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First, in order that you may understand the scope of our work, it will be necessary to explain the type of patients we have. Rhode Island (unlike any other state in the Union, with the exception of Massachusetts, I am told) attempts, in part at least, to care for its poor in an institution maintained by the state and known as the state infirmary. The population of our infirmary is a little over 600, with an admission rate of about 400 per year. We have men, women, and children ranging in age from newborn babies to those a hundred years old, and occasionally we have some even older. It is also the custom in Rhode Island to send to us unmarried women and girls who are pregnant and cannot be taken care of in their homes or by outside agencies. It is not difficult to understand the crying need for social adjustment and the opportunities presenting themselves for social salvage in such a conglomerate group of unfortunate human beings.

Social service activities at the Infirmary begins the moment the patient enters the institution, and includes all work done by agencies within the institution to uplift and enhance the social status of the patients and help to prepare them better to adapt themselves to outside environment when the opportune time comes for them again to assume the burdens of extramural life. We believe that preparedness is the underlying factor that makes for success in any undertaking. Many of our people, because of injury, physical handicaps, or lack of training, are absolutely unprepared to face extramural life, its problems, and difficulties with any assurance of success, but instead, with all prospects of being shipwrecked on the sea of mental and physical maladjustment. We cannot harvest potatoes until we have first prepared the soil, planted the seed, and cultivated the plant; neither can we successfully practice social service without first preparing the soil; and it is my belief that this should be started the moment the patient enters the institution, with rehabilitation as the ultimate always in mind.

I do not mean to imply that we reclaim, or even hope to reclaim, all of the 400 patients who come to us each year, because a great many (probably 30 per cent) before admission have reached a stage, because of some chronic illness or extreme age, where even the most optimistic would not dare predict a return to the community except as a result of a change in the social or economic status of the relatives which would enable them to take their mother, father, brother, or sister out and supply them with the necessary nursing care and medical attention. As a matter of fact, a change in the economic status of the family very often takes place or, with a little assistance, can be made to take place and I feel that we should always be on the alert for opportunities to lend a helping hand in assisting the relatives of our patients over a family crisis due to illness or financial reverses. In other words, I do not believe that social service should be limited exclusively to the patient, but also should include the relatives, friends, employers, social and domestic associates, with the end in view of bringing about some change that may be of benefit to the patient. In this connection

I wish to mention the feebleminded, of which we, like most institutions of this type, admit many each year.

Some of these, because of their very low mentality, need permanent institutional protection; others, because of their delinquent and criminal tendencies, need permanent segregation; but there are others who, especially after having formed regular habits as a result of their stay in the institution, can serve a very useful and necessary rôle in the industrial world providing they are intelligently placed in positions suited to their mental endowment, and with understanding employers who will not expect more of them than their degree of intelligence will permit them to give.

Undoubtedly our most difficult problem is that of unmarried mothers, yet it is with this group that we have the opportunity to do the greatest amount of constructive work. We have, on the average, twenty-five admissions of this type each year. These girls are the problem cases upon which one or several of the social agencies of the community or city from which they came have worked and failed, we getting them as a last resort. Here again we must set in motion, the moment the girls enter, our machinery for placing them out. Many of these girls are suffering from some physical illness which must be corrected; their histories show a social maladjustment; many of them are underdeveloped mentally. A social investigation is made, and their particular failings and shortcomings ascertained for use in future dealings with the case. Their homes, environments, and especially their early training are studied, for it is felt that upon these depend the formation of proper habits, character, and personality-in fact, the fundamental characteristics, which enable one to make satisfactory social adjustments. This sociological study, together with a study of their mental make-up, temperament, emotional stability, inhibitions, judgment, etc., helps us to determine and supply the training which they did not have and which they will need if they are ever to learn the fundamental principles of living or develop a philosophy of life, simple though it may be, that will enable them to go out into the world to face its problems and make satisfactory adjustments and adaptations.

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It is very hard to estimate with any degree of accuracy, or express in appropriate terms, the results of work among this group of people, but a brief consideration of the number and type of patients placed will, I think, show conclusively that social service has not been without worth-while results, measured not only in terms of service rendered to the patient and the community, but also when measured in terms of dollars and cents.

The cases mentioned do not include, of course, those who have gone home to relatives or friends, the arrangements for which were made through channels other than the social service. In other words, this group represents those who ordinarily would not have gone out, and for whom social service actually brought about the necessary arrangements or adjustments whereby they could go out, and for which the entire credit is due, therefore, to social service.

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In conclusion, may I state briefly what I have attempted to prove to you, namely, that in infirmaries, almshouses, city, county and town farms there is a real opportunity for constructuve' and worth-while social service work; that to accomplish results one must be human; one's manner and attitude must be tempered with a love for the cause of humanity. During the past three and onehalf years the Social Service Department has placed out in the community sixty-eight men, fifty-two women, and seventy-one unmarried mothers with their babies. Upon analysis of the group of unmarried mothers we find that eighteen were returned to their homes with their babies; forty-three were found employment, their babies boarded in licensed boarding houses, the board being paid by the mothers; and ten were found work in homes where they could have their babies with them. Out of this group there have been three failures, making it necessary that they be returned on account of misconduct. The others are doing well. Fourteen have bank accounts; eleven have married, and up to date have gotten along well. Out of the sixty-eight men placed, nineteen have been returned; the others, with the exception of seven who have died, are still in the community and self-supporting. The average age of the fifty-two women placed was sixty-five; eighteen have been returned after an average stay in the community of six months. These people had been in the institution five, ten, fifteen, twenty, twenty-five, and even thirty years. Figure the aggregate number of years these 191 persons placed represents; then multiply that by the per capita cost per year to get some idea of the loss, in dollars and cents, to the state, which might have been saved by social service. Add to that the accrued interest on money spent, plus the economic loss to the community, and contrast the result with the amount saved during the past three and one-half years as a result of not having to care for those who have been out. I dare say that even the most cold-blooded business man will admit that social service has more than justified its existence.

