Dispensaryization

Dispensaryization, a term derived from the word dispensary (see), which has become widespread in the USSR. Definition. The concept of D. has numerous formulations that do not always correspond to the content that should be invested in it. Under D. should be understood a method of activity of medical-sanitary institutions, consisting in the synthesis of treatment and preventive measures, systematic observation and study of working and living conditions as etiological factors of morbidity, and having as its goal the elimination or mitigation of harmful environmental influences on the health of the collective, ensuring its proper physical development and prevention of morbidity and disability through the implementation of appropriate measures of therapeutic, preventive, and social assistance. All these measures are carried out on the basis of broad involvement of the workers themselves in the activities of medical-sanitary institutions. Considering disease as a social phenomenon, Soviet medicine through the method of D. has been able to fully determine the sanitary condition of the served collective and establish in the etiology of the individual's disease social and other factors of the external environment that cause it. On this basis, a system of measures is built for improving the health of the collective, preventing diseases, and therapeutic intervention with respect to each individual member of the collective. The question of the role of the external environment in the origin of diseases and the necessity of taking this factor into account in scientifically constructed therapy has long been raised in the medical literature. As early as the beginning of the 1890s, one of the largest Russian clinicians, Ostroumov, said: 'Therapy is a way to verify through changes in the living conditions of the organism and its functional activity our assumptions about the causes of pathological changes in the organism in the environment. In diagnosis, we tried to find a connection between changes in the organism and the conditions of the environment surrounding it, and we came to the conclusion that the pathological changes of a given organism depend on such environmental conditions that it could not balance due to the mismatch between the requirements of the environment and the strength of the organism. The prognosis aims to determine under what conditions of the environment and the organism and to what extent a given individual can restore balance to his functions. In therapy, we give new conditions to verify our conclusions.' However, these positions in practical therapeutic activity for the most part did not find implementation due to the existing conditions of the bourgeois-landowner system, and only individual advanced zemstvo medical sites, despite enormous obstacles in work, were lonely pioneers in the penetration of preventive principles into therapeutic work. The historical forerunner of the dispensary was the rural medical site. This last circumstance shows that it is by no means utopian to wish that every medical institution would turn into a kind of dispensary (Semashko). From the very first steps of Soviet medicine, the need for an organic combination of treatment and preventive measures, which becomes possible only under the conditions of the Soviet state, was emphasized. New methods of work began to be implemented first in individual links of the medical-sanitary network, namely in the field of combating social diseases and child mortality: in tubercular, venereal dispensaries, in children's preventive clinics, consultations for the protection of motherhood and infancy, malaria stations, eye detachments, etc., but then gradually began to be applied in the activities of other medical institutions. In 1922, in Ukraine, the organization of regional polyclinics began, which included in their composition, in addition to a number of special offices, a tubercular dispensary, a venereal dispensary, and a children's consultation. These polyclinics united around themselves the regional sanitary and school-sanitary organizations and directed the work of the corresponding 'first aid' points at enterprises. Some polyclinics, especially in industrial areas, began to conduct health examinations of workers, conditions of their work and living, and to participate in implementing measures to improve the production-labor and social-living conditions. Administrative and economic conferences were organized at these polyclinics, which included representatives of the insurance fund and factory committees of the served enterprises. Worker polyclinics corresponded in the nature of their activity to outpatient associations (see Outpatient clinics), the organization of which dates back to 1923. The latter became the starting point in the matter of reorganizing medical assistance on the basis of the widespread introduction of dispensary methods of work into the activities of the medical network in Moscow. An important stage in the development and dissemination of the ideas of D. was the V Congress of health departments in May 1924, at which the main milestones for work on D. were outlined, according to the report of Z.P. Solovyov: the study of living and working conditions not only through sanitary supervision bodies but also through medical institutions, timely and accurate registration of all changes occurring in the environment, establishment of the main harmful factors in the work and living conditions of the worker, clarification of the nature and spread of social diseases, identification of those individuals, groups, and enterprises that cause certain concerns and force to pay special attention to them and apply organized intervention to them. At this congress, the great importance of the broad development of methods of social assistance, which constitutes an organic part of D., was particularly emphasized. The Congress recognized the urgent need to apply dispensary methods of work, first of all, in industrial areas and in medical institutions serving the insured. The XII All-Russian Congress of Soviets (1924) approved the policy of the People's Commissariat of Health, aimed at combining medical activities with the tasks of preventing diseases, combating the harmfulness of labor and living conditions, and involving the entire population in the matter of protecting its health. The IX All-Russian Congress of bacteriologists, epidemiologists, and sanitary physicians in 1925 emphasized the need for