But all there was in writing was filed in the office on a 3×5 card, just the information required on a death certificate. Each time the patient was readmitted all the information was taken afresh, and the new card was clipped to the old ones, with the names of friends or relatives on the back. Sometimes an emphatic note said "Do not readmit this man." But the admission officer, even if he knew the applicant as an unwelcome guest, couldn't resist the bad actor's seeming repentance, and would administer a scolding, note on the admission card that he promised to stay, or to obey-anyway, to repent—and back came the boarder. The admission officer had been too busy to register the applicant with the Social Service Exchange. When I went to the City Hospitals I registered about one thousand persons with the Exchange and found that about 33 per cent were already known. No doubt we could have identified many more if our information had not been so meager. An admission office needs all the information and advice available in determining the eligibility of an applicant.

Now a carbon copy of all information taken at the admission office accompanies the man to the hospital. This includes the names, addresses, occupations of relatives who will bury him, and, if he has an army record, the question whether he has a pension, sick benefit, insurance, etc., which brings up interesting problems of how much responsibility the almshouse should assume in protecting these little bits of property from the clutches of otherwise indifferent relatives and friends. In the same way the hospital is trying to send back to the admission office any further information obtained later. The individual, on arrival at the institution, is seen and admitted by a doctor. We have acquired now a larger card for our records at the hospitals. About ten admissions can be made on the same card. There is room for more information; the identifying information is taken once, and in a form which will be true, presumably, for a lifetime. Every man has a dispensary history which starts with the physical examination made when he arrived, and soon we hope to have a history of that individual in his work life, if he was able to do any work as determined by the doctor-what he did and how he did it while in the institution. In time we hope that we will have a social card attached. When the man is discharged the whole history is returned to the admission office, to be waiting for him if he applies for readmission, and as a guide both to the admission office and the institution.

If we are going to improve methods of admission and records we are going to give ourselves more work, we are going to assume more responsibility. There is no point in opening doors if we are not prepared to enter. The admission office cannot do a good job unless it has a staff adequate to its work, and unless it can turn over its beginnings to others in the institution, trained in social work, to carry through. The almshouse is a very discouraging and depressing place to work; it is full of all the failures. But if one has any interest or sympathy for failures, any concern for the many community problems which an almshouse population reveals, there is much social work waiting to be done in city and county almshouses.

1

THE FUTURE DEVELOPMENT OF THE ALMSHOUSE

Ellen C. Potter, M.D., Secretary, Pennsylvania Department of
Welfare, Harrisburg

Poor law administration in the United States, particularly in the eastern United States, is handicapped by antiquated law and tradition based upon it. Speaking for Pennsylvania, with which I am most familiar, our poor law originated in the Elizabethan system. A general code, based upon the system of the mother country, was passed in 1771, adapted to the conditions of the colony. Responsibility for the care of dependents was thereby placed upon local governmental units. This act was reaffirmed following the Declaration of Independence and was not modified materially until 1836.

During the latter part of the eighteenth century, Pennsylvania's increase in population was exceedingly rapid because of her open-door policy in regard to emigration, and a problem of dependency and unemployment of considerable proportions was created. The burden became too heavy for certain of the smaller governmental units to bear, so in 1798 an act was passed "To provide for the creation of a house of employment and support of the poor in the counties of Chester and Lancaster," with the avowed purpose of providing that ablebodied paupers should contribute to their own support. This act became the model for seventy-eight special acts creating almshouse districts in the interval between 1800 and 1873. Since 1836 some changes have been made, but in principle our present system finds its basis in the old English law.

In consequence of the conditions just noted, we find ourselves with eightyfive almshouses which vary in size from small cottages to massive institutions; which render a variety of care from that of very poor custodial service to the best type of hospital care; and which depend for their support on a population which ranges from 1,661 in the smallest township unit to 1,800,000 in the city of Philadelphia; at a per capita cost per diem which varies from 41 cents to $4.77, with certain of the smaller institutions supported throughout the year by the taxpayers, but which serve no inmates. It is obvious that such a wide variation in type of structure, quality of service, per capita cost, and taxable unit requires that public officials should study the situation with great care and, in the light of the facts obtained, press for the necessary changes which will provide adequate and proper service at reasonable cost. The lack of economy in state, county, and municipal public service has been brought forcibly to the attention of the taxpayer both by the President and by the studies made by the Department of Commerce within recent months. This fact leads me to hope that we have arrived at the point at which the interests of social welfare and of big business (incidentally the big taxpayers) coincide, and that we may look for progress in the development of our poor-relief administration.

In Pennsylvania, in the space of two centuries, we have passed through four periods. In our first period we granted "doles" in the form of outdoor re

lief; second, we organized a "house for the use of the poor"; third, we established "county farms," on which able-bodied paupers were expected to pay their own way by work, and in addition to carry in part the expense of maintaining the other paupers; fourth, in which stage we now are, the "county farm" became the "county home," rendering kindly custodial care, but leaving much undone which must be done if we are to meet the needs of the present-day problem of dependency. Through all these periods the dole has continued as outdoor relief. This fourth period finds us with a very few of our present-day county homes emerging into a fifth phase, characterized by a real hospital service, while there are many, particularly of the township and borough almshouses, which are still operating after the fashion of 1729, when provision was made for the first "house for the use of the poor."

