CHAPTER I.. _of Professional Conduct, Relative to Hospitals, or Other Medical

Of Professional Conduct, relative to Hospitals, or other Medical Charities.

§ 1. Hospital Physicians and Surgeons should minister to the sick with due impressions of the importance of their office; reflecting that the ease, the health, and the lives of those committed to their charge depend on their skill, attention, and fidelity. They should study, also, in their deportment, so to unite tenderness with steadiness, and condescension with authority, as to inspire the minds of their patients with gratitude, respect, and confidence.

§ 2. The choice of a Physician or Surgeon cannot be allowed to hospital patients, consistently with the regular and established succession of medical attendance. Yet personal confidence is not less important to the comfort and relief of the sick poor, than of the rich under similar circumstances; and it would be equally just and humane to enquire into and to indulge their partialities, by occasionally calling into consultation the favourite practitioner. The rectitude and wisdom of this conduct will be still more apparent, when it is recollected, that patients in hospitals not unfrequently request their discharge on a deceitful plea of having received relief, and afterwards procure another recommendation, that they may be admitted under the Physician or Surgeon of their choice. Such practices involve in them a degree of falsehood, produce unnecessary trouble, and may be the occasion of irreparable loss of time in the treatment of diseases.

§ 3. The feelings and emotions of the patients, under critical circumstances, require to be known and to be attended to, no less than the symptoms of their diseases: thus, extreme timidity with respect to venesection contra-indicates its use in certain cases and constitutions. Even the prejudices of the sick are not to be contemned, or opposed with harshness; for, though silenced by authority, they will operate secretly and forcibly on the mind, creating fear, anxiety, and watchfulness.

§ 4. As misapprehension may magnify real evils, or create imaginary ones, no discussion concerning the nature of the case should be entered into before the patients, either with the House-Surgeon, the pupils of the hospital, or any medical visitor.

§ 5. In the large wards of an infirmary the patients should be interrogated concerning their complaints in a tone of voice which cannot be overheard. Secrecy, also, when required by peculiar circumstances, should be strictly observed. And females should always be treated with the most scrupulous delicacy. To neglect or to sport with their feelings is cruelty; and every wound thus inflicted tends to produce a callousness of mind, a contempt of decorum, and an insensibility to modesty and virtue. Let these considerations be forcibly and repeatedly urged on the hospital pupils.

§ 6. The moral and religious influence of sickness is so favourable to the best interests of men and of society, that it is justly regarded as an important object in the establishment of every hospital. The institutions for promoting it should therefore be encouraged by the Physicians and Surgeons, whenever seasonable opportunities occur; and, by pointing out these to the officiating clergyman, the sacred offices will be performed with propriety, discrimination, and greater certainty of success. The character of a Physician is usually remote either from superstition or enthusiasm; and the aid, which he is now exhorted to give, will tend to their exclusion from the sick wards of the hospital, where their effects have often been known to be not only baneful, but even fatal.

§ 7. It is one of the circumstances which softens the lot of the poor, that they are exempt from the solicitudes attendant on the disposal of property. Yet there are exceptions to this observation; and it may be necessary that an hospital patient, on the bed of sickness and death, should be reminded by some friendly monitor of the importance of a last will and testament to his wife, children, or relatives, who otherwise might be deprived of his effects, of his expected prize-money, or of some future residuary legacy. This kind office will be best performed by the House-Surgeon, whose frequent attendance on the sick diminishes their reserve, and entitles him to their familiar confidence. And he will doubtless regard the performance of it as a duty; for whatever is right to be done, and cannot by another be so well done, has the full force of moral and personal obligation.

§ 8. The Physicians and Surgeons should not suffer themselves to be restrained by parsimonious considerations from prescribing wine, and drugs even of high price, when required in diseases of extraordinary malignity and danger. The efficacy of every medicine is proportionate to its purity and goodness; and on the degree of these properties, caeteris paribus, both the cure of the sick and the speediness of its accomplishment must depend. But, when drugs of inferior quality are employed, it is requisite to administer them in larger doses, and to continue the use of them a longer period of time; circumstances which probably more than counterbalance any savings in their original price. If the case, however, were far otherwise, no economy of a fatal tendency ought to be admitted into institutions, founded on principles of the purest beneficence, and which, in this age and country, when well conducted, can never want contributions adequate to their liberal support.

§ 9. The Medical gentlemen of every charitable institution are in some degree responsible for, and the guardians of, the honour of each other. No Physician or Surgeon, therefore, should reveal occurrences in the hospital, which may injure the reputation of any one of his colleagues; except under the restriction contained in the succeeding article.

