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and often insanitary dwellings. Much of the milk bought by
the poor is cheap that is, it costs little ; but it lacks freshness,
is inferior in quality, and often contains chemical preserva-
tives. For these reasons it often fails as a food, and the
mother then has recourse to some proprietary article. The
prime necessity is to place within reach of the poor a suit-
able milk supply for the use of infants. Such a duty might
be taken in hand by the municipal authorities.

In various places milk depots have been established on
these lines, and it is being freely suggested that municipal
bodies should undertake the supply of sterilised milk or the
provision of milk laboratories. Such a scheme seems to me
costly, unnecessary, and outside the scope of their functions.
To carry out the work of a milk laboratory efficiently would
necessitate the appointment of a resident medical officer to
devote all his time to the work, the modification of the milk
for particular infants, and systematic weighing of each child ;
or the depot would have to be run as a kind of milk-chemist's
shop, the food being ordered in the form of a medical pre-
scription by a doctor, and made up at the depot by a trained
assistant. The evolution of this scheme has arisen out of
the system of feeding infants on modified milk of definite



OUT-PATIENT DEPABTMENTS AND EEAEING- OF CHILDEEN 13

percentage composition. This system is largely adopted in
America, but, though used in this country, it has not produced
all the results claimed for it, and has not made much head-
way. As a general rule it is not necessary.

A scheme might be developed which would enable the
poor to obtain good milk at a reasonable cost, or even
gratuitously in the case of the very poor, without throwing
an undue expense upon the ratepayers, without tending to
pauperisation, and without encouraging the neglect of breast-
feeding.

I would suggest that every seller of milk should be under
the direct control of the municipal body of his district, that
his premises should be frequently visited, that the sources of
his milk supply should be ascertained, and that the milk
should be frequently analysed. In compensation for this
supervision and for the benefit of the public he should receive
monthly certificates as to the quality of the milk, and, if the
supply is up to the required standard, the name of the seller
should be placed on a list of municipal dairies at which milk
can be obtained, guaranteed up to the proper standard of
quality, purity, cleanliness, freshness, and freedom from
chemical preservatives.

To bring such establishments into a working connection
with the out-patient departments of the hospitals the authori-
ties might provide printed forms of orders for milk on any
one of these establishments, and the physicians might make
use of these for such cases as they thought deserving of such
assistance. Free orders would not be very largely required,
while the advantage of being able to recommend to the
mothers where to obtain this guaranteed milk would be
enormous. At present it is only through some of the local
charitable bodies that it is possible to obtain milk, and other
foods, for the necessitous poor during illness. To obtain
such assistance from the Poor-Law Authorities is slow,
cumbrous, unsatisfactory, and often unavailing, even in cases
where food is needed rather than medicine.



14 METHODS OF SOCIAL ADVANCE

The scheme proposed would be much more economical
than the establishment of milk laboratories. It would provide
all that is really needful in the majority of the cases, and is
free from many of the drawbacks which will be found to
obtain if laboratories are instituted on a large scale.

(3) Home Supervision. It is not, however, enough to
provide a good milk supply if the mother does not know how
to make a proper use of the milk when she has got it. In
this respect the milk laboratory has an advantage. Here the
milk is put up in bottles of a suitable size to contain milk for
each feed, and all the mother has to do is to warm the food
in the bottle, to put on a teat, and give it to the child. The
method is charmingly simple if the food happens to suit, but
no food suits every child. It is a rule-of-thumb system, and
babies cannot satisfactorily be thus brought up. The mother
is relieved of all responsibility, and it seems to me both
wrong and foolish for municipal authorities to take over the
responsibility rather than to teach the mother proper methods,
which she would be able to make use of for future children,
and would disseminate by advising others and by gossip
among her neighbours.

Granted that a good milk supply is obtainable, the next
step is to provide for teaching mothers how to make use of it
by actual demonstration. Unless the mother has a consider-
able degree of intelligence she will not carry out the fullest
directions accurately, until she has been shown practically
how to do so.