As a basis for thought in this matter we have two comprehensive documents, one issued in 1925 by the Department of Commerce, Bureau of the Census, entitled Paupers in Almshouses, and the other issued in 1925 by the Department of Labor, Bureau of Labor Statistics, The Cost of American Almshouses. In addition, Pennsylvania has been giving her own system of poor relief close study as a major project under the Department of Welfare, and the Pennsylvania Poor Law Commission has added material for consideration. Several comprehensive reports on old age pensions and mothers' pensions and workmen's compensation are also available. In addition to the material in our own special field we have pertinent studies in the field of vital statistics.

A consideration of all these data leads us to some very definite conclusions: First, the field of poor-law administration has in recent years been greatly restricted and the almshouse population diminished in proportion to the total population by the operation of military, civil, and industrial pensions and allowances to mothers with young children, and in addition by workmen's compensation and other forms of sickness and accident insurance; second, these forms of pension and insurance have, to a considerable degree, eliminated from the almshouse population the younger age groups, many of whom were capable of performing a good day's work in the fields or in domestic service; third, the increased expectation of life, the result of improved sanitation, and an energetic campaign of health education is insuring as candidates for almshouse care an ever increasing number of middle-aged and old persons suffering from the degenerative disorders of heart, kidneys, vascular system, and metabolic disorders (the statistics of Massachusetts show an increased life expectancy of 15.48 years in the last 55 years. The Registration Area of the United States notes an increase of 7.08 years in the last twenty years); fourth, the able-bodied in almshouses have decreased, according to the United States Census figures, from 21.6 per cent of the total inmates in 1910 to 7.1 per cent in 1923, in Pennsylvania 10 per cent being reported as able-bodied. This being the case, it is obvious that the almshouse population cannot be depended upon to run a farm or even to do the domestic work of the institutions successfully; fifth, the invest

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ments in almshouse plant and equipment are enormous and the costs of maintenance are excessive, especially in view of the unsatisfactory results obtained (the investment for the United States exceeding $150,400,000; that for Pennsylvania, $16,500,000; while the maintenance cost for one year exceeds $28,700,ooo for the United States, and for Pennsylvania, $3,100,000); sixth, the annual admissions to almshouses for the United States number 63,807, with 78,090 in residence on January 1, 1923. Of these, at least 32 per cent had been previously admitted for from one to four or more times. This percentage or readmissions is of interest as paralleling so closely the percentage of recidivists in our penal and reformatory institutions. Individuals readmitted to Pennsylvania almshouses constitute 25 per cent of the total; seventh, the duration of stay of persons discharged from the almshouse in a given year (1922) indicates, contrary to expectation, that they are relatively a transient group, for out of 44,066 inmates discharged or transferred, only 12 per cent (5,681) had been in the institution for more than one year. Seventy-eight of the number had been in residence twenty years or over. Pennsylvania's figures show that over 86 per cent remained in the almshouse less than one year.

It is obvious from the facts just cited that those who drift in and out of our almshouses are susceptible of improvement as to physical, mental, or economic condition, and that it is the part of statesmanship as public servants to utilize that fact as the basis of a constructive program for the benefit of the individual and the relief of the taxpayer. Pennsylvania taxpayers have in the last ten years paid $100,000,000 for poor-law purposes, almshouse expense, and outdoor relief, and yet the service tendered is such that no one wants to "go on the county," and no one willingly or cheerfully goes to the almshouse.

A consideration of the admissions by age groups is of significance. An individual, if in health, should be in the period of his full productive maturity between the ages of twenty-five and sixty-four. A study of the statistics shows that of 63,807 admissions for the year 1922, slightly more than 50 per cent fell within this age period. The question then resolves itself into this: Is there need for reorganization of our poor-law administration so as to diminish the number of those in the prime of life who seek asylum in the almshouse, to diminish the number of repeaters, and to give better value for the expenditure of public funds?

My answer to the question is that the time has come for such a change, and that we should frankly step forward into the fifth period in the development of the almshouse: from a county home to a county hospital with a fully developed social service department, the avowed purpose of this change of emphasis from "farm operation" to "hospital administration" being the physical and social rehabilitation of those capable of salvage and the intelligent institutionalizing of the residue. I make this emphatic statement because of our personal observations in Pennsylvania, which I will ask you to consider.

The inmate population of fifty-seven almshouses was studied for 1925. The

total number in care was 4,227. These inmates were seen personally by our representative, when possible in company with the physician employed by the directors of the poor, and a diagnosis was obtained in each case.

Using the classification of Dr. Boas, or New York, we found the distribution of cases in relation to need of hospital care as shown in Table I. Those whose

C (needing custodial care)

D (able to attend to their own personal needs, but able to do

little else).

physical ailments were sufficiently definite for diagnosis by the physicians (who all too often render merely perfunctory service) numbered 1,840. A rough grouping of conditions diagnosed is shown in the Table II.

It is interesting to note that for the year 1923 only 1.5 per cent of the total almshouse maintenance (for eighty-five almshouses) was expended for medicine

and hospital supplies, or about $5.89 per capita for the year for each of the 8,060 inmates. This will serve as an index of the inadequacy of the present medical service. It is obvious that adequate hospital service cannot be provided for patients in the small institutions run under the township and borough plan of poor law administration, and any effort to care for an individual who is sick and dependent is at excessive cost to the taxpayer, as witness this report which came to my desk this week: A township overseer of the poor, being called upon to provide for a woman who had suffered a paralytic stroke, the woman having re