Charles Richmond Henderson.

Introduction to the study of the dependent, defective, and delinquent classes, and of their social treatment online

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We are here to consider those aspects of medical charity in
respect to which the general public is competent to form an
intelligent judgment of policy and results, and in respect to
which they are called upon to act, either as patrons or as voting
citizens. The purely professional questions, medical, surgical,
and nursing, cannot be discussed by a layman. Where expert
opinions form the basis for social judgment and action, we aim
to use competent medical authorities.

1. Social Function and Service. — The most direct and obvious
end of medical charity, and its primary inspiration, is relief of
distress of the dependent poor. But on the way to promote this
end many incidental advantages accrue to society. Economi-
cally, the public derives great advantage from the prevention of
loss of socially valuable human life, energy, training, and power
of self support. It costs wealth to rear a productive laborer to
adult life, and prolonged sickness or lameness means a loss to
all. Working people are restored to industrial pursuits by medi-
cal and surgical skill, and thus enabled to maintain their family,
to produce goods and perform services, instead of making drafts
on the resources of the community as recipients of alms. Their
acquired skill is maintained for a prolonged period; and this is
social wealth.

Medical science is advanced by the clinical experience and
observation of public hospitals. Since teaching is a feature of
the best institutions, physicians of a higher class are attracted,
improvements are made, and there is so much more medical skill
and training of nurses, from which persons of all classes derive


122 Relief and Care of Dependents.

benefit. The medical profession receives much of its technical
preparation in the service of the poor, in hospitals and dispensaries.

This professional experience is of course directly helpful to
physicians. Egoistic motives mingle with those of public spirit;
and this fact is at once a help and a peril. For while society
is aided by securing superior skill, egoism may lead some men
to forget the interest of the community in the keen desire to
promote their own practice, prestige, and fame.

The principle of mutual insurance enters wherever charity
establishes institutions of medical relief. No man knows at
what moment he may be stricken down by accident or disease,
and become dependent on hospital care. Many thousands of
salaried and professional people would, after a few months of
enforced idleness, be at the end of their resources.

Medical charity is a means of diffusing information about
hygiene and sanitation. Organized medical charity protects
public health where there is exposure to communicable diseases,
as scarlet fever, measles, smallpox, diphtheria, yellow fever,
cholera, and venereal maladies. If the indigent sick were left
without public care under medical direction and control, every
citizen and every household would be exposed to danger.

Medical relief is, in general, less exposed to abuse than many
other forms of charity. It is true that sickness is sometimes
feigned. Mutual benefit associations, which pay sick benefits to
members, are compelled to visit and investigate all cases, and to
resist false claims. It is a common trick of impostors to rest
their appeal on the pretended sickness of some member of the
family. Mutilation is sometimes, though rarely, practised, to
excite sympathy. A physician can usually detect actual fraud.
It is rare that any person will lie in bed very long in order to
receive the stipend of temporary and partial relief. Still more
rarely do people make themselves really ill with set purpose to
establish a claim upon charity.

It is admitted that many persons will apply for medical advice
at dispensaries and hospitals, who will not beg for any other

Medical Charities. 123

form of aid; and many persons who are able to pay will accept
gratuitous service of physicians, nurses, and hospitals. Methods
of restricting this abuse, which is not so frequent as is often sup-
posed, will be discussed at a later point. On the whole, medical
charity is comparatively free from such abuses. There are mul-
titudes who are quite willing to neglect industry and temperance,
and so qualify themselves for alms, but seldom will a man maim
himself for life or wilfully take typhoid fever in order to find a
legal home in a poorhouse or infirmary.

The Socialists, and some others who lean toward their theory,
have proposed to make all medical relief a public charge;
so that all, rich and poor, would be treated by medical officers
and nursed in hospitals, just as they are all now served with light
in the streets, with scavenger and sewerage service.

If one shrinks from this proposition, let him remember that it
is apparently merely a question of degree, since society has
already accepted the principle in certain classes of cases.
Municipal medical authorities not only offer their aid in times
of epidemic, but they go farther, and compel citizens to come
under their control. The staff of the board of health enters the
dwelling where scarlet fever is even suspected, obliges the family
physician to make known dangerous places, and the door of the
dwelling is placarded although the very industry which furnishes a
livelihood is thereby suspended. The person afflicted with the
smallpox must be taken to the public pest-house if his surround-
ings require that course.

In any case, hospitals and dispensaries should be required to
make reports to an administrative board as a guide to officers of
health, and for information in relation to the extent and causes
of disease in various localities. To this extent all must admit
medical relief should be socialized.

