country or to keep their people from contact with America. The establishment of Jewish, Polish, or Italian hospitals springs rather from the failure of nearly all American hospitals to adapt themselves to the special demands of the immigrant.

NEED FOR A COMMUNITY PLAN

The desirability of separate immigrant hospitals must be finally judged by its effect upon the best medical service to the community. Many small unrelated hospital units, each serving a special group, are not so efficient as a smaller number of large related units.

If a community has ten hospitals of from fifty to one hundred beds, each can command only a limited amount of the highest grade of medical service in the various branches of modern medicine and surgery. Most of them will find it hard to provide adequate laboratory and X-ray facilities and other expensive but necessary diagnostic and therapeutic equipment. They cannot readily secure the best grade of skill for their executive officer, for the head of the nurses' training school, or for the various housekeeping departments.

The location of each is likely to be planned independently, without relation one to another or to the needs of the community as a whole. The distribution of beds among the various types of medical and surgical service cannot be nearly so effective in ten small independent units as in three or four large ones.

It is difficult to bring ten small institutions into effective co-ordination one with another and with the outside medical and health agencies of the community.

This is particularly true if several of these ten hospitals have special affiliations with race groups.

There must be a hospital plan for the community as a whole. The scheme for the town of ten thousand will differ radically from that for a great city, but no hospital can work at any problem, such as adaptation to foreign-born patients, with full effectiveness, unless most or all of the hospitals of the community are working with it. Such a community plan is discussed in a later chapter and applies to hospitals as well as other institutions.

At the opening of this chapter hospitals were classified under two fundamental types-public service and proprietary hospitals. The direct bearing of this study has been obviously upon hospitals of the first class; but in many large cities a considerable number of the hospitals are proprietary, and not a few of the smaller communities have no other hospital facilities. Clearly, a hospital which is established as a business enterprise can serve only those who can afford to pay a profit as well as a price for their care. Individual charity cases can be taken but rarely.

Proprietary hospitals cannot be expected to adapt their service to any special group of patients except on a business basis. Either the community must establish its own hospital or else arrange with one or more of the proprietary institutions to take partpaying or free cases at public expense. Such arrangements are not infrequent, the proprietary hospital receiving a per capita return for this public service from the municipality, the county, or an industrial establishment.

Such arrangements, however, do not render the

administration of the hospital sufficiently sensitive to community needs and to the requirements of particular types of patients, the foreign born among others. The only adequate remedy for this situation is the relegation of the proprietary hospital to its proper sphere of serving the well-to-do, and the development in all communities, or at centers accessible to all, of hospitals founded primarily on a publicservice basis.

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XV

THE DISPENSARY

THE increase in the number of dispensaries in the United States during the last twenty years has been one of the outstanding features in medical and publichealth work. The earliest dispensaries, as the name implies, were places for distributing medicine to the poor. The modern dispensary includes a group of clinics for treatment in most or all of the chief specialties of medicine and surgery. The giving of medicine is now incidental. The modern dispensary is a place for organized, or institutional, medical service to patients who are able to be up and about. It is an institution complementary to the hospital, whose patients are in such condition that they must be in bed.

Most of the larger dispensaries are branches or, as they are called, out-patient departments of hospitals. Some of equal size are independent of hospitals. The growth of these institutions has been very considerable; at the opening of the twentieth century their number did not much exceed one hundred, whereas in 1917 there were about nine hundred in the United States. The greater number of these were in the larger cities, particularly in the East and Middle West. 1 Davis and Warner, Dispensaries, Their Management and Development, pp. 4-36.

Even more striking has been the development of the public-health dispensaries, established as the outcome of one or another of the militant health movements, such as the antituberculosis or infant-welfare campaigns. These clinics are usually local in their range of operation, and small compared with the large dispensaries treating general diseases. They were practically unknown before 1900. A few tuberculosis clinics had been started previous to that year-not more than twenty in the whole country. By 1917 there were estimated to be thirteen hundred of these various special dispensaries, and the number was greatly increased during the war, owing to the stimulus given to campaigns against infant mortality and venereal disease.

Some of the public-health dispensaries confine their attention to preventive and educational work, such as advice to mothers concerning the care of babies and the supervision of baby feeding. But the tuberculosis, venereal disease, and mental clinics, and to a greater or less extent the infant-welfare clinics themselves, diagnose and treat disease as well as push educational and preventive measures.

It is important to bear in mind the general distinction between the large, centrally located dispensary, usually an out-patient department of a hospital, treating patients in many specialties of medicine and surgery, and the public-health clinic, usually drawing its patients from a limited area and confining itself to a special branch of work. A third type combines features of the first two. It is the dispensary of moderate size, including a certain number of specialties as well as general clinics, and reaching a more or less