§ 10. No professional charge should be made by a Physician or Surgeon, either publicly or privately, against any associate, without previously laying the complaint before the gentlemen of the Faculty belonging to the institution, that they may judge concerning the reasonableness of its grounds, and the measures to be adopted.

§ 11. A proper discrimination being established in all hospitals between the Medical and Chirurgical cases, it should be faithfully adhered to by the Physicians and Surgeons on the admission of patients.

§ 12. Whenever cases occur, attended with circumstances not heretofore observed, or in which the ordinary modes of practice have been attempted without success, it is for the public good, and in an especial degree advantageous to the poor, (who, being the most numerous class of society, are the greatest beneficiaries of the healing art,) that new remedies and new methods of Chirurgical treatment should be devised. But in the accomplishment of this salutary purpose the gentlemen of the Faculty should be scrupulously and conscientiously governed by sound reason, just analogy, or well authenticated facts. And no such trials should be instituted without a previous consultation of the Physicians or Surgeons, according to the nature of the case.

§ 13. To advance professional improvement, a friendly and unreserved intercourse should subsist between the gentlemen of the Faculty, with a free communication of whatever is extraordinary or interesting in the course of their hospital practice. And an account of every case or operation, which is rare, curious, or instructive, should be drawn up by the Physician or Surgeon to whose charge it devolves, and entered in a register kept for the purpose, but open only to the Physicians and Surgeons of the charity.

§ 14. Hospital registers usually contain only a simple report of the number of patients admitted and discharged. By adopting a more comprehensive plan they might be rendered subservient to Medical science and beneficial to mankind. The following sketch is offered with deference to the gentlemen of the Faculty. Let the register consist of three tables: the first specifying the number of patients admitted, cured, relieved, discharged, or dead; the second, the several diseases of the patients, with their events; the third, the sexes, ages, and occupations of the patients. The ages should be reduced into classes; and the tables adapted to the four divisions of the year. By such an institution, the increase or decrease of sickness; the attack, progress, and cessation of epidemics; the comparative healthiness of different situations, climates, and seasons; the influence of particular trades and manufactures on health and life; with many other curious circumstances, not more interesting to Physicians than to the community, would be ascertained with sufficient precision.

§ 15. By the adoption of the register recommended in the foregoing article, Physicians and Surgeons would obtain a clearer insight into the comparative success of their hospital and private practice; and would be incited to a diligent investigation of the causes of such difference. In particular diseases it will be found to subsist in a very remarkable degree: and the discretionary power of the Physician or Surgeon in the admission of patients, could not be exerted with more justice or humanity, than in refusing to consign to lingering suffering and almost certain death a numerous class of patients, inadvertently recommended as objects of these charitable institutions. “In judging of diseases with regard to the propriety of their reception into hospitals,” says an excellent writer, “the following general circumstances are to be considered:—

“Whether they be capable of speedy relief; because, as it is the intention of charity to relieve as great a number as possible, a quick change of objects is to be wished; and also because the inbred disease of hospitals will almost inevitably creep in some degree upon one who continues a long time in them, but will rarely attack one whose stay is short.

“Whether they require in a particular manner the superintendence of skilful persons, either on account of their acute and dangerous nature, or any singularity or intricacy attending them, or erroneous opinions prevailing among the common people concerning their treatment....

“Whether they be contagious, or subject in a peculiar degree to corrupt the air and generate pestilential diseases....

“Whether a fresh and pure air be peculiarly requisite for their cure, and they be remarkably injured by any vitiation of it.”

§ 16. But no precautions relative to the reception of patients who labour under maladies incapable of relief, contagious in their nature, or liable to be aggravated by confinement in an impure atmosphere, can obviate the evils arising from close wards, and the false economy of crowding a number of persons into the least possible space. There are inbred diseases which it is the duty of the Physician or Surgeon to prevent, as far as lies in his power, by a strict and persevering attention to the whole medical polity of the hospital. This comprehends the discrimination of cases admissible, air, diet, cleanliness, and drugs; each of which articles should be subjected to a rigid scrutiny at stated periods of time.

§ 17. The establishment of a committee of the gentlemen of the Faculty, to be held monthly, would tend to facilitate this interesting investigation, and to accomplish the most important objects of it. By the free communication of remarks, various improvements would be suggested; by the regular discussion of them, they would be reduced to a definite and consistent form; and by the authority of united suffrages, they would have full influence over the governors of the charity. The exertions of individuals, however benevolent or judicious, often give rise to jealousy, are opposed by those who have not been consulted, and prove inefficient by wanting the collective energy of numbers.

§ 18. The harmonious intercourse which has been recommended to the gentlemen of the Faculty will naturally produce frequent consultations, viz. of the Physicians on Medical cases, of the Surgeons on Chirurgical cases, and of both united in cases of a compound nature, which, falling under the department of each, may admit of elucidation by the reciprocal aid of the two professions.

