Popular Science Monthly/Volume 9/October 1876/Relations of Hospitals to Pauperism

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CIVILIZATION has not reached that state of perfection where hospitals can be dispensed with. 1. As long as armies exist, hospitals will be necessary. Soldiers when sick must be provided with special accommodations; and, after a battle, the wounded cannot be properly cared for except in hospitals constructed especially for the purpose. 2. During epidemics of contagious and infectious diseases, it becomes a necessity to separate those infected from the well, and for their accommodation hospitals must be erected. 3. In every community, especially in large cities, there are always a certain number of paupers without any homes, who must be cared for when sick, and the only practical way of providing for them is to establish hospitals. 4. In large cities provision must be made for street casualties, and hospital accommodations are necessary. 5. On account of difficulty in making suitable provision for the insane in private houses, hospitals or asylums for the insane are necessary.

In this country, in all large cities, any one representing himself as poor and sick can apply either to the public hospitals supported by the State or to hospitals supported by voluntary contributions, and is admitted in many cases without any special inquiry or investigation as to his circumstances. In some places—as New York City—hospitals are so numerous, and admission to them so freely granted, that there is little or no restraint on impostors. If refused admission to one institution, they go to another and receive treatment and care without cost, when they are fully able to provide for themselves. And so numerous are the dispensaries where medicines and medical advice can be obtained free of cost, merely for the asking, and so easy and readily can care and attention be had in free hospitals, that the poor have no necessity to make provision for sickness.

It is estimated that about $10,000,000 are expended in public and private charities annually in the city of New York, a city of 1,000,000 inhabitants. A considerable portion of this sum is expended on the hospitals, which alone contain more than 6,000 beds, not including insane or other asylums, but only institutions known by the name of hospitals. About 4,000 of the 6,000 beds are in public city or State hospitals, the remaining 2,000 being in hospitals supported by voluntary charity. The official reports of the thirty-odd free dispensaries give 307,060 as the number of patients applying for and receiving treatment in 1875 at the dispensaries, against 20,631 treated at their homes.

To say that $10,000,000 are expended in charities, that there are 6,000 free beds in the hospitals, and that over 300,000 persons receive medicine and medical advice free of cost at the dispensaries, is certainly evidence of the generosity and Christian spirit of charity that prevail. But, when looked at in a direct, practical way, these figures show something else. If these official reports are to be relied upon, then, in a population of 1,000,000, over 300,000 persons receive alms every year. We doubt if the number of individuals is so large, for it is the custom of some dispensaries to count each visit a patient makes as a patient treated. But the actual number is immense, and increasing out of all proportion to the increase of population. The truth is, the majority of our hospitals, as they are at present managed, are liable to do more harm than good. Apparently they do much good, and for the time do relieve suffering and want, but in the end may do much harm. Giving help too readily even during sickness is hurtful, and when it is offered freely without the certain knowledge that it is really needed, it very naturally removes the healthful stimulus of necessity, the dread of which prompts every individual to provide for the misfortune of sickness.

The dispensaries as they are now managed are nothing less than a promiscuous charity, exactly similar to the notorious "soup-kitchen"—medicine being substituted for soup. They offer to the ignorant and poor an easy and ever-ready inducement to take alms. They are the first stepping-stones to the degradation of pauperism. The self-respect of an individual is injured the moment he accepts alms, and a habit of taking alms invariably tends to a complete loss of self-respect and consequent degradation. It matters but little whether alms be medicine or food, the principle remains the same. The hungry must be fed; but we know that, instead of continuing to feed the hungry, and gradually destroying their power to help themselves, it is infinitely better to teach them how to help themselves and seek out and remove the cause that induced the miserable condition of helplessness. For exactly the same reason, would it not be better to teach the poor how to avoid getting sick, and by every means in our power remove the causes that induce disease among them, rather than to offer them the best care and attention without being sure that they need help, and thus teaching them to become careless about avoiding sickness?

It would be more creditable to the citizens of New York if they could say that no such institution as a pauper hospital was needed within the limits of the city than to be able to say that two hundred established charitable institutions and organizations are maintained; and instead of so many millions being spent in caring for the sick, would it not be better if the same money, or perhaps only a small part of it, were spent in carrying out sanitary works, and teaching the people the laws of health?

Suppose, during the prevalence of a contagious epidemic, the authorities should content themselves with providing for those infected, and neglect to take the necessary steps to remove the cause of the disease by doing all that sanitary science indicated—they would soon be called to account for neglect of duty. It is a well-known fact that the great majority of the cases of disease treated in our hospitals are induced by the bad sanitary condition of the homes of the poor, and to the direct violation, through ignorance, of the plainest hygienic laws; yet what direct steps are taken to correct this constantly-acting cause of sickness? The Health Department of New York City is expected to do little else than prevent epidemics of contagious and infectious diseases. The meagre appropriation prevents them from doing much more.

This statement concerning the charities of New York City cannot be called a fair example of the condition of the hospitals and other charities in smaller places, but it shows very plainly and truthfully the prevailing faults in the administration of charities throughout the country; and if the condition and results of the charities of smaller places are not so bad, it is due to local circumstances, and not to a better understanding of the subject, nor to the adoption of a more enlightened system.

