grouped by sex or age or simply as they happen to attend the dispensary on a certain day of the week, and given as much instruction as the time before their admission allows. At the formation of the class a lecture may be given on the subject of prevention and treatment with a description of the institution which they are about to enter. Like all other features of the work the physical condition, daily routine and discipline of sanatorium or hospital should be portrayed truthfully in order to guard against possible "delusions of grandeur" with their consequent disappointment and dissatisfaction. At this first meeting the use of the sputum-cup and paper napkin should be demonstrated and emphasized. It is also wise to go over the list of articles required for camp life at this time to determine whether the patients are able to supply the same. Subsequent sessions may deal with the details of the use of fresh air, rest, diet, and the avoidance of evil habits. This instruction by the physician in the dispensary when followed by its necessary complement, the observation and encouragement of the nurse upon her visits to the home, will go a long way toward lightening the burden of sanatorium director or hospital resident.

It is time that the educational value of institutional life is of almost as great avantage as the physical benefit derived.

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In Pennsylvania we have 116 dispensaries and three large institutions where sanatorium and hospital facilities are combined, operated by the State Department of Health through a special Division for the control of Tuberculosis, which was established May 14, 1907, and since has received a special appropriation of over $1,000,000 each year. There is at least one dispensary in each county, and in the larger or congested counties as many as the density of population and transportation facilities require. Alleghany County, for example, has six dispensaries. The sanatoria and hospitals are located within easy reach of the large centers of population from which the greatest number of applications come. The locations of the dispensaries make it possible for them to be easily reached by any one of our 8,000,000 people. There are 193 dispensary physicians and 126 nurses.

The majority of the patients presenting themselves or referred by agencies are advanced cases. The incipient cases on the dispensary rolls are gathered through the nurses' investigation of the family and industrial or social contacts and through the co-operation of the Division of School inspection. This division examines annually 395,000 school-children. In the fourth - class districts alone, 50,000 are examined, i.e., districts of less than 5,000 population, where as early as 1907 the disease was found to be surprisingly prevalent. As the school code of Pennsylvania provides specifically that no pupil, teacher or employee who has tuberculosis shall remain

in school unless it be a special fresh-air school, the work of the school inspector and that of the dispensary physician frequently dovetail in the discovery and disposition of the early cases of infection.

The work of transferring patients from the dispensaries to the sanatoria is carried on through the office of the Commissioner of Health. Each dispensary is required to forward the patients application forms which set forth financial and moral status as well as his medical history and symptoms, also a chart giving the results of the physical examination and a report of the nurse's social survey. These forms are carefully reviewed at Harrisburg, and if defective are returned for correction. From the conditions described the patients are assigned to camp or hospital at the state institution nearest to them, and are notified by preliminary and final letters when their turns are reached upon the waitinglist, which in spite of the total bed capacity of 2,042 averages about 1,000. The notices give full particulars as to the time-table and route of travel. In the case of children tags are forwarded, and wherever they are obliged to change cars nurses from the nearest dispensary are ordered to be on hand to supervise their transfer. The dispensaries also send to the sanatoria through the Harrisburg office reference cards signed by the nearest relative to facilitate communication in case of emergency, and moval agreements whereby the relatives agree to prompt removal of the patient whenever in the judgment of the director this is advisable.

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Upon the patient's discharge from the sanatorium he is instructed to report to the dispensary from which he came to keep in touch with it during the critical period of his readjustment to the ordinary conditions of life. At the same time the dispensary is notified of his discharge and if he fails to report within one month the dispensary nurse is sent to learn the

reason.

We have at present approximately 11,000 patients on the rolls of dispensaries and 2,000 under care at sanatoria and hospitals. The death rate from tuberculosis in 1907 was 13.1 and in 1914 was 9.9, which is equivalent to a saving of about 12,000 lives. For the past two years a special systematic effort has been made. to determine the amount of benefit conferred upon patients who have attended the dispensaries without sanatorium care and those who have had that additional advantage. The results of this investigation appear in the annual reports of the Department beginning with that of 1913 and prove the superiority of institutional care.

It is thus seen that there is a very close interrelationship between dispensary and sanatorium or hospital as a public service. This is one of the chief features in the official campaign against tuberculosis to which Pennsylvania may ascribe her success and national recognition.

MEASURES AVAILABLE IN THE STRUGGLE AGAINST TUBERCULOSIS.

