Each county of Ohio, except Cuyahoga, conducts an institution known as the county infirmary. There are also two large institutions conducted by the cities of Cincinnati and Cleveland. In these institutions are found various types of persons, whether viewed from a mental, physical or moral angle.

It is no easy task to manage an infirmary so as to be just and considerate to those who are sensible of such treatment and at the same time maintain a certain amount of discipline, which is necessary to "keep peace in the family."

At the National Conference of Social Work at Pittsburgh in May, 1917, special attention was given to the management of such institutions. In the Ohio Bulletin of Charities and Correction for June, 1917, there appeared an address on "Standards of Almhouse Administration," by Francis Bardwell, Inspector of Almshouses of the Massachusetts State Board of Charity. Superintendents and other responsible persons who have not read Mr. Bardwell's address are earnestly urged to do so.

We are presenting herewith another very thoughtful address by Dr. Nascher, who deals with several phases of institutional problems which are not given much consideration, as a rule.

THE INSTITUTIONAL CARE OF THE AGED

I. L. Nascher, M. D., Chief of Clinic, Department of Internal Medicine,
Mount Sinai Hospital Dispensary, New York.

There is probably no class of dependents whose welfare has been more completely neglected, who have received less scientific study and care, than the aged. The child dependent has the world for its guardian; the aged dependent is disowned by his own. There are scores of works dealing with the child in the home and in institutions; until recently there was not a single work considering the institutional care of the aged, not a journal of any kind sufficiently interested in the welfare of the aged to devote special space to this subject.

So completely has the welfare of the aged as a scientific study been ignored that today there is not a home for the aged, so far as I know, in which the vital problem of the proper feeding of the aged is understood or even considered. As a rule their dietaries are arranged either haphazard on the guiding principle to get the most food for the least cost, or else the dietaries are based upon the dietaries of institutions of a different character. Yet it has been found that the aged require only about half of the amount of food, calculated in calories or food energy, that young, active individuals require and the proportions of the three classes of food are different. The aged require less than half of the protein class, the tissue-forming food such as meat, cheese, and white of egg. They require about half the amount of carbohydrates or energy-producing food. The principal foods of this class are the starchy foods and sugar. Of fat, the heat-producing food, they require almost as much as in earlier life. When the teeth fall out, food which must be masticated must either be omitted or else so prepared that it can be swallowed and digested without difficulty. The principal article of food that must be masticated is meat; almost all other foods can be crushed between the gums or between the tongue and hard palate, or can be brought into a semi-liquid form. If meat is given at all after the teeth fall out it must be thoroughly boiled and chopped fine. There are physiological reasons why food should be in a liquid or mushy state when swallowed, and why vegetables that contain a large amount of cellulose or woody fiber should be used. The principal foods of this character are beets, carrots, onions, turnips, cabbage, the greens, like spinach, lettuce, kale sprouts, etc.

Tea constipates and is therefore objectionable, as most aged persons suffer from constipation. Milk, the most healthful of all foods, contains a comparatively large amount of lime. In the young, lime is required for bone growth, but in old age the body retains the lime that is taken in excess of the body requirements, and it deposits the lime in the joints, making them stiff and hard, in the arteries producing arteriosclerosis, and in other situations causing other disease conditions. Milk can be used in small quantities, but as a beverage buttermilk is better. The only material difference between milk and buttermilk is in the fat content, milk containing 4.5 per cent fat, while buttermilk contains only 0.5 per cent; but buttermilk contains less lime. If time permitted we could in this way take up one food after another and show how we can apply scientific feeding to the aged, especially in institutions, and how the present haphazard mode of feeding is wrong, injurious, and wasteful.

Let us consider for a moment what the problems are that we have to deal with in the institutional care of the aged. They are, from the sentimental standpoint, to make the inmates happy; from the broad, humanitarian standpoint,, to make them healthy and prolong their lives; from the practical, economic standpoint, to lessen the burden that they impose upon the community, by utilizing their economic possibilities and diminishing the cost of their maintenance. These problems are interrelated, and each must be considered in its relation to the others. Yet we find institutions in which only the economic side is considered without regard for the health and happiness of the inmate-where the measures taken to secure the happiness of the inmates are detrimental to health and the question of cost is disregarded.

