EXPLANATORY REMARKS ON THE GREAT UTILITY OF HOSPITALS FOR THE SICK AND POOR.
BY A GOVERNOR OF ADDENBROOKE's HOSPITAL.
CAMBRIDGE
PRINTED: And Sold by Mess. MERRILLS, WOODYER, and FLETCHER and HODSON.
M.DCC.LXXVI.
[Price SIX PENCE.]
SIR,
YOU may remember when I had the pleasure of spending a day with you at your Seat in—
shire,
that the discourse after dinner turned on the Subject of Hospitals, as lately erected in many of the Counties in England. The Company in general applauded such undertakings; a few doubted whether they were always conducted in the most proper manner, while one person ventured to say, they did more harm than good. I perceived your Humanity was hurt at this last insinuation, and saw by the significancy of your Looks, that you wished as you knew how highly I approve such Institutions, that I would have stood forth in their defence.
What I then declined doing in conversation, I am very willing to do by Letter. I had two reasons for not entering on the Subject at that time; One, because I was not prepared to treat it fully; the other, because a large company is very seldom an attentive one. You must often have observed that in the unrestrained freedom essential to social debates, too many are apt to speak at once; and thus bring objections faster and in greater number, than the defendant has time to remove or comprehend; whereas several objections would successively vanish before an uninterrupted explanation; and arguments are known to derive accumulated force, from relative and necessary connections.
It is possible I believe for minds to be so influenced by Error as to indulge speculation to the exclusion of practical duties; it must have been from such a principle that any one ever thought the life of a mutilated Slave, not worth preserving, or that we were under the dominion of such a Fatality, as rendered succour to the sick, needless.
It is not to such as these I direct my thoughts, but to such as convinced of the utility and necessity of this branch of benevolence, wish only to see it practised in the best manner it is capable of, and as little injured as may be, by the imperfections of human management.
The chief and foundation Stone of these benevolent Structures, is the relief of sick and suffering Poverty. Thus far all build alike; this is the undoubted aim of every contributor. And yet though this principle seems of a very simple kind, it becomes when reduced to practice more complicated than could be wished; and hence it is that the Rules and Orders of most Infirmaries, can so seldom be entirely complied with. They generally exist previous to any trial, how far they may chance to be more or less beneficial to the main design; Experience, and Experience only, can properly teach us this. There is a variety of perplexed circumstances in the Case of many who petition for relief in Hospitals, which no Rule can regulate, and many Rules make worse: while the relaxation of a rule, begins confusion, and a temporary suspension compleats it.
The Rules and Orders of every Hospital are designed to operate in two points: for the benefit of the Patient, and the good order of the house; to state what are the Qualifications that render the sick, proper objects of charity; and what conduct of theirs is necessary to give them a chance for relief. To which is added, and with great propriety, what kind of Behaviour is expected from them in return.
I shall speak to each of these articles, by which it will appear how difficult it is to confine them to uniform Rules.
With respect to
Poverty,
I would have that always rest upon the Credit of the Recommender, as it would be impossible to examine into it, during the time allotted for the admission of patients; besides that the state which qualifies the Petitioner to be favourably heard, does not entirely depend on his being in absolute want. The poor Wretch who has by severe labour accumulated a few pounds, may be very unable to support himself and family, under a severe illness, without ruining his little hoard; and spending perhaps in a few weeks, what was the labour of years to acquire. Humanity seldom errs, tho' judgement may.
But the nature of the distemper is a more difficult circumstance. There is a certain fence between the Pauper and this kind of Charity, which one knows not easily where to place. There will in most Infirmaries be more Candidates for relief, than money to accomplish the good design; it is very proper therefore to lay it out where there is the greatest likelihood of success, and to withhold it from such as seem incapable of benefit. On this principle is founded the regulation of
excepted cases.
Some Disorders proclaim at first sight the impossibility of a Cure, and are therefore properly rejected; others are so far advanced that we have little chance of removing them; yet it is not always safe to pronounce the disorder in the last stage, and the Patient in a dying Condition; here the Physician holds the scale with a trembling hand, to see whether Pity or Justice must preponderate.