To meet this difficulty there is needed a supply of efficiently
trained women, not necessarily trained nurses, who will work
in connection with the out-patient departments of the hospitals.
Their duties would consist in visiting the homes of cases
selected by the physicians, and there teaching the mothers
how to keep milk and other foods from contamination, to
inculcate the importance of cleanliness of all utensils used in
preparing the food and of all feeding-bottles, and to show
practically how the feeds should be prepared and given, and



OUT-PATIENT DEPARTMENTS AND BEARING OF CHILDREN 15

how the child should be washed and clothed. A few such
lessons would be quite sufficient in most cases, with occasional
subsequent visits to see that the instructions were being
properly carried out.

To a certain extent such 'work is undertaken by the Invalid
Children's Association, on application from the doctor in charge
of the patient, and by district nurses. The funds of the former
are too small to enable them to do much in this respect, and
the time of the latter is mainly devoted to maternity and
surgical work. As a rule, too, they are not sufficiently trained
in this special branch to make them very good guides.

Unfortunately, the hospitals for children have rarely
sufficient funds to carry on their ordinary work without
getting into debt, and in the present state of their finances
they would not be justified in undertaking this additional
burden. They would be the best and most appropriate bodies
to carry out the scheme, for these home visitors would have to
be more or less under their control, receiving directions and
instructions from the medical officers of the hospital.

There are many charitable bodies in existence engaged in
working for the poor, but their efforts are ill co-ordinated,
and often overlap. It is greatly to the detriment of their
usefulness that these bodies, some of which supply food,
clothing, coal, and nursing in suitable cases, do not put them-
selves more in contact with the hospitals. Many of these
bodies are connected with religious work, and their assistance
is only available in a particular district or among a limited
sect. If it is desired to obtain any such assistance for a
hospital patient, the difficulty is great from the fact that very
often their existence is unknown to either the medical men or
the hospital authorities. Much good would be done if the
work of these bodies could be made available for use in the
manner above suggested.

(4) Education. Ultimately the best results will arise from
an advance in the education and intelligence of the poor at
large. Progress is necessarily slow and almost imperceptible



16 METHODS OF SOCIAL ADVANCE

in this direction, for the gradual dissemination of knowledge is
a matter of years. In my own experience, at the Belgrave
Hospital for Children, such a spread of knowledge of the
subject has taken place in the district that mothers frequently
come to obtain a copy of the pamphlet of directions for their
own use or for friends. Many children, who subsequently
come to the hospital for various ailments, are found to have
been brought up according to these directions.

Educational authorities do good by teaching the future
mothers the importance of cleanliness in the home life, in the
preparation of food and its preservation, the necessity of
ventilation, fresh air and exercise, and simple facts connected
with the value of different articles of food. Unfortunately,
school life ends early, and its teachings are to a great extent
forgotten or are stifled by the handing down, from a more
ignorant parent, of a variety of prejudices and superstitions.

I have treated the subject on general lines, and have left
out of account the many benefits which would be derived from
the establishment of a system of home visitation, by the older
children and the parents. It is obvious that once such a
system were in working order, and trained women in this way
obtained an entrance into the homes of the poor, they would
be of the greatest service in the nursing and management of
older children suffering from various ailments, and that they
might have an enormous influence in improving the home life
by tactful advice as to cleanliness, ventilation, clothing, and
exercise.

The co-ordination of educational bodies with hospitals
would be also advantageous, At present they are, to a certain
extent, antagonistic. School boards look with suspicion on
medical certificates of unfitness of children to attend school,
when their officers see the children playing about the streets
as if nothing were the matter. Many evils arise from over-
education among the ill-developed and under-fed children of
the poor, evils which are frequently cured by simply stopping
all mental work for the time being. These evils are partly due



OUT-PATIENT DEPARTMENTS AND BEARING OF CHILDREN 17

to overstrain of an ill-nourished brain, and partly due to
insufficient air and exercise. During the winter months
especially, a large portion of the day is spent in school,
and the atmospheric conditions of schools containing a large
number of poor children are distinctly prejudicial to health,
and most of the rest is spent in close, insanitary dwellings.

