A Once Charitable Enterprise: Hospitals and Health Care in Brooklyn and New York, 1885-1915

by David Rosner

Overview

This work, examines the transformation of American hospitals from a series of community- based charitable institutions into the large, bureaucratic system that existed by the end of the Progressive era.

Originally published in 1986.

The Princeton Legacy Library uses the latest print-on-demand technology to again make available previously out-of-print books from the distinguished backlist of Princeton University Press. These editions preserve the original texts of these important books while presenting them in durable paperback and hardcover editions. The goal of the Princeton Legacy Library is to vastly increase access to the rich scholarly heritage found in the thousands of books published by Princeton University Press since its founding in 1905.

Product Details

ISBN-13:	9780691610276
Publisher:	Princeton University Press
Publication date:	07/14/2014
Series:	Princeton Legacy Library , #490
Edition description:	Reprint
Pages:	246
Product dimensions:	6.90(w) x 9.80(h) x 0.50(d)

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A Once Charitable Enterprise

Hospitals and Health Care in Brooklyn and New York, 1885â"1915

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By David Rosner

PRINCETON UNIVERSITY PRESS

Copyright © 1982 Cambridge University Press
All rights reserved.
ISBN: 978-0-691-02835-4

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CHAPTER 1

Health care and community change

The neighborhood focus of nineteenth-century medical practice

Nineteenth-century American life revolved around small communities and narrow personal contacts. Most Americans lived in rural villages and towns that were essentially isolated from each other, and even those who lived in the city lived in highly structured communities separated from each other by culture, ethnicity, and sometimes language. Because there were no adequate transportation and communication systems early in the century, there was little chance for relationships beyond one's immediate neighborhood. In these so-called walking cities, life revolved around the local church, school, and other small institutions. Government was a neighborhood responsibility watched over by the local ward boss, who, as part of the political machine, was able to attend to the needs of the community.

A strong neighborhood focus of necessity characterized nineteenth-century medical practice as well. For much of the century, New York City was a highly congested series of neighborhoods spread between the southern tip of Manhattan and Fifty-ninth Street. Before the introduction of electric trolleys and elevated railroad lines, the horse was the major means of transportation. Although the city's gentry owned private carts and wagons for transportation, most of the working people depended upon slow and undependable horse-drawn trolleys, which had to negotiate streets that were continually "torn up, blown up or dug up" for construction. In the 1860s, it was reported that "a considerable part of the working population spend a sixth part of their days on street-cars or omnibuses," and this was only for relatively limited travel in the neighborhoods below Fifty-ninth Street. The "upper part of the city [above Fifty-ninth Street] is made almost useless to persons engaged in any daily business," it was noted. Unless an extreme emergency forced people to travel, most patients sought medical treatment as well as other services in their own neighborhoods.

Not only were laborers and merchants hampered by the poor system of transportation, but doctors, too, sought to avoid any great amount of travel. One physician reminisced about his early days at Metropolitan Hospital, originally a homeopathic municipal institution located on Wards Island. He estimated that the trip to the hospital from a residence in Manhattan took no less than three hours of travel time by horse and buggy and ferry. Recalling the difficulties faced by younger house staff who lived at the hospital, this doctor remembered that only if someone "was fortunate enough to have friends in the village of Harlem" could he find entertainment, because "it was almost impossible for anyone ... to go to parties or the theatre in the city and get back the same day."

Some practitioners committed to certain forms of practice or in need of clinical experience or prestigious appointments were willing to travel long distances regularly. But for the vast majority of practitioners the inconvenience of travel made a local community practice extremely attractive. Only when urban redevelopment forced relocations would established practitioners leave their communities. The "elder and better established of the profession never left the older sections of the city/' remembered Dr. Frederick Dearborn, "unless the encroachment of their clientele made a change necessary."

Because nineteenth-century medical knowledge was inexact and professionals were not at all in agreement about the causes of illness or the proper management of disease, the choice of treatment was generally a reflection more of the customs and medical beliefs of a particular community or practitioner than of sound scientific knowledge. The medicine practiced in one area of the country was often quite different from that in another. In much of rural America, lay people combined local folk custom with information gleaned from medical dictionaries and popular medical texts to form an idiosyncratic body of therapeutic practices. Doctors, not yet an elite professional group, generally pursued formal medical school training and apprenticeships in their own locales. The majority of medical schools were "proprietary" or "profit-making" institutions that attracted persons from lower-middle-class and working-class backgrounds and produced practitioners of varying skill and dubious scientific training. Formal medical education was largely unregulated and nonstandardized and could vary in length, content, and structure, depending upon the demands of different areas of the country. Not only did training differ for rural and urban practitioners, but a diversity of training and background could be found among those treating different classes and ethnic groups within the population.

