In the almshouse at the middle of the nineteenth century were gathered children, insane, feeble-minded, the sick, the aged, and vagrants, with little attempt at classification, and with no facilities for providing special ized care for different classes of inmates. There are some states in which primitive conditions of this kind are still to be found. The devolution of the almshouse proceeds by such regular stages that the character of its population and of its administration are a fair index of the state of public sentiment, and of the degree of enlightenment which the community has attained. The removal of the insane to special hospitals, in which they are looked upon as sick persons, rather than as paupers, and in which there is a large expenditure for the treatment of those whose condition is acute and curable, is one of the early stages in the differentiation of the almshouse population. The cost of the care of the insane is, of course, likely to be greater after this separation has been made because higher pro fessional skill is brought to bear upon their treatment, a more appropriate dietary introduced, a higher degree of comfort maintained, and an environment created favorable for recovery. The knowledge of these improvements will inevitably attract, as it is desirable that it should, persons whose affliction might otherwise be concealed, or for whom at least no suitable treatment would have been provided. Strict investigation of admissions, reinvesti gation from time to time, and the prompt discharge of patients who have recovered, or are so far improved as to make further hospital care unnecessary, and the enforce ment of payment— in whole or in part — by those who are found to be in position to make such payment, are the means by which the abuse of public hospital relief can be prevented. It is not necessary that any conditions favorable to recovery shall be lacking to keep the growth of the population of the institution in check. Lavish expenditure for unessentials is, of course, to be con demned, but expenditures for the curably insane have been niggardly and inadequate far more frequently than they have been excessive.
The removal of children from the almshouse to separate institutions, or to the care of placing-out agencies, is another step so obvious and so imperative that it is strange to find communities in which it has not yet been taken. The association of dependent children with adult paupers is directly demoralizing, but even if they were kept physically apart, the complete absence in the alms house of any suitable educational facilities, and the im possibility of providing any of the features of a natural environment for growing children, would of themselves condemn the practice of receiving children into any such institution. So great is the temptation to effect a petty economy, and so ignorant are many local officials charged with the support of the poor, that statutory prohibition of the reception of children into almshouses is justified, and even the enactment of such statutes has accomplished the removal only with difficulty.
The epileptic have also, in several states, ceased to be inmates of the almshouse, and have been removed to special institutions, some of which are conducted on the farm colony plan. The uniform effect of this change,
accompanied by a study of the disease and of the more efficient application of approved methods, has been a lessening in the frequency and severity of attacks. For a fair proportion of epileptics the colony becomes a means of self-support. With the sympathy and special attention given within the colony, patients are able to do an amount and kind of work that fully recompenses the state for its outlay on their behalf, although such patients might not be able to care for themselves under the conditions prevailing outside the institution. Feeble-minded and idiotic persons, whether children or adults, are also more humanely cared for in special institutions created for them, and in many institutions improvement in their physical and mental condition can be brought about.
Hope of greatly increasing the number of recoveries has not been to any great extent realized. In New York State a threefold classification has been made : teachable, feeble-minded children being cared for in one institution, feeble-minded women of child-bearing age in another, and unteachable idiots in a third. In the first of these stress is laid upon education, in the others upon custodial care, with, however, the introduction of whatever will make life more endurable, or will lead to the improve ment of individuals who may be found to be teachable. The custodial asylum for women has had an appreciable effect in lessening illegitimacy, and especially in pre venting the propagation of various forms of degeneracy in which feeble-mindedness is a connecting link from generation to generation.
Connected with the almshouse there is usually a hospital, and in those of larger size a series of hospitals, enabling more acute cases to be separated from those of a chronic kind. Consumptives, mentally disturbed pa tients who cannot be considered insane, and other special classes may also be treated in special wards or hospitals if their numbers are sufficient to warrant it. There is a disposition to make a more complete separation of hospi tals, however, from the almshouse proper, even if they are under the same administration. Those who are patients in the hospital are treated rather with reference to their diseases than as paupers, as the insane, children, and the physically afflicted have already come to be treated according to their respective needs, rather than merely as public charges to be fed and housed at the least possible expense. In a striking paper published in Charities,' Homer Folks, Com missioner of Public Charities in New York City, raised the question as to whether, after the elimination of various classes from the almshouse, we have not left, instead of an undistributed residuum, merely a final special class, viz., aged or infirm persons who are, after all, quite as much entitled to be treated with reference to their special needs as any of the various classes that have previously been removed. Mr. Folks shows that the almshouse has 1 Monthly magazine number, October 3, 1903.