School teachers could assist considerably by taking careful
note of the health of their pupils and by dismissing, for
medical advice, those who seemed ailing or unusually inatten-
tive to their work. Probably the only true solution of the
medical aspects of education and the spread of disease by the
aggregation of children in schools consists in constant super-
vision of the children by specially appointed members of the
medical profession.

E. C.



18 METHODS OF SOCIAL ADVANCE



II

THE WOEK OF A HOSPITAL ALMONER

4 With a view to promote the better organisation and greater use-
fulness of the Out-Patient Department, the House Committee have
appointed an Almoner to work among the out-patients. . . . She
will systematically interview the applicants for out-patient relief
with a view to eliminate from among them those whose circum-
stances do not seem to entitle them to treatment, or who might
be better provided for by a provident dispensary or by the Poor-law
authorities. At the same time every applicant will be attended to
at the first visit, and no patient will be subsequently rejected if the
physician or surgeon in charge desires the case to be continued
under treatment.

' The almoner will undertake the duty of helping the patients,
so far as opportunity will allow, to obtain surgical appliances, letters
for convalescent homes, or such other aid as the staff may consider
them to need.'

SUCH is the outline of an out-patient almoner's work as
sketched by the House Committee of the Hospital. It will be
seen that no unnecessary restrictions were to be placed upon
the work. The almoner was to endeavour to stop abuse in
every direction abuse by the well-to-do, abuse by the thrift-
less, and abuse by those who through ignorance or inability
of any kind could not carry out the treatment necessary
to recovery. How this was to be done depended in great
measure upon the resources at her command.

It is evident that this work among such a number as flock
to an out-patient department would be impossible single-
handed, and necessarily incomplete in all circumstances. To
begin in a small way, therefore, and to build up gradually a



THE WORK OF A HOSPITAL ALMONER 19

system upon a few structural principles, was the only way
open ; the proof of the soundness of the principles being that
the work would gradually simplify itself and so become more
easy to handle.

I. Co-operation within and without the hospital was
one of the corner-stones of the foundation. Within the
hospital the endeavour was to make the medical and nursing
staff, the students, and even the hospital porters, realise that
any case they might take to her as apparently what they
would call a ' deserving ' one would have her serious con-
sideration, however difficult the problem to be solved might be.

A rule of reporting the action taken whenever this had
been done, and of explaining carefully why it did not appear
possible to assist in certain cases, resulted, it seems, in the
general acceptance of the belief that the post of almoner was a
useful one. Cases are now not only referred to her for inquiry
as to the best means of procuring assistance, but for inquiry
as to ability to pay for treatment outside the hospital, or for
general advice; and those within the hospital are always
ready to assist her office, by giving their medical opinion,
perhaps hastening an admission, supporting a decision, or in
various other ways which make the work more possible than
it otherwise could be.

A few examples may show more clearly than general
statements what can be done by co-operation within the
hospital.

1. A student had been much perplexed by a maternity case to
which he had been called. The husband was out of work, there
was no fire or food, and many children. He asked for a visit, which
proved the case to be one for the Poor Law. The man was sent to
the Relieving Officer and a nurse asked to visit every morning
through the clergy.

2. A girl from the country had to attend the hospital daily for
the light treatment for lupus, but could find no suitable lodging.
She was finally referred by the doctor to the almoner, who put her
into communication with the Travellers' Aid Society. A room for

c 2



20 METHODS OF SOCIAL ADVANCE

her was found at a girls' home, and here she remained comfortably
for six months.

