Columbiana counties the largest district in the state, in point of population. The newest of the district hospitals was opened in 1918 at Chillicothe by Ross, Jackson, Pike, Scioto, Highland and Fayette counties.

The two new districts recently organized comprise, respectively, Ottawa, Sandusky, Erie and

Lorain counties and Wood, Hancock, Seneca, and Crawford counties. Commissioners of the former group of counties have decided to appropriate $125,000 for their hospital, while the latter counties will spend $100,000. The original proposal for the former district included Huron County and that for the latter included Wyandot County, but these two counties have not yet decided to join the districts. Sites for these new hospitals have not yet been selected. When these two hospitals are established, forty or more Ohio counties will be equipped wtih municipal, county or district tuberculosis hospitals, and the total bed capacity available for public use in the state will be approximately 1,700. It has been estimated that 5,000 beds is a minimum statement of what the state should have to exercise a reasonably effective control over tuberculosis.

Besides these two proposed districts which have effected preliminary organizations, establishment of hospitals is being seriously considered in two other groups of counties. Tuscarawas, Harrison, Jefferson and Belmont counties have organized on a temporary basis, with Carroll considering the question of joining them. Commissioners representing Guernsey, Noble, Morgan, Monroe Washington counties last month formed a temporary organization

and

also. In this latter group the purchase of the Rocky Glen Sanatorium, privately operated at McConnelsville, has been considered as a possible solution of the district's problem. trict's problem. Other proposed districts, in some of which there is an encouraging amount of interest in tuberculosis hospitals, are indicated on the accompanying map.

The eleven existing state, county, municipal and district sanatoria, according to as accurate an estimate as can be made in the absence of exact figures in many instances, represent a capital investment of over two and one-half millions of dollars (see the accompanying table for detailed figures by institutions). Comparison between costs of various hospitals are best made on the basis of cost per bed, and even this comparison is misleading in many instances. Butler County's hospital, for instance, while its cost is extremely low, lacks much of the equipment which is essential to efficient work, and both it and the Lucas County institution are located on infirmary ground, involving no outlay for site, power, water supply, sewage disposal, laundry, etc. The low cost of the Springfield hospital is attributable to the fact that it is housed in a former dwelling, purchased at a low price but not entirely satisfactory as a hospital structure. While the Springfield Lake cost per bed runs abnormally high on the basis of its originally designed capacity of 110, that institution has succeeded in caring for 130 patients without increasing its capital investment, making the actual cost per bed little more than half the sum stated in the table. The State Sanatorium has a heavy investment in administrative buildings and could make extensive ad

ditions to its bed capacity with a comparatively small expenditure. The new Dayton hospital includes a power plant and service building sufficient to supply the needs of a 100-bed hospital, and will have a cost per bed of approximately $1,750 whenever cottages are erected (costing about $50,000) to enlarge its capacity to that figure.

The Dayton and Chillicothe costs, since these institutions are the ones most recently constructed, nay perhaps be taken as the best indication of the investment necessary at present to establish a satisfactory tuberculosis hospital. In view of rising costs of construction, these figures ($1,750 and $1,560 per bed, respectively) are probably a little below the amount that would have to be spent now. In general the State Department of Health is advising new districts to figure on a maximum expenditure of about $2,000 per bed. On large institutions this cost can be reduced somewhat, but it is probably a fair estimate of the cost on a moderatesized hospital such as most districts. prefer as a beginning. With the necessary administrative buildings erected, cottages can be added at a cost of about $500 per bed.

No definite statement of maintenance cost can be made, as the hospital records are mostly incomplete in this regard. The unit for comparing maintenance cost is the cost per patient-day- the average cost of keeping one patient for one day. Such figures as are available indicate that this item amounts to not less than $1.50 per patient-day. Two dollars is considered a more accurate estimate, taking into account the general rise in prices. Relatively low overhead costs will make the maintenance expense per patient-day, like the cost per bed,

lower in the large institution than in the smaller one. In this fact lies one of the great arguments for building district rather than county hospitals - the other important point in favor of the large institution being that it can obtain a higher grade of personnel than the small institution at a cost proportionately no greater.

The cost of constructing a hospital (capital investment) is divided among the counties of the district in amounts proportionate to their respective tax duplicates. Maintenance costs for a given year are apportioned according to the number of patient-days' treatment received by patients from each county during the year.

