fl.—22a.

14

(4.) The consumptive annexe should be attached to the hospital, base or subsidiary, as the Case, may be, in that part of the district likely to afford the best climate for the outdoor treatment of consumption, and where there would be enough land adjoining to allow the principles of the openair treatment to be followed out. Separate accommodation would, of course, have to be made for curable and indigent incurable cases, but not necessarily at the same hospital. (5.) The old people's home is, of course, a necessity, and little need be said about it now, except that its accommodation should be so arranged that a careful classification of the inmates could be made, so that the really unfortunate and deserving poor should not have to occupy the same rooms as the less desirable inmates which are to be found in such institutions. (6.) The chronic and incurable ward should be reserved for indigent chronic and incurable patients, and should be erected in the immediate vicinity of and administered in conjunction with the old people's home. It is most undesirable that these cases should be treated in the wards or in the immediate neighbourhood of a general hospital. The hospital should, as I have previously said, be reserved for the acutely sick only, and the admission to the wards of the chronic and incurable not only tends to keep acute cases from being admitted to the hospital, but many patients are reasonably reluctant to enter a hospital where such cases predominate. There is another reason why the chronic and incurable ward should be attached to the old people's home. There are many chronic patients who will stay in a hospital for a great length of time without paying or attempting to pay maintenance fees; but if they are sent to the chronic and incurable ward of an old people's home either the patients themselves or their relatives will make a great effort to pay such maintenance fees or to support them outside. Another argument in favour of having the chronic ward so selected is that a number of the aged in the old people's home are, from their age and infirmity, constantly ailing and on the verge of acute illness — at any moment they may require skilled nursing. Now, I think that most of you will agree with me that no home for the aged should lack the services of skilled nurses, and the present system of allowing these old people, in many instances suffering from paralysis and bladder-troubles, to rely solely on the ministrations of their fellowinmates is a great blot on our present system, and should not be tolerated any longer. (7.) A system of poor-law relief co-operating with private charity : I will defer discussing this essential of each district until I come to the subject of charitable aid. Briefly, I would suggest a modification of what is known as the Elberfeld system. (8.) The district nurse : I now come, last but not least, to the person who will supply the link in the chain between the base hospital and the remote backblocks : I refer to the district nurse. The establishment in our remote country districts of a nursing system would be a great boon to those people who have to face the discomforts and hardships of backblocks life. In this matter 1 do not speak from hearsay; some of you may not be aware that I practised for some years in a large country district, which often necessitated my taking very long of thirty, forty, yes, and even eighty miles to my patients. I have seen women so cut off by distance and bad roads that they have not seen one of their own sex from year's end to year's end. I have had on many occasions to do the duties of nurse as well as doctor to a woman during her confinement. Now, knowing what I do of the hardships of backblocks settlers, it would ill become me if I did not speak out on their behalf. From a professional point of view, it is most unsatisfactory to treat a case a long way from home. Of what avail a journey, at considerable expense to the patient, if the doctor's orders are not carried out? I know what it is to ride away from such cases feeling that if I could have left a good nurse in charge the prospects of the patient's recovery would have been infinitely better. If Boards established district nurses in the backblocks they would benefit a class of people who are all the more worthy of consideration because one hardly ever hears them complain. Consider the possibilities of such appointments: (1.) Fortunately, there are now few districts unconnected with the telephone : In the event of illness the district nurse could ring up the nearest doctor, describe the symptoms, temperature, &c, of the patient, and give the doctor indications whether or not it would be necessary for him to visit the patient. If he did not think a visit necessary, she could faithfully carry out his instructions, and report from day to day on the condition of the patient. By such means much distress and money might be saved the backblocks settler. But, besides this, the district nurse could (2) locally supervise the midwives of her district, and periodically inspect their kit and instruments to see that they are kept properly clean. (3.) In case of accident she could give "first aid," and accompany the patient to the nearest hospital. (4.) She could be the " eyes and ears "of the Boards under which she served, and, having made herself acquainted with the conditions of the various families in the district, could be better able to give information as to the circumstances surrounding those persons applying for charitable relief. Nor would such a nurse be a great expense to the Boards. She would be in a position to know what people could afford to pay for her services, and advise her Board accordingly. I quite believe that a great portion of her salary could be paid by these means. If the scheme did not prove too expensive, additional nurses could be gradually appointed, so that no part of the hospital district would be without its district nurse, and the gaps in the chain would be complete. (5.) Under the same conditions the district nurse could attend to those incurable cases who might be reluctant to go to the incurable ward in the old people's home. From many country districts we hear of demands for Government subsidies to encourage medical men to settle, and such requests are sometimes granted, but not enough is given to allow the doctor appointed to make a fair living. Would not those districts be better served by a district nurse, in conjunction with a doctor at a distance, as I have already indicated? The money raised locally by the settlers, after paying the nurse's salary, would be better spent in guaranteeing the expenses of the doctor's visits when the nurse considered his services necessary. I have suggested this to some of the backblocks settlers, and they seemed to view the matter favourably. Of course, there are considerable difficulties in the way, chiefly as regards getting suitable nurses, but these difficulties can be gradually overcome. Efforts should be made to supply the district nurses from the base hospitals.