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 HOSPITAL ABUSE. 
 
 BT 
 
 GEO. B. ARMSTRONG, M.D., 
 
 Associate Professor of Clinical Surgery, MeGlU University ; Surgeon to the Montreal 
 
 Gtoneral Hospital ; Attending Surgeon to the Western Hospital, Min treat ; 
 
 Consulting Surgeon to the ProteHtant Hospital for the Insane, Verdnn. 
 
 {RqmrU^ from the Montre<U Medical Journal, June, 1808.) 
 
HOSPITAL ABUSEJ 
 
 BY 
 
 George E. Armstrong, M.D., 
 
 Associate Professor of Clinical Surgery, McGill University ; Surgeon to the Montreal 
 
 General Hospital ; Attending Surgeon to the Western Hospital, Montreal ; 
 
 Gonsalting Snrgecm to the Protestant Hospital for the Insane, Verdun. 
 
 Hospital abuse is a fair.iliar term in British and American cities, and 
 not unheard on the Continent. A different signification, however, 
 attaches to the term now, than did in the rarly part of this century. 
 Formerly, the term " hospital abuse," " asT lum abuse," " prison abuse,'* 
 intimated that the treatment in the institutions was unkind, inefficient, 
 unscientific. At present its meaning is altogether changed. The 
 term hospital abuse has come to mean, when applied to the public, the 
 seeking and acceptance of medical treatment from a hospital, by 
 persons who are able but unwilling to pay for the same, and when 
 applied to a hospital, the treatment without any or v^nly a nominal 
 charge, of those who are not fit objects of public charity. 
 
 Objection is raised by the giving public — the hospital supporter, 
 that monies donated by them are improperly applied, and by the 
 medical profession, that hospitals, supported by the charitable public, 
 by treating free of charge, people who are able to pay, interfere with 
 their earning a livelihood for themselves and their families, and both 
 classes urge that the result is a lessening of self-respect and a lower- 
 ing of the moral tone of those patients who are well-to-do. 
 
 Hospital abuse is a growing evil and has come to be one of the 
 social questions of our day. The welfare of our profession is being 
 seriously affected by the growing popularity of the out-patient depart- 
 ments of our hospitals. Complaint is made by members of our pro- 
 fession in many large English as well as American cities and the 
 responsibility for the evil put upon Hospital Boards, Hospital Medical 
 Staffs and the public. It is difficult, in fact impossible, to make very 
 definite statements as to the proportion of people attending out-door 
 departments, who are able to pay a moderate fee. One English 
 writer puts it as high as 40 per cent. The New York State Board of 
 Charities for the year 1897, reports as follows : " While statistics are 
 often misleading and deficient, there are good grounds for believing 
 that nearly 50 per cent, of the population of New York City obtains 
 practically free medical treatment. Dr. Wiggin makes the following 
 
 ' Read before the Montreal Medico-Cbirurgical Society, May 9th, 1806. 
 
2 
 
 statement in an article published in the Philadelphia Medical Journal, 
 April 23, 1898, that, prior to 1870, tiie number of applicants for 
 medical and surgical relief bore only the ratio of 1*5 per cent, to the 
 total population, as against the present estimate of 50 per cent, and 
 the number of applicants is increasing every year. In Montreal we 
 are suffering from hospital abuse but to a lesser extent probably than 
 in the large centres in England and in the United States. I am not 
 aware of the existence of any statistics that I can place before you 
 but from conversations had with the members of the different hospi- 
 tal staffs and with general practitioners not connected with hospitals, 
 I am convinced that the evil of hospital abuse is with us, and in very 
 considerable proportions. A physician told me a few weeks ago that 
 he had visited the out-patient department of one of our city hospitals, 
 and to use his own words, " fully half of the women present as patients 
 were better dressed than I could afford to dress my own wife, and 
 there were three fine seal skin jackets in the room." The evil is not 
 limited to the out-patient department alone. In the public wards 
 people are seen who are known to be worth from ten to a hundred 
 thousand dollars. 
 
 Now let us try and find out if we can some of the conditions of 
 things which have led up to this unhealthy state. 
 
