undertaken to ascertain whether its action on man is the same as on animals. We have made thirteen experiments on four men, seven, three, two, and one respectively. These men, it is well to state, were not in good health; three were in a delicate anzemic state, the other had slight fever from some obscure cause, though his pulse was not quickened.” ‘‘Tt contracts the pupil, excites profuse perspiration, free salivation, running at the eyes and nose; it purges, sometimes excites nausea and vomiting. .... The perspiration stood in large drops on the face after the larger doses, the nightdress became soaked, and the skin felt sodden. .... In five the drug produced a frequent hacking cough.” Elsewhere we read :— “To test the effect of gelsemium in the circulation, I made thirty-three series of observations on patients in whom we induced the full toxic effects.”’ And again :—— ‘In order to test the effects of gelsemium on man, I gave it to six persons on seventeen occasions in doses sufficient to pro- duce decided toxic effects.” Later on we are told :— “One patient experienced pain over the occiput, with a sen- sation as if the crown of the head were being lifted in two DIECESi4 .. 4. |: Giddiness was another prominent and early symptom. ... When well marked, the patients staggered, ~ and were afraid even to stand, much less walk. So giddy was one patient that he nearly fell off the form. .... In every case the sight was effected.” In another place Dr. Ringer reports :— ‘‘Tn conjunction with Mr. Bury, I have made some investi- gations concerning the action of salicine on the human body, 16 using healthy children for our experiments, to whom we gave does sufficient to produce toxic symptoms. And he further tells us that ‘‘the headache is often very severe, so that the patient buries his head in the pillow.” ‘*‘ Our first set of experiments were made on a lad aged ten. He was admitted with belladonna poisoning, but our observations were not commenced till some days after his com- plete recovery. ... Though a very lively boy, he became very dull and stupid, lying with his eyes closed, and answering questions slowly. He complained of tingling like pins and needles in his right ankle, and suffered from very decided muscular weakness, soon accompanied by muscular twitchings and tremblings of the legs and arms.” Concerning the therapeutics of lead salts we read :— ‘‘There, too, is the fact, in further confirmation of Dr. Garrod’s discoveries, that if to a gouty person, free at the time from an acute attack, a salt of lead is administered, it develops acute gout, with its accompanying symptoms of severe pain and high fever. The author has repeatedly verified this fact.” Before we leave Dr. Ringer, mention may be made of the well-known report by himself and Dr. Murrell, of Westminster Hospital, on the action of nitrite of sodium. The report appeared in the Lancet for November 3rd, 1883, and from it the following extracts are taken. ‘‘In addition to these experiments we have made some obser- vations clinically. To eighteen adults, fourteen men and four women, we ordered ten grains of the pure nitrite of sodium in one ounce of water, and of these seventeen declared that they were unable to take it. They came back protesting loudly and required no questioning as to the symptoms produced. They seemed to be pretty unanimous on one point, that it was the worst medicine they had ever taken. They said if they ever took another dose they would expect to drop down dead, — and it would serve them right. One man, a burly strong fellow, suffering a little from rheumatism only, said that after 17 taking the first dose he felt giddy, as if he would go off in- sensible. His lips, face and hands turned blue, and he had to lie down for an hour and a half before he dared move. His heart fluttered and he suffered from throbbing pains in the head. He was urged to take another dose, but declined on the ground that he had a wife and family. Another patient had to sit down for an hour after the dose, and said that it took all his strength away. He, too, seemed to think that the medicine did not agree with him. The women appear to have suffered more than the men; at all events, they expressed their opinions more forcibly. One woman said that ten minutes after taking the first dose (she did not take a second), she felt a trembling sensation all over and suddenly fell to the floor. Whilst lying there she perspired profusely, her face and head seemed swollen and throbbed violently until she thought they would burst. Another woman said she thought she would have died after taking a dose, it threw her into a violent perspiration, and in less than five minutes her lips turned quite black and throbbed for hours; it upset her so much that she was afraid she would never get over it. The only one of the fourteen patients who made no complaint after taking ten grains was powerfully affected by fifteen..... The effect on these patients was so unpleasant that it was deemed unadvisable to repeat the dose.” Dr. W. R. Gowers