Generally the educational requirements of various schools reflected their different medical nosologies and theoretical positions. Rural areas produced a wide variety of "sects" whose therapeutics depended mostly on herbal treatments. Thomsonians and later "eclectics" were among the various "botanists" in New England, the South, and the Midwest who incorporated local folk and Native American custom into their therapeutics. In urban areas, regular practitioners, homeopaths, and a host of others with differing medical viewpoints and practices competed strongly with each other for the patronage of patients. Today patients have little choice about their medical treatment, but patients in nineteenth-century America could choose among a host of practitioners and a fairly wide variety of therapies. Almost all nineteenth-century doctors were "family" or "community" practitioners who engaged in general medicine. The small number of doctors who specialized in surgery, ophthalmology, or other areas saw their specialism as tangential to their practice.

The family practitioners who constituted the bulk of the profession generally lived within the communities they served and provided health services at the homes of patients or in offices in their own homes. Generally the doctor's patients lived within a few blocks of his house and were members of the church or local community organizations to which he belonged. Without question, the family doctor presided at the significant events in people's lives; he would be "fetched" for births as well as deaths, and at times would move into the patient's house for the duration of an illness.

The motive for this kind of personal treatment was certainly, though not solely, the best care of the patient. Because there were a large number of loosely organized medical schools and lenient licensure requirements, there existed a surplus of practitioners who were in competition with each other for patients. Without the mid-twentieth-century options of research positions in universities or hospitals, and without highly specialized forms of practice, doctors depended entirely upon their patients for income. Consequently, competition among practitioners for patients had become fierce by the end of the century. As one contemporary observer remarked, "a new doctor must create his practice out of that taken from other physicians." In the absence of more formalized methods of evaluating status or competence, patients generally chose their practitioner on the basis of such criteria as familiarity, dress, courtesy, and cultivation. D. W. Cathell, a physician who wrote a widely distributed and oft-reprinted late-nineteenth-century practical guidebook for practitioners, began his volume by pointing out that "there is nothing more pitiful than to see a worthy physician deficient in these qualities, waiting year after year for a practice ... that never comets]."

One European physician who moved to New York in the 1870s noted the significance of this uniquely American environment for the American physician's relationship to his clients. He observed that the "science and technique of practice" were less important to American doctors than were "the personal relations between physician and patient." He remarked that "physicians in America ,were concerned more with establishing a feeling of confidence and trust, hence comfort in patients, than were" Europeans. He ascribed this concern to the highly competitive nature of their practice and to the relatively low social and educational status of American practitioners. The "medical man had to be more modest; he had to be more circumspect, even deferential" when treating patients, even when the patients were ignorant or ill-mannered. The unique quality of highly isolated communities created a marketplace where personal relationships determined professional success.

Because medical knowledge was not standardized and practitioners depended directly on their patients for a livelihood, they tended to practice in ways that were familiar to and would please their patients. It was not that doctors did not believe in their treatments; in many ways, in fact, their knowledge was only slightly more sophisticated than that of their patients. The largest group of physicians, regular practitioners, employed bleeding, cupping, purging, and other seemingly draconian measures. Because illness was often equated with moral failings, treatments we view as cruel were sometimes considered an appropriate punishment for transgressions. Those who rejected therapeutics often turned to other milder forms of practice like homeopathy. Widely accepted and preferred by merchants and other urban groups, homeopathy provided more elegant rationales. The lack of scientific rigor and specificity in these practices was made up for by the intimacy of the practitioner's social relationship to the patient.

Hospitals of the late-nineteenth-century city

After the Civil War, large numbers of hospitals were established in response to diverse but specific social and medical needs. Very often the elite of a community, generally local merchants, businessmen, and members of the clergy, would initiate and sponsor the formation of a hospital to serve the working class and the dependent poor. Hospitals generally differed in religious and ethnic orientation, source of financial support, size, medical orientation, and the type of service provided. Often an ethnic or religious group would establish a hospital for the dependent poor of a particular faith or neighborhood. Of the 4,500 institutions that began in the United States during the period this book examines, many bore names that identified them with a particular religious or ethnic community. Among the 130 or more hospitals that began in New York and Brooklyn, for instance, one could find religiously supported institutions like Jews Hospital, St. Vincent's Hospital, and Methodist, Lutheran, and Episcopal hospitals. German Hospital (now Lenox Hill) and Norwegian, Swedish, and Lincoln hospitals (the latter for Freedmen) all provided services for their own ethnic population. Often local benefactors would establish a hospital in response to a particular social need in the community. Children's hospitals often arose to care for orphaned children, whether in medical need or not. Maternity hospitals in working-class neighborhoods often sheltered unwed mothers in addition to providing maternity medical service. In communities with a significant number of elderly and dependent persons, local merchants often organized a home or hospital for "incurables" or for the chronically ill.

