seems desirable, accordingly, to inquire briefly into the present conditions as compared with those of 1899 and previously, so as to throw light on these questions, and also on the further question whether or not there are points wherein observance of the law may be extended with good results.

Considerable information as to prior conditions is found in the thorough-going report of the special committee of the State Board of Charities, consisting of Commissioners Smith, Stoddard and Bergen, which appears as an appended paper in the annual report of that body for the year 1899, and the current publications of the same year. As to present conditions the

records of the Board, the annual reports of the Committee on Dispensaries, and a special inquiry during the past year made by the Board's Inspector of Dispensaries, Mr. John B. Prest, in reference to the extent of compliance with the Dispensary law, are illuminating. For convenience in comparison these two sets of ascertained facts past and present are set forth side by side.

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tenements and drug stores, and without adequate or proper equipment.

The abuse known as "the drug store dispensary" is discussed forcefully in the New York Times of September 14, 1899.

The report of the special committee before referred to contains the following statement:

ed, together with seats for all applicants.

The Dispensary law prohibits the opening of a distenementpensary in a house or drug store, and the State Board of Charities issues no license except upon a report of its inspector, showing that the premises in which it is proposed to locate the dispensary are suitable for the purpose. A recent inquiry by the Board's inspector shows that in 109 out of 119 dispensaries suitable equipment and are require supplies furnished; ments which it demands.

"Some of the new dispensaries have still more approved buildings, but considered in the light of modern medical science, it is scarcely possible to find a dispensary building fully answering the

"There are dispensaries in full operation in tenement houses, in drug stores, and in dilapidated old buildings and shanties. A dispensary that reports treating 48,000 patients annually, is conducted in a wooden structure 20x12 feet, and 8 feet high. A visitor to that dispensary on a day of average attendance of patients will not be able to enter the building, so great and persistent is the crowd. There are seats for not than ten of the fifty or more waiting.

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"Few dispensaries are properly provided with necessary furniture. The sittings for patients are rude benches, and rarely in sufficient numbers to meet the wants of the crowds attending at the sessions of the largest classes. The apparatus and appliances are of poor construction, and not kept in proper repair nor with aseptic cleanliness."

The following is an extract from a report of inspection made immediately after the enactment of the law:

"Water for use of doctor and patients was carried in a galvanized bucket from the next building. Did not see any basins or other vessels to hold water, other than the bucket. The whole place is about as desolate, cold and dirty as it was possible to be."

4. Supervision of the work of dispensaries by their board of managers was lax, in many instances.

Although the majority of dispensaries had responsible boards of managers, some were under the control of a single indi

seats for all applicants are provided at all times in 107 out of 119 dispensaries, and in most of the remaining 12 the overcrowding is only occasional, and due to special circumstances. Under a rule of the Board cleanliness and order must be maintained, and the inspector's recent investigation showed that such cleanliness and order were maintained in 115 cases.

4. The responsibility of the managers of a dispensary for the work done is now constantly emphasized.

The inspector's reports upon dispensaries visited are now invariably forwarded to the managers for their information or

vidual, and those dispensaries which had boards of managers were not always carefully supervised. In one case the managers visited annually, and in another five times since 1869; in one instance they had never visited. There was no stated way of bringing home to a board of managers its responsibility for the dispensary under its control.

5. In a number of dispensaries gynecological examinations were made and treatments given by male physicians without a nurse or woman attendant being present.

6. The records kept in dispensaries were often unsystematic, inaccurate and incomplete.

The report of the Board's committee in 1899 showed that in 21 dispensaries no record whatever was kept, and that in 17 others the records were very brief, while in the greater number of dispensaries that reported keeping records, an examination showed them to be worthless for any practical purposes. Four dispensaries kept no financial accounts whatever.

7. There was no standard of fitness for apothecaries in dispensaries.

The report of the special committee before referred to contains the following statement:

"While most of the old dispensaries exercise proper care in the selection of their dispensers, many of the new dispensaries have as druggists men whose only qualification is that they have served a term, long or short, in a drug store. In dispensary which treats 52,000 patients annually, and issued prescriptions for the same number, there were three persons acting as druggists, not one of whom was a graduate of a college of pharmacy. In an

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for the correction of defects, and are a constant reminder of their duties as managers.

5. Under a rule of the Board the matron or a female nurse must be present at all gynecological examinations and

treatments.

The inspector's recent inquiry showed that in but 3 dispensaries out of 119 are such treatments given without a woman being present.

6. As a rule, fairly complete, systematic and accurate records are now kept.

Each dispensary is required to have a registrar, one of whose duties it is to make and preserve all records. There is still some lack of uniformity in these records, but the statistics required for the annual report to the State Board and those requested by the inspector upon his visits may, as a rule, be obtained from the books of any dispensary. A uniform system of records, combining simplicity and elasticity, would be ceedingly desirable, and an outline for such a system is now in preparation.

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7. By a rule of the Board apothecaries in

other dispensary reporting

12,000 patients treated in the year 1895, and prescriptions prepared, the druggist, a man of very limited education, had only served in a subordinate capacity in a drug department of a hospital."