assistance from sanitary physicians and planned cooperation with medical institutions in carrying out D. Under D. and at this congress was understood the implementation of preventive principles in medical work. These congresses, which indicated the main direction for work on D., contributed to the awakening of a lively interest in the problem of D. at the local level and the intensification of activity in this area. In recent times and abroad, where socio-economic conditions serve as a huge obstacle to the development of the ideas of D., among individual, most advanced figures in medical practice, the idea is spreading about the need to establish an organic connection between treatment and preventive measures and to take into account the influence of the social environment (soziale Umwelt) in medical activity. Incipient forms of social assistance in the practice of medical institutions date back to the 17th century. In 1634, Vincent de Paul organized in Paris a women's society for providing assistance to hospital patients - Compagnie des dames pour le service de l'Hotel de Dieu de Paris. In England, at the end of the XVIII century and in the XIX century, similar societies were organized. Rathbone (M. Rathbone) in Liverpool in 1862 and Dr. Chapin in New York at the Post-graduate hospital in 1889 made it the duty of sisters to investigate the home environment of patients. In 1904, the beginning of the organization of a special system of medical-social assistance, called 'follow-up-system', was laid in the Presbyterian hospital in New York, the essence of which was the establishment of systematic observation of poor patients after their discharge from medical institutions. For each such patient upon admission, a special sanitary journal was compiled, which was then given for review to the city doctor to whom the patient had the right to turn for outpatient treatment in the future. In 1905, Dr. Cabot in Boston developed this system, organizing the so-called hospital social service. The essence of this system was that at the hospital a social assistance department was established, which deals with clarifying the working and living conditions of patients, providing the necessary information about these conditions to the treating physician, and communicating the latter's advice about desirable changes in lifestyle and occupation to the patient. This department - social service department - tries to help the patient in finding suitable employment, better housing, obtaining necessary care, prostheses, directs patients for this purpose to the appropriate charitable societies. At this department in Boston, there are 50 social service sisters, and it is headed by a supervisory committee consisting of physicians, persons in public service, and persons interested in public work. In 1921, already 286 medical institutions in the U.S.A. and Canada had introduced this system, and in New York in 1926, already 50 medical institutions had social service sisters. The work of medical-social assistance is carried out under the guidance of 2 private charitable societies: The American association of hospital social workers and The national conference of social work. In addition, The American Hospital Association and The National Association for Public Health have special departments of hospital social service. Each of the North American states has a corresponding charitable organization.

In the organization of periodic medical examinations, detection of pre-clinical forms of diseases, and in carrying out health measures (health improvement of Framingham), American life insurance societies play a prominent role, and in the first place - Metropolitan life insurance company. In England, only a small number of medical institutions pay attention to the issues of preventive care. In London in 1926, there were 13 such institutions, in the provinces - 16; special departments or social assistance services exist at them, the so-called 'social service departments' modeled after corresponding American departments. In each polyclinic department, there is a social assistance sister. In St. Thomas Hospital, which has 592 beds and a large polyclinic, 22 social assistance sisters and 14 technical personnel work to carry out social assistance work. In England as well, social assistance is provided on a charitable basis^ all the mentioned institutions do not set themselves broad tasks in terms of improving the social environment of the patient. In France, medical-social assistance in medical institutions was first organized - Tassistance sociale - by Dr. Marfan in Paris in a children's hospital in 1913; during the imperialist war, with the assistance of the American Red Cross and Rockefeller Foundation, social assistance began to be provided in obstetric institutions in Paris, from 1918 - in tuberculosis institutions (special general committees were created), and in 1921 the society for social-hospital assistance was formed (Le service social a l'hdpital). Sections were organized to provide social assistance to corresponding patients - tuberculosis, pediatric, surgical, for the protection of motherhood, and for general therapy of internal diseases, including venereal diseases. Each section has its board consisting of physicians from corresponding institutions, prominent philanthropists, a legal consultant, and social assistance workers. In 1926, this public organization had 34 assistance bureaus and 47 social assistance sisters. The funds necessary for providing social-preventive care are mostly drawn from charitable sources, part comes in the form of subsidies from municipal self-governments and state agencies. The same social-preventive care is also provided by medical institutions in Marseille, Lyon, Toulouse, and Rouen. In recent years in France, in some departments (districts), a special type of so-called polyvalent dispensary (general dispensary) is beginning to spread, especially in small towns and rural areas - le dispensaire polyvalent - which, along with general reception, fights against tbc, venerealism, alcoholism, child mortality, and also develops work for the protection of motherhood and infancy and for sanitary education (see Dispensary). In Germany, the social assistance measures applied by hospital institutions are covered by the concept 'soziale Krankenhaus-fiirsorge'. In 1926, there were already social assistance sisters in 77 German cities at hospitals. Through social assistance sisters, the medical institution receives