Monstra fiunt in Medicinâ,
is a well known and indisputable axiom, and to say exactly when nature has done her all, and Art can do no more, is in some Cases impossible. You see by this that my Inclination tends to admit of almost hopeless Cases, in order for
trial.
How trifling does the objection of hazarding a little expence appear, when set in opposition to the attempt of saving a useful Life?
But supposing our hope of success should be too sanguine, and the impossibility of giving any relief confirmed, and the Patient during the experiment become too bad for removal, what is to be done then? I make no scruple to answer, the Patient ought to die with us. I acknowledge that the primary Intention of these Charities is the Restoration of Health and Ease, and that when the undertaking appears very unfavourable, we should deliberate before we determine to receive the Patient; but should we be accidentally obliged to let the Patient die with us, I insist we are
Charitable
still. There are some sufferings at the close of some lives, which Humanity must ever wish to soften; and which these Institutions certainly do; nay the letting one single Life expire with us, may be the preservation of many. The pauper would probably at home have expired (perhaps offensively) in the same small bed, with his wife and infant family; Distemper might thus be propagated, for want of Air and Room, to a whole Cottage, and seven perish instead of one. We improve on Humanity, while we prevent those evils which we are not certain we could cure, and do as much good and at less expence, by obviating as by removing complaints.
It is acknowledged on all hands, because it is demonstrable, that the expence of the In-Patients is considerably encreased by the length of time they are obliged to stay in the house; but would the superficial readers of our annual accounts, or the rigid advocates for unremitting Oeconomy, but deign to visit these Scenes of suffering, they would acknowledge their money was not wantonly expended, and that the number of wretched sufferers must occasion a considerably larger disbursement; still however as far as may be, to reconcile Oeconomy with Humanity, let it be seriously remembered, that would the Paupers themselves, or their friends or Parish Officers for them, send them for help at the beginning of Sores, Hurts in the Joints, &c. their Cures would be compleated in a much shorter time, with infinitely less pain to themselves, and proportionally less expence to us. If they come to us however in a far advanced State of Evil, in God's name let us spare no expence for their recovery. I had rather Addenbrooke's Hospital should never be any bigger than it is, than figure away in our account with twenty times the number of Patients, and not do half the good.
To obviate however every objection of this kind as much as may be, and to keep clear of a tax which Infirmaries moderately endowed can ill support, it is one of our rules, that Patients living at a great distance where we cannot examine them ourselves, should send by an Apothecary or Surgeon, the exact state of their Case, that their coming may be prevented, if deemed unnecessary or improper.
One of the Cases generally refused admittance into Hospitals is that of Epileptic Fits, and with great propriety; as the sight of them has been known to occasion the same disorder, in persons not before afflicted with them. Indeed they are in many Instances so unconquerable, that all attempts to relieve them are fruitless. But even to allow these Objects every possible Chance, they are constantly admitted on the List as Out Patients. It were however to be wished that all Objects of this kind could reside in the same Town in which the Infirmary is placed; as such persons being obliged to walk a considerable way, to or from an Hospital, may chance to fall in going over narrow planks, walking by the side of Ditches, &c.
The only poor to whom I think we should deny, or but sparingly afford our assistance, are the Veterans in iniquitous Habits; not from any want of common humanity, or from a presumptuous condemning of others, but because we here strive against the Stream, we attempt impossibilities. The Disease, as well as Habit, is become incurable from a repetition of the same Causes, which first produced it, and the constant continuance of which feeds and inflames it. Habitual Drunkenness is therefore the greatest disqualification of an object that desires relief in this way. And indeed the very few Patients of this Class, who have not entirely drowned their understandings, are sensible enough of the impropriety of their application, and acknowledge their expectation of relief to be very little; because they own they have drank hard in their time, which generally means, as long as they were able.