The most important of the problems, and the one which has received the least consideration, is the utilization of the economic possibilities of the aged in institutions. While this is primarily an economic problem, it affects vitally the health and happiness of the inmates. In the New York City Farms Colony, which is a branch of the New York City Homes for the Aged and Infirm, there are about a thousand inmates, male and female. Every one of these inmates, except those in the infirmary, is employed at some useful occupation. The cobblers are in the shoe shop mending shoes and the tailors are in the tailor shop repairing clothing; the printers work in the printing office, and the painters do the painting about the institution. Those having no trades work on the farm or in shops where skilled labor is not required, and those least capable do light work, such as setting the table and removing the dishes, or are employed as doorkeepers, gatekeepers, messengers, etc. They are urged, but not compelled, to work, and so thoroughly systematized is the work that almost all of the labor about the institution, including the erection of buildings, is done by inmates. The practical results are: (1) the cost of maintenance is extremely low; (2) the inmates being employed, their minds are occupied with their work and not on regretful restrospection or gloomy forebodings; they are happy, since they feel that they are contributing toward their support and are not useless paupers; (3) being employed, they do not suffer from certain ailments that are due to inactivity and mental depression. We see in this institution how the three problems, the sentimental, the humanitarian, and the economic are interrelated, and the solution of the one solves the other two. Not far from the City Farms Colony is another home for the aged one of the richest and most beautifully equipped institutions of the kind in the country. The inmates, most of whom are accustomed to hotel life, have there all the comforts of a good family hotel, midst ideal country surroundings. The organization maintaining this institution has abundant funds and there is no need to practice strict economy; indeed, each inmate receives a couple of dollars a month for incidental expenses. Kind friends throughout the country do what they can to make the inmates, or guests as they are called, happy and contented. Yet these old people, who have made thousands, perhaps millions, of others happy, are not happy themselves. They are grateful for the freedom from worry and care, and for a short time after their admission they are happy in their new surroundings. After a while the novelty wears off, the inactivity and sameness becomes monotonous. They have nothing to do but think and wait, as one inmate said; wait for the time when the good Lord would take them.

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I have heard similar expressions in other institutons. An inmate of a public almshouse, looking wistfully across the river where he could see men working and children playing, said, “Give me something to do, to keep my mind off myself and death." A relative who had been in a private home for the aged had the same complaint. “I do nothing all day but sit and think, think of my wasted past and of the dismal future. If I had something to do to keep my mind occupied, I would be satisfied."

Give them something to do to keep their minds occupied. In institutions where economy must be practiced and expenses must be kept down, give them work which they can do and which is now being done by paid employes. Or give them productive work which can be disposed of for the benefit of the institution. In large institutions where there are many inmates representing many vocations, the work can be so systemized that all may be usefully employed and each one contribute some service which will lessen the expenses of the institution. It may be necessary to urge some to work, but most of the inmates will work willingly, if only to show that they are still able to earn something, that they still possess self-respect and that they do not want to be looked upon as worthless paupers.

Systematic employment can be introduced in all classes of institutions for the aged, the nature of the work depending upon the character of the institution and the inmates, their mental and physical ability, and the facilities possessed by the institution for giving suitable employment to the inmates. In public institutions where economy must be practiced, the primary object should be to stop leaks in the expense account by replacing paid employes. In other institutions inmates can either help in or about the institution or be engaged upon the manufacture of articles requiring little physical strength, and which can be disposed of for the benefit of the institution or themselves. Even in the richly endowed homes work can be provided which will be interesting and profitable. The ultimate benefit will be better health and greater happiness of the inmates beside a lessening of the burden of their support.

An important factor in utilizing the working capacity of the inmates of institutions is the improvement of the vision through proper glasses. A very large proportion of aged persons need glasses, yet I have been told by inmates of homes that though they had defective vision their eyes were never examined, they had no glasses, and consequently they had not been able to read a book in years. This could easily be remedied at but little expense.

The keynote of the treatment of aged persons is mental stimulation, to overcome the mental depression natural to the aged, especially those who are dependent upon others for their support. This mental stimulation may be brought about through recreation or amusement, or through arousing an interest in the affairs of the day, or in agreeable work, or in a hobby, or in self or another, or in the institution itself. I saw this well exemplified in a home for aged pensioners near Vienna which I visited a few years ago. The inmates were proud of their institution and my guide took pains to show me how they helped each other to keep their dormitories, dining rooms and other rooms, halls, and walks clean and neat. They were proud of the appearance of the shops and of the skill of the inmates who worked there. The men took pride in their appearance. and before going out they washed themselves and brushed their clothes, hats and shoes. They had a band and an orchestra composed of inmates who gave occasional performances and always had appreciative audiences. Provision was made for their recreation; there was a well-stocked library, and a canteen was established for them on the grounds. The canteen was maintained from the proceeds of knickknacks made by the inmates, of concerts by the band, contributions from visitors and a slight profit on the sale of things supplied by the canteen all of which went into a common fund. Similar provision for the recreation of inmates could be made in all homes for the aged at but little cost.

Nothing will stimulate pride in appearance and an interest in life as much as association with the opposite sex, and this applies to both sexes. There has been cases of improprieties in institutions where the sexes were not segregated, but these are so rare

that this cause for segregation may be disregarded when we consider the benefits to be derived from the association of the sexes. It is a cruel hardship to separate old couples, especially when they are housed in the same building. I know a couple in a almshouse who had no opportunity to speak to each other for a year after they entered the institution, and they could see each other only from a distance at church services. The superintendent was persuaded to waive the rules and permit these old people to meet occasion. ally. The aged should, however, be segregated from the able-bodied lazy individuals; also from cripples and especially from the insane. There are many factors connected with the housing and the construction of the buildings that influence the health, happiness and comfort of the inmates. There is no uniformity in the housing of the aged, even in the same class of institutions. In public institutions there are usually large dormitories; some have separate rooms holding from four to six, some have dormitories for men and small rooms for women. In some there are large dormitories, but married couples occupy cottages, each couple having one large room. This is not the most economical, but it is the most satisfactory and humane method of keeping old couples together. Private institutions generally have rooms holding from one to six beds, but some have large dormitories. Where there are many inmates the cottage system requires much more ground, the initial cost is greater, the cost of maintenance is more, and the administration is more difficult than where all the inmates are housed in one or two buildings. It is, however, the ideal method of housing couples who can find in their own room a semblance of home, and for small institutions which are not bound down by rigid economy and can afford to give each inmate a separate room.