necessary information about the living conditions of the patient, home environment, nature of work, nutrition conditions, needs of the patient, etc., and tries to use this information to provide social assistance to the indigent patient through the Wohlf-alirtsamt and other care agencies. Tasks and goals. Dispensaryization became a necessary stage in the development of medical care. To get out of the crisis and deadlock into which clinical medicine had fallen, with the extreme development of technicism having completely gone into the therapy of individual organs, overlooking the patient's organism as a whole and completely ignoring the influence of the external environment - there was only one way: to transition to dispensary methods of work. These methods make it possible to combine specialized medical care, the high level of its technique with holistic and unified service to the patient, taken in the specific conditions of his work and daily life. Naturally, this transition is made with great difficulty and is still far from complete. Due to the novelty of the matter, insufficient correspondence of material prerequisites with growing needs, the dominance of old medical habits instilled by the previous system of medical education - most treating physicians have not understood, especially at first, and still do not fully realize the need for a synthesis of treatment functions with the tasks of preventive medicine; they do not build their treatment activity as a starting point for a series of social-hygienic measures. Meanwhile, 'filling the treatment organization with preventive content, we raise it to an even higher level, give it even greater significance. Fertilized by prevention, the treatment organization expands its work even more, connects with the working population, comprehends its purely treatment activity, becomes a powerful factor in improving labor and living conditions' (Semashko). D., at the same time having as its task the prevention and early detection of diseases, contributes to the rapid and complete restoration of lost capacity to work and thus has enormous significance for the national economy, contributing to the preservation and development of the country's labor resources. Prerequisites. The main conditions for carrying out D. are: 1. Accessibility, qualification, and specialization of medical care, the inalienable and constant connection of all its types in order to achieve the greatest effect in terms of disease detection and pre-disease conditions, successful treatment of patients and prevention of diseases. 2. Unity of the work plan and organic connection of treatment medicine with preventive medicine, carried out throughout the entire medical-sanitary organization - from peripheral grassroots cells to leading institutions. 3. Familiarity of medical personnel with the corresponding living and production conditions (social composition of the population, conditions and nature of work of enterprises in the given area, most important and common professional hazards, conditions of home life, etc.) and closeness to the needs and interests of the broad working masses in order to establish the influence of the external environment on the nature of the disease itself and the setting of rational therapy. 4. Implementation of preventive measures to improve the environment (improvement of working conditions, housing conditions, nutrition, etc.), resulting from observations made in the course of the current work of institutions conducting D., and corresponding examinations - the health status of certain groups of workers taken under dispensary care. 5. Correct distribution of all types of treatment-preventive care on the basis of medical and social indications, taking into account primarily the needs of groups of the working population with the greatest social significance and greatest vulnerability to health in connection with the conditions of production and domestic environment. 6. Active participation of workers through trade unions, insurance bodies, labor protection bodies, etc. (commissions for improving labor and living conditions, health cells, health sections).-In D., treatment-preventive institutions must reorganize their work in such a way that the material of observations on individual patients is used not only for therapeutic intervention in relation to these patients, but also becomes mainly the starting point for carrying out corresponding practical health measures in relation to entire population groups.-D. (dispensary care) is conducted 1) in relation to individual pathological forms, such as tbc, venereal diseases, professional diseases, drug addiction, etc., 2) individual sexual and age groups of the population (pregnant, breastfeeding mothers, infant, preschool, and school ages, working adolescents), 3) in relation to individual social groups, distinguished by poor physical development, high morbidity and mortality, or representing special interest due to their social significance or working and living in unfavorable conditions (workers of harmful professions, professional or party activists, etc.). Methods. To carry out D., it is first necessary to regionalize medical care by uniting around a central specialized district polyclinic all other treatment-preventive and sanitary institutions of the corresponding district, which also include an investigative apparatus (social assistance sisters). Thus, a kind of urban district medical-sanitary area is formed (called in Moscow the polyclinic association, in Leningrad the treatment-preventive association). According to the indicated scheme, in which the central district polyclinic comes to the forefront, carrying out together with other links of the district network of treatment-preventive institutions dispensary care of a certain population group, D. is conducted in many provincial cities and industrial centers - Nizhny Novgorod, Ivanovo-Voznesensk, Tver, Yaroslavl, Saratov, Tambov, Kursk, Ulyanovsk, Samara, Orenburg, Kazan, in cities and industrial centers of Ukraine, etc. D. is carried out as follows: first, a primary thorough medical examination is conducted to obtain basic data on the health status and physical development of groups taken for dispensary observation; at the same time, the conditions of their work and daily life are clarified through appropriate sanitary surveys; further, at certain intervals, repeated examinations of the health status of the population groups under dispensary care are conducted.