Another species of Disease, at least in an advanced State is rejected, because very troublesome in its consequences, very tedious in its Cure, requiring sometimes uncommon attendance, and usually the lot of the very profligate. Our Hospital, as far as it can, endeavours to send out its patients more virtuous than it receives them; endeavouring to promote as will hereafter be observed, every good disposition by Prayers, Advice and Books.
There is yet one kind of Patients more who must ever be deemed proper Objects of our Charity. I mean those, who are taken ill during a constant residence here in a diligent exercise of their employment, though barely sufficient for the maintenance of themselves, or family. To send these in a dangerous or languishing State to such Hospitals as from their settlement they would have a claim to, would be often impossible, and always inhuman. And it should be remembered that the benevolent Founder of our Hospital, meant it to be for any poor sick person whatever, not limiting them to Place or County; and whatever regulations have been obliged to be introduced of this kind, are entirely owing to the impossibility of fulfilling his wish, and the propriety of giving a preference, when necessary, to our Town, County, and the Isle of Ely.
Having now finished my Observations on what seem the necessary Qualifications to render Patients proper Objects for an Infirmary to relieve, it comes next in turn to consider by what methods the relief of each can best be attempted.
As no Hospital can properly contain the numbers that every week sollicit to be admitted, the sick are on this account necessarily divided into In and Out Patients. This is unavoidable, and attention is therefore paid to the most immediate distress, and Objects of this sort preferred to be taken in. But it often happens that patients are not excluded for want of room, but because they cannot find time to come in. The heads of families cannot always be spared from home. If a mother, she is wanted to look after the children; if a Father, he must try to work, however little, to maintain them. Whatever be the Cause, the consequence is clear, that Out Patients cannot have equal assistance, with those within; and some inconveniences follow, and cannot be avoided both to themselves, and the Charity that assists them. Assistance can only be given to such Sufferers by obliging them to come to the Hospital for Advice and Medicines. They must come for these upon a stated day of the week, whatever may chance to lengthen the Intervals between their coming. If they come in bad weather, they encrease their complaints; if they wait too long for good they are without medicines. It often happens that they come miles, and almost always that they walk. These circumstances it is to be feared, abate the efficacy of prescriptions, and sometimes entirely frustrate their design. Besides which the treatment cannot always be so well adapted to their complaint, as in the House; some remedies require caution in the administring, and most find an auxiliary in proper diet, little of which I suppose is to be met with in poor Cottages; nay the very form of the medicines participate in some measure of the inconvenience, and as the time of year happens, such as will keep longest must have the preference to others that would exert their effect more speedily or powerfully.
And here let me note a prevalent error among the ignorant part of mankind in general, and that is a notion that the first prescription is always meant for the immediate eradication of the Disease, and therefore if they find themselves disappointed in this, they give over, and take no more. Whereas some Cases and constitutions require a little previous preparation to give medicines a Chance of doing good, and perhaps to prevent them doing harm. Bleeding and some other evacuations, belong to this introductory Class of Relief. And I have sometimes had reason to suspect that more harm has been done by thus unseasonably stopping short, than would have followed from having done nothing at all.
I have dwelt the longer on this explanation, in order to account for the reason of the great number of Out Patients generally remaining on Hospital Books, as also for the tediousness as well as additional expence of their Cure, which probably would not in some Instances have been greater in the house.
There is no stronger Instance of the superior advantage of being an
In,
to that of being an
Out Patient,
than what is taken from those complaints which arise entirely from the want of proper warmth and nourishment, and which is often the fate of the Country Poor. I have seen some of these in vain attempted to be relieved at home, who when they came into the house scarce wanted any other prescription than a warm bed and a full belly, and which often compleated their cure in a fortnight.
Nor let it be said that relief in these circumstances is rather given to the parish than to the poor, for distempers are equally such, whether brought on by poverty or any other Cause. Nay such a sufferer surely deserves double compassion, who owes his sufferings to a neglect he dares not complain of, and yet wants strength of constitution to support.
Parishes are often burthened with a numerous Poor; and like the rest of their fellow creatures, there are good and bad among them. It is not easy for Officers to know the exact merit of each family; it is more likely that to save themselves trouble, they will lay down one uniform mode of relief, without nicely distinguishing between them; to which the modest will ever submit without reply, whatever fatal consequences it brings upon their health.