§ 19. In consultations on Medical cases the junior Physician present should deliver his opinion first, and the others in the progressive order of their seniority. The same order should be observed in Chirurgical cases; and a majority should be decisive in both: but if the numbers be equal, the decision should rest with the Physician or Surgeon under whose care the patient is placed. No decision, however, should restrain the acting practitioner from making such variations in the mode of treatment, as future contingencies may require, or a farther insight into the nature of the disorder may shew to be expedient.

§ 20. In consultations on mixed cases the junior Surgeon should deliver his opinion first, and his brethren afterwards in succession, according to progressive seniority. The junior Physician present should deliver his opinion after the senior Surgeon, and the other Physicians in the order above prescribed.

§ 21. In every consultation the case to be considered should be concisely stated by the Physician or Surgeon who requests the aid of his brethren. The opinions relative to it should be delivered with brevity, agreeably to the preceding arrangement, and the decisions collected in the same order. The order of seniority among the Physicians and Surgeons may be regulated by the dates of their respective appointments in the hospital.

§ 22. Due notice should be given of a consultation, and no person admitted to it except the Physicians and Surgeons of the hospital, and the House-Surgeon, without the unanimous consent of the gentlemen present. If an examination of the patient be previously necessary, the particular circumstances of danger or difficulty should be carefully concealed from him, and every just precaution used to guard him from anxiety or alarm.

§ 23. No important operation should be determined upon, without a consultation of the Physicians and Surgeons, and the acquiescence of a majority of them. Twenty-four hours notice should be given of the proposed operation, except in dangerous accidents, or when peculiar circumstances occur which may render delay hazardous. The presence of a spectator should not be allowed during an operation, without the express permission of the operator. All extra-official interference in the management of it should be forbidden. A decorous silence ought to be observed. It may be humane and salutary, however, for one of the attending Physicians or Surgeons to speak occasionally to the patient, to comfort him under his sufferings, and to give him assurance (if consistent with truth,) that the operation goes on well, and promises a speedy and successful termination.

As a hospital is the best school for practical Surgery, it would be liberal and beneficial to invite in rotation two Surgeons of the town, who do not belong to the institution, to be present at each operation.

§ 24. Hospital consultations ought not to be held on Sundays, except in cases of urgent necessity; and on such occasions an hour should be appointed which does not interfere with attendance on public worship.

§ 25. It is an established usage in some hospitals to have a stated day in the week for the performance of operations. But this may occasion improper delay, or equally unjustifiable anticipation. When several operations are to take place in succession, one patient should not have his mind agitated by the knowledge of the sufferings of another. The Surgeon should change his apron, when besmeared; and the table or instruments should be freed from all marks of blood, and every thing that may excite terror.

§ 26. Dispensaries afford the widest sphere for the treatment of diseases, comprehending not only such as ordinarily occur, but those which are so infectious, malignant, and fatal, as to be excluded from admission into infirmaries. Happily also they neither tend to counteract that spirit of independence which should be sedulously fostered in the poor, nor to preclude the practical exercise of those relative duties, “the charities of father, son, and brother,” which constitute the strongest moral bonds of society. Being institutions less splendid and expensive than hospitals, they are well adapted to towns of moderate size; and might even be established without difficulty in populous country districts. Physicians and Surgeons in such situations have generally great influence; and it would be truly honourable to exert it in a cause subservient to the interests of Medical science, of commerce, and of philanthropy.

The duties which devolve on gentlemen of the Faculty engaged in the conduct of Dispensaries, are so nearly similar to those of hospital Physicians and Surgeons, as to be comprehended under the same professional and moral rules. But greater authority and greater condescension will be found requisite in domestic attendance on the poor; and human nature must be intimately studied, to acquire that full ascendancy over the prejudices, the caprices, and the passions of the sick and of their relatives, which is essential to Medical success.

§ 27. Hospitals appropriated to particular maladies are established in different places, and claim both the patronage and the aid of the gentlemen of the Faculty. To an asylum for female patients labouring under syphilis it is to be lamented that discouragements have been too often and successfully opposed. Yet whoever reflects on the variety of diseases to which the human body is incident, will find that a considerable part of them are derived from immoderate passions and vicious indulgences. Sloth, intemperance, and irregular desires are the great sources of those evils which contract the duration and imbitter the enjoyment of life. But humanity, whilst she bewails the vices of mankind, incites us to alleviate the miseries which flow from them. And it may be proved that a Lock Hospital is an institution founded on the most benevolent principles, consonant to sound policy, and favourable to reformation and to virtue. It provides relief for a painful and loathsome distemper, which contaminates in its progress the innocent as well as the guilty, and extends its baneful influence to future generations. It restores to virtue and to religion those votaries whom pleasure has seduced or villany betrayed, and who now feel by sad experience that ruin, misery, and disgrace are the wages of sin. Over such objects pity sheds the generous tear, austerity softens into forgiveness, and benevolence expands at the united pleas of frailty, penitence, and wretchedness.

