At the present time the hospital system in American cities appears to be in a transitional stage. There exist endowed hospitals, hospitals which are supported by annual contributions and payment of fees by patients, and those which are supported by public appropriations ; and many institutions rely, in varying degrees, upon all such sources of income. The financial problem of both public and private hospitals has become increasingly serious. In New York City alone there are twenty private hospitals, which, at the time of this writing, have an aggregate annual deficit of nearly half a million dollars, and officers and managers are anxiously scanning the future to determine whether there is any manner in which the encroach ment upon endowment funds, or the increase of indebt edness, may be prevented and the hospitals enlarged to meet the ever increasing demands upon them. Frank Tucker, in an article in Charities of January 2, 1904, pro posed the creation of an endowment of $10,000,000, under the control of an independent board of trustees, to meet this deficiency. This paper gave rise to an extended and spirited discussion, in the course of which Dr. F. R. Sturgis suggested that the city should cease to make any payments to private hospitals, and should expend the funds now devoted to that purpose to the maintenance and enlargement of its own institutions. Dr. Sturgis suggested that some of the existing private hospitals should be dis continued, by mutual consent ; that the remaining ones would receive only patients who are able to pay for their board ; and that indigent patients would be cared for by the city in its own hospitals. If the hospital system should indeed develop in this direction, it is probable that we would eventually have what might be called a hospital hotel or boarding-house, in which patients would pay for their boarding, while each would make his own arrange ments as to medical care with a physician of his own selection, precisely as if he were living in his own home or an ordinary hotel or boarding-house. There are those who distinctly favor a differentiation, in this manner, be tween the professional care and the board, both of which are now provided by the hospital. The facilities of the hospital hotel, with its service of nurses and attendants, would be equally at the disposal of all physicians for patients who need to be removed from their homes, and who are in a position to pay for care in private hospitals. While so radical a departure from the existing system would seem improbable, it is quite within the possibility of the immediate future that there shall be a sharper distinc tion between those who are indigent and are therefore legitimate public charges, on the one hand, and who, as a i result, will be cared for in public hospitals, or private hospitals at public expense; and, on the other, those who can pay for their own treatment, or who can at least pay something for their care, the remainder being made up by income from endowment or by private donations. The recognition of this distinction, and the assumption by the city of the expense of caring for those who are unable to pay anything for their support during illness, would probably reduce the financial problem of the private hospitals to manageable proportions.
When once the community has passed through the pending revolution, and is adjusted to the conditions made necessary, on the one hand, by our congested population and the substitution of tenements, flats, and apartments for private houses; and made possible, on the other, by the advances in medical and surgical science and in nursing, it will be found that the care of the sick in hospitals is not only more efficient, but is much more economical.
At the moment, this adjustment not having taken place, there is much confusion in the hospital situation. Many patients are treated without charge who could afford to pay a proportionate cost for treatment. The income of the hospitals has come in part, as has been indicated, from private contributions, in part from paying patients, in part from public subsidies, and in part from the voluntary service of physicians and others. No clear and consistent policy has been followed by the city and state governments in the making of appropriations, and there has been great diversity among the hospitals in their requirement of pay from patients. Affiliation with medical colleges has intro
duced another element, since in such hospitals the supply of patients as material for instruction and practice becomes as important as any other aspect of the hospital adminis tration.
Because of the uncertainty on the part of the charitable public as to the extent of the imposition practised by patients who are not really indigent, and the further uncertainty as to how far the hospitals are really needed for purposes of medical instruction, response has been less freely made than the case demands to the appeals for that part of the support of the hospitals which must come from them. The medical profession, aside from those who are directly interested in the hospitals, a weighty exception, since a large and increasing number of influential physicians are connected with the hospitals in an advisory capacity, — naturally looks askance at the growth of the hospital and dispensary system, especially at the free treatment of the class that has heretofore paid for the services of a family physician. Medical associa tions have, therefore, insisted upon greater discrimination on the part of the free hospitals and dispensaries, and a rigid investigation of applicants, to ascertain whether they should not be excluded as able to employ a private physi cian. The hospital, as a strictly eleemosynary institution, would naturally accept this policy ; as interested, however, in medical education, it must welcome a large number of patients, and especially those who offer an interesting and fruitful field for observation and study. The actual devel opment of the hospital system will be influenced by all of these considerations.
Our present purpose is merely to point out that in addi tion to these facts, which are well known, a sound relief policy on the part of the community is in harmony with the interests of medical institutions in favoring a consid erable increase in hospital facilities and a liberal support of the existing institutions ; but is likewise in harmony with the demands of the medical profession that discrimi nation should be exercised in the selection and admission of patients, and that the increase should come, not by con tinuing to receive patients who are normally self-support ing, but rather by seeking out and securing necessary treatment and care for those who are now neglected or who are vainly attempting to keep their place in the indus trial world, to which they might be restored after a longer or shorter period of suitable material and medical relief.
The lengthening of adult life to which attention has been called should naturally operate to lessen the need of child labor, and consequently to defer the period at which wage earning occupations begin. This is, however, one of the phases of ,social progress in which there has been the great est inequality. In many communities the industrial and social conditions have permitted a shocking sacrifice of child life, and the movement for legislation to prohibit child labor affords one of the best illustrations of the social effects which may naturally be expected to follow from the recognition of the need of a comprehensive policy. Laws prohibiting child labor in mines, factories, stores, and offices, and requiring school attendance, are essential for the physical and mental welfare of the child. The laws on this subject, in the various states, are seriously defec tive and curiously diverse : for example, the age below which child labor is prohibited varies from four to ten years ; eleven states and territories have no restriction whatever as to age. The number of employments in which children may not work also varies greatly—from all employments during school hours in one state to min ing only in another. Seven states require compulsory school attendance throughout the entire period during which employment is prohibited. In New York State, un til 1903, according to the child-labor law, a child could not begin work under the age of fourteen, except during the vacation of the public schools. Under the compulsory education law, however, children between twelve and fourteen need attend school only eighty days in the year, and were thus left free to work for the remainder of the school year. The temptation for false affidavits was one to which parents yielded on a large scale.