that there is in all hospitals a tendency to produce an atmospheric condition within their walls, exceedingly adverse to the restoration of health, and especially to those conservative efforts of the constitution necessary to recovery after surgical operations. Of all places in the world, a hospital should be that in which the sick should find the most chances for relief, and yet not unfrequently it presents the least. In this particular, the Philadelphia hospital is remarkably faulty. Patients do not readily recover after severe operations, the mortality on such occasions being exceedingly large. Indeed, not unfrequently the surgeons refrain from operating on that account, even though the patient may be suffering under a mortal disease, sure to destroy life if no operation is performed. At the earnest, I might say, the peremptory solicitation of the surgeons, an appropriation of $5,000 has been made this year, for a building outside the almshouse walls, for this class of cases. Of course it can be only a make-shift unworthy of the honor of the city, but it will be the means of saving many lives. In the plan I propose for the disposal of the different classes of subjects at the almshouse, the sick are to remain where they are. A hospital like this is a necessity of a large city, and though, like the other departments, it suffers somewhat from this proximity, yet this evil is more than balanced by unquestionable advantages. One is that it is easy of access, and this is an indispensable requisite of such an institution. Speedy and easy transportation is required for the safety of the patients, whose ailments might be aggravated in getting to and from a railway. Close proximity to the city is also required for the efficient performance of the medical service, as that implies the daily visits of from four to twelve medical gentlemen, some of them being made in the night, and some at a sudden call. The surroundings are as favorable as they well could be in such a populous community. As a school of instruction, too, for which it has been justly distinguished, it has fully done its part in drawing to Philadelphia young men who are preparing to enter the profession. The parts of the almshouse, vacated by the paupers, the insane and the children, would furnish the desirable amount of room, and all that it could thus get would be none too much. But to fit it properly for its work, every floor should be relaid, the walls replastered and finished with putty coat, the interior arrangements made more convenient, an efficient method

of warming and a forced ventilation provided. Books, pictures, flowers and amusements should be introduced, not merely as a matter of ornamentation, but as a necessity-as an indispensable means for producing salutary mental influences. All these improvements will fall far short of the end in view, if the hospital is to be managed in the spirit of a pauper establishment. The paramount consideration must be, not how cheaply the patients can be kept, but how speedily they can be cured, and how far their sufferings can be alleviated.

No department of the almshouse has occasioned so much solicitude to the guardians and all others concerned in its management, as the lying-in-hospital. The number of women who came under its care during the year 1872, was 209. By the rules of the house they are required to stay fifteen months and nurse the children, but the rule is not unfrequently evaded. The best results of hospital care could not be expected from this class of persons, but after making every allowance on the score of constitution and habits, there is reason to believe that much of the sickness and death is produced by causes peculiar to the establishment. It is understood and admitted by medical men that the death-rate in lying-in hospitals is larger on the whole than it is in private practice. Their statistics show a vast difference among them in this particular, some of them showing a mortality much less than that of some private practice. During the last five years the average mortality at the Blockley has been one in twenty-two. Of the twenty-one hospitals, the statistics of which I have examined, not one shows so great a mortality as this, while in several the mortality has been less than one in two hundred. By statistics like these, by the testimony of the physicians, and by my own observation, I am led to the conclusion that the mortality would be greatly lessened under different arrangements. This conclusion will be strengthened by considering certain incidents and conditions of the hospital that bear directly on the health of its inmates.

In common with all establishments of the kind, it shares in the fatal results that flow from the congregation of large numbers passing through this notable process of nature. Puerperal fever, that scourge of lying-in hospitals, has frequently appeared within its walls, in its most appalling forms, carrying off, one year, one

Its ravages were

in eighteen of all the patients under treatment. stayed by removing the women into the open grounds and sheltering them in sheds. Like other hospitals, too, this retains attached to its floors and ceilings, in some inscrutable manner, the germs of disease, ever ready, under favoring conditions, to be developed into some active form. Not a season passes in which this result is not apprehended, and frequently no amount of care can entirely prevent it.

In this as well as other departments, the old wretched policy has prevailed of employing paupers for nurses. Occasionally, a good one is thus obtained, but it needs little knowledge of human nature to perceive what kind of service can be expected from unpaid, or poorly paid, irresponsible women.

