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for the out-patient department is so contracted it hardly seems possible to conduct the operations of the dispensary in a comfortable and orderly manner.

We have given careful attention to the statement of one of the attending staff as to the desirability of assigning beds and wards to other than emergency patients for the purpose of affording temporary relief to cases which are not strictly accident cases, and much may be said in favor of this practice, but we are of the opinion that the present provision for this class is much larger than is necessary. It would be a better policy to reduce the present number of beds, to limit the stay in the emergency department to a few days-three to five days-or until the patient can be safely removed to one of the general hospitals of the city, and not to receive any bed cases of a chronic character for the purposes of performing operations.

We believe that emergency cases and wards for the sick have no proper place in a dispensary building, and that as a rule they should be at once removed to a general hospital, which is better arranged for the immediate and after care of the patient. The care of an average of twelve bed cases in this institution also involves the maintenance of a kitchen service, the purchase of supplies, a laundry, and a variety of paid services, requiring an expenditure out of proportion to the number treated. All of these functions have no proper place in a dispensary. An enlargement of the grounds and buildings has been suggested. It may be a question whether the proposed enlargement will furnish the desired relief, and there is a reasonable apprehension that the cost of maintenance will be materially increased and the general conditions now existing will be aggravated. If it should still be deemed advisable to enlarge the scope of the work of this institution, we would think it the better plan to dispose of the present property and seek a location with larger superficial space elsewhere.

The ambulance service connected with this hospital seems more complete than that in connection with any hospital in the District. It ought, however, to be still further perfected by the erection of a stable upon the premises. At present an inevitable delay occurs in sending out the ambulance, by reason of its location at a neighboring stable. In accident cases a delay of even a few moments in bringing a competent ambulance wagon to the scene may be fatal.

An excellent laboratory exists in connection with this hospital, founded and maintained by a member of the attending staff.

Trained nurses are on duty at this hospital, but no training school, as such, has been organized. In view of the very special character of the nursing done here, it is very useful to afford graduates of other schools these admirable facilities for additional instruction.

The cost per patient per day for 1896 has not been given.

5. The Columbia Hospital for Women.-This hospital comprises a department for surgical gynecology and maternity wards, accommo

dating an average of 46 patients daily. Of the physical condition of this institution an inspection confirms all that has been shown in the hearing before the joint committee. The main building was not originally constructed for hospital purposes. The principal work is done in wooden pavilions which have been annexed to it. The whole is poorly furnished and presents a dilapidated, ill-appointed appearance, which seems quite unsuited to the skillful surgical work which is performed here. It might be a question why the managers and medical staff have assented so long to be responsible for its appearance or continuance without a vigorous protest. To undertake to modify and modernize this hospital would involve a considerable outlay, and then it would be unsatisfactory. If it is conceded that there is some necessity of connecting a gynecological ward and operating room with maternity wards, there are stronger reasons why general gynecology should be separated and relegated to the gynecological wards of a general hospital. There are also important considerations which favor the creation of a single maternity department for the whole city, which would save the duplication of this service. To attempt to satisfactorily modify this building would, in our judgment, amount to a reconstruction, and be a wasteful expenditure.

The ground upon which the hospital now stands is very valuable, and it would be true economy to sell it and to build with the proceeds a model lying-in hospital. The nursing is conscientiously and efficiently performed. The training school is also charged with the nursing of children at the Children's Hospital. The daily per capita of maintenance of patients for 1896 has not been given.

6. The Freedmen's Hospital.-The Freedmen's Hospital comprises a portion of the medical school building of the Howard University, which is used for officers, a dispensary service, and an operating room, and pavilion wards, which are annexed. The medical staff have quarters in the main building. The pavilions are wooden structures. The interior and exterior of these latter buildings show a gradual deterioration from constant use and neglect or inability to make necessary repairs. The pavilion wards suggest but a temporary use and a makeshift at some emergency period. The water-closet arrangements are primitive and insanitary. The ventilation when the windows are closed must be imperfect; the heating is by stoves and of the most primitive character, attended with constant danger of fire. The furnishing is poor. The general appearance is depressing, and, aside from the shelter the hospital affords, the relief and care which are furnished the unfortunate and suffering inmates, the opportunities which colored medical students and colored women secure here to acquire medical experience and nurse training, there is nothing to commend nor any good reasons why it should continue to exist in its present state.

If at any time the necessity existed to create this hospital, and if the reasons that first called it into existence have force now, the buildings

should be reconstructed according to improved hospital plans, and the present buildings abandoned altogether. In our opinion the present structures should be condemned for hospital uses if it is not deemed practicable or advisable to maintain them or restore them.

A perusal of the report of the surgeon in chief conveys the impression that the service of this hospital is large and active. On the day of our visit the number of patients in the hospital was 148. Of this number 70 were acute cases, including 24 in the maternity wards, and 78 were chronic cases, most of whom would be equally comfortable in some home or asylum.

It has been claimed that this hospital is essentially a national insti tution. If this is true the beholder will turn from its premises with sad impressions at the exhibition of suffering and squalor which is here presented and the inadequacy of the plant provided for its relief.

The nursing and medical care seem excellent. The training school for colored nurses is in successful operation. The daily per capita cost of maintenance of patients is stated by the surgeon in chief to be 47 cents.

This hospital has an extensive lying-in service.