2. Outdoor Medical Relief. — A very general custom prevails in
this country of furnishing advice and medicines to the destitute
in their homes. This form of legal relief is administered by
town and county authorities, who appoint physicians for the pur-

124 Relief and Care of Dependents.

pose. If the poor law of the state does not expressly require
such relief it is usually optional with the local authorities. The
social demand f6r this kind of aid is evident enough, since all
see that the sick poor are instantly helpless, and the income
from daily labor is cut off when the breadwinner is ill. In the
rural communities the poor's doctor may be required to serve in
the almshouse as well as in destitute families, while in cities a
considerable number of physicians may be necessary simply to
visit homes. Medicines are furnished either by the physician or
by druggists on his prescription, according to the nature of the

Dangers afid Abuses. — A stingy policy may be uneconomi-
cal if it give inadequate and incompetent service by making a
hard bargain in respect to medicines or offer a salary only high
enough to attract quacks. The spoils system of political selection
has not left this field of charity without injury, and much suffer-
ing and many deaths result from the heartless jobbery and
dishonesty of this system.

Fledgling gratuitous service of young doctors, who are willing
to accept the position practically for nothing, and in hope of
gaiiiing skill and reputation, is frequently a cruelty.

Regulative Maxims. — Adequate compensation is necessary
to secure competent physicians. Appointments should be
made on the nomination of a board of health, of a reputable
medical society, or of a commission; and none but graduates of
genuine medical schools should be eligible. The methods and
results should be supervised by competent medical men.

3. The Charity Hospital. — Hospitals grew out of the chari-
table impulses of the community, and still continue to find much
of their support in that motive. But experience with charity
has shown that hospitals offer many advantages in many forms of
disease or surgical work for persons of all classes, and they are
more generally used than formerly on the recommendation of
family physicians.

4. Specialization, — The county infirmary, which is con-

Medical Charities. 125

nected with the poorhouse, is a general hospital, and is com-
pelled to treat all forms of ailments of the inmates. Sometimes
a pest-house is erected on the county farm, not very remote from
the principal establishment. Paupers require a great deal of
nursing and medical attention, as they are so generally weak and

The municipal hospital is the urban counterpart of the county
infirmary. In large towns this institution may have distinct
buildings or wards for special classes of patients; as for cancer pa-
tients, and for those afflicted with venereal diseases, erysipelas,
and consumption. This partial specialization must be carried
further with smallpox or scarlet fever, and a separate house is
needed to isolate those who are likely to communicate these

Hospitals for contagious and infectious diseases are demanded
by the conditions of urban life. As the communicable charac-
ter of tuberculosis is more fully recognized by the public as
well as by the medical profession, the movement to establish
special country homes and colonies in the South, or in any suit-
able locality, gains strength. Patients afflicted with consump-
tion are a source of peril to others in ordinary hospital wards
and in the homes of the poor in congested tenements.

Hospitals for the treatment of venereal diseases are demanded
by enlightened humanity and by public safety; as a means of
rescuing the unfortunate who wish to reform, an asylum for the
repentant, girl or man, and as the means of checking the ravages
of a terrible malady which attacks the innocent as well as the
guilty, and threatens the foundations of national life.

All hospitals for infectious and contagious diseases should be
free and under public control. A fee would keep many from
entering whose treatment is desirable as a protection to the

Separate buildings are very desirable for cancerous patients,
because the odor from this disease is intolerable.

Emergency hospitals are erected near the centres of traffic and

126 Relief and Care of Dependents.

travel in order to give immediate shelter and aid to the sick and
injured, those suffering from serious wounds and sunstroke,
and who cannot be carried a long distance in an ambulance
without danger.

Maternity hospitals are required to meet the needs of the poor
in cities, where the crowded dwellings are utterly unfit for the
treatment of mothers in their critical hour. Provision is made
in special wards of general hospitals, or county asylums, or in
separate institutions.

Orthopedic hospitals serve a highly useful purpose by correct-
ing deformities of growing children, and thus fitting cripples for
self support. Children's hospitals are established for the treat-
ment of ordinary maladies, and for the isolation of infectious

This process of specialization begins in a general hospital by
setting apart wards, floors, or even separate buildings for par-
ticular classes of disease. As cities grow in population and
wealth, there is a tendency to erect different hospitals, with
special adaptation in structure and management, to the peculiar
needs of various kinds of patients.

5. Financial Basis and Management of Charity Hospitals. — The
modes of support are : public, as county and municipal hospitals;
or private, those supported by endowments of the rich or by the
gifts of many contributors, together with income from pay
patients. Many general hospitals have a limited number of
free beds, which are furnished and maintained at the cost of
individuals, societies, or endowments.

Private hospitals are occasionally supported, in part, by sub-
sidies from public funds. In such cases the correct method is
to pay out of the poor fund by contract at a specific rate for the
actual number of patients who are a public charge, and to count
the number of days of treatment. It is not wise to agree to pay
a fixed sum per year without regard to the actual service ren-
dered. The best way is for the community to own its hospitals.

