They sprang from great humanitarian impulses, and their roots have sunk deep into our institutions. Designed originally by philanthropists for the poor and suffering, their design primarily was to bring private charity to the relief of the indigent sick.

Of late, however, there has grown up in connection with these corporate institutions wards for the care of persons who are able to pay in whole or in part for medical treatment or surgical operation. Of course no patient in a general hospital, no matter how liberally he may pay, ever pays the full value of what he receives. The interest on the expensive plant, the surgical skill at instant command, the arrangements for hygienic care and nursing-these and many similar items can not be paid for at a weekly rate. All patients, whether paying or not, who avail themselves of the facilities of the hospitals are recipients of charity. Hence, in these corporate hospitals there should be a definite recognition of the fact that there is a place for every case of acute disease. Provision should be made for all classes of persons. Thus far, in America, as a rule, to which we know of but a single exception, the best development of hospitals has been in connection with corporate institutions, and hence they have been fostered and have had a recognized place in all philanthropic plans. They are expected to make ample provision for paying patients, and wealthy benevolent citizens have liberally supplemented their facilities for the care of indigent persons.

In no other manner can the springs of private benevolence be kept from drying up. Communities have no right to expect a government to relieve them from the duty of exercising charity toward the sick and helpless. The corporate hospital may be fostered, and in a degree assisted, but it can never be superseded by the municipal hospital, and should not be. It may be remarked in this connection that most of the hospitals of the District of Columbia are corporate hospitals whose affairs are managed by boards of trustees or managers, even when, as happens in some instances, the funds for their support are supplied by the General Government. This arrangement has undoubtedly been a wise one, and its effect has been to build up the hospitals of the District.

Municipal hospitals for the care of the destitute and for the reception of cases of chronic and incurable disease are also necessary to the welfare of every city. They ought not to be constructed in connection with almshouses or institutions for the insane.

From the above findings certain general conclusions may be drawn, which may be briefly stated prior to a consideration of the special points to which our attention has been directed by your chairman:

1. Crowding and disproportionate accommodation.-Several of the hospitals, notably the Providence Hospital, the Central Dispensary, and Emergency Hospital, and the almshouse and asylum hospital, are much crowded beyond the original intention of those who designed

the buildings. Others, like the Columbia Hospital for Women and Lying-in Asylum, the Garfield Hospital, and the Freedmen's Hospital, are crowded in certain departments and present an apparent excess of accommodation in other departments.

2. Contagious diseases, etc.-Beyond a few beds in the Children's Hospital and some rooms over a stable in connection with the Providence Hospital, no provision whatever exists for the case of contagious diseases in the District of Columbia.

No detention ward exists in connection with any hospital for the temporary care of cases of acute insanity pending their examination and transfer to permanent quarters in a hospital for the insane.

3. Admission and discharge of indigent patients.-No rules exist for the admission of patients to hospitals or their discharge therefrom, with the sole exception of the Garfield Hospital, where the time limit of sixty days is said to exist. In the majority of them no inquiries are made as to the legal residence of patients, nor are there any means of ascertaining whether the patients admitted are a just charge upon the charities of the District of Columbia.

4. Lack of supervision on the part of the Government.-At present the United States Government is in the position of a minority stockholder in most of the hospitals to which appropriations are made. Although it supports either wholly or in part all the hospitals visited, the title of but two institutions is vested in the Government, viz, the Columbia Hospital for Women and Lying-In Asylum, and the almshouse and asylum hospital. The remaining seven are owned by private corporations and receive aid only. In some instances this aid has extended to the purchase of land and the erection of new buildings in addition to appropriations for the maintenance of patients. At the Freedmen's Hospital, which is nominally under the charge of the Secretary of the Interior, the Providence Hospital, which is similarly under the SurgeonGeneral of the Army, and the Columbia Hospital, which has one of the District Commissioners upon the board of trustees, there is a quasi control, but it is in reality of the most formal character. Beyond an investigation of disbursements to ascertain that the disbursing officer is complying strictly with the law, no supervision exists in the other hospitals, and there is no one to report whether or not the money appropriated has been judiciously expended for the proper care of the sick poor of the District of Columbia.

5. Duplication of work of hospitals.-A lack of coordination in the work of the various hospitals receiving aid from the Government is evident, and some branches of hospital service seem unnecessarily duplicated. Thus, at five different hospitals lying-in patients are received, and in some of them separate provision was made for both white and colored patients. All of the hospitals, with two exceptions, receive pay patients, and in some instances the pay patients' departments seem developed at the expense of the free departments-that is, the free departments lack accommodation for those who require such care, and

the rooms for paying patients are not filled. At the Freedmen's Hospital, designed originally for colored patients, at least one-third of the patients are white. At least five hospitals are engaged in gynecological work.

6. Hospital for chronic diseases.--No hospital worthy the name exists for the care and treatment of chronic diseases, the only approach to such a hospital being a group of temporary wooden buildings in connection with the almshouse, and an institution of very limited capacity known as the Home for Incurables. The former is unfit for the care of chronic cases and the latter is wholly inadequate to admit them as a class.

