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care of, well and economically, all those people in the county wh account of illness and injury, might become temporarily depe Besides, if the hospital building was provided with a certain nume private rooms, and a properly equipped operating room, it might easily arranged that the physicians of the county could care gratuitously for county poor, who were in the hospital, for the privilege of having the of the private rooms for such patients as they might want to put in the And, in the provision made for the organization of the administration the county hospital, enough work would be found in the garden, and int domestic economy of the institution for all paupers of either sex able to i anything. At the same time, the care of the infirmary cottages could i properly supervised, and the paupers who might become ill could easily transferred to the hospital for treatment, and back again when recovered The residence of the ordinary individual in this hospital as a patien would be in itself a considerable training in sick nursing, so that when t went out he would have a fair knowledge of the rudiments of the care the sick, as well as some information to guide him in the future in the avoidance of the ordinary causes of illness. Then, too, this hospital would provide the means to train nurses for whose services there would be a constant demand, and, in connection with the management of the hospital there could be established a system of district nursing on somewhat similar lines to those laid down in the organization of district nursing in the cities. In cases of illness among the very poor, or those who would be unable to pay the salary of a regular nurse, these district nurses might be sent out to take charge of the case temporarily; instruct the members of the family in the rudiments of nursing, and teach some of the simple lessons of hygiene and sanitation, which are so important, and the ignorance of which so frequently leads to disastrous results when contagious and infectious diseases make their appearance. After establishing a regime of order and method, the nurse could go on to another case to give similar instruction; returning from time to time, so as to keep under supervision a certain number of cases which might be placed in her charge. This method would not only be much better than any now in vogue, but also much cheaper than the present method; because, if these families that are liable to become a charge upon the county, are looked after properly in the beginning of their trouble, the illness is much more liable to be short lived, and less likely to leave in its trail chronic conditions to permanently unfit the individual to care for himself. Besides, the adoption of this method would give the country neighborhood facilities for the care of the sick, very nearly on a par with those existing in the cities, and provide proper facilities for the care and treatment of the sick, as well as a staff of nurses whose services would be generally available. Very much of the danger attending disease would be done away with, and the community educated in the practical application of the methods of personal hygiene, and the details of domestic sanitation. Indeed, such an institution might become a school in which young women could well afford to take a course of instruction to fit them to properly care for themselves, and intelligently

counter the vicissitudes of maternity and the bringing up of a family. The district nurse would be more useful in the country than in the city, *nd her usefulness would not necessarily be restricted to the personal care of the sick. If she had the tact and judgment that should be a part of her equipment, she could be a missionary in more senses than one. People err through ignorance, and most of the discomfort and unhappiness in this world are the result of misdirected and futile effort. Besides, the home is the center of our social life, and we have constantly to guard against every thing that threatens its welfare; would rob it of its attractiveness, or its ere function as the refuge of the family. No one thing will do more to make people dissatisfied with the home, and tend to drive them away from it, : than physical discomfort; and physical discomfort practically always has its basis in ill health. Ill health, in its turn, is dependent upon unsanitary surroundings, and unhygienic living. Therefore it should be a part of the duty of every community to provide the means for practical instruction in the rudiments of hygiene and domestic sanitation, and this instruction should be given by those who, by training and experience, have become competent to give it; for it can not be gained from books nor intelligently given by those who have not had practical experience. There are no agencies through which this instruction can be so successfully given as those of the hospital and the trained nurse. There can be no question but that trained intelligence is the most efficient, and that work systematically done is more satisfactory and better done than that which is accomplished by haphazard means. A properly trained nurse is an individual whose intelligence has been so instructed, and whose faculties have been so cultivated, that she knows what is necessary to be done for the patient placed in her care; how to do it with the least friction and most advantage, and why she does as she does. A nurse with such training, and the skill that it gives, can do many things, and teach many things beside the actual personal care of the sick person, and her influence can not help but be beneficial in many ways outside of the routine work of the sick room.

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DISCUSSION.

DR. CLARK: I am much interested in this paper of Dr. Tomlinson's as he has covered the subject in his usual very thorough and interesting manner. In a short paper read last year I broached this matter of district hospitals, and I am very glad Dr. Tomlinson has taken it up this year. In the cases which come under the care of the county physician are numbered a great many who are not ordinarily met with in the pauper population, by reason of the fact that sickness and injury come very often to the working men, bringing with them penury and inability to provide the proper care and attention. They are not the ordinary persons that the county has the care of. They have all the sensibilities of the honest, hard-working, wage-earner.

