and in 1118 a leprosarium was built in London for isolation
purposes. Russia seems the one country where the interconnexion
of hospital and monastery was not to be observed.
After the period already reached, the 13th century, hospitals
became common enough to demand individual or at any rate
national treatment.
History of the Hospital Movement.—We have now to consider the principles upon which the provision of the best form of medical care in hospitals can be secured for all classes of people. Though hospitals cannot be claimed as a direct result of Christianity, no doubt it softened the relations between men, and gradually tended to instil humanitarian views and to make them popular with the civilized peoples of the world. These principles, as civilization grew, education improved, and the tastes and requirements of the common people were developed, made men and women of many races realize that the treatment of disease in buildings set apart exclusively for the care of the sick was, in fact, a necessity in urban districts. The establishment of a hospital freed the streets of the abuses attendant upon beggars and other poor creatures, who made their ailments the chief ground of appeal for alms. As the knowledge of hygiene and of the doctrine of cleanliness and purity in regard not only to dwellings and towns, but also in relation to food of all descriptions, including water, became known and appreciated, hospitals were found to be of even greater importance, if that is possible, to the healthy in crowded communities, than to the sick. It took many centuries before sound hygiene really began to occupy the position of importance which it is now known to possess, not only in regard to the treatment and cure of disease, but to its prevention and eradication. So the history of the world shows, that, whereas a few of the larger towns in most countries contained hospitals of sorts, up to and including the middle ages, it was not until the commencement of the 18th century that inhabitants of important but relatively small towns of from 50,000 to 100,000 inhabitants began to provide themselves with a hospital for the care of the sick. Thus, twenty-three of the principal English counties appear to have had no general hospital prior to 1710, while London itself at that date, so far as the relief of the sick was concerned, was mainly, if not entirely, dependent upon St Bartholomew’s and St Thomas’s Hospitals. These facts are interesting to note, because we are enabled from them to deduce from recent events that hospital buildings in the past, though the planning of most of them was faulty to begin with and became more and more faulty as extensions were added to the original buildings, did in fact suffice to satisfy the requirements of the medical profession for nearly two centuries. In other words, under the old condition of affairs the life of a building devoted to the care of the sick might be considered as at least 150 years. To-day, under the conditions which modern science impose upon the management, probably few hospital buildings are likely to be regarded as efficient for the purpose of treating the sick for more than from 30 to 50 years.
The foregoing statement is based upon the history of British hospitals of importance throughout the country, but the same remark will apply in practice to hospital buildings almost everywhere throughout the world. In truth, hospitals have been more developed and improved in Great Britain than in other countries, though, since the last quarter of the 19th century, German scientists especially have added much to the efficiency of the accommodation for the sick, not only at hospitals but in private clinics, and many German ideas have been accepted and copied by other countries. In Great Britain hospitals for the treatment of general and special diseases are mainly maintained upon what is known as the voluntary system. On the European continent, hospitals as a rule are maintained by the state or municipalities, and this system is so fully developed in Sweden and elsewhere that a sound economical principle has been embroidered upon the hospital system, to the great physical and moral advantage of all classes of the community. The system referred to confers great benefits upon inhabitants in large towns by bringing the poor-law and voluntary institutions into more intimate association, although they may be managed by separate governing bodies. The plan pursued is to demand payment from all patients who are admitted to the hospital under a scale of charges divided into three or four grades. The first grade pays a substantial sum and obtains anything or everything the patient may care to have or to pay for, subject to the control of the medical attendant. The second pays much less, but a remunerative rate, for all they receive at the hospital; and the third and fourth classes are very poor people or paupers, who are paid for on a graduated scale by the poor-law authorities, or the communal government, or the municipality. Under this system well-to-do thrifty artisans and improvident paupers are all treated by one staff, controlled by one administration, and are located in immediate proximity to each other though in separate pavilions. We have no doubt, as the result of many years’ investigation and an accurate knowledge of the working of the system, that this is the true principle to enforce in providing adequate medical relief for large urban populations everywhere throughout the world. It should be accompanied by a system of government insurance, whereby all classes who desire to be thrifty may pay a small annual premium in the days of health, and secure adequate hospital treatment and care when ill. Provided that pay wings were added to the existing voluntary and municipal hospitals, it should be found that the relatively small annual premium of £3 per annum should enable the policyholders to defray the cost of medical treatment in a pay ward or at a consultation department of a great hospital as a matter of business. In the United States of America most large towns have great hospitals, usually known as city hospitals, administered and mainly supported by the municipality. Many such institutions have pay wards, but nowhere, so far as we have been able to discover, has the system of medical relief in its entirety been organized as yet upon the business system we have just referred to.
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