Obviously many of these "hospitals" were not the large complexes we know today, but often homes that were quickly put to use when a need arose in the community. An extreme example of how quickly small hospitals were established is the Chinese Hospital of Brooklyn. As part of their missionary work among the city's newly arrived Chinese, the King's Daughters of China established a tiny five-bed hospital in Brooklyn Heights. In little over one month late in the fall of 1890, this missionary society conceived of the facility, rented space, and opened the doors to patients. "The project for a Chinese Hospital ... owes its fruition and consummation to the 'King's Daughters of China,' " began Dr. Joseph Thorns, the superintendent of the facility, in the hospital's First Annual Report in 1892. "The rent being guaranteed by these ladies and acting upon their advice, I leased for the term of one year, the premises at No. 45 Hicks Street for Hospital uses, commencing our term as tenants upon November 1,1890, at the rate of $50 per month/' he continued. "Preparations were made at once to receive patients, and by the last week of the month we were ready for them, beginning with only 5 beds." On December 7, only five weeks from the time of its founding, the hospital opened.

There were a number of large, publicly sponsored institutions like Bellevue Hospital in Manhattan, Kings County Hospital in Brooklyn, and Boston City Hospital in Massachusetts, and a few large charity institutions like New York Hospital, Presbyterian, and St. Luke's in New York and Massachusetts General Hospital in Boston. The public hospitals were generally organized as adjuncts to the local almshouse or prison to serve numbers of those not accommodated in the local charity facilities. Because small charity facilities often had fewer than fifty beds, they generally sent the "unworthy" poor, alcoholics, and criminals to the public hospital and served primarily the dependent poor and working-class people of their communities. The local sponsors who were the trustees of these small institutions were rarely prominent outside their particular neighborhood and often saw their commitment to the hospital as a commitment to their community or faith.

Unlike its modern-day counterpart, the nineteenth-century hospital was not solely a medical facility but a facility that provided shelter, food, and care for those in need. Because the community's leaders and the middle class were generally cared for in their homes, hospitals treated those working-class people who resided in the homes of the wealthy or lacked the resources to be treated in their own homes. Methodist Hospital, located on the border of the elite, upper-middleclass neighborhood of Park Slope, reported as late as 1896 that a large number of its young female patients were domestic servants working and living in the brownstone homes of the neighborhood. "Few, when sick, are in sorer need of a hospital than they," the trustees reported. This "need" was a reflection less of a young woman's physical condition than of the social circumstances that surrounded her work and living arrangements: When women in such circumstances became ill, not only were they unable to perform the daily chores that kept the household running, but they also occupied rooms and needed care. This was experienced as a severe inconvenience by the families who supported them. "The families in which they lived feel embarrassed," the trustees pointed out, but "the work must go on and ... another must take her place." Clearly, the servant who entered the home to perform household chores needed a place to sleep. "What can be done with the poor invalid? Her room is required. She is in the way." The tension created for the employer was minor compared to that created for the sick servant herself. The trustees pointed out that the young woman was "a burden and she knows it" and that this only increased the danger of her illness, as "the poor girl grows feverish with anxiety." The hospital provided a solution for both the wealthy family and the servant. "Her employer comes and represents the case to us," the trustees observed, "and we open the way for her to occupy a free bed." This relieved the employer of responsibility to care for her and prevented the young woman from being homeless.

This situation illustrates the varied and ambiguous role of the nineteenth-century community hospital, which functioned simultaneously as a health-care facility, a social service, and an agent of social control. Admission to the hospital depended less on a patient's medical state that on the determination by a wealthy patron that the patient's physical or social circumstances made him or her an appropriate candidate for admission. "Some [patients] were at the point of death and others were apparently in robust health, their diseases ... obscure or simply annoying," casually reported Methodist Hospital's superintendent. But one thing was sure: The patient's patron had determined that the patient was "morally worthy."

(Continues...)

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Excerpted from A Once Charitable Enterprise by David Rosner. Copyright © 1982 Cambridge University Press. Excerpted by permission of PRINCETON UNIVERSITY PRESS.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents

• FrontMatter, pg. i
• Contents, pg. v
• Preface, pg. vii
• Introduction, pg. 1
• 1. Health care and community change, pg. 13
• 2. Embattled benefactors: the crisis in hospital financing, pg. 36
• 3. Social class and hospital care, pg. 62
• 4. Conflict in the new hospital, pg. 94
• 5. Taking control: political reform and hospital governance, pg. 122
• 6. Consolidating control over the small dispensary: the doctors, the city, and the state, pg. 146
• 7. The battle for Morningside Heights: power and politics in the boardroom of New York Hospital, pg. 164
• 8. Looking backward, pg. 187
• Notes on sources, pg. 192
• Notes, pg. 194
• Select bibliography, pg. 228
• Index, pg. 231

Editorial Reviews

"Opening with an engaging description of the informal working of late 19th-century medical practice, Rosner captures health care at a moment of crucial transitions."-- "Technology and Culture"

From the Publisher

"Opening with an engaging description of the informal working of late 19th-century medical practice, Rosner captures health care at a moment of crucial transitions."

Technology and Culture