Besides the contagion of disease so active at the Blockley, there is contagion of another description, no less deplorable in its effects-that of vice. Lying-in hospitals are never schools of virtue, but if their inmates leave them morally worse than when they entered, we are bound to ask whether this sad result could not be prevented by some practicable change. Exposed as these women are, by lack of suitable means of classification, to others of their sex of the lowest morals, all of them more or less degraded by habits of intemperance, disease and sin, it would be little short of a miracle, if any one left without being all the more decidedly prepared to pursue the kind of life thus begun. And yet among these sinners are many in the very morning of life, more the victims of circumstance than the willing slaves of vicious propensities, anxious, if possible, to retrace their steps; but deserted and cast out, they readily yield to the wiles of temptation, especially when it comes in the shape of kindness and sympathy. These patients, at the end of the first month, if not before, should be sent to an establishment in the country, for the purpose of obtaining better sanitary conditions and shielding them from bad associations. For the others I am not sure that any change of location is practicable, even if desirable. The necessities of the case require close proximity to the city, and by the removal of some of the other departments sufficient room would be gained to prevent the evils of crowding, and permit a suitable classification. The interior of the house should be completely reconstructed, and better architectural arrangements provided fo

meeting the varying conditions of the patients. The whole system of pauper nursing should be abolished, and a corps of reliable nurses employed at fair wages. These changes would unquestionably effect the saving of many lives, and every year they are delayed will only add so many more deaths to our charge.

There only remains to be considered that department of the almshouse called the Children's Asylum, averaging about one hundred inmates. It is composed of children sent from the obstetrical wards as soon as they are weaned, of those who come into the house at a later period and of foundlings. They are well cared for, and I doubt if much could be done there that would increase their comfort or prolong their lives. Their food is abundant and of the most suitable kind, and they have the best medical attendance and faithful nursing. And yet the mortality in the asylum is very large. It is no part of my purpose to dwell upon this fact. It will be enough for those who wish to learn its details to refer to the carefully prepared paper read two winters ago to the association by Dr. Parry of this city. From this we learn that while about thirty per cent. of all the children in Philadelphia, two years old and under, died, the mortality of the corresponding class in the asylum was over seventy-three per cent. During the last two or three years the death rate has lessened, but still it is much higher than it is in common life. This excessive mortality can be charged to no single cause, but results from a combination of adverse influences, and therefore the evil would not be abated by the removal of any one of them alone, some, indeed, being beyond all human reach. But it is clearly our duty to do what we can in this direction-to dispose of these children in the manner which has been satisfactorily shown to be most conducive to health. Among the things on this subject which may be regarded as settled, is this, that foundlings thrive better in the country, even when nursed by hand, than they do in the city, though in charge of wet nurses. Unquestionably, the best disposition of the asylum would be to place it in the country with room enough around it to afford ample play grounds, and give it the necessary seclusion. If, however, it should be concluded to keep it where it is, the building should be thoroughly reconstructed, and the apartments differently arranged.

That a change of some kind, if not precisely that here advo

cated, in the disposal of our pauper classes, is needed, can scarcely be questioned, and it becomes only a matter of time. It would seem to need little argument to prove that the city cannot afford to keep its paupers on land worth one dollar the square foot. If a change of location is to be made, the sooner it is accomplished the better. The present buildings need extensive repairs to make them habitable, but it is money thrown away to lay it out on buildings soon to be abandoned. The Insane Department alone requires an immediate outlay of $10,000 or $15,000 on the roofs and floors, and as much more would be spent by any prudent landlord on other parts of the structure. There or somewhere else more patients must be provided for in order to meet the reg. ular increase of the insane. The need of more room is as imperative now as it was two years ago when the new buildings were called for. To continue this crowding together of the insane, as is still done at Blockley, is simply to perpetrate a great crime against humanity. To ignore the fact and to be reckless of the consequences, is no better in point of morals, than it would be for a railway company to use a bridge after it had been pronounced defective and dangerous. Removing the insane, the children and the paupers proper, into the country, ample room, but none too much, would be obtained for the hospital, while the land outside the present inclosures could be put into the market, if not previously given away. It has been proposed to remove our paupers, of all descriptions, I suppose, to buildings erected for them on the grounds occupied by the House of Correction. I trust this project will be abandoned. Besides the sanitary and moral evils which make the association of such large numbers exceedingly objectionable, the House of Correction would render all the other departments disreputable. We could commit no greater breach. of moral propriety than thus to place upon a single honest pauper, sane or insane, the stigma of crime. ISAAC RAY.