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In every large population of the aged and infirm, acute illness, accidents, or conditions requiring surgical operations will continually develop. The hospital ward is a necessary adjunct of the almshouse. And if there are included as hospital patients those suffering from incurable diseases which permit long years of life, the hospital portion becomes a large factor. At the New York City Home for the Aged and Infirm, from one-quarter to one-third of the entire population are cared for in buildings known as hospitals and organized so far as practicable on a hospital basis. The diseases are of such a character that it is difficult, if not impossible, to maintain training-schools for nurses. It is not that the patients are objectionable or that the diseases are objectionable, but that they do not afford sufficient opportunities for the care of acute illness or acute surgical conditions. The same reason makes it difficult to secure a satisfactory medical service; the great majority of cases have but little interest or "value" to the ordinary practitioner. To provide graduated nurses in any considerable number is impossible because of the great expense involved. The more usual course is to employ untrained nurses of about the class who ordinarily go into domestic service and to employ one or more skilled supervising nurses who are graduates of training-schools.

It is interesting to note that one of the charges seriously made against the trustees of pauper institutions in the city of Boston is that they have maintained a training-school for nurses and have spent too much money on operating-room furniture. If the trustees have been able to establish an efficient training-school for nurses in the almshouse hospital, they should receive general and warm commendation for having devised a plan for securing the best quality of nursing at the lowest cost. The training-school for nurses is the most economical plan ever devised for caring efficiently for the sick in large hospitals. If, by the establishment of the training-school and by providing hospital operating-room furniture and other necessary facilities for medical and surgical work, the trustees of the pauper institutions of the city of Boston have succeeded in securing efficient nursing and high-grade medical and surgical service for the hospital portion of their population, they have measurably solved one of the most difficult problems in municipal charitable administration, long recognized as such, both here and abroad.

IV.

Aside from the hospital portion of the home for the aged and infirm, every large municipal department of charities finds it necessary to maintain hospitals for the care and treatment of the sick, both accident and acute cases and those of a more chronic character. A problem arises as to the proper standards of administration of municipal hospitals: Shall they be as good as the best, or shall they, in view of the fact that they care only for the destitute, many of whom have become such probably through their own faults, be conducted on a simpler and less expensive plan? Who has not heard the wise citizen, the sage doctor of philosophy, or the head of a wealthy church, in visiting a public hospital, remark under his breath, but apparently with misgiving, that the patients are receiving better food and clothing, and withal are more comfortable and are living under more sanitary and cleanly surroundings than they did in their own homes? The implication seems to be that the patients are getting better than they deserve, or that it is hardly fair for the citizens to be called upon to do so much at public expense for this purpose, or that in some way the social structure is involved in serious though vague danger in thus forcing higher standards of living upon this class of people. Never were there more shallow attempts at reasoning nor a more thoroughly uncharitable attitude. As has been well said, the best occupation of the sick man is getting well -- best not merely for him, but for his family, for the city which otherwise continues to contribute to his support in a hospital, and for the community of which he otherwise remains a non-productive member and a burden. There can be only one rational, only one truly charitable standard for the administration of public hospitals: they should be equal to the best, so far as essentials are concerned. Nothing that will contribute to recovery is too expensive to be economical. We can omit ornamental features, but in the essentials of sanitation, cleanliness, medicines and surgical facilities, clothing, and, above all, a plentiful supply of food, well cooked and well served, there should be no scrimping. These conditions not only conduce to the early cure of the patients, but exert a marked educational influence, and raise the standards of life of all who become for a time the subjects of city care.

V.

Recent advances in medical science have made the care of consumptives one of the serious problems in municipal charity administration. Municipal hospitals and almshouses have always sheltered large numbers of consumptives, but the knowledge of the communicability of the disease in all stages and the curability of some cases in the earlier stages changes radically the nature of the problem. It is no longer simply a question of providing shelter, food, and clothing for a given number of unfortunates; it has become a question of such care for these sufferers as will protect the other patients and inmates of the city institutions from infection, will extend to the consumptives all the opportunities and advantages which modern science suggests for their N improvement, if not for their cure, and will make the hospital for consumptives a large factor in the substantial eradication of the "white plague" from our large cities -- an end towards which some of our municipalities are beginning consciously to direct their enormous powers. So great has been the education of public opinion very recently in this matter that it seems almost impossible that less than two years ago hundreds of consumptives were still cared for in the general wards of public hospitals in New York City, that other hundreds were in wards devoted to this disease but in the same buildings as medical and surgical wards, and that many others were left to wander about the streets of the city spreading infection and with no place to which they could turn with certainty of admission and care for any period of time. The segregation of consumptives from other patients in the hospitals of New York City during the last two years, the establishment in the hospital devoted to their care of most of the features which have been successful in sanatoria for consumptives in other States and cities, and the set purpose, carried into effect, to turn away no consumptives asking for care, and to discharge no one from the Hospital for Consumptives, unless for serious misconduct, except upon his own urgent request or as substantially cured, have been considered the most important achievement of the Charities Department during the Low administration. The example set by New York and other cities (New York was not the first to move in the matter, though it has probably carried its plan into effect more thoroughly than any other city) should be the adoption of similar measures in the charities departments of all the large municipalities of the country. It is not necessary to wait for the construction of expensive permanent buildings; tent-cottages or temporary wooden structures are probably better suited to the purpose, in that they afford better opportunities for the fresh-air treatment, are much less expensive at least for the original outlay, and, what is perhaps of greater importance, can be made available with very little delay. The tent-cottages, of which there are twelve at the Tuberculosis Infirmary of the Department of Public Charities, on Blackwells Island, accommodating about one hundred and forty patients, were modelled after a design by Dr. Holmes, of Denver. (2)