Methods of admission.-Little needs to be added to what has been stated under the two preceding headings. A central authority representing the Government should pass upon the two questions of indigence and of legal settlement in the case of every applicant for free admission to the charitable wards of the hospitals of the District of Columbia.

RECOMMENDATIONS.

In submitting the following recommendations we would be understood to speak only of the care of indigent patients in the District of Columbia clearly chargeable to the public, and to have no reference to patients who are able to pay for their care and treatment.

1. It is recommended that the Providence Hospital and the Garfield Hospital be selected to assume the charge of cases of acute diseases and such accident and emergency cases as may be in their immediate neighborhood, and that the police or District officers empowered to send such patients be instructed to send them to the hospital for which they express a preference. In every instance an effort should be made to ascertain the legal settlement of the patient, and if he is found to be a nonresident he should be sent to his proper place of residence whenever practicable. All admissions of such acute cases should be for a period not to exceed ninety days, unless sooner recovered, and at the end of this period he should be reported to a proper authority if unrecovered, or not likely to improve, for transfer to a hospital for chronic diseases. For this service a liberal daily per capita sum should be paid by the Government, such sum as may be deemed equitable by both parties.

It should be the understood policy to be encouraged that these two hospitals, as now existing, being well equipped to render to the sick and injured the best quality of service of healing and also the largest quantity of it, should be used for cases of acute disease, and that cases of chronic disease should be removed to other less expensive institutions or transferred to a municipal hospital.

This will insure a more rapid movement of patients and better care and attention for sick patients. Hence there should be power vested in some competent central authority to direct the removal and transfer of such chronic cases who are a public charge.

If there are indigent patients who prefer this form of medical treatment, power might be given to this officer to send such patients likewise to the National Homeopathic Hospital under conditions similar to those prescribed for the above-mentioned hospitals.

2. It is recommended to abandon or curtail the Emergency Hospital service, in view of the fact that the hospitals named above have or should have sufficient room for most of the bed cases now received at the Central Dispensary and Emergency Hospital. It is believed that if any beds are maintained at this institution they should be a limited S. Rep. 700-——————5

number, where accident cases too feeble to be moved might remain two or three days. No other cases need be taken to this hospital, as with an efficient and active ambulance service either of the two hospitals named could readily bring all patients directly to their wards.

3. It is recommended that the Columbia Hospital surrender the valuable grounds upon which it is now located and be established elsewhere. The present buildings, except the nurses' house, have no special value, and the cost of modification and reconstruction would be attended with an outlay equivalent to the cost of a new hospital. As the gynecological and maternity services have no necessary connection, except in exceptional cases, it is recommended that they be disassociated, with advantage to both classes, and that the new hospital to be erected be a maternity hospital of sufficient size to render all of the charitable hospital maternity service now performed in this or other hospitals of the whole District. Gynecological surgery, it is believed, can be better done in acute general hospitals, with less danger of interfering with the operations of the maternity hospital.

4. It is recommended and proposed that a municipal hospital be erected to receive all patients, inmates of the Garfield, Providence, or any other hospital in the District, and inmates of the Washington Asylum (or almshouse) who may be proper subjects for such an institutionthat is, those who have been under treatment in the hospitals of the city at public charge and have become chronic, or are, in the opinion of physicians, incurable patients. These could be transferred to the proposed municipal hospital.

The proposed municipal hospital should be a well-constructed building, with modern appointments as to ventilation, heating, sanitary appliances, and medical service equal to the best in the District, with plain and becoming furnishings, on grounds entirely separated and disassociated from the almshouse, jail, and House of Correction. This would remove objections made by the worthy poor to treatment in an almshouse hospital.. Many chronic invalids do not require the more expensive standard of care of an acute general hospital. On the other hand, the acute hospitals would show an increase of the per capita cost.

5. It is recommended that the work now done at the Freedmen's Hospital be transferred to the proposed municipal hospital. Whatever reasons may have once existed for designating any class as "freedmen," and making special hospital provision for them at the expense of the Government, can not be said to exist any longer. All of its present inmates have claims for care and treatment when sick and found to be poor. If deemed advisable, the colored people might be assured of the enjoyment of the same advantages to be derived from hospital service and experience as they now possess in any new arrangement which may be made. This proposition would practically consolidate all hospital service for the poor and dependent of the chronic class in one institution, to which no professional objection can be raised. If the

Freedmen's Hospital were not the property of a private corporation, and if its site and plant were under the control of the Government, it might be converted into a municipal hospital, under the management of the District authorities.

6. It is recommended that at the Garfield, Providence, and Children's hospitals contagious disease wards be erected on the premises to receive all contagious diseases excepting smallpox.

7. It is recommended that a ward for the temporary detention of insane persons and of cases of alcoholism who may be arrested on the streets, or who may fall into the custody of the police to be detained pending their examination and legal disposition, be erected in connection with the municipal hospitals, and that the temporary detention of insane persons in the station houses or jail pending such examinations be prohibited.

8. To bring all of the hospitals, charitable institutions, and reformatory institutions of the District under governmental supervision and inspection and to establish a system whereby their operations may be unified and coordinated, it is recommended that a board of charities and corrections be created for the District of Columbia. This board should serve without pay. A portion of its members should be women. It should have a paid secretary, who shall be a physician familiar with hospital, charitable, and institutional work. This board need not possess administrative powers, but should visit and report annually, and be the medium through which Congress may be informed of the practical and detailed operations of all institutions coming within their purview. The board, through its secretary or agent, should have authority to ascertain the residence and legal settlement of persons in the hospitals or other institutions, and power to return such cases to the place from whence they come. They should receive monthly reports from the hospitals, and verify them. They should have power to make orders of admission to hospitals, to make transfers from one hospital to another, and to discharge patients from hospitals.