The agencies upon which we must rely in our struggle against tuberculosis may be roughly divided into those favoring general bodily resistance to disease and those aimed specifically against the spread of the tubercle bacillus.

In the first group may be placed such things as good personal hygiene, temperate habits, proper housing conditions, improvement in occupational hygiene, well-balanced nutrition, adequate wages and the like. It is noteworthy that our English colleagues, both in precept and practice, place much greater stress upon this feature of anti-tuberculosis work than is the rule in America.

Doubtless the trend in American tuberculosis work does not place sufficient emphasis upon these fundamental factors, but, on the other hand, their precise quantitative relationship to the prevention of tuberculosis is tantalizingly vague and elusive.

In the other group we may place such specific objects as

(1) Widespread popular education regarding the nature of tuberculosis.

(2) Elimination of tubercle bacilli from food (i.e., tubercle bacillus free milk and butter).

(3) Special hygiene for the "pretuberculous" child.

(4) Reporting of cases and supervising of the personal hygiene of the consumptive.

(5) Isolation of the dangerous consumptive by hospitalization.

(6) Specific instruction in prophylaxis for the consumptive and his family.

THE PLACE OF THE TUBERCULOSIS DISPENSARY

The evolution of anti-tuberculosis work has demonstrated the absolute necessity of the tuberculosis dispensary. It is an essential cog in the anti-tuberculosis machine if the specific objects just enumerated are to be followed out effectively. Without the tuberculosis dispensary or its equivalent none of the specific objects mentioned can be properly carried out, save, perhaps, the elimination of tubercle bacilli from food. With it not only can these things be done but environmental and general hygienic measures can be pushed much more vigorously and effectively.

The tuberculosis dispensary has been most appropriately called the clearing-house for anti

*A paper presented before the New England Conference on Tuberculosis, October, 20, 1915.

tuberculosis work. So it is. It is also vastly more than a clearing-house. It is the central dynamo from which all the other anti-tuberculosis agencies should largely receive their charge of energy. It is the one means by which we can ever hope to answer the important question: "How much actual value has been the vast amount of money and energy already expended against tuberculosis in reducing the morbidity and mortality rates from the disease?" It is the most practical and businesslike agency available for determining where our money and energy should go in the future to get a maximum of return in tuberculosis reduction. Furthermore, the tuberculosis dispensary that is alive to its opportunities should be the most potent of all factors in the carrying on of that great fundamental in anti-tuberculosis work,-hygienic education.

THE ESSENTIALS OF AN EFFICIENT TUBERCULOSIS DISPENSARY

In a phrase I would sum up the essentials of an efficient tuberculosis dispensary as 80 per cent. "nurse," 15 per cent. medical service, and 5 per cent. equipment. The term "nurse" in the present sense means the qualified tuberculosis social worker; whether she be a "trained" nurse or not is largely immaterial.

The essentials of equipment may be dismissed very briefly. They are reasonably well defined, I think, in the minimum requirements of the State Department of Health. They are decently clean, modestly equipped, conveniently located rooms so arranged that patients can be properly examined and records properly kept.

The essentials of medical service are a physician or physicians who can detect early tuberculosis with a reasonable percentage of accuracy, who are humanly interested in the tuberculosis problem and who are not so driven by other professional duties that they cannot attend clinics regularly, and who are not afraid of work.

The essentials of the efficient tuberculosis dispensary nurse! It is another task to undertake to depict them. In the first place, it should be recognized that her duties are radically different from those of the attending physician. Attendance at the clinic hours constitutes the major portion of his duties, while the actual dispensary hours are a minor part of the duties of the successful tuberculosis nurse. The physician is expected to furnish technical knowledge when the patient is first examined by him, and to give proper advice, direction and encouragement when the patient is brought before him from time

