All of these evils have at various times been the subject of complaint, investigation and attempted remedy. The problem as a whole, however, remains obvious, deprecated, but unsolved.

To the President of your Association we are all deeply indebted for a careful study of this subject with his incisive criticisms and suggested remedies. The key-note of Dr. Goldwater's plan is a more equal distribution of numbers among the dispensaries and leads up directly to the plan of operation which it is my purpose to outline in this paper.

In the past few years, however, a new factor has appeared to further complicate the difficulties in the way of satisfactory dispensary work. This is the advent of the "Social Service Idea," in medicine, which has found its widest application in dispensary practice. Fostered in Boston under the stimulating influence of Dr. Richard C. Cabot, and his associates, this tardily recognized phase of medical work among the poor has been enthusiastically taken up, and must now be recognized as an essential feature of any comprehensive plan for the rehabilitation of dispensary administration. Based as it is upon a close study of the patient as an individual dependent in disease as in health, upon his circumstances of life, his intelligence and educaton, his occupation and his home surroundings, Social Service goes far to meet the demands of modern medicine for a rational system of therapeutics. Inasmuch, however, as its success depends absolutely upon individualism in the management of each case, and the scrupulous attention to every detail, the machinery necessary for its satisfactory operation is both considerable and expensive.

According to this plan, a dispensary physician can treat only a few cases instead of "running off" a multitude. A salaried nurse or visitor must keep in touch with the home life. Individual effort and personal instruction, and possibly costly apparatus takes the place of routine medication; and the social needs which are unearthed call for remedies which usually mean financial expenditure.

Personally, I am far from discrediting all of the good work and personal sacrifice that has attended dispensary work in the past, simply because a newer and wider sphere of its application is now suggested. Exaggerated statements of the futility of all that has been done in the past can only

react unfavorably upon themselves. It is nevertheless also useless to deny that the strength of this recent movement lies in the inherent truth of its fundamental principles, and that therefore it must be accepted and provided for as a necessary addition to the dispensary work of the future.

Happily, however, experience thus far tends to indicate that instead of further complicating the situation, the application of these new principles may in themselves help to solve many of the dispensary problems with which we have been burdened.

As the horizon of dispensary work has thus widened, we have discovered that it touches on all sides other social and charitable activities, and that the dispensary problem can no longer be considered a separate entity, but only one factor in the more complex question of adequately meeting the responsibilities of the community toward the sick poor as well as providing for the necessities of the individual.

Working side by side with us we find the social workers; these may be from the neighborhood settlements, the churches or the charitable societies, and each is striving along different lines to aid the individual sufferer from disease or poverty.

Either one of two results is inevitable under such circumstances. These various interests will be found disastrously interfering with or duplicating the work of the other, or they will join forces in efficient co-operation. Here and there in the process of adaptation, examples of the former alternative are probably unavoidable, but it is towards the latter that all successful effort must tend.

Results in this direction have already been noticeable in two departments of the dispensary, Pulmonary Tuberculosis and Diseases of Children.

In New York the management of tuberculosis patients has been placed upon a fairly well systematized basis, and it is natural that in this disease the new teachings of sociological medicine should be most quickly appreciated because of the numerous social aspects of tuberculosis and the widespread campaign of education that has been for some time. directed against it.

The Special Tuberculosis Clinic was an early result of these teachings, the main features of which may be summarized somewhat as follows:

First: Greater individual attention and study are given. to each patient by physicians who are more interested and more skilled in their treatment than is the case in a general dispensary class.

Second: More complete control of the patients is possible both in the waiting and consultation rooms, so that any danger of infection to other patients is minimized.

Third: By means of visiting nurses, the social conditions and home surroundings of each case are studied and supervised in conjunction with the advice and treatment given at the clinic. A widespread campaign of education is thus carried on in the tenements.

Fourth Extra diet in the form of milk and eggs is. given to such patients as are unable to supply themselves. Such diet is dispensed upon the physician's prescription as a part of the treatment, and not as charitable relief.