I am surprised to learn that Rice County, which contains about the same population as Washington County, had no sick requiring hospital treatment. We have about forty cases a year of severe sickness and injury, quite a large percentage of whom have not been enervated by public assistance and dependence upon others

work.

for their living. Consequently, when provision is not made for the proper can
these people, they suffer, not only in body but in mind, and some of them t
because of this neglect, became paupers, I hold it to be one of the necess
things, in this state, to provide for this class of people, either by county provis
or, in some sections sparsely settled, by the co-operation of three or four counte
One or two points occurred to me which might have been developed in regard
the usefulness of such hospitals. One is, in the examination of the insane under t
present procedure, in which the patient is brought before the probate cou
physicians are summoned who have no knowledge of the patient except what the
acquire in the examination; it is often difficult to say whether it is necessary
send the patient to the insane hospital. It is impossible to say whether, unie
proper care, they might be restored to their homes, thus lessening the burdens lai
on our state hospitals. In our own county we are making provision for that
We are finishing off in the third story of our hospital, a room, making it
safe and comfortable, a good place to take care of these suspects, as yo
might say, such cases as come before the probate court in which there is somt
doubt as to the necessity of sending them away.
We shall keep them there until such
time as it is made manifest whether or not it is necessary to send them to the state
hospital. Again, we are providing two rooms for the care of tubercular cases, a
disease that causes a large percentage of the county sick.
separated by a wide hall, and provision will be made during the summer months
to place those patients out of doors. It is not the ideal way of handling them, but
we separate them as far as possible from the rest of the patients, and we have
them under supervision. We can
see that they are not contaminating their
surroundings, and this helps to prevent the spread of this dread disease.
Now, in the building of these hospitals they need not be expensive; we do not
have to have the equipment of a state hospital, but for a comparatively small
amount we can put up a building in which those cases can be handled, and provision
made also for the training of nurses, as suggested by Dr. Tomlinson. I think the
suggestion of trained district nurses is a good one, for there are many cases in
which a trained nurse could be sent to the family, and the patient kept at home. It
is a saving of expense to the State. The patient will, under proper circumstances
recover sooner; it will save the mental disturbance which comes from taking them
to a hospital, which is great in some cases, and it will be found to be an exceedingly
valuable adjunct to the treatment of the sick poor.

We have two wards

I think this is a very important subject, and one in which not much progress has been made as yet in the state, and I for one am very much indebted to Dr. Tomlinson for his able and exhaustive paper.

MR. MCDONALD: Dr. Clark, has anything been done for treatment of delirium tremens cases, in your county?

DR. CLARK: Not in our county. Some years ago a department was set apart at Rochester for the treatment of those cases; that is the only thing I know of in the state, but in connection with the suggestion of Mr. McDonald, of the treatment of the inebriates in the workhouse, I would say that the Keeley cure can be administered at the workhouse in Minneapolis at a comparatively small expense, but that would involve an indeterminate sentence. A man would be sent to the workhouse to be cured of his intemperance, and he should be sentenced to remain until the superintendent thinks it is safe to send him out.

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THE FREE DISPENSARY IN THE CARE OF TUBERCULOSIS

PATIENTS.

GEORGE DOUGLAS HEAD, M. D., MINNEAPOLIS.

The prevention and treatment of pulmonary tuberculosis opens a wide field of activity along civic, social and medical lines. The disease is so widespread, and affects persons in such different walks of life, living under

EE DISPENSARY AND CARE OF TUBERCULOSIS PATIENTS. 39

ch varied surroundings, many of whom are bound by such iron laws of cessity, that all the forces of preventative and curative medicine and all e efforts which can be put forth by boards of health, public charities, ate or national organizations, and philanthropic citizens will be needed order to free the human race of this most general of all infectious iseases..

