done at each dispensary, and also a definite statement from some one in authority as to the probable attitude of each institution toward co-operation with the work of the Association.

For our present purpose it is interesting to note that of the 67 dispensaries in the city 19 now have visiting nurses, and the home conditions of patients are said to be investigated by 21. Thirty-six of these dispensaries state that they are in favor of the extension of the special tuberculosis clinics, 11 that they are opposed to such extension, and 20 are non-committal. Forty-five are willing to co-operate with the present district scheme for tuberculosis, while 11 are unwilling, and 11 do not state their position. These figures are encouraging when it is realized that no special effort has been made as yet to influence these dispensaries, and shows that a spirit of co-operation and a need for the social service idea is already felt among the various dispensaries of the city, and that the time is ripening for the application of these same principles to general dispensary work.

The lines along which this development is likely to occur are not difficult to see. Already, as has been said, many dispensaries are re-organizing the department of children's diseases, and include visiting nurses with the resulting home supervision and instruction. A few also are leading the way where the others will be forced soon to follow, in the establishment of a similar system for the more general classes of medicine and surgery in the dispensary.

The history of our experience in tuberculosis will undoubtedly then repeat itself, and the extension of dispensary supervision into the homes of the patients will bring with it the solution of many of the vexing problems of the abuse of the dispensaries.

Improper dispensary patients will be excluded, the overcrowding will be diminished, and the dispensary practice will become much more satisfactory and valuable both to the patient and to the physician. More than this, however, the necessity for co-operation with other dispensaries will soon be apparent, and toward this need I believe that no one plan would be more helpful than that some sort of district apportionment between the various dispensaries. This, in fact, becomes practically a necessity as soon as visiting nursing is instituted. That numerous theoretical and practical

difficulties lie in the way of such a scheme I am well aware, but as is in the experience of our Association these have practically disappeared in the management of tuberculosis, so I am confident it will be with other dispensary work.

Less difficulty will in our experience be encountered with the patients and the physicians than with the dispensary managers and the medical schools, but here, too, the old ideas of rivalry in point of numbers and of mutual jealousy, are disappearing, and in their stead is coming an honest endeavor that the best possible service be given to each individual patient, and that all similar institutions shall join hands for the best interests of the whole community.

The development and re-organization of this Association of Tuberculosis Clinics of New York has certainly resulted most successfully for the solution of many aspects of this tuberculosis problem, and that it may also be of value as a working basis for similar efforts in the general dispensaries does not seem either improbable or impracticable.

To those who have been privileged to practice medicine in the dispensary under both systems, the one which has been described of a sociological, in addition to a medical basis of study, and a limitation of the work of each dispensary to a definite geographical area, offers such enormous returns both in satisfaction and efficiency that doubt of the ultimate solution of dispensary problems along these lines seems impossible.

THE DEVELOPMENT OF THE WORK AND THE RESTRICTION OF THE ABUSE OF THE OUT-PATIENT DEPARTMENT.

JOHN M. PETERS, M.D.

Rhode Island Hospital, Providence.

Five years ago the question of medical abuse was discussed at one of the meetings of this Association, and it has been thought wise to bring up the subject again at this meeting. I have recently written to the superintendents of thirty hospitals in regard to the practice of checking this abuse, and have learned that in most of them means, more or less satisfactory, were employed to check it. The most satisfactory system of meeting or lessening this abuse seems to be by the employment of one or more agents who question applicants as they apply for admission, and by the refusal of admission to such applicants to the dispensary as seem, in the judgment of the agent, to be doubtful charity cases. In some hospitals this work is done by a trained medical man, generally the assistant superintendent; in others by a paid agent who devotes his time to this work; and again in others by trained workers in charity who not only question applicants, but who visit them at their homes and work in conjunction with other charity organization workers who are brought in contact in one way or another with the several charities in their citties. In the answers submitted to my questions, the per cent of rejected applicants varies from one per cent in one of the large general hospitals to eight and one-third per cent in another smaller one. One of the hospitals, The Lakeside of Cleveland, employs two visiting nurses, one of whom investigates all doubtful cases. The Toronto General gives to the applicant a card to be signed by a physician or clergyman for second examination or treatment, stating that the patient is not able to pay. The Michael

Reese Relief Bureau investigates both in and out-patients and reports are made in two days. There are many applications in this work such as in teaching hospitals. One hospital requires a doctor's certificate for all cases, except emergency, before admitted to the department.