Fifth Close association with charitable societies, sanatoria, hospitals, and other facilities are available for any patient, and to place any such care or assistance at his disposal as may be necessary.

Sixth Patients who are discharged from hospitals and sanatoria, upon returning to the city, are supervised both at home and at the clinic, and the danger of a relapse is consequently much diminished.

The first of these clinics was established in New York a little over five years ago, and there are now eleven such in the Borough of Manhattan and Bronx, and three in Brooklyn.

It very soon became evident, however, that even these special clinics left a good deal to be desired, and that many evils and defects still remained. The chief among these defects were a lack of uniformity between the methods in operation at the different clinics, an insufficient knowledge on the part of the clinic physicians of the modern scientific principles upon which the social portion of the work should be conducted, and the waste of time and energy occasioned by each clinic sending nurses to visit its patients in all parts of the city indiscriminately. It was apparent, therefore, that some co-operaton between the different clinics would be necessary to insure truly efficient work.

Fortunately for our purpose the physicians in charge of the various clinics were at the time brought together regu

larly each week to dispense a tuberculosis relief fund by the Charity Organization Society with whose representatives we formed a special committee for this purpose.

These conferences resulted in a clearer mutual understanding of the problems involved, both on the part of the physicians and of the charity experts, and later when this relief fund was exhausted the committee was re-organized to form the Association of Tuberculosis Clinics, with the clinic physicians as active members and the representatives of the various charitable and social organizations who are interested in tuberculosis as associate members.

The purposes of this Association are as follows:

First: To organize dispensary control of pulmonary tuberculosis in New York City.

Second: To develop a uniform system of operation of such dispensaries as are organized for this purpose.

Third: To retain patients for observation until they are satisfactorily disposed of and to prevent them drifting from one dispensary to another.

Fourth: To facilitate the attendance of patients at the dispensary most convenient to their homes.

Fifth To facilitate the work of visiting nurses in the homes of patients.

Sixth: To provide for each patient requiring it, assistance by special funds or benevolent organizations and proper hospital or sanatorium care.

Seventh: To co-operate with, and assist as far as possible, the department of health in the supervision of pulmonary tuberculosis.

The most radical, and at the same time the most successful, attempt to secure co-operation between the various dispensaries has been the adoption of a district system for the whole city.

The advantages to be derived from such a system are obvious and they have all been realized. The patient no longer takes a long fatiguing journey to the clinic, and he makes the shorter trip oftener; the nurses can visit more patients and each one more frequently; the physician can exercise better supervision of each case, and require more careful attention to details from both patient and nurse. The

dispensary rounder thus becomes an impossibility, and the nurse's investigation in the homes eliminates the abuse of the dispensary by patients who are able to pay.

Our method consists simply in referring each applicant at a clinic who does not live in the district to the proper dispensary, a reference card being used, one half of which is given to the patient and the other mailed to the clinic. Should a patient so referred not appear within a week, he is looked up at his home by the nurse from the clinic which has received the notification of his transfer.

The chief objections that have been raised to such a system are:

1. The reluctance of the patients to give up their free choice of physicians or institutions.

2. The unequal distribution of numbers among the clinics, and

3. The hesitation on the part of teaching institutions to part with their interesting clinical material.

In experience, none of these anticipated objections has materialized. There have been practically no complaints on the part of the patients; the numbers at all of the clinics have increased because of more efficient visiting, and the better care given to the patients; and a little adjustment of district boundaries easily corrected the slightly unequal distribution that resulted at first; and as for teaching, all clinics have had more material than ever before.

During the first year nearly 1,100 cases were transferred between the various clinics according to the above described plan, and at the present time in the neighborhood of 250 patients are being transferred each month. Eventually we hope to have each district so compact that every house in it will be familiar to the clinic nurse. This will require the co-operation of a much larger number of the dispensaries in the city.

That this should not be difficult is evidenced by the results of a canvass of all the dispensaries of the city that has been recently made under the combined auspices of the Association of Tuberculosis Clinics and the Public Health Section of the Academy of Medicine.

By means of this investigation, valuable information has been obtained concerning the character and amount of work