Administration. — There are four departments of adminis-

Medical Charities. 127

tration of a hospital : business, housekeeping, medical and sur-
gical treatment, and nursing, and all these must be unified and
harmonized for successful and economic action.

The board of control, composed of trustees or directors, is
the body which represents the general policy and interest of the
founders or of the public. The board of a public hospital
should be composed of appointed persons, who serve for honor
and without pay. It is the function of such a board to act as
representatives of the public in the determination of a general
policy, the appointment of a competent and responsible superin-
tendent, the observation of management, the control of accounts
and reports, and the judgment and publication of results. These
activities are legislative, judicial, financial, and executive, but
not administrative. A board should not seek to administer
details. Such an attempt would cripple the superintendent,
drive away a competent man, and require a salaried board of
persons who give their whole strength to the institution, and
who in any case must waste time in debate over petty details
which they cannot all know.

Among the managers or trustees should be representatives of
the business talent, medical knowledge, feminine taste, tact,
and gentleness, and liberality of the supporting association or

The superintendent should be capable of administering the
affairs of the kind of hospital over which he is placed, and
should have power corresponding to his responsibility. Should
he be a physician or a layman? There is much controversy over
this question. In favor of professional medical training it is
urged that only a physician is capable of directing an institution
whose purpose is healing. In favor of the layman it is said that
the office is one which requires more business experience than a
professional man is likely to possess; that buying materials, care
of buildings, employment of servants, payment of wages, and col-
lecting fees do not require medical skill, but do require business
qualities and experience. It is feared that a medical superin-

128 Relief and Care of Dependents.

tendent will be sorely tempted to use his position to build up a
private practice, or at least to concentrate his interest and atten-
tion upon the medical work rather than the financial side. Feel-
ings of suspicion and rivalry are more likely to arise even where
the official is careful to avoid cause of offence. It is quite pos-
sible to intrust the professional details to young house physicians,
who are under control of a board of older physicians, while indi-
vidual cases are best treated by experienced physicians called
in by the patients or supplied by the authorities. In some
institutions the board of trustees appoint a business manager for
direction of accounts and housekeeping, and a medical superin-
tendent for the control of professional work, both officers being
coordinate in rank, and each independent in his sphere.

The medical assistants are young members of the profession,
called internes, and with these are the nurses. The modes of their
appointment vary in different places. It seems desirable that
the internes should be appointed by the medical board or super-
intendent, and the household corps by the superintendent. The
merit system should govern all appointments in public establish-
ments. The superintendent, if a medical man, should be chosen
on the basis of an academic diploma and previous training in a
subordinate position, and on the recommendation of a medical
commission. The assistants should be admitted to probation
only after written and oral examination set by a non-partisan board,
should be secure in their positions while they give satisfaction,
and should be graded and promoted for efficiency and fidelity.

Since the hospital is not only a house of healing and a business
establishment, but also a home, at least temporarily, for the sick
and for the staff, it should be managed with the sense of order,
neatness, cleanliness, and quiet which no one but a capable
woman can secure.

A competent medical staff is the most essential factor of suc-
cessful management. This corps will be appointed by the
directors, or, in a public institution, by the designated legal
authority. In any case they must be men of eminence in their

Medical Charities. 129

calling. Experience proves that the best talent can be secured
on condition that clinical teaching is connected with the visits
of physicians in charity hospitals.

Records. — The records and reports of hospitals should show
the average daily number of patients, the whole number of dif-
ferent patients, the average length of time patients are kept, and
the ratio of deaths to the whole number disposed of. Publicity
of accounts and records is required for the protection of patients,
patrons, and the public.

6. Cooperation of Private Charity. — Public medical relief
tends to be somewhat hasty, mechanical, and general, fitted to a
rather slow average method. Private charity can supplement
public agents in many ways, both in hospitals and in outdoor
medical relief. Delicacies are provided by societies of benevo-
lent women, as special articles of food, dainties to tempt appe-
tite, flowers, and fruit. Personal visits cheer the patients and
bring news of the family at home to the temporary exile, and
anxieties are relieved by attention to those in need of aid.
Religious services are held in hospitals by the young people of
the churches. All such activities must be under the strict control
of the superintendent, in order that the sick may not be annoyed
and injured by zealous and uninstructed persons. Voluntary
associations provide utensils and instruments and furniture for
sick persons. Spectacles are furnished to meet the prescriptions
of oculists; trusses and artificial limbs make industry possible.
Bedding, sheets, pillow cases, ice boxes, bags, towels, thermome-
ters, bedpans, wheel chairs, bathtubs, are frequently required by
the situation of a poor family, yet beyond their means. During
the illness of a mother the household often is thrown into confu-
sion and distress, children are neglected; and there the gentle
and tactful hand of a trained visitor is a gracious help. Poor
women at childbirth often secure from their more fortunate sis-
ters the care of a nurse, freedom from work and anxiety, clothing
for the babe, and those kind attentions which help to restore her
to strength.