to time. The nurse must first locate the patient and then bring him in touch with the doctor. Further, the patient and his family, his surroundings, his past, his habits, his finances, his possible sources of aid, his religion, even his prejudices, must be studied. This study she must make in such a sympathetic and friendly fashion that by it he and his family and friends will eventually realize that her only object is the betterment of his condition and the protection of those about him. In addition the nurse must take counsel with the local authorities and the dispensary doctor and perchance philanthropic organizations, religious organizations, educational authorities, etc., to determine what is the best practical solution of each individual tuberculosis problem. Right at this point will come the most of the discouragements of the tuberculosis nurse. She will see clearly that the sanatorium is best for this patient, the orthopedic clinic for that, the local tuberculosis hospital for another, and a careful home régime sufficient for a fourth. But there is no vacancy in the sanatorium, nor will there be one for months. She will have to undergo the disheartening experience of seeing an early favorable case develop into an advanced unfavorable one before the patient can even get a chance at the sanatorium. In another instance the parents cannot be made to realize that the "growing pains" are as serious as the nurse and dispensary doctor claim, and so the nurse must helplessly watch an early tuberculous hip develop into a late, badly damaged one before the orthopedic clinic will be seriously considered.

Or perhaps there is no local tuberculosis hospital. Then the nurse must rely upon the intelligence and care with which her carefully explained directions are followed out by the consumptive's family. She knows that upon this depends their safety and freedom from infection. These things, and they are the commonplace things in an active tuberculosis nurse's work, are sufficiently discouraging in themselves.

Hence the essential characteristics of the successful tuberculosis dispensary nurse must include a certain optimism that refuses to be beaten by these discouragements; a certain doggedness and determination of character, obstinacy if you will, that impels her to fight the harder for the things that should be simply because they are not; a certain vision of the possibilities of the tuberculosis campaign as a whole that can enable her to see that she fights not alone nor in a losing cause no matter what the present limitations of her local sphere of action may be; a certain serenity of soul, an internal "preservative of the spirit as it were, that will keep the "milk of human kindness" from souring utterly and her daily work degenerating into mechanical routine; a certain equanimity of spirit that will enable her to face the petty and malicious annoyances of her daily life cheerfully and undismayed; a certain saving sense of humor that will keep her from falling into the ridiculous when she is striving to achieve the impressive; and above all an endowment in liberal measure of that most blessed of all mental equipments,-common

sense.

I would end this enumeration of the essential characteristics of the good tuberculosis dispensary nurse right at this point were it not that some will say, "What about training experience?" To this query I can only say training and experience are most valuable; they are the things that our present tuberculosis dispensary nurses lack the most, and, lacking, are thereby most handicapped; but after all, experience is something that we can achieve. Optimism, equanimity, imagination, common sense-these are things inborn; without them experience alone is of doubtful value.

It has been my good fortune to visit many of the tuberculosis dispensaries in the state in the past few months, and, through the district health officers, the nurses' conference and correspondence, to get a very good insight into the results and possibilities of them all. Therefore, I feel that I can safely predict that the wisdom of the tuberculosis dispensary law is going to be made very evident in all the fifty-four cities and towns affected thereby, with perhaps three or four exceptions. The principal reason why I feel so confident on this point is because I know that as a group the nurses connected with these dispensaries possess in a marked degree the characteristics that I have mentioned as essential to

success.

THE MASSACHUSETTS DISPENSARY LAW

Little needs to be said relative to the putting into effect of the law requiring "each city and town having a population of 10,000 or over at the 1910 Census to maintain a free dispensary for the discovery, treatment and supervision of needy persons resident within its limits and afflicted with tuberculosis." This law was on the statute books, was mandatory in nature, and gave no loophole for the exceptional community, and the State Department of Health was explicitly charged with its enforcement. Accordingly, the State Commissioner of Health, early in the present year, served notice on all the cities and towns affected by the law that they would be given till July 1 to comply with its provisions. All the cities and towns complied.

The tactful services of the state district health officers, in advising and assisting the local boards of health to carry out the requirements of the law, deserve special mention. But the fairminded spirit in which the local authorities, in almost every instance, did their share is equally noteworthy. Even in instances, and they were many, where the local authorities believed that there was no need for such an institution as a tuberculosis dispensary in their town they evinced a spirit of co-operation and willingness to give it a fair trial that was most encouraging.

If time permitted it would be most interesting to point out in detail some of the difficulties that were encountered in attempting to apply a general law to so diversified a group of communities, and the policies worked out by the district health officers in trying to square legal requirements with the common-sense needs of the individual community. In all instances the

district health officer has been and is the final referee as to the fitness of the dispensary.

