215 progresses. There is no reason why, because this disease is found incurable, a patient suffering from it should be sent to an almshouse hospital to die, and should find that while there she has less comfort, less care, less treatment, than she would have had in a general hospital. At present, owing to the fact that there is no municipal hospital for consumptives in Boston, very many cases of tuberculosis are sent to the Long Island Hospital. Should not these cases receive the same care that they would in a general hospital? I can see no room for any argument on the other side of this question. is true that the expenses of the Long Island Hospital are not so great It as those of the Boston City Hospital, because at the City Hospital there are many cases of acute illness and surgical cases, requiring a greater number of attendants and different food and treatment. per capita cost of the Boston City Hospital per week is, according to its The latest report, $13.47, while that of the Almshouse Hospital on Long Island is only $4.19. I think you will admit that the per capita cost of the Long Island Hospital is low; and yet it is not too much to say that for this modest sum the patients receive care, treatment, and comfort which are on the average of those afforded by a good general hospital. Much of the excellence of the hospital is due to the untiring devotion of the members of the Visiting Medical Staff. Their interest and regular attendance have done more to raise the grade of the hospital than any one factor. Every member of the staff believes in making the hospital as good a hospital as is possible, in justice to the citizens who maintain it and the patients who occupy it. There are eleven members of the visiting staff, including two surgeons and various specialists. The resident staff of the hospital consists of the superintendent of the Boston Almshouse and Hospital (who is a physician and a member of the visiting staff), two resident medical officers, and four internes. seen that the hospital is equipped with competent medical service, It will thus be and a number of minor and a few major operations are performed there. One indisputable proof of the improvement in the Long Island Hospital is to be found in the fact that persons from outside are much more ready to send patients there than formerly. We are assured of this, not only by physicians, but by statisticians who keep accurate records of the institution. It is a pleasant thought that the stigma of pauperism need not necessarily attach to the hospital, but that it can be looked upon, more or less, as the chronic hospital of the city of Boston. It has several times been suggested that the hospital department should be separated from the almshouse department; and indeed, in all essential points, it is already distinct. The building is separate, the accounts are kept separately, and in every way the hospital has an individuality of its own apart from the main institution. This development of the Almshouse Hospital in Boston I have dwelt upon at length because it is an institution with which I am familiar, having been for five years a member of the board of trustees. I wish, however, to speak also of the excellence of the Birmingham Infirmary, where almshouse cases are treated (though not exclusively) and where the standard of nursing is remarkably high. This institution, built upon the pavilion plan, and superintended equally by a matron and master, each having separate and distinct duties, is a model of its kind, possibly because of its good construction and management, but also because, in the superintendent of nurses, the managers have found a remarkable woman. The care and attention given to the patients is equal to that in any wellequipped hospital that I have ever seen. The idea does not seem to prevail in Birmingham that a hospital receiving almshouse cases should be in any respect different from a general hospital. This is the plea which I wish to enter,— that the sick poor, no matter where they may be found, should receive the same care as sick persons elsewhere. They need just the same nursing, they need the same nourishing food to restore them to health, they need the same cleanliness and care. It is better for them to have it, it is better for the community to give it, and it is an education for the nurses in any hospital to realize that the standard cannot be too high. It is the duty of the community to care for the dependent sick. I do not know how others feel upon this subject, but it is borne in upon me very strongly that there is no reason why an almshouse hospital should not be as well planned, as well built, as well ventilated, as well managed, as any other hospital. As I stated in the beginning, this is the burden of my plea. It might seem from my point of view as if no one could fail to agree with this proposition, but I have heard arguments brought forward to prove that an almshouse hospital need not be as good as other hospitals. I have heard it stated by a leading physician, when our own almshouse hospital was unworthy of the name, that "it was good enough for the purpose for which it was intended." I feel that it is a great opportunity to come here to bear my testimony to the firm belief that is in me, that an almshouse hospital cannot be too good; that the citizens who pay for it can better afford to maintain it at a high standard of excellence than they can afford to allow the sick to linger uncured or uncared for or not cared for as they should be cared for by a great city. I am aware that there are many points in which the hospital at Long Island could be improved. No one who has charge of an institution can ever feel that it has reached the point of excellence where no growth is possible, but certainly it is a benefit to any hospital to have the decided interest, and more or less authority, of a visiting staff of