8. The medical service in dispensaries was sometimes inefficient and irregular.

From the report of the special committee the following statement is quoted:

"It has long been an opinion current in the medical profession that the treatment of patients is very inefficient in the dispensaries. This fact is better known to physicians connected with the hospitals where the results of treatment at the dispensaries come under their special notice through the patients who come from the latter to the former."

The report then goes on to say that it is not surprising that even the best physician in a dispensary fails frequently in his diagnosis when the conditions under which he performs his duties are considered. These conditions were, in brief, the lack of seclusion and quiet, the large number of patients to be treated in a given time, and the absence of proper facilities. The following is an excerpt from an inspector's report made in 1899, which indicates lack of faithfulness on the part of the medical staff connected with the dispen

saries must пого be licensed pharmacists or medical graduates.

In only 3 cases out of 119 is this rule not followed, and in these cases simple prescriptions only are compounded in the dispensary.

"Called January 2d at the hour of opening, as indicated by the printed card, viz., 2 o'clock; place was closed; waited until 3.30, and no one appearing, retired."

"January 4th, visited the place again; found it open at 2 o'clock, and three women awaiting the arrival of the doctor, who did not appear until 3.30."

9. Lack of care in the handling of contagious diseases and in the separation of the sexes was

common.

The report of the special committee referred to

8. Considerable improvement in the faithfulness and efficiency of medical service in dispensaries is noted.

With very rare exceptions dispensaries are open during the advertised hours, and physicians perform their duties with care and interest. Any neglect on their part is brought to the attention of the managers. In a few dispensaries, which are fortunately the exceptionchiefly the small dispensaries connected with struggling churches-the medical staff is sometimes less punctual and faithful than is to be desired.

9. Persons suffering from contagious discases are now excluded from dispensaries, and where such persons apply for treatment they are immediately isolated, and the matter reported to the Board of Health.

Each dispensary is required by a rule of the

reported by the dispensaries until several days or even weeks after the application is made. These investigations are not always made by the Society until after more pressing cases are disposed of and, consequently, the reports reach the dispensary too late to be of much value. Considerable progress must be made in these matters before satisfactory conditions are obtained.

The facts stated do not answer the query raised at the outset completely or finally, but they show a degree of progress that is most encouraging when the complexity and the difficulty of the situation which the law was designed to meet are duly considered. Further progress is apparently both possible and desirable, but it cannot be secured by the State Board of Charities or by the Medical Association alone. The interest and cooperation of dispensary officers, physicians and managers in this State are essential if genuine and lasting progress is to continue. The fact must be thoroughly appreciated by all parties concerned in this matter that the Dispensary Law is not a creation of the State Board of Charities or of a few physicians, or of any group of people, but is the expression of the serious purpose of the community as a whole to safeguard its social interests in two ways, first by restricting the bestowal of medical charity to persons unable to pay for the services of a physician, and second, and at the same time by insuring to the actually poor prompt, careful and considerate treatment.

THE EXPERIENCE OF THE SPECIAL INSPECTOR OF DISPENSARIES.1

I

BY JOHN B. PREST,

Inspector New York State Board of Charities.

HAVE been asked to address you, giving the experience of the special Inspector of Dispensaries of the New York State Board of Charities. My qualifications to speak upon this subject consist of about five years' service for the State, during which time I have visited every dispensary from New York to Buffalo, from five to upwards of twenty times; have investigated on behalf of the State a considerable number of unlicensed dispensaries, medical companies, medical institutes and money-making schemes; I have examined new dispensary organizations and studied their growth and operations from many points of view.

In addition to reading much that has been written upon the question of dispensary abuse, at home and abroad, I have inspected the casualty and out-patient departments connected with several of the large hospitals in London and I have gained by personal observation some impressions relating to dispensaries in other localities.

During the first year of operation of the New York Dispensary Law, the Board had no special

Read before the New York County Medical Association, New York, October 16, 1905.

inspector to visit these important charities, but assigned one of its women inspectors. She was able to give the work only that fraction of her time which could be spared from other duties. The next year the Legislature provided the salary for a man inspector and I was chosen. Since December, 1900, practically my entire time has been devoted to dispensaries.

Prior to the commencement of my duties with the State Board of Charities, about 125 licenses had been granted to dispensaries in various parts of the State; the rules and regulations in accordance with which dispensaries were to give medical and surgical advice and treatment had been given a year's trial, and the original rules which had proven rather too drastic had been modified by amendment.

When I first commenced to go to the dispensaries, some of which had never been visited by a State inspector before, considerable hostility was shown. Some of the persons in charge of administration appeared surprised to see me and others questioned my authority to inquire into the methods and the every-day workings of the dispensary. In several instances it was made clear that as an inspector, I was unwelcome. A few seemed interested to know what advantage there was in answering all sorts of questions put to them by a stranger. Opinions were expressed that the dispensary law was a failure.