is the author of what is probably the most valued work on Nervous Diseases, and was the Gulstonian lecturer to the Royal College of Physicians in 1880. From the report of one of these lectures we extract the following :— ‘‘ A very interesting fact has, however, been ascertained by Dr. Ramskill, viz., that picrotoxine in large doses of from fifteen to eighteen milligrammes will almost invariably produce a fit in twenty or thirty minutes. ‘Tn one patient, for instance (according to the notes of Mr. Broster, who carried out the experiments), the dose was daily increased, and when more than five milligrammes were injected a sensation of giddiness followed similar to that with which 18 the attacks commenced. The same effect followed larger in- jections, and when the dose reached eighteen milligrammes a severe attack occurred thirty minutes later, and an attack always followed the injection of this dose. In another patient a similar progressive increase of the dose was followed by giddiness and headache when eight milligrammes were in- jected. When the dose of fifteen milligrammes was reached a severe epileptic fit followed. Next day a second dose of fifteen milligrammes did not cause a fit, but eighteen milli- grammes, two days later, caused a fit in half-an-hour. After a week’s intermission twenty-four milligrammes were injected, and a severe fit occurred in twenty-five minutes. In a third patient a fit occurred after one injection of eight milligrammes, but ten milligrammes next day caused a fit in fifteen minutes. Seventeen milligrammes next day caused a fit in thirty minutes. In a fourth patient a single dose of eighteen milli- grammes caused in ten minutes giddiness and slight dazzling before the eyes, and in thirty minutes there occurred the usual aura of an attack—a sensation of something creeping up the right arm to the top of the head, and numbness and twitching in the right thigh, but no fit followed, although the patient was stupid and dull for a time as after a fit.”,—Lancet, April 10th, 1880. It is therefore quite idle to protest that no experi- mentation is performed on patients in hospitals, quite apart from any possible good which might result to them from such treatment. It is seen that drugs are occasion- ally given without the patient’s condition being in the least considered; in some cases being given even to healthy persons. Whilst it may be urged that these experiments are never carried to such an extent in England as seriously to endanger life, it is obvious that much suffering is caused, and the line of demarcation between causing suffering and placing a patient in danger is not a very clear one, and is easily overstepped. Such experiments as those whose records I have quoted must 19 be clearly marked off from another form of experiment, namely, the trying of a new drug with the sole idea of benefiting the patient on whom the trial is made; though even then the nature of the experiment should be clearly explained to the subject. The same distinction must be made between dangerous surgical operations performed to give a man a last chance and similar operations per- formed to relieve a condition of less danger than the operation itself. This distinction is often overlooked by the sentimentalists who occasionally air their well-meant but somewhat ill-founded views in the columns of the daily papers. Operations performed otherwise than for the good of the patients I believe to be very rare. At the same time they are not unknown, and we find Dr. Cyon, from whose work I have already quoted, saying that ‘‘many a surgical operation is performed less for the benefit of the patient than for the service of science, and the utility of the knowledge aimed at thereby is often much more trifling than that attained by vivisection of an animal.” Again, we may quote from the report of Dr. Parkes on the fatal operations performed at the Chelsea Hospital for Women: — ‘The aim of the majority of these operations is to mitigate pain and discomfort, and not primarily to save life; the diseased conditions, for the relief of which such operative treatment is applied, being for the most part chronic in their natures and by no means tending to an early fatal termination. It is evident, therefore, that the question of the justifiability of such operations must arise, unless it is possible to reduce the risk of fatal issue from such operations to an extremely low figure.”’ Further comment on these extracts is unnecessary. The talk of experimentation in English hospitals, though often absurdly exaggerated, is thus seen to be not without 20 foundatiun. Though, as has been stated, this kind of thing is comparatively rare, yet the more fact of its occasional existence, without producing any signs of dis- approval on the part of other members of the profession, is sufficient to necessitate the limitation of the power of the medical staff. FaitnH AND CHARITY. But there are many other grievances almost equally serious and much more common than direct experimenta- tion. The ordinary method of conducting extern obstetric practice in connection with the hospitals is one which urgently requires reform. Most of the London hospitals to which medical schools are attached arrange for the medical attendance on a large number of maternity cases in the patients’ homes. These cases are almost entirely attended by students, and very rarely is any precaution taken to ensure that a stu den has any practical, or even theoretical, acquaintance with midwifery. Often a student attends his first case entirely alone. It is true that an overworked resident obstetric officer (just qualified) is attached to each hospital; and to him the student may send in case of emergency if he recognises it. The wasted pain and subsequent injury which such unskilled treatment entails must be something enormous. Nor is the present system of out-patient relief adopted at the hospitals much more satisfactory. Sir William Gull, at a meeting of the Charity Organisation Society, characterised it as ‘“‘a disgrace to any civilised com- munity,’’ and the British Medical Journal (May 4th, 1878) writes that :— “‘Tt is a notorious fact that a fractional part only of the 21 outpatients who crowd the London hospital doors can obtain more than a few hurried words of advice from the medical staff, let alone careful diagnosis or treatment; yet so rooted is the conviction among the poorer and uneducated classes that skilled medical treatment is to be found at the hospitals only, that thither they flock, often after a weary and painful journey, necessitating the loss of a day’s work or the neglect of household duties, only to receive instructions to return for treatment some other day..... As a consequence of this excess of numbers, the poor are made to wait an inordinate time for the advice given; and such advice, when obtained, is often hurried and worthless.” Quite apart from the question of physical good treatment, is another matter which requires remedying. This is the custom of regarding hospitals as charitable or pauper- ising institutions, although one medical man who gave evidence before the Royal Commission on hospitals re- gretted that they were not looked upon more in this light. He ‘‘ regarded it as unfortunate that people should accept hospital relief without feeling that they were paupers.”’ As a result of this way of regarding the patients, they are often treated with the greatest insolence by students and members of the staff. It is a fairly common way of displaying his otherwise inapparent superiority, for an out-patient surgeon or physician to subject a nervous old woman to a bullying cross-examination such as few barristers would apply to a criminal. This kind of thing would not be tolerated but for the fact that the patient is receiving charity, and that so much power rests in the hands of the medical officers. In this connection, I may quote from a little book called ‘‘ What to Ask”’, written for the guidance of young practitioners by a London physician, Dr. Milner Fothergill: ‘* The student sees a patient in the hospital: he is a number 22 in a ward; his friends are people who come bothering asking questions, or wanting to see him at inconvenient hours. When he goes to private practice he is apt to carry a good deal of the hospital house-surgeon about him—I am not insinuating that this is wrong: but certainly it is sometimes injudicious. A hospital patient is the recipient of charity, and must conceal his feelings, unless flagrantly outraged.” A private patient can call in the other doctor. Wuat 18 WANTED. As to the remedy for this maltreatment of patients and waste of money, little more than main lines of reform can be suggested. The most important reform of all will probably be the last, namely, the humanising of medical education. The superior position which abstract science holds over humanity or respect for life, is a great draw- back to successful hospital reform. The important part which vivisection plays in present-day medical teaching is of itself a very serious foe to humane habits. But still, much may be done. In the first place the hospitals should be taken over by the various County Councils within whose jurisdiction they happen to be situated. It would probably be found advisable for the Council to elect a board, the majority of which should consist of members of the Council and the small minority of eminent surgeons and physicians elected by the hospital staff. This Board would take the place of the present Boards of management, and would appoint instructors and salaried resident officers instead of the present unskilled resident staff who are there to learn, and the unpaid visiting staff in search of ambition and a job. It would supervise the financial arrangements of the hospitals, and all complaints might safely be made to it. The hospitals should be 23 thrown open to all who cared to use them, provided they were ill enough, regardless of class or character. The old ‘‘charity ”’ fetish would thus die, insolence would become impossible and experimentation