control of the Out-Patient Department; over the students, the nursing force, the clerks in the record room, the doorkeeper, and the maids and messenger boys. He must check the arrival and departure of the physicians and obtain substitutes for them when they cannot come. Under him is a graduate nurse of experience and executive ability who has direct control of nurses and servants. There are three graduate head nurses in charge of departments and six pupil nurses serve two months here as a part of their training. Other pupil nurses are called from the "house" for a few hours daily. The women and boys are messengers in the morning and cleaners in the afternoon; they also sort and stretch the washed gauze and wind the washed bandages.

The record room employs three clerks. Here are filed all the history cards in numerical sequence. These are indexed and catalogued on cards by name and by disease. Thus the history card of a patient long absent is easily found and groups of diseases are readily studied by the investigator and are available for use at medical clinics. A lunch counter is opened at noon when students, patients and patients' friends may procure a light lunch. Five cents gives a glass of milk, two large crackers and a piece of cheese. The electric and x-Ray rooms, the hydrotherapeutic room, the Zander room and the pharmacy are directly under the control of the administration. They are not considered departments, but are for the treatment of patients referred from the regular medical, surgical and special departments. The Zander room and hydrotherapeutic room are under the charge of an expert trained in the best German school. The surgical apparatus shop is used chiefly in connection with the orthopedic department and orthopedic ward of the hospital. Here we also make apparatus for the private work of orthopedic surgeons in our neighborhood. The establishment of this shop seemed necessary because of the unsatisfactory nature of the work done outside. It pays a small profit annually.

The medical departments are now ten in number, namely: Male and female medical, children's medical, male and female surgical and genito-urinary, nerve, skin, throat and nose and orthopedic. The eye and dental departments have been discontinued because of the establishment in the neighborhood of hospitals devoted to these specialties. There are

nine physicians and nine surgeons serving three at a time for four months each, and two physicians or surgeons to each of the special departments. There are also assistant physicians to each special department varying in number from two to four. The rules provide for the appointment of graduate assistants and student assistants for short periods of work and each medical and surgical house officer serves four months of his term in the Out-Patient Department.

It is interesting to note the change in the last few years toward a more rational treatment of patients. The increase in the use of baths, medico-mechanical apparatus, opsonins and massage is co-incident as might be expected with a large decrease in the number of prescriptions issued. The investigation of the home surroundings of patients, and the endeavor to help them in carrying out the mode of life and treatment prescribed, is of great value. This is one of the lines of work undertaken by the Social Service workers, and we are indebted for this very largely to the initiative and public spirit of Dr. Richard C. Cabot of Boston. These workers are paid and voluntary. Their endeavor is to use all existing institutions; to put the patient in touch with the local church and the local charitable society. They help mothers who need to be temporarily relieved of the care of their families. They advise and help pregnant girls and give much needed assistance in many directions.

Tuberculosis classes are now held in our Out-Patient Department. The patients are taught hygiene and proper living in the manner familiar to you all. There are visiting nurses to see these patients in their homes and insure the carrying out of instructions. In connection with the neurological department, there are classes to teach the ataxic patient to make use of new nerve fibres in walking; work classes for neurasthenic patients and a special adviser for the last named class.

Of the teaching in the Out-Patient Department I need say little. It is encouraged in every way consistent with the good of the patient as it is believed that it is the best means for the staff to keep abreast of the times. Many of our staff have some connection with the Harvard Medical School and some do post-graduate teaching too. We expect the instruction to be given by members of the staff not at that time on duty in the Out-Patient Department so that the

That

patients are not made to wait for the students. This does not mean of course that a physician shall not instruct students working in his clinic as he works on his cases. we want and expect. The Out-Patient Department is liberally supplied with lecture rooms, large and small, and laboratories for students.

Let us now consider for a moment the lines of work in sight for progress in the care of out-door patients. There are many patients needing treatment who can only come in the evening, men and women who need to work all day to support their families. Will it not be necessary for us to have evening clinics eventually? If this is to come, can we reasonably expect physicians to give up their evenings to this work? Perhaps for a short time the younger men would do it, but year in and year out we would find it necessary to pay them to retain their services. I believe that in the future the staffs of hospitals will be paid, but this is not within the range of my paper.

Must we not in the future have more assistants as we more and more give careful attention and study to the individual patients? There are in every large city many young men who would be glad to have official recognition in a hospital, and there is plenty of room for their work. Again, they should be paid so that they will readily give their time and so that the hospital may have the proper control over them.

We should recognize that an out-patient appointment is sufficient in itself and not merely a stepping stone to a position in the "house." There should be several grades in the Out-Patient Department and promotion should be made by merit rather than by seniority.

We should strive for better records, and if this means the hiring of stenographers, the hospital should undertake this

expense.

We should have classes for instruction of groups of cases, diabetics, cardiacs and others, as well as the tubercular. Again, these instructors must be paid eventually. Perhaps this teaching can be done by paid nurses under the supervision of physicians.

It has been suggested that work shops might be started in connection with out-patient departments, where patients

too handicapped to do a full day's work may earn a little money. Such patients may sadly need financial help and the consequent relief to their minds would aid in their cure.

Such are a few of the lines of progress which readily suggest themselves. We should all be thankful that it is given to each of us to add his mite to the advancement of this great work.

METHOD OF INVESTIGATING OUT-PATIENT APPLICANTS AT WORCESTER HOSPITALS.*

BY THOMAS HOWELL, M. D.

Superintendent City Hospital, Worcester, Mass.

For several years there had been complaints that outpatient departments of the Worcester Hospitals were treating many patients able to pay a physician for his services. These complaints came mostly from members of the hospital staffs. Feeling strongly that they should not be called upon to treat gratuitously patients who were able to pay, they, about three years ago, began a study of the situation. They went over the ground carefully, visited dispensaries in other cities and consulted several persons who had given special attention to the correction of out-patient abuses. They also studied the applicants who applied at the Worcester dispensaries. It was found that these applicants could be divided into ten classes, namely:

First. Patients who are able to pay but who do not appreciate that they are abusing a charitable institution. when they apply for free treatment. This class commonly believes that the physicians receive salaries and are under obligations to treat all applicants.

Second. Those who come expecting to pay something.

Third. Those who go to the hospital because they have no regular physician and feel sure of proper attention at the hospital. In other words, they desire to consult a physician on whom the hospital has placed its stamp of approval. This class includes many people who have recently moved to the city and who have not yet selected a family physician.

*Read by Dr. W. H. Smith, Hartford, Conn.