In general, the most difficult problem has been the 10,000 to 20,000 town. In many such communities I believe there is ample room, even pressing need, for the full time of a skilled tuberculosis worker. In others the need is not so evident. To meet these situations it has been the policy of the State Department of Health, if the local authorities or organizations displayed any tendency in this direction, to encourage from the outset a broadening of the functions of the dispensary so that they would include all those that can be considered the functions of a publichealth social-service center.

Such, probably, will be the logical evolution of most of our tuberculosis dispensaries in the smaller cities and towns, and possibly in many of the larger cities as well.

Even in those towns where public sentiment did not seem yet ready to sponsor the general public-health dispensary idea, if the work of the tuberculosis dispensary would not obviously necessitate the entire services of a nurse a definite policy has been carried out of combining with the services of the tuberculosis dispensary nurse several of the fields of public-health nursing. In other words, the dispensary nurse is also the school nurse, or the factory nurse, or the board of health nurse, or the baby hygiene nurse, or the district nurse, or several of these rolled in one. This scheme is working out splendidly in many instances. Its greatest weakness is in the danger of underestimating the already existing but unrecognized local needs in many of these lines of public-health service, resulting in inadequate service and superficial work in every line. It is obvious that for such public-health nursing positions a hospital training-school course, supplemented by practical field experience in one or more lines of publichealth nursing, is much more essential than that the nurse devote herself to social service tuberculosis work alone. The question of whether or not such a readjustment of public-health nursing work for larger centers is desirable opens up too big a field for consideration here.

From personal observation, however, I am compelled to testify that in certain instances this tendency toward generalization of the publichealth nurse's work results in such serious overloading of a single worker that either no part of her manifold duties are properly done, or else she is always in imminent danger of succumbing to the fate of the classic chameleon, who, you will remember, turned red with ease when placed on the red cloth, green with equal readiness upon the green cloth, and blue upon the blue cloth, but killed himself trying to successfully qualify on the Scotch plaid.

RESULTS

It is rather premature to speak of results as yet in connection with the state-wide tuberculosis dispensary policy of Massachusetts, but a few general statements may be of interest.

The tuberculosis dispensaries of the state

report altogether a total of 2,778 individuals who have had first examinations since July 1 of this year. Of this total, 27 per cent. are examinations made by dispensaries that were nonexistent before July. Thirty-two per cent. are reported from Boston and 68 per cent. by the other dispensaries of the state.

For a beginning this showing is distinctly encouraging, but it is only a fraction of the total showing as regards actual utilization of the examining facilities of the tuberculosis dispensaries that many of these dispensaries will show in the next few months.

However, the actual examinations are only a rough index of the activity and value of the dispensary. Many of our new nurses are very wisely contenting themselves so far with studying the local tuberculosis situation, getting in touch with the doctors, and getting acquainted in their new fields of work. They have hardly begun to get patients into the dispensary for examination, to say nothing of the "contacts." In the near future many of these nurses will bring scores of such cases into touch with the dispensary service.

At present a very large percentage of cases examined are found to be not only positive, but advanced. If the dispensaries are doing true preventive work we should see a steady increase in the percentage of cases examined and found incipient, doubtful or not tuberculous.

Every dispensary nurse should make it one of her fixed policies to endeavor to have all members of a consumptive's family examined in the dispensary or elsewhere, whether they exhibit any symptoms of the disease or not. Further, they should be kept under close observation for at least two years after the death or permanent removal of the patient.

This thought suggests another line of results that are highly significant, although their ultimate possibilities have not begun to be realized yet by either the medical profession, the health authorities or the dispensary nurses themselves. The dispensary nurse need not, should not, confine her field work to the dispensary clientele alone. In every city and town she should cooperate with the practicing physicians as well. Some physicians seem to feel that it is the policy of the state to step in and carry their tuberculosis patients off to the dispensary regardless of the doctor's wishes, and I fear the enthusiasm of some of our dispensary nurses has led them into injudicious urging of tuberculosis sufferers to consult the dispensary without first consulting the physician who is already in attendance upon the case and hearing his wishes in the matter. On the contrary, the physician should feel that in the tuberculosis dispensary nurse he has an ally, an assistant who is at all times at his service to supplement and elucidate to his tuberculosis patients and their families the rules of hygiene and prophylaxis that the physician wishes them to carry out. It is very encouraging to note that several nurses have already demonstrated that this sort of co-operation can be worked out. For example, in one of the most successful of our smaller town dispensaries the nurse (it is significant that she is a full-time