XI.

Medical Charities.

USES AND ABUSES OF MEDICAL CHARITIES.

BY STEPHEN SMITH, M.D., NEW YORK.

A "medical charity" is hereby defined, for the purpose of this discussion, to be an institution devoted to the gratuitous medical relief of the sick poor who are living on the border line of selfsupport and pauperism. The object of the medical charity is to provide such persons with gratuitous relief during the stress and strain of sickness, and restore them to a condition of self-support. This definition excludes the various institutions devoted to the care and treatment of persons unable to maintain themselves, or, in other words, of paupers.

Medical charities of the kind under discussion may be classified as: (1) "hospitals," which receive the sick into the institution and treat them away from home, called "in-treatment"; and (2)" dispensaries," which the sick visit for advice and medicine, and return to their homes, called "out-treatment."

Hospitals and dispensaries in some form have existed from the earliest period of recorded history. In the form in which we are to study them, as medical charities, they are the growth of the last and of the present century. Our hospital and dispensary systems of giving gratuitous medical relief to the sick poor were derived from England. All of the hospitals of London were founded as medical charities, designed expressly for the relief of the sick poor who were unable to employ a physician, and incur the necessary expenses attendant upon sickness in their homes. The dispensary is simply an outgrowth of the hospital system in its aims and purposes. It was originally designed to supplement the work of the hospital. The first dispensary was organized in London in 1770. The hospi

tals at that time were overcrowded with the sick poor; and, to meet the pressing wants of this class, the managers of St. Bartholomew's Hospital established a department where the applicants for medical relief who were not so ill as to be obliged to remain in bed could receive advice and medicines, and then return home. This branch of the hospital service was called the "outdoor department," or the "out-treatment," in contra-distinction to the "indoor department," or "in-treatment," of the hospital proper. It was also known as "the dispensary," and received the title of "The Royal General Dispensary." This method of meeting the wants of the sick poor became very popular, and dispensaries rapidly increased in England. The colonies followed the example of the mother country. In 1765 the first hospital was established in this country at Philadelphia, and in 1770 the New York Hospital was incorporated in this city, both institutions having the same foundations as the English hospitals; namely, the treatment of the sick poor. In 1786 appeared the first dispensary, also at Philadelphia; and in 1791 was established the New York Dispensary. These institutions had their origin in the medical profession, which has always given its services freely to the care and treatment of the sick poor.

During the early part of the present century the hospitals and dispensaries of both England and the United States confined their operations to the original objects for which they were created; namely, the treatment of the sick poor. Their increase was very gradual, and for the most part in proportion to the increase and wants of the class for which they were created. During the last half of the century, however, there has been an enormous increase of these institutions, and out of all proportion to the wants of the really destitute sick.

The causes which have led to the great increase of medical charities in these latter days are numerous. First, and perhaps most important, is the predominant charitable feeling induced by Christian civilization. In every community where the religious sentiment has the largest influence upon the public conscience, these institutions are most numerous and the best sustained. Second may be noticed the modern uses of these charities for medical education by the schools of medicine. A quarter of a century ago the relations of the medical colleges and these charities had no importance or significance. But a remarkable change has taken place; and now no

medical school is regarded as fully equipped for its work that has not its hospital or dispensary, or both. Third may be mentioned the vast increase of hospitals and dispensaries for the treatment of special forms of disease. This is due to the modern tendency to specialism in the practice of medicine. Those who cultivate and practise in the narrow and limited field which a single disease affords do not find in the general hospital or dispensary sufficient opportunities for the observation and study of the disease to which they are devoting themselves, and, consequently, they establish a hospital or dispensary devoted to the treatment of that one disease, and advertise free advice and medicines to all who apply. Fourth

in the order of incentives for the establishment of hospitals and dispensaries is the desire of religious bodies to employ them as the means of improving the moral and spiritual condition of the sick poor.

The necessary result of the organization of medical charities from other motives than those which originally inspired the founders of our first hospitals and dispensaries—namely, to relieve the poor of the pauperizing effects of disease. has been the more or less indiscriminate treatment of all who apply for medical relief. From this perversion of their true objects have sprung most of the alleged abuses of their management. These abuses have long agitated the medical profession and the workers in charities in England; and this agitation is at present in an acute stage, and has led to an investigation by a royal commission. It is within a comparatively limited period that the evils of indiscriminate gratuitous medical relief have attracted much attention in this country. But their rapid increase during the last score of years and the large and still larger percentage of the population which resort to them have recently excited professional and public interest. Of late the question of the proper measures of relief from evils which they are alleged to create has become predominant in several States.