130 Relief and Care of Dependents.

7. Care of Convalescents. — A man who has been severely ill
from fever is not able to go back to work the next day after the
physician and hospital have done their part. He is emaciated,
and staggers in his walk; the muscles are not rebuilt; the nerves
are irritable; the heart is weak. People of means under these
circumstances go to the seashore or country and gather up their
energies before they grapple with duties of ofTfice or sanctum.
Poor men often inflict on themselves lasting injury by going back
to work before the process of restoration is complete. Only of
recent years has public attention been called to this branch of
charitable relief; and it demands liberal gifts and effective

8. Dispensaries and Out- Patients. — Abundant experience in
Europe and America has shown the high value of medical advice
and remedies in connection with dispensaries and hospitals.
Many indigent persons are able to walk to the office of phy-
sicians at a hospital who do not need to be boarded away from
home, and yet cannot pay for the counsel and medicines which
are necessary to restore them to industrial efficiency. Neglected
disease may be spread through a neighborhood, and the health
of the community be jeopardized. It is no small advantage to
members of the medical profession to have the varied clinical
experience which a dispensary affords.

Does the free dispensary injure the practice of regular phy-
sicians by providing gratuitous care to many who would be able
to pay for it? This question is the centre of a controversy, and
the evidence is contradictory. It has been proved that under
careless methods many accept free aid who are able to pay, and
to this extent there is ground for complaint. On the other hand,
physicians of high rank actually compete for the chance of prac-
tice in this field, since it increases their skill and reputation, and
offers clinical opportunities to their students.

It has been strongly asserted, as an objection to the manage-
ment of free dispensaries, that they pauperize many persons who
accept medical assistance without an equivalent. This contro-

Medical Charities. 131

versy has led to investigations, with conflicting results, inter-
pretations, and conclusions. Out of thirty-five thousand cases
in New York City the Charity Organization Society investigated
fifteen hundred, of whom one fourth were able to pay, one fourth
gave wrong addresses and could not be found, and one half were
probably in actual need of gratuitous help.

The abuse of this form of medical charity is limited by the
fact that few persons are tempted to become sick in order to
receive advice; and the physicians can detect imposture. The
crowd at the dispensary is often so disagreeable, and the waiting
so uncomfortable, that few persons will submit to the conditions
unless they are driven by necessity.

A thorough investigation of the cases would tend to exclude
persons who have means to pay. But there are difficulties in the
way of such investigation. Patients who require instant relief
or who are in acute distress cannot be put off pending investiga-
tion. Then the process of inquiry costs labor and money, — not
a little. The physicians have no time to turn aside from their
professional labors to inquire minutely into the pecuniary ability
of the patients who throng the office and wait in pain or weakness
for their help.

Some protection against abuse is found in the exaction of a
small fee, of about ten cents, which is paid for medicines; but
physicians have as good a right to claim a share of this fee as
druggists, unless we set the clinical practice over against the
labor and time. Perhaps a further check on fraud might be
found in investigations by the Charity Organization Society of
all suspected cases, and of one in twenty of the other cases taken
at random. The fear of detection would hinder imposition on
the part of those who are competent to pay.

All dispensaries should publish carefully analyzed reports, with
material for judgments on all professional and social matters of

The New York law (1899) gives its state board of charities
power to regulate dispensaries, and the rules of that board require

132 Relief and Care of Dependents.

the posting of a notice announcing the penalty for obtaining
medical or surgical treatment on false pretences. The applicant
must make a statement of his income, and the registrar is required
to investigate doubtful cases. The regulations cover the care of
the receiving room and clinical instruction.

Provident dispensaries are established on the same principle
as other forms of cooperation and mutual benefit societies.
Indeed, the extension of lodges and associations which offer
medicines, nursing, and medical attendance as " sick benefits "
to their contributing members, is a desirable substitute for the
free dispensary, so far as the very poor can find means to meet
the dues. Something may be hoped from the growing custom of
great factories and mills, shops, and railroads, which collect a
small sum from employees each week, add a certain contribution,
and provide free medical service to all. We have not in this
country come within sight of introducing the German govern-
ment insurance for all wage-workers. But by voluntary associa-
tions we may hope to extend the custom of employing physicians
by the year for groups of families, not merely to treat the dis-
abled but even to teach the clients how to avoid preventable
diseases. The tendency of business to concentration in corpora-
tions is favorable to the introduction and permanent mainte-
nance of such schemes. Individual manufacturers and small firms
are not sure enough of the future to take up and carry out plans
of relief which involve the collection and holding of consider-
able sums of benefit funds; and the working-men are not so

Online LibraryCharles Richmond HendersonIntroduction to the study of the dependent, defective, and delinquent classes, and of their social treatment → online text (page 11 of 35)