dangerous. A coroner’s inquiry should be held on all deaths in the hospitals, so as to render reckless operators somewhat more careful. The money wasted in advertising, and the other necessities of the competitive system would be saved, and beds would never have to be closed for want of funds. The hospital rate would become as natural a thing as the school-rate or the library-rate, and would in reality be a sort of insurance against illness. The hospital would, moreover, come to have a considerable educational influence on its inmates,—rich and poor, educated and uneducated, idler and worker, mixing together for once on terms of equality. To any form of public control of the hospitals the strongest opposition will come from the medical pro- fession. Thus we find Mr. Burdett, in his ‘‘ Hospitals of the World,” writing such antique stuff as this: ‘« Anything more opposed to the best interests of the people than the substitution of State hospitals for the voluntary hospitals as they at present exist cannot be imagined..... There is a loss to the whole community in the lessened moral sense which State institutions create. The voluntary charities afford an opening for the expression of the best of all human feelings—sympathy between man and man. They give to the rich an opening for the display of consideration towards the poor which is fruitful in results. They create a feeling of widespread sympathy with those who suffer, and impress upon the population the duty of almsgiving to an extent which no other charity can do..... They provide a field of labour wherein some of the most devoted and best members of society can cultivate the higher feelings of humanity and learn to bear their own sufferings and afflictions with resignation and patience.” 24 It is unnecessary to make any comment on this effusion. It may simply be remarked that the arguments which Mr. Burdett uses on behalf of voluntary hospitals apply equally strongly on behalf of the system of slavery, and apply much more strongly in favour of general mendicancy. It is now generally acknowledged that almsgiving, though at present it may often be necessary, is unwholesome in its effect on both parties; whilst the plea for injustice to the poor in order that the well- disposed rich may occasionally have an opportunity of airing their consideration and charity, is scarcely likely to commend itself to rational people. Unless the defenders of the voluntary system have some stronger arguments than those of Mr. Burdett, we may surely hupe for the early attainment of the reforms advocated in this pamphlet. MANIFESTO OF THE HUMANITARIAN LEAGUE. Tae Humanitarian League has been established on the basis of an intelligible and consistent principle of humaneness—that it is iniquitous to inflict suffer- ing, directly or indirectly, on any sentient being, except when self-defence or absolute necessity can be justly pleaded. This principle the Humanitarian League will apply and emphasise in those cases where it appears to be most flagrantly overlooked, and will protest not only against the cruelties inflicted by men on men, in the name of law, authority, and conventional usage, but also (in accordance with the same sentiment of humanity) against the wanton ill-treatment of the lower animals. The Humanitarian League will therefore propose a thorough revision and more equitable administration of the present Criminal Code, under which a very large amount of injustice and oppression is constantly perpetrated. It will deprecate the various provocations and incentives to aggressive warfare, and will point to the evils that result from the ever-increasing array of military and naval armaments. It will inculcate the public duty of affording protection to the weak and helpless, and will urge the need of amending the present social conditions, under which a large portion of the people is in a state of chronic destitution. It will contend that the practice of vivisection is incompatible with the fundamental principles both of humanity and sound science, and that the infliction of suffering for ends purely selfish, such as sport, fashion, profit, or professional advancement, has been largely instrumental in debasing the general standard of morality. Furthermore, the Humanitarian League will aim at the prevention of the terrible sufferings to which animals are subjected in the cattle-traffic and the shambles, and will advocate, as an initial measure, the abolition of private slaughter-houses, the presence of which in our large centres is a cause of widespread demoralisation. The Humanitarian League will look to its members to do their utmost, both in private and public, to promote the above-mentioned scheme. Its work will involve no sort of opposition to that of any existing institution ; on the contrary, it is designed to supplement and reinforce such efforts as have already been organised for similar objects. The distinctive purpose and guiding policy of the League will be to consolidate and give consistent expression to those principles of humaneness, the recognition of which is essential to the understanding and realisation of all that is highest and best in Humanity. Communications to be addressed to the Secretary, 38, GuoucesTER Roap, Reerent’s Park, Lonpon, N.W. N.B.