On the other hand, there are some Cases which cannot bear the close air of Wards, but require the purer effluvia of Hills and Country, and these are of course and with propriety refused admittance within.
Thus much is sufficient to explain the different methods of relieving Patients. It remains in the last place to say something of that Behaviour, which we expect from the Paupers to their Benefactors, the rules of which in some degree are not so convenient as could be wished.
The Out Patients as well as In, are required when cured, to attend the Governors at the Board, to return thanks for all favours received, when a little book of prayers or advice is put into their hands, if they or any of their family can read; and they are enjoined to return God thanks the first convenient opportunity at their respective places of worship for their Cure. Now the regular attendance of Patients from great distances while under cure has been shewn to be in some instances scarce possible, and in many, what they do not like. In the present case it operates much stronger. Persons of that Education which is usually the lot of the illiterate, are more strongly actuated by a present sense of Pain, than by a sense of gratitude when it is once past, especially if attended with trouble to themselves; indeed in bad weather it is not required of them; where it proceeds from an ungrateful temper, no alleviation should be proposed: but where it is particularly inconvenient to them on account of the distance, or other unfavourable circumstances, I think it might in part be dispensed with by their returning their thanks to the Charity in the person of their Physician, and being by him furnished with books and customary monitions; by which means too, their Boxes, Gallipots or Phials, would be more punctually returned, than at present.
These Observations may appear trifling at first sight, but are of some importance as connected with another rule, whose natural tendency operates to the disadvantage of this unthinking class. It is always more desirable to prevent faults, than to punish them; and an attempt at too much regularity, generally introduces confusion. In proportion as you introduce allowances and admit exceptions, you get farther removed from, and insensibly destroy your first design. It were better to make laws if possible, of a comprehensive nature at first, that should virtually include every power which we might in any case wish to exert, than such as we must entirely run counter to, upon every unforeseen event.
Now the reason of an unprofitable or faulty attendance of the Out Patients being so numerous, as has been explained, it is difficult to know when to adopt the usually prescribed punishment, of dismissing them for this fault, and rendering them incapable of the Benefit of the Hospital
for ever.
This Interdiction indeed is directed to be taken off, when they give a proper reason for their absence. That Reason however sometimes does not come till months after the Patient and his fault are forgotten, and 'tis often very difficult to know whether that Reason be a true one. It might therefore perhaps be better to substitute in its place, the obliging persons to get a fresh recommendation, who have forfeited the reasonable advantages of the first. Their friends to whom they would apply in this case, would if they found them faulty reprimand them properly, or refuse them, and if innocent, vindicate them much better than they can do themselves.
It is very difficult to make the Country poor understand the formalities, necessary for their admission, they cannot comprehend what recommendation can be wanted to a Christian Hospital, besides the Pain, the Poverty, or Sores of the Object; all beyond is unintelligible to them, such as that there must be a written or printed Recommendation, signed by a Subscriber, that Subscriber not three months in arrear, not having a Patient at the same time in the House, nor having had more than a certain number, &c. They do not see how this tends to their immediate relief. And indeed the pathetic exclamation of "must I go back and die" accompanied with the haggard look of despair, may well get the better of the best planned schemes of prudent and provident regulations. But for this difficulty also I would suggest a Remedy, that those Subscribers who live in other Counties, or are never resident within reach of the Charity to recommend for themselves, should leave their recommendations in the hands of some friend who would take care to use them only for the service of proper Objects, when their own recommendations and those of their neighbours were exhausted.
But it is time to release you, for I have made these observations longer than I intended. I cannot however conclude without doing justice to the managers of our most excellent Charity. They are ever attentive to do all the Good they can with the money appropriated for that Use: to do good where they can, with strict Oeconomy, but at all events, to do it. That useful Charities may ever abound, and that all Charities may be rendered as useful as possible, is the sincere prayer of
SIR,
Your very humble Servant,
Cambridge,
March
30, 1776.