In the Massachusetts General Hospital there were refused treatment to 1,678 patients in one year, 2,161 the next year, and 1,778 the next. The use of a social worker in connection with the O. P. D. as commenced at the Massachusetts General Hospital by Dr. Richard C. Cabot is a great step forward and has been adopted by other hospitals. "A social worker," as so well stated by Dr. Linsly R. Williams in the N. N. Medical Journal of January 15, 1907, "is a bureau of information who not only gives information to the physician in the dispensary, but also applies that information for the benefit of the patient. She gives advice as to food, nursing, employment, admission to homes for incurables and convalescents; gets proper food; instructs in hygiene; 'follows up' the patient in her home; encourages her; educates her; instructs mothers as to the care and food of the babies. Especially important in cases of tuberculosis."

A condensed report of The Chicago Dispensaries says: "In Chicago, where dispensary records are not yet kept with the exactitude desired by the committee of the Chicago Medical Society now working in that direction, twenty-nine of the fifty-five dispensaries duly listed in one year treated 223,110 persons, the sixteen dispensaries in which figures are carefully balanced reporting the visits of 93,806 persons, with a total of 246,140 treatments. The number of applicants refused attention, because palpably able to pay outside physicians, was 1,170. Since the investigation of dispensary applicants, though now partially conducted by the Chicago Bureau of Charities, has not yet become general or thoroughly systematic, these figures must be taken as mere suggestions of the true state of affairs. In order to correct the abuse of medical charity, a committee was appointed. This committee made the following recommendations: (1) That a committee be appointed by the president of the Chicago Medical Society, whose duty it shall be to bring into one federation the managers of all reputable dispensaries for the purpose of overcoming the evils that now exist through co-operation of the dispensaries themselves, through the

public press, if need be, and if this is not successful, to inaugurate legislation to correct this abuse. (2) That all dispensaries be required to keep complete records of all cases, which records should be open to the inspection of the officers of the federation, and tthat all dispensaries be required to furnish sanitary and hygienic accommodations for both sexes which should be inspected by the Department of Health. We also recommend that these facts be brought to the attention of the commissioner of health. (3) That all dispensaries should have a sign in a conspicuous place, stating that the free dispensary is for the deserving poor only, and should employ a distributor, who should inquire carefully into the ability of the patient to pay, referring all doubtful cases at once to the Chicago Bureau of Charities for investigation. (4) That none but the deserving poor should receive treatment or should be received at any dispensary, and these should be required to sign a statement that they are not able to pay. (5) Wherever possible, all patients treated gratuitously at free dispensaries should be used for teaching purposes, as this tends to systematize the record of cases, and gives the patient more careful and helpful treatment."

Dr. Goldwater of the Mt. Sinai Hospital says, "The most advanced dispensary work is work of certain tuberculosis clinics which have undertaken to carry treatment and teaching into the homes of patients."

Dr. Richard C. Cabot, in speaking of the improvement in treatment of out-patient departments, states that the weak points in most out-patient departments are, "First, the hurry and consequent makeshift; second, the wholesale drugging." Correction of it means, more dispensaries, smaller clinics, wherein more attention can be given to the individual patients; it would mean more but smaller clinics; more men who could and would give more attention to each patient in co-operation with trained workers or nurses who could give the specific directions as to diet, work, sanitation, and who could follow up such patients in their homes and suggest or procure sufficient and proper food and medicines, and who could advise as to sanitary measures. The workers, whether paid or voluntary, form one of the greatest advances made in recent years in this line of work. "If dispensaries are to undertake the development of their