The circumstances are very much in favor of the smaller cities and towns. Leaving out the many well-known causes that tend to generate pauperism, and thus increase the relative number of paupers in a large city that do not exist in towns or small cities, the main reason that charity does not do so much harm in the latter is, that the circumstances and the character of every one are well known to the people, and this personal knowledge guides and directs the givers of charity; whereas in the large cities it is seldom that the giver of charity knows to whom he is giving, and personal knowledge rarely exists at all. The difference between the lives of the rich and the poor is so great that the rich cannot comprehend the real needs of the poor. Unless these personal relations exist between those that give and those that receive, no act of generosity deserves the name of that charity which "blesseth twice," for gratitude is not developed in those receiving help. They give nothing in return for what they receive. Experience teaches that to do for an individual that which it is possible for him to do for himself will invariably tend to harm, unless he gives in return an equivalent, either by actual payment or in gratitude. And experience also teaches that human nature can only feel gratitude toward an individual.

Besides this tendency in hospitals as charitable institutions to increase pauperism, another serious objection to the use of public hospitals for the purpose of treating the sick beyond the extent absolutely demanded by necessity is, that every time an individual is removed from his home—let that home be ever so humble—and taken to a hospital, the family as an institution receives a blow.

Then, too, except to those already degraded, life in a pauper hospital, especially in the case of the young, is hardening to the feelings, while in many cases it subjects the moral to the influence of the immoral.

Another objection to hospitals is the bad sanitary condition of many of them, and unless this is improved, both as to the plan and the construction of the buildings, and the general and internal management, so as to give a smaller death-rate and fewer deaths from hospital-diseases than in the vast majority of hospitals now in use, it will be decidedly better, on sanitary grounds alone, to treat in their homes all the sick poor who have homes, even though they may be very bad and unhealthy places to live in. As to the expense of treating the poor at their homes, it certainly would not be greater than the expense of running the hospitals, if the interest-money is added which could be had from the immense sums that are sunk in the massive, many-storied hospital buildings, and the expensive city lots on which they stand.

But as poor-relief is now administered, and, no doubt, under the best system that could be devised, a certain number of hospitals for treating the sick poor will be necessary. When properly constructed and managed they are a great blessing to the poor, while, from the advantages they afford for the study and teaching of clinical medicine and nursing, they are of incalculable value to the whole community.

Since the establishment of the Training-School for Nurses in connection with St. Thomas's Hospital, by Miss Nightingale, in England, fifteen years ago, and, in this country, of the School for Nurses in connection with Bellevue Hospital, New York, three years ago, the great advantages of hospital-instruction are recognized for those who are studying nursing.

In the founding of hospitals, the question of their usefulness to medical education has not been given due consideration. As a rule, the idea of rendering immediate personal relief to the suffering poor is the first, and in many cases the only acknowledged object aimed at in establishing them.

The objections to civil hospitals as now stated may be said to be: 1. As institutions, they tend to weaken the family tie by separating the sick from their homes and their relatives, who are often too ready to relieve themselves of the burden of the sick and heirless of their family. Besides, when one or more of a family are removed those left at home are in an uncertain state of mind, and, in many instances in an unprotected condition. 2. The inmates of pauper hospitals are liable to come in contact with bad influences: familiarity with suffering, unaccompanied by the occupation of relieving those who are suffering, ends in hardening the sensibility, especially in the young. 3. Like all public and general charities without the safeguard that personal knowledge affords, hospitals tend to foster idleness and helplessness, and their natural results, pauperism and crime. 4. When badly constructed or badly managed, they are liable to cause hospital-diseases among the inmates, and become centres of infection, thus defeating the very object they are intended to promote.

On the other hand, the arguments in favor of civil hospitals are: 1. They are a necessity under many circumstances for giving shelter to the sick and helpless, and are supposed to be the most economical method of providing for the sick poor. 2. They are of very great value as affording an opportunity for the comparative study of diseases, and for giving practical instruction in the science of medicine and the art of nursing to the greatest advantage, and thus, by helping directly a few individuals, indirectly rendering a service of incalculable value to the world. 3. During contagious epidemics they are a ready means of providing for those who are infected, and, by their isolation, preventing the spread of disease.

As means toward checking the undesirable multiplication of expensive institutions, toward preventing hospitals from breaking up or interfering with the family tie, and at the same time to keep them from engendering pauperism, we suggest: 1. Do all that can be done to enlighten the poor to help themselves, and to avoid the causes of disease. 2. Give indirect help by improving the condition of the homes of the poor, by strict laws in regard to the existence and building of all dwelling-houses, manufactories, schools, etc., etc., and in regard to the sale of food. 3. Limit hospital accommodations to those who have no homes, and to those who cannot be assisted at their homes.

It is doubtful if the state can give direct out-door help, even medical help, without doing more harm than good. It can only be done wisely by establishing a Bureau of Intelligence in connection with the police department, with offices at each police station, where the names and the numbers of the inmates in every house in the precinct or district would be known, and where, from personal knowledge, a record of all individuals receiving help—as to their circumstances, the amount of aid given, etc.—would be kept. As far as possible, all help rendered should be guided by this knowledge, and it should be obligatory on all charitable institutions and associations to give information of all assistance rendered by them to individuals living in the district.

Through this Intelligence Bureau reliable personal knowledge of every applicant for hospital-relief could be obtained. We fully appreciate the great difficulty of organizing and uniting voluntary charities in this country, where there are so many different religious sects; but by establishing such a system as the above much could be done toward distributing help where it is really needed, and toward preventing indiscriminate charity, and in detecting impostors. To avoid the injurious moral effects of hospitals on the characters of the inmates, and to prevent such bad sanitary conditions in hospitals as are sure to result in retarding cures, and often in the generation of fatal hospital-diseases, it is necessary to have hospitals constructed and managed in accordance with the teachings of sanitary science.

  1. Extract from Boylston Medical Prize Essay, Harvard University, on "Civil Hospital Construction," 1876.