 First, I should say is the increased efficiency, comfort, attractive- 
 ness, even luxuriousness, of the modern hospital- ward. Hospital archi- 
 tecture is now almost perfection. The public wards of a modern 
 hospital are warm in winter, cool in summer, well lighted by day and 
 night, perfectly ventilated, the beds are about the best, the food 
 abundant and of excellent quality, and the nursing such as only the 
 wealthy can afford in their own homes. What more could any one 
 desire, except the exclusiveness of a private ward. It is not to be 
 wondered at that people flock to these hospitals, particularly when 
 they are invited to come " without money and without price." 
 
 Secondly, the rapid increase of hospitals in number and amount of 
 accommodation. The wealthy and liberal have felt that money given 
 to a hospital, almost any hospital, was well bestowed. The hospital 
 when built and equipped must of course be filled, and but little care 
 has been taken to determine the suitability of applicants for public 
 charity. Hospital managers have apparently taken it for granted 
 that th.e old time honour and independence of character still obtained, 
 and that the willingness on the pnit of an applicant to accept free 
 hospital and medical charity was sufficient evidence that they were 
 needy and puor. 
 
 Thirdly, the increased number of hospitals has given rise, very 
 
properly and naturally, to a laudable rivalry, each one endeavouring 
 to attain the highest possible standard of eflBciency and usefulness. 
 But emulation has not stopped here. Hospitals have become anxious 
 to excel also in the amount of work done, and in the number of 
 patients treated, until there has grown up almost as much competition 
 among them as among physicians for patients to treat. 
 
 Fourthly, the advances in medicine and surgery during the past 
 twenty years have increased the expense of medical and surgical 
 treatment. I need only to point out the increased expense of nursing. 
 The perfection of nursing now attained has rendered apparent the 
 want of it when it is not to be had. A physician to-day feels that he 
 cannot do justice to a case of typhoid or pneumonia without a trained 
 nurse. Trained nurses cost more than people of only moderate means 
 can afford, if the illness is at all prolonged. Hence another reason 
 for sending to the hospital. In surgery the same holds true to even 
 a greater extent. For a major operation there are needed proper 
 preparation of room, an anaesthetist, one or two assistants and one or 
 two nurses. Thus it is seen that the dividing line between those who 
 can and those who cannot pay is a moveable line aud families who 
 could afford satisfactory treatment in their own homes twenty years 
 ago cannot do so on the same income, to-day. 
 
 Fifthly, the spirit of the times in which we live. This is essentially 
 a commercial age. The acquirement of wealth, the love of luxury 
 and display, are the gods worshipped by large classes in the com- 
 munity. People will buy pianos, bicycles and good clothes, who leave 
 their doctor's bill unpaid or go to the hospital for free treatment when 
 sick. And they will unblushingly accept medical charity before any 
 other. True they can put up with many of the necessaries of life 
 that are not the most expensive, and equally true that • oen ill they 
 cannot afford anything but the best medical treatment an(' the best 
 nursing, but this is not the principle that governs the actions of the 
 class to whom I refer. 
 
 Sixthly, the starting of the modem abomination, the private dispen- 
 sary and hospital, by members of our profession for purely selfish and 
 personal reasons. 
 
 Lastly, hospitals dependent upon the public for support, must, to 
 avoid alienating sympathy and subscriptions, sometimes receive into 
 their wards those who are very well able to pay. For instance, a 
 large corporation, a large employer of labour, skilled and unskilled, 
 contributes a handsome annual donation. This corporation naturally 
 expects that their employees when injured or sick shall receive prompt 
 and proper attention. But when one of their foremen, earning per- 
 
haps several thousand dollars a year applies for treatment, the attend- 
 ing staff sometimes feel that the annual donation should not be 
 expected to secure free treatment for one so well able to pay. This 
 foreman very likely is earning more, many times over, than the phy- 
 sician who is expected to minister to his needs. However, if objection 
 is raised, a perfect whirlwind of correspondence is started, to be 
 followed by explanations, and perhaps even apologies. This is not 
 right, and I hold that it is quite within our province to object, and to 
 try to promote views more in harmony with equity and justice to all 
 both physician and patient 
 
 Now, I think it will be evident to one and all that the blame for 
 the evil of hospital abuse must be divided. It rests not wholly on 
 the hospitals, nor on the medical staffs of the hospitals, nor on the 
 public. It is an outgrowth of the conditions under which we exist. 
 How can it best be remedied ? The medical profession takes great 
 credit to itself for the existence of our beautiful and efficient hospitals, 
 and rightly so. It naturally follows then th'at we are responsible, 
 chiefly for the evil, concerning which we hear such loud complaints. 
 As physicians, as citizens, we should stand united in trying to arrest 
 this growing evil which is demoralizing in its tendencies and inimical 
 to the welfare of our profession. 
 