physicians; certainly it is a benefit to any hospital to have it known that the trustees who have charge of it desire a high rather than a low standard; certainly it is a benefit to any hospital to have in connection with it a pathological department where students can be made to feel that disease is to be studied scientifically. All these things we struggle to secure in the Long Island Hospital. year 120 autopsies were conducted there successfully. the special specimens in connection with contagious disease, which are sent to the Harvard Medical School by the Boston City Hospital, the Long Island Hospital has furnished one-half of the material provided in this school for students. This record alone would show what excellent work is being done by the Pathological Department at Long Island. During the past I will ask your pardon if I have seemed to speak too exclusively of the one institution with which I am familiar. I have intended to speak of it as a type, not of what a model almshouse hospital should be, but of what an almshouse hospital may eventually become, if the right interest in it is felt by the municipality to which it belongs, by the superintendent and officers who administer it, by the physicians who visit it, and by the trustees who have it in charge. I should be very glad to hear any argument which may be brought forward against the development of an almshouse hospital; but I could hardly be expected to believe this argument, because for nearly ten years it has been a source of deep interest and satisfaction to me to watch the steady growth of the special institution of which I am a representative, and to whose progress many different causes have contributed. VIII. Tuberculosis. WHAT SHALL WE DO WITH THE CONSUMPTIVE POOR? BY S. A. KNOPF, M.D., NEW YORK. In an audience of charity workers, largely composed of laymen, it goes without saying that I shall not attempt to answer this question from a purely medical point of view. What we will try to learn. here to-day, what we are anxious to know, is, above all, how we can help in the solution of the tuberculosis problem in its sociological aspect. Yet it seems to me essential that those of us who labor not only with tuberculous patients, but also with their friends and relatives, and the large portion of the community whose sympathy we desire to enlist in our cause, should know the true status of a consumptive. We must have a concise, correct, and just idea of what kind of a malady pulmonary tuberculosis, or consumption, really is, in order to combat it successfully as a social disease; that is to say, a disease of the masses. Permit me, therefore, to summarize to you our present knowledge in this respect, and to state the basis on which a trained and scientific charity organization should work. Tuberculosis is only in the rarest instances transmitted from parent to child. When an infant becomes tuberculous, it is usually the result of an infection after birth from a careless or ignorant tuberculous mother or other consumptive adult. The disposition to tuberculosis can of course be inherited as well as acquired. We now know that tuberculosis, especially in its pulmonary form, is an infectious and communicable disease. I lay stress upon the word "communicable"; for I do not classify pulmonary tuberculosis with the dangerous contagious diseases, and I shall give you briefly my reasons for not doing so. It is my firm conviction, based on the experiences and experiments of our greatest European and American scientists, such as Koch, Straus, Grancher, Prudden, Biggs, and others, and on a somewhat extensive experience of my own, that tuberculosis is not a dangerous contagious disease, but only a communicable one. To be in contact with a tuberculous individual who takes care of his expectoration or other secretions which may contain bacilli is not dangerous. In sanatoria for consumptives, where the precautions concerning the sputum are most strictly adhered to, one is, perhaps, safer from contracting tuberculosis than anywhere. else. The great danger from infection lies in the indiscriminate deposit of sputum containing the bacilli, which, when dry and pulverized, may be inhaled by susceptible individuals, and then cause the disease to be developed. The communication of the germ of the disease is, however, less obscure to us in its process, and far more easily guarded against, than the contagion arising from such maladies as diphtheria, scarlet fever, or small-pox. What has just been said concerning the absolute security from infection in a wellkept sanatorium cannot very well be said of a small-pox hospital, n☛ matter how well directed the hygienic precautions may be. Against the danger from contracting small-pox we have thus far no other means than preventive vaccination, and, in case of an outbreak of the disease, the most rigid isolation. It is entirely different with tuberculosis. The simple contact of a small-pox patient may suffice to convey the disease. This is never possible with a consumptive, even should he be careless or unclean. To the average individual a prolonged exposure is necessary to the transmission of the disease. Herein lies the difference between communicable and contagious. If pulmonary tuberculosis should be a dangerous contagious disease, as the authorities in the United States Marine Hospital Service would wish us to consider it, you scientific charity workers would be powerless to do anything toward the solution of the problem, which is as much a social as it is a medical one. You would not dare to enter the homes of these unfortunate ones to bring them comfort, consolation, and relief. From the admirable papers which you have heard from Dr. George F. Kean, of Providence, R.I., and from Dr. Lyle, of Cincinnati, at a previous meeting of this conference, and from the articles of other authors on the subject which have from |