3. A servant had been practically cured of lupus by the light
treatment, but needed convalescent treatment at the seaside to
complete the process. Her mistress had offered to pay for her, but
did not know where to send her or how to set about the arrange-
ments. The case was sent to the almoner by the doctor, and she
undertook the necessary preliminaries.

4. A man had been an in-patient with compound fracture of
the leg. He had been sent by the hospital for convalescent treat-
ment, and on his return attended daily for massage. He had a wife
and two children, was in serious want and obliged to contemplate
going into the infirmary. The massage nurse sent him to the
almoner, who referred him to the Charity Organisation Society.
He was assisted by a weekly allowance for fifteen weeks while he
received the massage, till he was fit for work again.

5. A boy attended with chorea. The father was out of work,
and there was insufficient food. The parents were advised to send
him to the infirmary, but they refused. The case was reported to
the physician, who also urged the infirmary and refused to treat
the child at the hospital. A friendly visit was made later by a
member of the Charity Organisation Society to see whether the
parents had consented to let the lad go. It was found they had
not, and he was worse. They finally promised to allow him to go.

6. A youth attended as out-patient, and was found to be suffering
more from want of food than anything else ; he seemed also to be
slightly wanting in intelligence. He was brought to the almoner
by the doctor. It was found he had walked from Leicester in
search of work. He was advised to go to the Church Army, and
his parents were communicated with. The reply came at once in
the shape of a very grateful letter. They said the lad had been out
of work and had suffered from depression and religious mania in
consequence. They were quite willing and able to support him,
and sent his fare, asking that he should be sent home, and
promising to exert themselves to find employment for him.

These examples show the necessity of having someone in
the out-patient department whose duty it is to attend to the
social aspect of a patient's life ; they also show how impossible
this would be unless she was in close touch with those outside



THE WORK OF A HOSPITAL ALMONER 21

the hospital who have the improvement of the condition of
the poor at heart. The almoner is the connecting link
between those who are working for the benefit of the poor
within and without the hospital. Further examples would be
tedious. Suffice it to say that the more the almoner knows
of the conditions under which the working classes live, their
thrift agencies, their wages and the workers who are doing
good or harm among them, the more useful she can be, and
the more co-operation she can obtain inside and outside the
hospital walls the more benefit will accrue to the work of all
parties concerned. Without this co-operation, if she took her
work seriously, she would be filled with despair, or if she took
it lightly she would make it a farce.

II. Another fundamental principle closely connected with
the above is that the creation of the almoner's office should
not be the creation of a new centre for the distribution of
relief. All moneys entrusted to her are given in conformity
with the principle of co-operation, and the patients themselves
do not know there are any funds at her disposal. This at
once places patient and almoner upon equal terms, and truth
is possible between them. A curious example of this was
given a short time ago. An old woman attended as a new
patient and was advised to get a belt cost about a guinea.
She stated she was living in one room at 3s. a week upon
what her daughter, who was abroad, could afford to give her.
It was evidently true she was living in a very humble way,
and she professed herself quite unable to provide what was
needed. It was explained to her that, though the hospital
could not give the belt, she could apply to the Charity
Organisation Society, who, after making some inquiries, might
be able to obtain assistance. Upon this it came out that the
daughter was the wife of a solicitor in Belgium, and the old
lady said she would apply to her first. If she could not
manage to pay for the belt, she would return to the almoner
for the address of the District Office. Nothing more was
heard of her.



22 METHODS OF SOCIAL ADVANCE

Many and various have been the engagements such as
this between almoner and patient, but the principle works
well by throwing the applicants for relief upon their own
resources, and when it is understood that the rule applies
equally it becomes appreciated, at all events by the better sort
among them.

A woman who came to pay her last instalment for con-
valescent treatment for her little girl was evidently hurt that
she should have had to struggle and deny herself much to
pay 5s. a week for the child, when a boy who went by the
same train had announced he was going away free. The
apparent injustice of the facts rankled in her mind, but it
had only to be explained that there was a just principle
behind to send her home happy in the thought that she had
managed to pay entirely herself, and there had been no
necessity to ask any Society for assistance.