—The condition of Membership is the acceptance of the general principle (not necessarily of the complete program) set forth in the Manifesto. The minimum annual subscription is half-a-crown, which entitles a subscriber to receive the publications issued in the current year. The back pamphlets are sent to new subscribers of five shillings and upwards. THE HUMANITARIAN LEAGUE'S PUBLICATIONS. No. 1—Humanitarianism : Its General Prin- ciples and Progress. By H.S. Sarr. 2d. The new Humanitarian League begins effectively what promises to be a series of publications. This thoughtful and persuasive paper must win the sympathy of all humane readers.— National Reformer. No. 2.—Royal Sport: Some Facts Concerning the Queen’s Buckhounds. By the Rev. J. Srratton. 2d. Do decent people generally know what devilish things are done daily in the Queen’s name and that of. ‘‘ Royal Sport ?’’— Weekly Times and Echo. No. 3.—Rabbit Coursing: An Appeal to Work- ing Men. By R. H. Jupz, D.Sc, M.A. 2d. The Humanitarian League has issued a well reasoned and, in the main, temperate protest against one of the least defensible forms of popular recreation.— The Globe. No. 4.—The Horrors of Sport. By Lapy Fiorence Drxiz. 24d. As eloquent a condemnation of the brutalising pastimes wailed ‘« Sports ’’’ in England as I have ever read.— Echo. No. 5.—Behind the Scenes in Slaughter- Houses. By H. F. Lesrzr. 2d. It is necessary that the attention of the public should be aroused to the evils attendant upov our present London system of private slaughter-houses, and to the duty humanity imposes on us to do all that may be done to abolish these evils.— Daily News. No. 6.—Vivisection. By Epwarp Carpenter and Epwarp Mairnanp. 64d. An admirable addition to the very useful series of publications which emanate from the Humanitarian League.—Zoophilist. No. 7—‘‘I Was in Prison’’: A Plea for the Amelioration of the Criminal Law. By Ropert Jounson. 6d. The contents of this little publication deserve to be deeply pon- dered by all who love their fellow-men, and especially by all who are concerned with the administration of the criminal law.—Daily — Chronicle. No. 8.—Women’s Wages, and the conditions under which they are earned. By Isasetza OEP RORD, 1! 2d: It succeeds in placing before the readers the horrible -conditions under which the mass of our working sisters contribute their propor- tion of the superabundant wealth of this country. —Justice. No. 9.—Dangerous Trades. By Mrs. C. Mater. 2d. A very readable and interesting pamphlet, which will help to in- fluence public opinion in favour of improving the sanitary condition of our industries.— British Medical Journal. No. 10.—The Extermination of Birds. By Epirn CarrinetTon. 2d. A strong appeal on behalf of the song birds of Britain.— Dundee Advertiser. No. 11.—The Horse: His Life, his Usage, and his End. By Coronet W. L. B. Covtson. 2d, Let every humane master who puts the care of horses into other people’s hands put into those hands one of these twopenny brown- paper-covered messages of mercy.— Echo. No. 12.—A Plea for Mercy to Offenders. By CarlaettLor woop, Q.0., MP) 2d ~The Head Constable of Liverpool, in his report for 1892 ‘testifies unmistakably to the success of Mr. Hopwood’s merciful +ys*em.— Weekly Times and Echo. No. 13.—The Humanizing of the Poor Law. By J. F. Oaxesnortr. 2d. All the more valuable in that it indicates clearly a definite program of Poor Law reform.—The Sun. No. 14.—Literee Humaniores: An Appeal to Teachers. By H.S. Sarr. 2d. A forcible appeal for the inculcation in children of habits of kind- ness towards the lower animals.— Bradford Argus. No. 15 —Cattle Ships, and Our Meat Supply. By Isapetia M. Gree and 8S. H Towers. 2d. It will serve a good purpose if it deepens a sense of responsibility for the cruelties inflicted upon animals brought by sea for slaughter. Manchester Guardian. No. 16.—Public Control of Hospitals. By Harry Roperts. 2d. WM. REEVES, 185, Fuesr Sreget, E.C. IVERSITY OF ILLIN Ti MN LOOM In paper cover, 1/-, eat wn Cruelties if Civilization A Program of Humane Reform: Being Vol. I. of the Publications of the Humanitarian League. Wa. REEVES, 185, FLEET STREET, E.C. This Volume contains the followings essays :— (1) HUMANITARIANISM : ITS GENERAL PRINCIPLES AND PROGRESS. By HH: ‘So 5act- (2) **I WAS IN PRISON”: A PLEA FOR THE SADIE LIORATION OF THE CRIMINAL LAW. By ROBERT JOHNSON. (3) A PLEA FOR MERCY TO OFFENDERS. By Cal: Horwoop, 0.C., M.P. (4) WOMEN’S WAGES, AND THE CONDITIONS UNDER WHICH THEY ARE EARNED. By Miss IsABELLA Forp. (5) DANGEROUS TRADES. By Mrs. C. MALLetT. (6) THE HUMANIZING OF THE POOR LAW. By — F. OAKESHOTT. A second Volume, containing the essays on Vivi- section, Sport, Private Slaughterhouses, etc., will shortly follow. A. Bonner, Printer, 34 Bouverie Street, Fleet Street, London E.C.