We now approach the specific points upon which information has been especially desired.

Organization. The hospitals of the District are well organized and directed, with efficient medical and surgical service and excellent nursing. In two of them additional members of the resident staff might with advantage be appointed.

Equipment. Various defects have been pointed out in all of the hos pitals of the city under the description of each hospital, and nothing needs to be added here except a brief summary:

At the asylum and almshouse hospital the buildings and fixtures are wholly unsuited to the purposes of the sick. Nothing short of the erection of a new hospital can remedy them.

The Children's Hospital requires fire escapes and fire walls, increased accommodations for orthopedic cases, and a detached building for the treatment of contagious diseases.

The Columbia Hospital for Women and Lying-In Asylum requires a new building with proper wards, proper ventilation, and proper methods of heating, with increased facilities for the accommodation of lying-in patients and better arrangements for the separation of suspected and infected patients. The necessity of remedying these defects is acknowledged by those who have the hospital in charge.

The Freedmen's Hospital needs a thorough reconstruction. With the exception of its amphitheater and operating room, there is little in the whole establishment which is worth saving. Its buildings are worn out and not worth repairing.

The Garfield Hospital requires a new operating room, an isolated ward for contagious diseases, a kitchen, laundry, and other service buildings; also a better ambulance service.

The Homeopathic Hospital is hampered by a faulty building which was not originally intended for a hospital.

The Providence Hospital needs a ward for the isolation of cases of contagious disease; also an ambulance service.

The Central Dispensary and Emergency Hospital requires additional room for laundry and kitchen service, a stable for the ambulance, and,

if it is to continue to receive other than accident cases, larger wards, more ample accommodations for nurses, and increased accommodations for servants.

Cost of maintenance.-The cost of maintenance, as will be seen by the appended tables, compares very favorably with the cost of maintenance in the various corporate hospitals of America.

If all of the hospitals of the District were engaged in the treatment of acute cases, in all probability a material increase in the daily per capita cost of the maintenance of patients would be perceived.

An effort has been made to obtain from all of the above hospitals an estimate of the daily per capita cost of the maintenance of patients, and wherever such statement has been received it has been printed with the description of the hospital. As it was impossible to secure similar returns from all of them based upon uniform data, it became necessary for the purposes of comparison to take the returns made to the joint select committee, as published in Senate Doc. No. 185, Fiftyfifth Congress, first session. These have been carefully examined by Dr. A. J. Ourt, of Philadelphia, an expert statistician, and the accompanying table has been prepared from the data given:

TABLE I.-Cost of support of patients in the hospitals of the District of Columbia in 1896.

a The average weekly and daily cost of maintenance is based on the report of expenditures in "Statements of charitable institutions," hearings before Joint Select Committee of Congress, District of Columbia, 1897, and, being the only data accessible, is assumed to be correct.

To show expenditures in other cities, the following table is appended.

TABLE II.-Cost of support of patients in hospitals outside of Washington, D. C.

a Includes cost of country branch. Excluding cost of country branch, weekly $6.93, daily 99 cents.

Relations of pay patients.-As has been previously stated, it is inevitable that all classes in every community will in future increasingly resort to hospitals, and it becomes a matter of self-protection to the government charged with the responsibility of providing for the poor or indigent that no charity shall be squandered upon any person able to pay for his own care and treatment. Hence every hospital should be encouraged to make provision for pay patients, and every person admitted who is pecuniarily able to contribute to his own support in the hospital should be expected to do so. Those who can not pay should not be neglected, but their right to free care ought to be properly established at the time of their admission, or, in emergency cases, as soon thereafter as it is possible to determine their degree of pecuniary responsibility or irresponsibility.

He who pays his way in a hospital helps to lift the burden of the support of the hospital from the charitable or from the Government. To give aid when it is not absolutely needed is demoralizing to the citizen and an evil example to the community. Every applicant for free treatment should be most carefully investigated, so that the needy sick man may receive the care and treatment which he requires ungrudgingly and without delay, and every other held to a strict accountability for the payment of his expenses. The wandering sick person who has seen the inside of many hospitals in many cities should go where he belongs.

The limits of charity.-What, then, are the limits of charity and to whom should the free beds of the hospitals of the District of Columbia be open?

(1) To the sick and destitute poor of the District.

(2) To indigent persons who are self-supporting when well, but who have no accumulated surplus to rely upon in case of illness. In many instances the members of a family may be kept together during the illness of the father or mother or some other producing member of it, provided the family is relieved of the expenses of taking care of the sick person at home. If such person can not be cared for in a hospital, then starvation stares them in the face. It is true charity to make such a patient a free inmate of a hospital.

(3) To indigent persons who are temporarily residing in the District and who fall ill before they have acquired a legal residence. Humanity requires that they be cared for.

(4) To accident cases, wherever they may reside.

With these help must come promptly at a time when there should be no delay to ask any questions.

Beyond these classes charity can not well go. It is clearly improper that sick persons from Virginia or Maryland or other States should go or be sent to Washington to be cared for at public expense, or that such service should be expected. Every community should provide for its own sick poor.