No peculiar rules of conduct are requisite in the Medical attendance on Lock Hospitals: but, as these institutions must from the nature of their object be in a great measure shut from the inspection of the public, it will behove the Faculty to consider themselves as responsible in an extraordinary degree for their right government; that the moral, no less than the Medical purposes of such establishments may be fully answered. The strictest decorum should be observed in the conduct towards the female patients; no young pupils should be admitted into the house; every ministering office should be performed by nurses properly instructed; and books adapted to the moral improvement of the patients should be put into their hands, and given them on their discharge. To provide against the danger of urgent want, a small sum of money and decent clothes should at this time be dispensed to them; and, when practicable, some mode should be pointed out of obtaining a reputable livelihood.

§ 28. Asylums for insanity possess accommodations and advantages, of which the poor must in all circumstances be destitute; and which no private family, however opulent, can provide. Of these schemes of benevolence all classes of men may have equal occasion to participate the benefits; for human nature itself becomes the mournful object of such institutions. Other diseases leave man a rational and moral agent, and sometimes improve both the faculties of the head and the affections of the heart. But lunacy subverts the whole rational and moral character, extinguishes every tender charity, and excludes the degraded sufferer from all the enjoyments and advantages of social intercourse. Painful is the office of a Physician, when he is called upon to minister to such humiliating objects of distress; yet great must be his felicity, when he can render himself instrumental, under Providence, in the restoration of reason and in the renewal of the lost image of GOD. Let no one, however, promise himself this divine privilege, if he be not deeply skilled in the philosophy of human nature; for, though casual success may sometimes be the result of empirical practice, the medicina mentis can only be administered with steady efficacy by him, who, to a knowledge of the animal economy and of the physical causes which regulate or disturb its movements, unites an intimate acquaintance with the laws of association, the control of fancy over judgement, the force of habit, the direction and comparative strength of opposite passions, and the reciprocal dependences and relations of the moral and intellectual powers of man.

§ 29. Even thus qualified with the pre-requisite attainments, the Physician will find that he has a new region of Medical science to explore; for it is a circumstance to be regretted both by the Faculty and the public, that the various diseases which are classed under the title of insanity remain less understood than any others with which mankind are visited. Hospital institutions furnish the best means of acquiring more accurate knowledge of their causes, nature, and cure; but this information cannot be attained, to any satisfactory extent, by the ordinary attention to single and unconnected cases. The synthetic plan should be adopted; and a regular journal should be kept of every species of the malady which occurs, arranged under proper heads, with a full detail of its rise, progress, and termination; of the remedies administered, and of their effects in its several stages. The age, sex, occupation, mode of life, and (if possible,) hereditary constitution of each patient should be noted; and, when the event proves fatal, the brain and other organs affected should be carefully examined, and the appearances on dissection minutely inserted in the journal. A register like this in the course of a few years would afford the most interesting and authentic documents, the want of which on a late melancholy occasion was felt and regretted by the whole kingdom.

§ 30. Lunatics are in a great measure secluded from the observation of those who are interested in their good treatment; and their complaints of ill-usage are so often false or fanciful, as to obtain little credit or attention, even when well founded. The Physician, therefore, must feel himself under the strictest obligation of honour, as well as of humanity, to secure to these unhappy sufferers all the tenderness and indulgence compatible with steady and effectual government.

§ 31. Certain cases of mania seem to require a boldness of practice, which a young Physician of sensibility may feel a reluctance to adopt. On such occasions he must not yield to timidity, but fortify his mind by the councils of his more experienced brethren of the Faculty. Yet, with this aid, it is more consonant to probity to err on the side of caution than of temerity.

Hospitals for the small-pox, for inoculation, for cancers, &c. &c., are established in different places; but require no professional duties, which are not included under, or deducible from, the precepts already delivered.

FOOTNOTES:

See Aikin’s Thoughts on Hospitals, p. 21.

The substance of the five preceding articles (§§ 19-23) was suggested by Dr. Ferriar and Mr. Simmons, at the time when I was desired by them and my other colleagues to frame a code of rules for the Manchester Infirmary. The additions now made are intended to adapt them to general use.

See two Reports, intended to promote the establishment of a Lock Hospital at Manchester, in the year 1774, inserted in the Author’s Essays Medical, Philosophical, and Experimental, vol. ii. p. 263. (Works, vol. iv. p. 203.)

See Notes and Illustrations, No. I.