In some places, more particularly outside of New York and Brooklyn, where inspections were infrequent and where hospital internes conducted the dispensary service, ignorance of the law was encountered. On two occasions in different cities of the State where I had gone to inspect the dispensaries, the superintendent informed me that their medical internes had declared that there was no State supervision of dispensaries and that the dispensary inspector was a myth. In each case the superintendent summoned the internes and showed apparent delight at the discomfiture of the young physicians on being confronted with. the inspector.

Opposition made itself apparent in other ways. Licenses were lost and few seemed to care whether they had a license or not. At many of the institutions the licenses were not framed. At other institutions some of the doctors seemed to think the licenses might be carried around in the pocket of the physician, and with the license in his possession, it would be legal for him to open a new dispensary anywhere and at any time. An instance of this was discovered when I went building vacant. A merchant doing business next to inspect a dispensary in Harlem and found the door to where the dispensary was formerly located, informed me that the dispensary closed a few months before, but he had since heard that it was started again about three or four blocks down the street. Following the directions given, I found, sure enough, the dispensary had opened up again and this time in a twenty-family tenement house. The facts were reported. That

dispensary is not doing business to-day. Its license has been canceled.

As is well known, the regulations provide that a public notice shall be posted in the reception room for applicants, calling attention to the fact that the dispensary is for the poor only and quoting a section of the law. Instead of posting a notice that could be seen across the room by newcomers, a typewritten notice was posted in an obscure corner in several of the dispensaries. In other institutions the required public notices were written with ink and a fine-pointed pen in letters hardly legible at short range. One institution was found where the registrar had a notice two by three inches in size fastened upon the wall with a pin.

Six years ago little was known as to the number of cases treated at the various dispensaries. Some figures had been compiled which seemed to indicate that half of the population of the City of New York was treated at dispensaries each year. This statement, however, was disputed. When I first visited the dispensaries and inquired as to the number of cases, in many instances I found that no record had been kept. On further inquiry as to the basis for the figures given in previous annual reports made to the State Board of Charities, I found that the number of cases reported had been estimated.

Such were some of the conditions which confronted the inspector in the early days of his work. The attitude of the managers and those members of the medical profession whom the inspector met at the dispensaries gradually changed. On successive visits I found that many of the physicians had become interested in the work and seemed to realize that some good might come out of it.

At first this interest in many cases was prompted by mere curiosity or impelled by a desire to know more of the affairs of a rival dispensary. There was a peculiar and almost amusing attitude noticed which, if I may be permitted, I will mention here. The physicians were always interested in the affairs of other institutions of a similar kind, especially those in the same locality. Often when I inquired about the use of the representation cards which are, as you know, designed to restrict the use of dispensaries to the poor, the physician in charge would remark that in his dispensary they were hardly necessary, saying, "Our dispensary treats only the very, very poor and needy patients," while "the dispensary across the street treats many rich patients and does not discriminate at all."

But in general it has been very apparent to me that while the law some years ago was little thought of by the medical men in charge of dispensaries, now to a very large extent the same persons look upon the law with favor. At that time they seemed to care nothing at all for the State license and considered the formalities necessary to acquire one an unnecessary bother. Many of them now look upon the license as a valuable

asset and they indicate clearly that they believe applications for new licenses should be closely scrutinized and issued only in most urgent and desirable cases.

The records kept at most of the dispensaries are now very complete, showing the total number of treatments and also the number of new cases; whereas, prior to the time when dispensaries were regularly inspected under the supervision of the State Board of Charities, the statistics were incomplete and were kept on a yearly basis. They are now compiled each month. This enables a more frequent comparison of results, stimulates interest and insures greater accuracy. This has been accomplished by frequent inspections at which the number of cases treated month by month was asked for. When such figures could not be furnished that fact would appear in the report of the inspector sent to the institution, and by this means conditions have been greatly improved.

The statistics now gathered by the State in regard to the volume of relief given at the dispensaries are precise, and trustworthy figures can be given to prove that one-half of the population. is not treated at dispensaries as formerly reported.

Of all the regulations governing dispensaries the one calling for use of the representation cards, which, as I have said, are designed to restrict the dispensary privilege to the needy poor, and the requirement that doubtful cases be investigated, has caused the most opposition and brought forth the loudest protest. The managers seem to want to make a record showing a large number of cases treated, influenced somewhat no doubt by the increased revenue resulting from a large number of ten-cent fees received from patients.

Hospital superintendents also tell me that if their dispensary registrars should restrict the cases admitted to those applicants who are clearly too poor to pay a physician, the clinics would be so reduced that it would be impossible to retain the most experienced specialists on their respective medical staffs.

I observe that the physicians are inclined to treat all who apply and in so doing they no doubt. meet a greater number of interesting cases which, as they receive no pay, are their only compensation.

My impression is that where the registrar has exercised extraordinary diligence in questioning applicants as to their ability to pay for treatment, such practice has met with disapproval and discouragement from the doctors.

However, even this much-abused regulation is now more generally observed than formerly-in some cases grudgingly, it is true, but it is being observed. An instance came to my attention in one of the up-State cities. In New York, as you are aware, doubtful cases are investigated by the Charity Organization Society, but in the city in question-there being no such organization-the superintendent of the hospital sent some of the