It is not considered our province here to enumerate all the powers and duties of such a board, as we are not sufficiently informed how far they might conflict with existing statutes, but we have seen the necessity of unification, accountability, and economy, and feel it a duty to urge the establishment of such a board.

The changes above suggested are far-reaching, and in all probability they can not be made at once. They look to a unification of hospital work on a comprehensive plan, and if adopted they will unquestionably prevent a duplication of hospital work and a waste of public appropriations. They will also assist in more accurately determining the duty of the Government to the helpless sick of the District of Columbia. Respectfully submitted.

HENRY M. HURD.

JOHN B. CHAPIN.

APPENDIX B.

HOSPITAL ORGANIZATION.

Letter from the Medical Association of the District of Columbia relative to the administration of hospitals.

Hon. JAMES MCMILLAN,

WASHINGTON, D. C., November 22, 1897.

Chairman of the Joint Select Committee to Investigate the Charities and Reformatory Institutions in the District of Columbia.

SIR: In the hearings held by your committee April 22, 1897, certain recommendations adopted by the Medical Association of the District of Columbia February 16, 1897, and which had in view the correcting of existing abuses in the administration of hospitals and dispensaries, were discussed and some of the rules subjected to adverse criticism. The Medical Association appointed, therefore, a special committee to correct any misapprehension as to the meaning and intent of their recommendations, and also to represent the association before your committee in matters relating to hospital and dispensary abuses.

Before proceeding with the argument we beg to refer briefly to the duties of the medical profession to the public, which have been clearly defined in the system of ethics adopted by the American Medical Association over fifty years ago.

Article I, paragraph 1, reads:

As good citizens, it is the duty of physicians to be ever vigilant for the welfare of the community, and to bear their part in sustaining its institutions and burdens; they should also be ever ready to give counsel to the public in relation to matters especially appertaining to their profession, as on subjects of medical police, public hygiene, and legal medicine. It is their province to enlighten the public in regard to quarantine regulations; the location, arrangement, and dietaries of hospitals, asyJums, schools, prisons, and similar institutions; in relation to the medical police of towns, as drainage, ventilation, etc., and in regard to measures for the prevention of epidemic and contagious diseases; and when pestilence prevails it is their duty to face the danger and to continue their labors for the alleviation of the suffering, even at the jeopardy of their own lives.

Paragraph.3:

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There is no profession by the members of which eleemosynary services are more liberally dispensed than the medical, but justice requires that some limits should be placed to the performance of such good offices. Poverty, professional brotherhood, and certain of the public duties referred to in the first section of this article should always be recognized as presenting valid claims for gratuitous services.

Article VII: Some general rules should be adopted by the faculty in every town or district relative to pecuniary acknowledgments from their patients, and it should be deemed a point of honor to adhere to these rules with as much uniformity as varying circumstances will admit.

In accordance with these precepts, the Medical Association of the District of Columbia adopted a table of standard fees, subject, however, to the several rules, some of which are as follows:

They shall be diminished at the discretion of the physician when he believes that the patient can not afford to pay the regular fees, and yet is able to make some com

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pensation. It shall be considered, however, as unprofessional to diminish the standard fees, except from motives of charity and benevolence. It is not designed by these regulations to prevent gratuitous services to those who are incapable of making remuneration without distressing themselves or families.

The letter and spirit of these regulations are sufficiently broad and benevolent, but the majority of hospital and dispensary boards of management seem to have lost sight of these dictates of humanity, and as a result their annual reports vie with each other in statements of the amount of work done without any consideration, as to how much of this work was done for the benefit of the real dependent classes, or how much was done at the expense of the profession at large.

While it is clearly the duty of the State and of society to take care of the indigent sick, it is also their duty to prevent imposition and abuse, and this, we regret to say, has not been done, and the evil has grown here, as elsewhere, "with a rapidity which threatens the impoverishment of the general practitioner."

The causes of this evil are manifold; there is always a large class of persons who pretend to be poor when in reality they are simply seeking good medical attendance without pay; Christian charity, or a want of business methods, on the part of hospital and dispensary authorities prevents a systematic inquiry into the actual needs of such applicants.

It is possible that liberal public and private support of these institutions are factors in the abuse of medical charity, for were they obliged to practice strict economy self-preservation would compel them to require evidence of dependency and the work would be limited to the deserving sick. But whatever the cause, the facts are that the true purpose of these institutions has been a mistaken one, and, with a view "of placing a limit on the performance of unrequited services, to sift charity from its abuse, and to keep the hospitals and dispensaries from absorbing patients who are able to pay for medical or surgical treatment," the Medical Association of the District of Columbia appointed a committee in October, 1896, to investigate the subject.

This committee, in its report presented November 10, showed that during the fiscal year ending June 30, 1895, there were treated in the hospital and dispensaries 43,030 applicants, while the physicians to the poor treated 15,150 patients. This makes a grand total of 58,180 patients treated, and a percentage to population of about 21. Mr. Wilson, the secretary of the Board of Associated Charities, testified before your committee that about 5 per cent of the cases investigated for the Central Dispensary proved fraudulent.

The report of our association committee contained certain conclusions and recommendations which were discussed in two general meetings, but the association, to avoid hasty action, referred the subject to another committee, and this second committee formulated the recommendations of February 16, 1897; these were unanimously adopted as amendments to the regulations on May 11, 1897. A copy of these rules was mailed to every hospital and dispensary board in the city,