7. Asylum and almshouse hospital. This institution is connected with the almshouse and workhouse and consists of five wards, accommodating about 70 patients sent directly from the city or transferred from the pauper department of the almshouse and other District institutions. The wards, or pavilions, are wooden structures erected in recent years, and are considered an improvement on former buildings. They are lacking in conveniences, have unsanitary water-closet arrangements, the furnishings are poor, and the number of nurses insufficient for the proper attendance upon the sick. In our opinion it has been an erroneous and unwise judgment to erect or to maintain a hospital for the worthy poor who are sick in the shadow and amid the environments and associations of an almshouse. While we sympathize with the efforts of officers, physicians, and others concerned to make the best use of the limited facilities placed at their disposal, yet, if we are to use plain language, we must declare the present standard of care and provision for the sick but little above that of the primitive country poorhouse of an earlier day.

The trained nurses who are struggling with this unfavorable environment in the care of the sick in this so-called hospital deserve high praise. It is doubtful, however, if it is in the power of any service, however devoted, to lift the hospital up to the proper standard in its present buildings with their present surroundings. There is a lying-in service at this hospital. The daily per capita cost of maintenance is stated by the intendant to be 31 cents.

8. National Homeopathic Hospital.-This hospital labors under the disadvantage of occupying a building which was not originally constructed for the purposes of a hospital. It was originally erected for

a brewery and subsequently used for a public school. In consequence of this its wards are not well arranged for convenient administration; some of the rooms are imperfectly lighted; access to bath rooms and water-closets is not easy, and patients can not be well classified. Notwithstanding these structural defects, the hospital is found in good condition. The surgical operating room is new and well arranged for antiseptic surgery and presents a most creditable appearance. It is doubtful if any better work is possible in the building occupied at present. There is a lying-in service at this hospital which includes both white and colored patients. The daily per capita cost of maintenance during the year 1896 has not been received. A training school for nurses exists in connection with this hospital.

9. The Home for Incurables.--This institution is badly located and badly arranged for active work. It contains many patients who do not properly belong in such an institution, and who would be more comfortable elsewhere. We refer to cases of defective mental development, cases of epilepsy, cases of mental disorder, and the like. The governing motive in the admission of many of them seemed to be a feeling of sympathy for the friends who might otherwise be charged with their care. It is evident that no fixed principle governs the admission of patients, and that the limits of this sort of charity are boundless. The Home is neatly kept, the nurses are attentive and kind, and the whole atmosphere of the establishment is homelike. It is, however, most desirable that the scope of the Home be better differentiated, and that many of its present occupants be placed in more appropriate institutions.

The nursing at this establishment was formerly under the charge of the training school connected with the Garfield Hospital. Recently, however, it has been necessary for this school to relinquish the work, and trained nurses are now engaged. The daily per capita cost of maintenance for 1896 has not been received.

Before entering into any remarks upon the above findings it is fitting, in our view of the scope of the inquiry, to speak of the growing use of hospitals among all classes of people during the past decade. Originally planned and constructed for the destitute, the homeless, and the friendless, the field of its usefulness has rapidly enlarged until now the hospital is increasingly resorted to by people of moderate means, and not infrequently the wealthy, or at least by those who do not in any sense require it as a charity. This increased use of hospital facilities by the whole community has been due to improved hospital construction and better hygienic conditions than formerly prevailed-so much better in fact as to excel those now attainable in the majority of homes-to skilled nursing under competent direction, and, above all, to the development of antiseptic surgery in connection with well-appointed surgical operating rooms. For this reason a demand has been created in every city for the erection of hospitals of a progressively better type, and hospitals everywhere have vied with each other to meet these

requirements. Since all members of the community are equally interested in having good hospitals, the duty of making proper provision for all classes of disease has been generally recognized. As one of the results of this widespread interest many special hospitals have been erected and many general hospitals have developed special departments. The effect of this activity has been to increase the burden which the support of hospitals entails upon the charitable public, and in some instances to suggest the necessity of increased aid from the Government.

General hospitals have usually existed under two forms-municipal hospitals, supported wholly by the State, and corporate hospitals, specially chartered for the care of the sick and maintained for the most part by the benefactions of the charitable, and in some degree by the payments of private patients. Municipal hospitals have generally grown out of the necessity of providing accommodations for the sick in connection with almshouses or other aggregations of dependent persons, and hence, unfortunately, have generally been connected with such pauper establishments. The majority of these patients suffered from chronic diseases and required shelter and custodial care rather than active medical or surgical interference. Hence, municipal hospitals as a rule have not been provided with buildings of the best type for hospitals, nor have they had the best facilities in other respects for the successful care of the acutely sick. The presence of large numbers of cases of chronic disease has been found by experience to lower the standard of care, because neither physicians, surgeons, nor nurses have the same incitement to active effort to save life or to relieve suffering as in an institution crowded by cases of acute disease.'

For this and similar reasons we must look for the best development of hospital construction, organization, and efficiency to the corporate hospital, of which notable examples are to be found in every large city. The most familiar examples of hospitals of this type, because they are the oldest, are the Pennsylvania Hospital in Philadelphia, the New York Hospital in New York, and the Massachusetts General Hospital in Boston. Erected from the first with the sole idea of providing for the acutely sick, they have been provided with the best attainable buildings, and have called into their service eminent business men as managers and equally eminent physicians and surgeons to direct their professional work. It is not surprising that under the circumstances corporate hospitals in every city have enjoyed great popularity and usefulness. They have attracted the sick of every class, and by the benefactions of the charitable they have been provided with means to rival each other in buildings and equipments. They were modeled originally upon the great foundations which had grown up in Europe.

A notable exception to this general statement respecting municipal hospitals is to be found in the Boston City Hospital, where there is an active service of the highest type in buildings constructed after the latest models and provided with an unsurpassed equipment.

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