ADMISSIONS AND RECORDS IN AN ALMSHOUSE

Emily B. Randall, City Hospitals, Baltimore

An almshouse is bound to have a more heterogeneous population than any other institution. There is but one element in common among its applicants, and that is poverty. The persons that come to the admission office are sick and well, young and old, good and bad, male and female, colored and white. Who should be admitted to an almshouse and who is admitted are two very different questions. An almshouse is primarily intended for the indigent poor, but all the dependent persons in a community must be provided for, and if the community lacks an institution to care for an individual, the almshouse is the place used for all the rag, tag, and bobtail of humanity. In a city almshouse, where the groups are larger, segregation and separation are possible. In a county alms

house individual cases cannot have special care provided, and nursing care for the sick and separation of young and old are not possible.

I have lately visited a number of county almshouses in Maryland. They averaged sixteen or eighteen persons each; there were quite a few chronically sick some bedridden, with only other inmates to give nursing care; there were some young persons; there was one whole family, the father being chronically sick, whose community lacked suitable provision for himself, his wife, and child; one almshouse had recently gotten rid of an insane person who had been housed with them for some weeks. Most of them keep simple record books with the names and dates of admission and discharge; one keeps no regular record book; but every now and then they take stock and note everyone who is with them on a certain date. Some almshouses are more modern than others, and may have solved problems that others are still battling with, but in a general way admissions must be very similar, and as a picture one large almshouse is a good deal like another. I am going to limit myself to talking about admissions and records, as I know them, in the Baltimore City Hospitals.

The Baltimore City Hospitals is an institution with a population of about 1,500, about 600 patients being in the infirmary or almshouse, about 350 in the insane hospital, about 175 in the general hospital, about 250 in the chronic hospital, and about 100 in the tubercular hospital. It is the hospital for the sick poor of the city. There is a natural prejudice in the city against going to a hospital very closely associated with the poorhouse, especially among people who are not very clear in their own minds as to whether they are one and the same thing.

In an institution of this kind the applicants are divided into three general groups: first, the hospital patients who are not eligible to the almshouse, who must be admitted and discharged as in any other general hospital; second, the almshouse patients who are also eligible to the hospitals, if they need hospital treatment; third, a small borderline group that other general hospitals do not have to contend with, such as a homeless drunken man who must be watched for a period of hours to be sure that he is not going to develop symptoms which would be serious. He is not really a hospital case, perhaps, neither is he definitely an almshouse case; he has to go somewhere, and the almshouse is the temporary solution.

Patients are admitted to the almshouse in several ways: the largest number come through the admission office; about 20 per cent come through the magistrates, who have the power to commit to the almshouse any aged, infirm, crippled, or not able-bodied individual who has no home and is a vagrant, or is found begging on the streets, with a sentence of from two weeks to one year; we also get emergency cases brought in by the police after hours, not sick enough to be in a hospital, not bad enough to be kept in the station house, and with nowhere to go. The emergency admissions and the police commitments do not come through the admission office. Therefore, unless they are old offenders, we

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have no history of them when they arrive at the institution. This information must be gotten at the institution, and because of lack of funds to employ a qualified person, the records of emergency cases are taken by an inmate who is eighty-six years old and a very remarkable character.

To the admission office come a great variety of applicants: homeless old people, respectable and disreputable; senile persons who may have homes, but cannot be taken care of in them; feebleminded persons, young and old, who need to be safeguarded in an institution; middle-aged and old blind people; cripples, young and old with venereal disease and in need of treatment; pregnant girls with venereal disease, whom no other institution will admit; colored pregnant girls under the jurisdiction of the court, for whom there is no other institution; drug addicts; transients awaiting transportation. Then we have a group of individuals who are unable to adjust themselves in a home situation. Often their families or friends would be willing to keep them except that they are old and eccentric and continually at odds with the world and particularly with those around them. The almshouse is a safe boarding house for them. The children who want to get rid of their old parents and make the city bear their burden present many problems. The admission office can try to collect board if the children are able to pay. Does the old person suffer more in humiliation in an almshouse than as an unwelcome guest in someone else's home?

Standards of admission are difficult to maintain when the power of rejection is withheld from the admission office. Any rejected applicant can go to the magistrate and get himself committed, or families can move away and abandon a sick relative, leaving him to the mercy of neighbors, knowing that the police will be called in and the person will get to the City Hospitals through them instead of through the admission office, where the reasons for rejection were good and proper. The magistrates do try to limit their commitments to the particular group eligible. But they, too, need a place for their problems, and the City Hospitals are elected to fill the bill.

The Baltimore City Hospitals being on the outskirts of the city, it has seemed. advisable to have its admission office centrally located in town. Until a few months ago the patient was questioned at the admission office, the information was recorded, a slip was issued with the individual's name, and he was sent out to the City Hospitals. There each person or department through whose hands he passed needed information, so they, in turn, repeated the questions. Sometimes the person's memory was weak and he didn't remember what he had told the last station. Sometimes he must have had a sense of humor, and thought it would be fun to change the stale facts. Anyway, the patient was asked over and over, and the results were not good.

When I first went to the City Hospitals I was impressed with how much information one could get about a person. The admission office knew a lot about him, the man under whom he may have worked, the dispensary where he went for pills, the man in charge of the room where he slept-they all knew him well.

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