The sanatorium should not be considered primarily either a hospital or a boarding house. It should be so conducted as to make the patients satisfied and willing to stay. It should be borne in mind that happiness is essential to the recovery of the tuberculous.

There are very considerable difficulties in adapting a hospital dietary to foreign-born patients. Several different nationalities may be present in the hospital at the same time, each represented by a varying number of patients. Considering, however, the importance of the food problem, it is surprising that a selected group of professionals in charge of the diet in a number of leading hospitals should have given apparently so little thought to the problem and made so little attempt to solve it.

Judged by the food test, the American hospital has not made any noteworthy effort to adapt itself to the foreign born. Chapter XI of this book, devoted to the food problem of the foreign born in relation to health, presents certain material and practical suggestions which bear upon the hospital dietary.

USES OF INTERPRETERS

Another point at which American hospitals can be adapted to foreign-born patients is in the use of interpreters. The hospital, as well as the visiting nurse, must find some way of communicating with the patient who speaks no English; but in the case of an institution to which the patients all come, it is a simpler problem to furnish interpreters than to the individual nurse who visits many homes. It is relatively so simple an administrative problem that it is hard to

believe so little has been done in the country to meet it.

A list of 30 well-known hospitals was prepared, each located in a city with a large immigrant population, and each known to be receiving a considerable proportion of foreign born. Inquiry was made, usually by personal letter, in a few cases by interview.

Reports received from 21 of the 30 reveal the following condition. One hospital employs 1 paid interpreter. This is one of the largest municipal hospitals in the country, with about 2,000 beds and a very large out-patient department. Of course, the employment of a single interpreter in an institution of this size, which receives patients from practically all immigrant races, is almost humorously inadequate. Fourteen of the 21 hospitals call upon employees or patients to interpret in various languages as needed. Five hospitals are not doing anything at all about interpreters, except occasionally.

Of the 14 hospitals which depend on patients or employees, 4 say that the method is not satisfactory in meeting their problem; 10 express themselves as reasonably satisfied with the scheme. In 2 of these 10 cases the so-called "star employee" is mentioned, some one who has been with the hospital quite a while, who is able to speak a number of languages, and who is called from his regular job, when necessary, to interpret. One large hospital has an arrangement with the United States Immigration Office and some local organizations of the foreign born to supply interpreters whenever needed.

These 21 hospitals are all large institutions, selected because of their location in foreign-born communities.

Their work naturally suffers from the inadequate system of interpretation. Patients' names and addresses are often obtained with difficulty or inaccurately. The medical history is taken under great risk of error or omission if the recorder has no knowledge of the immigrant's language and no satisfactory interpreter. The barrier of language raises serious obstacles to maximum efficiency in the administrative or medical work of the hospital. This is recognized by a considerable proportion of the superintendents of these 21 hospitals. Many, however, point out the difficulties in the way of securing satisfactory interpreters. One says:

We do not employ paid interpreters, but have to struggle along the best we can by utilizing employees or other patients for the purpose. Our experience in the matter is that the need of interpreters is very irregular and widely distributed over many languages and dialects, and we have been unable to formulate any working plan that will basically meet our needs and justify a definite salary schedule to cover the problem. Hence, in making our engagements with employees we try to bear in mind our need of interpreters when talking to applicants.

Another says:

I took a census of the hospital at one time and found we had as patients persons speaking fifteen different tongues, and it would take several interpreters to cover all of these languages. While we have been inconvenienced at times, we usually get on very well. For instance, I have an Italian orderly in our receiving ward, and we have had a floor polisher who speaks two or three of the Slavic dialects. We seem to have no difficulty in handling the French and German. There is, of course, some objection in taking a man from his work to do interpreting, and yet it is less

expensive than having a special interpreter. I think that I can safely say that for a considerable time our records have not suffered from the fact that we could not get a history on account of the language.

These two letters point out some practical reasons why hospitals have so generally failed to employ paid interpreters, and have depended so largely upon employees or patients who speak the needed languages. However, the admitting officer or the hospital internes must secure information concerning the medical and social history of the patient which an uneducated interpreter is often wholly unable to obtain. Whether in this respect or in meeting the patients' human needs, good interpretation can rarely be secured by this casual system.

Another attempt at solving the problem is illustrated by the following statement from a large general hospital in a Middle Western city.

We do not employ paid interpreters. Occasionally we do use employees or other patients, but in the majority of instances we rely upon other associations in the city for this work. The various councils give their services gratis in cases of necessity; and other institutions, such as the House of Friendliness, the Americanization Society, and similar organizations, will send interpreters to the hospital on request, who give their services without charge. We have found this arrangement to be very satisfactory, but I imagine that in some of the larger cities where this problem is a more difficult one the question of a paid interpreter would receive very earnest consideration.

It is apparent that in overcoming the language barrier a certain number of hospitals have made a distinct effort, and the hospitals show up much better

in this respect than in dealing with the food problem. Yet it is again apparent, generally speaking, that hospitals have dealt with the problem of interpretation only as a succession of incidental emergencies which had to be met as well as possible, on the spur of the moment, by utilizing employees or patients without any systematic plan.

One reason that even large hospitals have considered it financially impossible to maintain a corps of paid interpreters has been their failure to realize the full use to which these might be put. Hospitals having large out-patient departments, with many patients who speak no English, have too often regarded them as a subsidiary or unimportant element in their work, and starved them financially. Taking the patients of the hospital and the out-patient department together, the number of those speaking a given foreign language is sometimes sufficient to require the entire time of an interpreter. The use of full-time interpreters, however, must necessarily be limited to very large. institutions.

Smaller hospitals should solve the problem of interpretation by depending upon specially trained nurses or social workers or upon outside organizations interested in or composed of the foreign born. The latter should be encouraged to visit patients of their own race who have no other friends, and to help with difficult and special cases where interpretation is beyond the power of the hospital employees. Enough hospitals use this sort of outside co-operation to show that it is gladly provided by immigrant organizations and by American immigrant-welfare societies, without cost to the hospital and with mutual benefit. Such an