In the existing hospitals of the state there is no uniformity in executive and administrative organization. In theory the administrative authority rests with the board of trustees, which determines the general policies for the conduct of the institution and employs officials to put these policies into execution. There is wide variation in the distribution of tribution of executive powers among these officials and in the degree of freedom from interference by the trustees which they enjoy. In the large municipal hospitals, entire executive authority centers in the medical superintendent, who controls both the medical and the business sides of the hospital's activities, untrammeled as to methods by the trustees but responsible to them for the satisfactory carrying out of their policies. In the district and county hospitals centralization of executive authority in the superintendent is rare and there. is in most cases considerable disposition on the part of the trustees to oversee in considerable detail the methods followed by executive

officials. In these institutions, the medical head is ordinarily a parttime man, and he usually controls only the medical side of the hospital, business administration being ordinarily in the hands of a matron. Each of these officials is independent of the other and responsible only to the trustees. In the Dayton district, which comprises only two counties and therefore has only two trustees, this retention of control by the trustees works well enough, because of the small size of the board. In a large district, however, such as all the other districts are, division of executive authority and detailed supervision by the trustees naturally hinder efficient management of the hospital, inasmuch as minor questions of management, which could be settled instantly by an able superintendent, must be threshed out in a meeting of a half-dozen trustees.

Passing from methods to results, one need not go deeply into the subject to see that the full purpose of the tuberculosis sanatorium is not being achieved in most cases. The hospitals are devoting a far greater share of their time to advanced, incurable patients than they are to those in the incipient, curable stages of the disease. A summary of hospital admissions. during the three years 1915, 1916, and 1917, classified according to degree of advancement, gives the following statistics: early cases 580, moderately advanced 1,117, advanced 924, far advanced 511. The early cases and a certain unknown percentage of the moderately advanced cases may be considered reasonably curable; the chances for cures in the remainder of the moderately advanced and in the two other advanced classes are

slight. It is safe to say, therefore, that during the past three years more than two-thirds (possibly three-fourths would be a nearer estimate) of our hospital facilities. have been devoted to the care of cases not capable of cure. The figures on discharges during the same period bear out this statement, showing that 367 cases were pronounced arrested upon discharge, 994 improved and 924 unimproved, and that 847 cases (more than twice as many as were arrested) died in the hospitals. That some of these cases pronounced "improved" would have been arrested had they remained in the institutions longer, is a reasonable assumption. The explanation for this situation, of course, is the inadequacy of our present hospital capacity; the immediate need for taking care of advanced patients causes them to be sent to the hospitals, while many in earlier stages have to remain on the waiting lists as long as they are able to support themselves. Hospitalization of advanced tuberculosis cases is a valuable public health measure, inasmuch as it removes dangerous centers of infection from the community, but the arrest of cases before they reach the stage of menace to other persons is equally important.

The preceding paragraphs outline the hospital equipment available for anti-tuberculosis work in Ohio. Roughly speaking, we may say that we have about one-third the equipment which we should have. The two main needs, therefore, to be considered in discussing the future of Ohio's tuberculosis hospitals are these: the district system of organization must be extended until every county has a share in a hospital, and the useful

ness of each hospital in its own district must be greatly increased.

The increase in the number of districts, as has been noted, has been unusual in recent months and can be expected to continue steadily through the next years. The accompanying map shows where the field for extension lies, and work which has already been done in some of these proposed districts has been outlined in the foregoing paragraphs. With the law making organization of a hospital district a purely voluntary matter for the counties involved, the work of the State Department of Health is of necessity confined to the spreading of propaganda to impress upon county commissioners and the general public the need for such institutions. Representatives of the Department's Division of Tuberculosis are always ready to attend joint meetings of commissioners to discuss hospital projects. Local organizations of persons interested in promoting the public health can render valuable service in arousing the public to the importance of anti-tuberculosis meas

ures.

Extension and enlargement are means by which the hospital can increase its usefulness to the district. Enlargement of bed capacity is an obvious need in most district hospitals, the initial work having been done on a small scale with the idea of gradual development. Just how much enlargement is necessary in a given case depends upon. many individual considerations. In general, however, it may be said. that the minimum standard for a district hospital's capacity should be a number of beds equal to the annual total of tuberculosis deaths in the district. Figuring on the estimate of five living cases to each

death (probably much too low an estimate), the suggested minimum standard will mean that the hospital can give six months' care per year to forty percent of the cases in the district. Six months, again, is a minimum estimate of the average time which the patient ought to spend in the hospital to attain a reasonable degree of improvement, although it is more than the present average stay in Ohio. Forty percent of the existing cases is probably quite a reasonable estimate on the number which should have hospital care, both for their own protection and for that of the public. This estimate of needed bed capacity, therefore, must not be taken as a statement of the ultimate goal toward which a district should strive; it is rather a statement of the smallest amount of equipment with which the district should be content to operate for any considerable length of time.

Extension of the sanatorium within its district means the carrying out of the full intent of the district hospital law. The plan which such extension should follow is, in brief, as follows: Restriction of the district hospital's facilities to incipient cases; establishment in each county of a branch of the district hospital, under the jurisdiction of the district hospital's medical superintendent, for the care of that county's advanced cases; establishment in each county, also subject to the medical superintendent's control, of a tuberculosis dispensary, with one or, more nurses attached to it. This broadening of activities should be preceded or accompanied by a reorganization of the hospital management so as to give entire executive control to a full-time medical

superintendent. Such a plan of