 It will be quite evident to any one at all familiar with the workings 
 of hospitals, that no one hospital can act successfully alone, in com- 
 batting this evil. There must be concerted action. If an applicant 
 refused treatment at one out-patient department can get the same at 
 another out-patient department without any inconvenient questions 
 being asked, no lessening of hospital abuse will be likely to ensue. 
 
 The suggestion of the London Charity Organization Society as out- 
 lined by Sir William Broadbent, is worthy of consideration. The 
 proposal in a word, is the formation of a Central Hospital Board.. 
 The Board to be composed of representatives of the Management and 
 of the Medical Board of each hospital, together with a few general 
 practitioners who are not connected with any hospital. A Board 
 formed on these lines would be thoroughly representative. It would 
 bring together the three great classes concerned, the hospitals, the hos- 
 pital medical stafls and the general practitioners. It would probably 
 be well to have the representatives of the latter class selected from 
 districts. Each man would naturally be familiar in a general way 
 with the population of his district, their earning power and their 
 ability .to get constant employment, etc. 
 
 The formation of such a Board would remove any feeling that 
 might otherwise arise. It would do away with any misapprehension 
 
 I 
 
 I 
 I 
 
I 
 
 I 
 
 on the part of the public, that the action of the Board was prompted 
 by practitioners or hospital staffs at enmity with hospital work. This 
 s very important. Such a Board could employ an inquiry officer, 
 who could inquire into the circumstances of any cases referred to him, 
 and report to the Central Hospital Board. 
 
 I do not think that any one would desire that the first aid to the 
 injured should be interfered with. Our ambulances do a good and 
 highly appreciated work in rescuing accident cases and people pros- 
 trated by heat, or suffering from poisoning, and bringing them quickly 
 to the various hospitals where appropriate treatment is immediately 
 available. But after the first aid is rendered those able to pay should 
 be referred to the personal or family physician. 
 
 In regard to nursing, which is an expensive luxuiy — or more truly, 
 an expensive necessity in many cases, and one of the factors contribu- 
 ting to the increase of hospital abuse, the establishment of the district 
 nursing by the Victorian Order of Nurses and by others will be most 
 helpful. In this way the aid of the trained nurse can be obtained 
 once a day or oftener, to give a bath, assist at a surgical dressing, or 
 to instruct willing home helpers in the care of the sick. 
 
 One other point and I will close. I cannot but feel that hospitals 
 should confine their ministrations to the poor. I believe there is no 
 dispensary that does as much harm as the one that collects 5 cents or 
 10 cents from each patient. The pauperizing influence of that method 
 in my opinion exceeds by far the out and out free dispensary. In 
 hospitals, the acceptance of 50 cents a day from a patient for what 
 costs over $1.00 makes a patient feel that he is under no obligation to 
 any one, either the hospital or the medical attendant, that he has a 
 right to what he gets because he pays for it, and that he is perfectly 
 at liberty to return on any future occasion for treatment on the same 
 terms. 
 
 In my opinion it would be better if the hospital ministered to the 
 needs of those who could not pay anything and to no other. Private 
 enterprise may be trusted to see that those who can pay are not 
 allowed to suffer. 
 
 It is the pay patient and the private ward patients that set the 
 fashion, and popularize the hospitals. Once the hospitals are popular- 
 ized, as soon as it becomes " the correct thing " to go to the hospital 
 when ill, the next step is naturally and easily taken, viz., to get there 
 as cheaply as possible. 
 
 I have tried gentlemen, to put this question before you in a true, 
 broad and generous way, and I hope that in any discussion which may 
 follow, general broad principles only will be dealt with. It is a very 
 
6 
 
 complicated question. There are many different interests to be con- 
 sidered, and only by avoiding anything that might give offence to any 
 one of those interests can good be got out of this evening's deliberation 
 Our society is very representative. It is made up of members of hos- 
 pital managing committees, hospital medical boards and general prac- 
 titioners. None of us wish harm to our hospitals, and none of us wish 
 to put any obstacle in the way of their efficient working. Let us 
 strive together to evolve some scheme that will root out the tares 
 without injuring the wheat.