Custom, convenience, and civic pride favor the erection of large homes in the heart of the city, where they can be shown as monuments of the city's generosity. Such a situation disregards the fundamental problems in the institutional care of the aged; their health, their happiness and the cost of their maintenance. I regret that the time at my disposal does not permit me to discuss this factor in the welfare of the aged at length. I have found many faults in the construction of the buildings for housing the aged. Architects and builders do not take into consideration the many ailments of the aged, and this oversight is responsible for much distress among the inmates. Aged persons generally suffer from shortness of breath and many have heart disease. If there is no elevator in the building, dining rooms, dormitories, sleeping rooms, and toilets should be so placed that these sufferers will not be obliged to climb two or three flights of stairs to reach their beds or the toilets. Owing to the frequency of bowel, kidney and bladder diseases among the aged and the urgency of the use of the toilet in such cases there should be toilets on each floor. Insufficient and badly placed toilets form one of the most glaring faults in many institutions.

Another fault in many instituitons is poor washing facilities, especially baths. Aged persons generally dread the tub bath, owing to the difficulty in getting in and out of the tub. Stout, weak old women often find it impossible to get out of the tub without assistance. Shower baths, spray baths or specially constructed tubs will obviate this difficulty.

Every institution, however small, should have an infirmary ward and a separate room to which dying patients can be removed. There is nothing more depressing or harrowing to a sick old person than to witness the death struggle of a neighbor.

In winter, beds should be warmed before inmates retire. If there are any who suffer from bronchitis they will begin to cough as soon as they enter a cold bed, and they may keep the whole dormitory awake for hours. Many persons cannot sleep in a cold bed until the heat from their body has warmed the bed sufficiently to make it comfortable. As there is much less radiation of heat from the body of an old person than there is from the body of a young, active person, it takes much longer to warm the bed. Owing to poor circulation old people generally have cold feet and many cannot sleep until their feet are warmed. In one institution the inmates receive woolen bed socks on retiring. In another institution where many of the inmates complain of cold feet, cold beds, and insomnia, the superintendent, at my suggestion, brought a number of empty mineral

water jugs from the cellar. These were filled with hot water and each inmate upon retiring placed a jug in his bed, and when he got into bed he pushed the jug down to the foot of the bed and thus kept his feet warm.

It is not possible within the time limit to take up the many factors that contribute to the health and happiness of inmates of institutions, but I will mention a few things that impressed me in my visits to homes for the aged. In one where the inmates were paired so that each one had a companion, the companion of one had paralysis and the other gradually acquired through unconscious mimicry the dragging step of paralytic. It was necessary to employ harsh measures before he was cured of the habit. I have seen tremors and a lisp acquired in the same way. Many old persons have bromidrosis or bad-smelling perspiration. Where many such sufferers congregate they give off a very offensive odor, but persons who are constantly around them become accustomed to the odor and disregard it. To visitors it may be so repulsive that they cannot be near the sufferers, and they lose interest and sympathy for them. Many of the minor ailments of the aged are neglected because they are supposed to be due to old age, and nothing can be done for old age. This is as much the fault of physicians who do not understand senile ailments as of those who have charge of the aged. This, however, is a matter for the medical profession to take up, but there is little likelihood that the medical profession will take up seriously the conservation of the aged unless there is a public demand for it. And before the general public will make such a demand it will be necessary to rouse the public conscience to a realization of its neglect of the aged.

I have only skimmed over my subject, omitting many important features, laying stress only upon the one feature, the utilization of the economic possibilities of the aged in institutions. I hope that I have been able to show that the institutional care of the aged deserves thorough investigation, so that we may be able to correlate and solve the various problems that I have pointed out. There are features in many institutions that can be applied generally to advantage, but at the present time there is no uniformity, no standard, no guide to point out what is best and why. There is no doubt in my mind that a thorough investigation will result in revolutionizing our present methods of caring for the aged. Instead of forcing them into the humiliating, degrading position of being paupers of the almshouse, we will look upon them as we look upon the child in the asylum or the patient in the hospital, as inmates of homes for the aged; we will look upon them with pity instead of scorn, with sympathy instead of indifference. We will learn how to conserve their usefulness so that they will not be so heavy a burden upon the community, and may even become an asset instead of the positive liability that they are at present. In public institutions we will learn how to conserve their happiness by making the institution a home and not a prison. In public and private institutions we will learn how to instill self-respect, arouse hope and stimulate ambition, instead of killing every spark of self-respect, hope, and ambition that the aged dependent may have when he enters his final refuge. In all we will learn how to increase the happiness, promote the health and prolong the lives of those to whom we owe, in gratitude, our best endeavors.