These evils or abuses of medical charities are chiefly due to indiscriminate almsgiving. It is the contention of those having the largest practical experience that gratuitous medical relief to the sick poor, unless in urgent cases, and to the partially disabled, tends to undermine the independence of the poor, and that a large proportion of our pauperism notoriously originates in relief granted in sickness (Lubbock). Many English writers, who have been long familiar with

the operations of the poor laws of that country, maintain that gratuitous medical relief "is the inlet through which the habit of pauperism first creeps into the poor man's house: it is the ready introduction to permanent pauperism and deception." Langley, a poor law administrator, remarks, "It is a matter of general experience in poor law administration that the receipt of medical relief is most frequently the beginning of pauperism." Dr. Aschrott, long familiar with the operations of the poor law, states, "Those who have once accepted this kind of relief [medical] often lose the sense of responsibility and independence, and do not emerge again from the ranks of pauperism." Rev. Mr. Ede, also connected with this service, writes, "There is ample evidence to show that, when medical relief is given on easy terms, such relief leads on to further applications to the guardians, and to habitual pauperism." Another noticeable fact is their multiplication far beyond the demands of the really dependent classes. For example, during the first half-century the dispensaries of New York City treated about 16 per cent. of the population; but now they are treating upward of 50 per cent. The hospitals have increased in nearly the same proportion in New York, as appears from the fact that there are upward of 1,200 vacant beds constantly to be found in them; and 5,000 vacant beds exist in institutions for children.

In the mad race to organize new medical charities the necessity for that large and expensive equipment of hospitals which modern science requires for the proper treatment of the sick is too often neglected or entirely ignored. There are new hospitals on every hand, which in their structure and appointments for medical and surgical treatment are fair representatives of similar institutions of half a century ago.

The want of an adequate number of suitable rooms for the proper conduct of their business is a most urgent and lamentable necessity in most of the dispensaries. In many there is but one waiting-room for both sexes and for patients of all ages. As the applicants are often compelled to wait for hours for the arrival of the physician and are under no special care by an attendant, petty thefts, immoral acts, and sometimes violence occur. In other dispensaries both sexes are frequently examined in the same room, especially in surgical cases, and dressings applied. The conveniences for treating diseases of women are often of the rudest and most worthless character, and in but few dispensaries are there adequately lighted rooms for this ser

The same remark is true of the treatment of other special

vice. diseases.

In the out-department of hospitals and in dispensaries it is no uncommon occurrence to find among the waiting crowd infants suffering from diphtheria, children in the early stages of scarlet fever or measles, and adults in the later stages of consumption. Here this motley gathering of persons, suffering from all forms of contagious and infections diseases, mingle together for hours without any attempt at separation or isolation of classes or cases. When the hours are over, there is no adequate airing and ventilation of rooms; and the following day a new and susceptible crowd of people fill the rooms again from morning to night. It is quite impossible to devise a more ingenious method of propagating all our domestic pestilences than that furnished by the dispensaries. There are dispensaries in full operation in tenement houses, in drug stores, and in dilapidated old buildings and shanties. A dispensary that reports treating 48,000 patients annually is conducted in a wooden structure 20 by 12 feet, and 8 feet high. A visitor to that dispensary on a day of average attendance of patients will not be able to enter the building, so great and so persistent is the crowd. There are seats for not more than ten of the fifty or more waiting.

An inspection of existing medical charities proves that in a large number of them the essential features of good management are entirely absent. Some are under private control, and the responsibility for the management rests with a single individual. These institutions are generally deficient in every particular of good government. Even those having boards of management are not always carefully supervised by the managers.

Full and accurate records of the diagnosis and treatment of all cases is an essential feature of every well-managed dispensary; and yet, in no less than 21 dispensaries, in this city no record whatever is kept. In 17 others the records are very brief. Correct records of the receipt and expenditure of funds are perhaps of greater importance, and yet 4 dispensaries keep no financial accounts whatever. In the greater number of dispensaries that report keeping records an examination shows them worthless for any practical purpose.

An examination of applications to determine whether they are of the poor and needy class, entitled to gratuitous treatment, is very imperfectly practised in most of the dispensaries. In many the only