III. This brings us to a third principle. The almoner's
endeavour throughout the work is to encourage habits of
thrift and self-reliance in all who pass through her office.
It is not only pointed out to those in difficulties how they
can in future make some provision for the emergencies which
will inevitably appear in the course of their lives, but the
present need is, as far as possible, met by suggestions as to
how it may be possible to manage without having to ask
strangers for help. The mother of a family may refuse to
come into hospital, when it is necessary for her health that
she should do so, because she has no one with whom to leave
the children. A talk over ways and means often results in
her resolve to do a little organisation on her own account
among her relations.

A boy, a few days ago, needed a new artificial eye, and
the mother said she intended to get Surgical Aid letters for it
as she had done before, but after it was made clear that it
would be more satisfactory to save up weekly for it herself
she decided to do so, and the instrument maker reports that
patients return to him for small articles, such as elastic



THE WORK OF A HOSPITAL ALMONER 28

stockings and trusses, ready to pay for them themselves,
having been taught in the first instance to save up for them
by paying the cost in instalments through the hospital.

The same principle of discountenancing any schemes for
obtaining what is needed which may weaken a patient's
moral fibre underlies the almoner's attitude to the Poor Law.
Cases come before her which are on the border-line of the
Poor Law, but which, unless there is some definite reason,
she does not recommend to apply to the relieving officer.
Single men, unable to work, who have made no provision for
sickness are not urged to go into the infirmary. It seems
better that they should feel the pinch due to their own
neglect. It is disheartening to find how many ne'er-do-weels
look upon the Poor-law infirmary as a safe provision for
them in times of sickness. One of these, on being asked
what he should do without a club if he fell really ill, replied
' I shall go where better men than I have gone, miss
to the infirmary,' and this is the attitude usually taken up
by the thriftless. They even come to the hospital with the
purpose of obtaining certificates for the infirmary, which I
am glad to say they do not get unless the case is one of some
urgency.

There are occasions, however, on which the almoner
recommends resort to the Poor Law. If a man is suffering
with advanced phthisis, especially if he is living in one room
with a family of small children, every effort is made to send
him into the infirmary. If a lad who has just left school
and is suffering from epilepsy and mental deficiency is
beginning a loafing life, trouble is taken to get the Guardians
to send him to an epileptic colony ; or if a child cannot get
proper attention at home because the father is out of work,
the case not being suitable for admission to hospital, the
parents would be urged to apply to the relieving officer.
Where the safety of the community is threatened, therefore,
or where the patient is unable to protect himself, the Poor
Law is brought into use ; otherwise the ragged regiment is



24 METHODS OF SOCIAL ADVANCE

left to seek its aid or not as necessity may dictate. Bad
character is not, from the hospital point of view, a reason
pure and simple for referring cases to the Poor Law, and
this partly for the cause given above, and partly on account
of the fact that the hospital is a medical school and every
type of case should be seen there.

IV. A fourth principle now comes into prominence. It is
that the almoner, and through her the patient, must recognise
the true function of the hospital out-patient department viz.
the alleviation of disease which can be more suitably treated
there than elsewhere. As far as possible it should be the
consulting centre for the poor. In this way only can the best
cases be procured, and in this way only can the work of the
staff be sufficiently lightened to enable them to have the
necessary time for teaching. With this object in view, the
patients are encouraged to bring their doctors' cards ; they
are also encouraged to go back to their doctors to report
what has been done for them at the hospital. When a
patient comes with a passport from a general practitioner the
inquiry by the almoner is merely made with a view to
finding out whether he is in a position to carry out all the
treatment advised. Let us take as an example a man sent
up by his doctor and found to be suffering from early phthisis.
A great deal of organisation will probably be necessary to
obtain the open-air treatment for him. The patient's name


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