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THE LANCET.

LONDON: SATURDAY, AUGUST 1, 1925.

HOSPITAL ADMINISTRATION IN ITSBROADER OUTLOOK.

IT is 50 years since the Public Health Act of 1875,the charter of English preventive medicine, was

placed on the Statute Book. A long struggle hadled up to its enactment and the way for its passagehad been paved by the work of pioneers who were notalways popular. The efforts of Lord SHAFTESBURY,the factory legislation of the forties, the writings ofCHARLES KINGSLEY, under the name of Parson Lot,and the steady education of public opinion by a hostof other writers and speakers culminated in a newoutlook. Finally, at the end of this period the dis-coveries of PASTEUR and LisTER revolutionised ourviews on infective disease. To read through theclauses of the 1875 Act and the statutes, such as theRivers Pollution Prevention Act, which followedimmediately after, is to get a historical view of theeffort which was made by the sociologists of the

day to attain to a healthy standard of living. Withthe passing of the Public Health Act there came toan end the age-long practice of laissez fairc, whichheld that a man might do what he liked with hisown, and that his doings, even if inimical to health,were no concern of his neighbours and least of allof the State. Throughout this initial period of reformwe may trace three main lines of progress: (1) theattempt to make our expanding industrial systemsafe and healthy for the workers ; (2) the endeavourto improve the sanitation of rapidly growing town-ships with their tenement dwellings-the word slumis a product of this period-which the new industrieswere calling into existence ; and (3) the task of apply-ing the new standards of cleanliness, sterilisation,disinfection, and isolation, which the work of PASTEURand LISTER had introduced into infective andepidemic disease. Alongside these reforms therehad been slowly growing up a public conscience onthe question of poverty and destitution, and it isthe modern reflection of this feeling which findsexpression in the Social Service Department of thehospital.No country in the world has witnessed such efforts

as are made in our islands to relieve sickness andpoverty by voluntary means, but much of this effortcan only be described as indiscriminate charity;and it was inevitable that there should follow in thewake of the sanitary reforms, marking the closingyears of what ARNOLD TOYNBEE termed the industrialrevolution, an attempt to understand and relievethe causes and results of poverty. About the timeof the passing of the Public Health Act the develop-ment of the University Social Settlements under theinfluence of the late Canon SAMUEL BARNETT andTOYNBEE, and the foundation of charity organisationsocieties, began to emphasise the importance ofunderstanding these questions. To use the words ofCanon BARNETT, it was necessary that " citizensshould learn to understand the lives of each other,"and so, gradually, the State came to realise, throughthe pressure of hard facts, that the care of its less

fortunate citizens could not be left to indiscriminatecharity. The legislation of this century, therefore, hasseen a great increase in all measures for sociologicalamelioration. The care of the blind, the deaf, theepileptic, the feeble-minded, and the insane was

an essential first step in the work in which our examplehas been followed by other nations, but we have nowgone much further and have recognised that the schoolchild, the child of pre-school age, and the expectantmother must also be the concern of the State if a

healthy standard of living is to be maintained. Itwould be difficult to assess in actual figures the valueof the great voluntary hospitals of this country inthis movement, but in medical education, in research,in the high standard of clinical practice which theyhave maintained, the hospitals have made no smallcontribution. Great as these contributions havebeen there remains much yet to be done. Clinical

practice and surgical treatment have been raisedto a high level, but there is still a vast work in frontof us in correlating the sociological causes of disease.In this matter the hospitals may have been slow toact, but their hands have always been over-full. It

may perhaps be considered that this particular phaseof a vast set of problems lies outside the scope of thehospitals’ work, but at every stage in the progressof medical research, especially in clinical research,it becomes clear that the patient’s habits and mannerof life, his environment, his work, and his opportunitiesfor a healthy life are intimately relevant to histreatment.A reference to the reports of hospital almoners

-those most important officers of the Social ServiceDepartment of the institution-makes this clear,especially in special departments where a preliminarysorting of cases has already taken place. Themore carefully cases are followed up by home visita-tion and inquiry, the more it is realised that thefinancial side of the work forms only a small part ofthe Social Service Department of a hospital. It istrue that the prevention of abuse soon became oneof the essential needs and cardinal rules of the earlydays of hospital administration, but a great dealhas happened during the last quarter of a century,especially as a result of the war, to alter the pointof view of financial inquiry. Indeed, to a certainextent, it can be said inquiry into hospital abusemay obscure real sociological issues. The work ofthe Social Service Department, if it is to be inter-preted rightly, is an essential part of clinical research,and from the point of view of medical educationthe sociological background must have a bearingon all teaching, whether clinical or preventive.General practice to-day is becoming more and morepreventive and educational in its outlook,. and theyoungest student sees the narrow limits of the

palliative measures with which a past generation hadto be content. Thus the outlook is steadily changing.In the past too much stress has been laid on rulesand regulations, especially negatives-the things whichpatients must not do. Nowadays, stress is beingmore and more laid on the positive educational sideof hygiene. The modern patient has had an oppor-tunity of acquiring a knowledge of elementaryhygiene and physiology in school and in the popularscience press, and he is keen to know the reasonsfor things and able to appreciate their importanceand significance. The period under review has seenthe introduction of many new words in sociologicalliterature ; preventive medicine is by no means

the happiest of these. We need a term which is widein its embrace of all the problems and is educationaland constructive in its outlook.