In the consideration of tuberculosis, from whatever aspect it may be iewed, it is important to remember that we are dealing not with an acute out with a chronic disease, one whose natural history is all too imperfectly understood, even by a profession which has spent years in its study; a disease which has its quiescient and active stages, the patient today seemingly in restored health, tomorrow showing evidence of new foci of infection; a long chronic process, the germs of which may lie dormant for years in a partially healed focus of the lung, only to break forth in renewed the activity when some sudden exposure or undermined condition of the health the offers a favorable opportunity.

Bearing in mind therefore the nature of the malady, the methods used to combat it must of necessity be along lines radically different from those employed in preventing and curing acute diseases. This is certainly generally understood by persons informed upon the subject, but there are a large number of the individuals, who, reading of the good results secured in the sanatorium treatment of tuberculosis, come to believe that the thing needed to do away with consumption is to erect sanatoria, where the incipent cases can be cured. This, however, is not the true condition of affairs. The sanatoria as now conducted care only for one class of the afflicted multitude, namely those harboring a beginning infection. In this great movement some provision must be made for those who are tuberculous, but whom necessity compels to remain at home; those whom the sanatorium has treated and dismissed as cured or improved; and those who harbor the disease in stages too far advanced for sanatorium treatment. The first of these conditions was well expressed by a poor shoemaker with consumption, who came not long ago to the University Dispensary. When told that he must go into the pine woods for the summer, he replied, "Doctor, how can I go? I have a wife and children depending upon me for their living, I must stay here and work for their support until I die."

As has often been said tuberculosis is a home disease. For years to come the vast majority of the cases, especially among the poor, must of necessity be managed at home. There is no more potent agency at our command for dealing with the home treatment of the consumptive poor, than the free dispensary. It makes no difference whether such a dispensary be conducted by the state, by a medical school, by a church, as an adjunct to a hospital, or by private philanthropy. It is not necessary that such a dispensary be a separately constructed building, whose service is exclusively given over to the treatment of tuberculous patients, though such an institution should be able to do better and more systematic work. The dispensaries we have in the large cities of our state, and the small

dispensaries which could be maintained in the small towns by physicians, with a lay managing board, would meet all present The free dispensary is the poor man's consulting doctor. He accustomed for years to go there for his walking ailments. It is k utilize this institution already organized for the care of the sick poo than to waste time and money in attempting the constructi equipment of new institutions entirely given over to the work of car the tuberculous poor. Any of the dispensaries of Minneapolis, or an city in this state, could readily provide themselves properly to take can the tuberculous poor along the most approved lines, provided the fund maintenence were supplied. Any of the small cities and towns of Min could organize and maintain at a small cost to its philanthropic citize even if necessary the state itself, a small tuberculosis dispensary.

of

Before going farther it might be well to explain exactly what is t by a dispensary, how it carries on its work, and what has been its met in the past in dealing with the cases of tuberculosis under its charge. A dispensary is usually organized either by a hospital, a medical school, charitable persons, to treat the poor of the community in which it is locate In Minneapolis, for example, there is a large free dispensary conducted the state university, another by Hamline University, and several by th various hospitals of the city. The state university provides a large building for its dispensary, while the dispensaries of the various hospitals ar conducted in the basement of these institutions. The object, as I have said. is to treat the poor, and any one who is not able to pay for a physician's services is admitted free for treatment. The attending staff is made up practising physicians who give their services without compensation. The service is divided into various departments each of which treats distinct classes of cases. There is a surgical, medical, gynecological, nose and throat, eye and ear, skin and venereal, and children's department. Cases are assigned to the various departments by a registering clerk, who records the names of patients, their places of residence, and other data important for reference. For many years these dispensaries have been treating patients with tuberculosis in common with those coming for other ailments. The great majority of the tubercular cases are assigned to the medical department, since tuberculosis of the lungs is the most prevalent form of the disease. However, cases of laryngeal tuberculosis are assigned to the nose and throat department; cases of bone tuberculosis to the surgical department; cases of skin tuberculosis (lupus) to the skin and venereal department, etc. The patients when assigned to the medical department are examined, and if tubercular, are so informed, told to be careful of their sputum, and given such advice and treatment as the clinician sees fit. Little attempt has been made in the past at the education of these patients in modes of living, personal hygiene, and ventilation of homes. patient carried out the instructions given by the physician was not known, Whether the as no nurse was available to send on a tour of home inspection. Clinical notes was kept upon the cases, but they were often meagre and not systematically made. Usually the sputum was examined and the patient

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