In the conduct of D. all the main links of the health-prophylactic network participate: first aid points at enterprises, home care points, outpatient clinics and polyclinics, hospitals, separate dispensaries, etc., carrying out a series of tasks according to a specific plan, with the forms and extent of this participation being established in accordance with the nature of the work of the given institution, the degree of its provision with medical personnel, and its general preparedness for preventive activity. - First aid points help establish direct contact between the district health-prophylactic association and production, they collect information about working conditions, the sanitary-hygienic conditions of production, the living conditions of workers, participate in measures aimed at improving these conditions, observe the health status of workers, etc. - The organization of home care plays a significant role in improving living conditions, promoting the spread of sanitary-hygienic knowledge in the family, and carrying out necessary preventive measures (maintaining housing cleanliness, ventilation, disinfection, etc.). - The outpatient clinic, which heads the district association, establishes connections with all health-prophylactic institutions of the district to ensure continuity of observations and timely intervention for providing medical, preventive, and social assistance. The outpatient clinic organizes periodic medical examinations through appropriate physicians, clarifies working and living conditions through the sanitary organization and labor protection commissions at enterprises, as well as living conditions through sister-investigators and home care physicians, registers¹ in a special personal sanitary journal all observations of the health status of persons taken under dispensary service, while concentrating as much as possible all information about these persons available from them and in other health-prophylactic institutions that have treated them. - Inpatient institutions engage in clinical observation and study of the etiology of diseases in connection with dispensary provision of medical care and continue observation for discharged patients with the help of outpatient clinics. - Sanitary physicians carry out corresponding tasks for D. through systematic sanitary investigations of working and living conditions and conducting measures to improve them. In a number of places there are special district sanitary physicians who are part of district associations or attached to them. The connection of the outpatient clinic with medical control and examination authorities is also of great importance, through which the nature of disability, its causes, and often the paths leading to complete or partial restoration of working capacity are determined. At district associations, special auxiliary institutions are organized to serve those undergoing dispensary service (diet kitchens, canteens, day and night sanatoriums, areas for air and sun baths and simplest forms of hydrotherapy, etc.). These institutions play a huge role in the work of D., facilitating rational therapy without removing patients from production. From the group of workers taken under registration, persons are identified who, due to their health status, require constant observation and various types of medical and social-prophylactic assistance, such as referral to sanatoriums, rest homes, diet kitchens, canteens, physical therapy institutions, sanatorium-resort treatment, preventive leave, transfer to lighter and more suitable work, improvement of housing conditions, etc. The degree of satisfaction of this need varies in different regions depending on the power of the network, the health budget, and other local conditions. Along with medical-prophylactic measures for individuals, there are measures aimed at improving general sanitary conditions, the production environment, housing conditions, public catering conditions, etc. The next and most important aspect of D. is systematic observation of the health of the population group under dispensary service. This observation is carried out through periodic repeat examinations and in the order of current attendance. In the early years of D. work, there was a strong tendency to favor one-time mass examinations as a means of studying the social environment. Even in Moscow, at first, almost all attention was focused on mass examinations of the physical condition of workers, which led to some displacement of the main aspects of D. - systematic dispensary observation and provision of medical and social assistance - to the background. In some places, these examinations were equated with D. The XII Congress of Bacteriologists, S12 epidemiologists, and sanitary physicians took a negative view of one-time mass research as an irrational method for studying the environment; they had to give way to in-depth dispensary service. Systematic dispensary observation is usually conducted by outpatient clinic physicians; in Moscow it is entrusted to so-called dispensarizers (see below). To facilitate this observation, in a number of cities, persons taken under dispensary service have been attached to specific health-prophylactic institutions. In small cities, the need for such attachment is unnecessary. It is clear that dispensary observation is combined with appropriate repeat examinations of working and living conditions. In most cities and in significant industrial centers where D. is conducted, workers are dispensed with at their place of work, i.e., they are served by medical and preventive institutions of the district in which the factory and plant enterprises are located, while families are served at their place of residence, with in most cases D. of workers not being accompanied by D. of their families, which represents a significant shortcoming. In small cities and industrial areas where the same health-prophylactic institutions serve both workers and their families, simultaneous D. of both workers and their families can be carried out. Unlike Moscow, Leningrad places home care organization at the center of dispensary service for the working population, linking it with the aforementioned 'health-prophylactic associations' the so-called district system of home care. The latter consists of attaching a qualified physician to a specific territory, with the assignment to him, in addition to duties in providing home care, also of outpatient treatment of patients from this district and general responsibilities for protecting the health of the population of his area, which facilitated the study of the patient's living conditions, his family circumstances, i.e., the conduct of dispensary service. Leningrad considers it advisable to conduct D. at the patient's place of residence; although this results in detachment from the enterprise, this significant defect is somewhat mitigated by the fact that the study of mass professional hazards can be carried out independently, and necessary additional information about working conditions can be obtained through the first aid points (see) at enterprises. Instead, the possibility is achieved of more accurately accounting for the influences of living conditions, conducting dispensary service for the worker together with his family, establishing close ties with the preventive institutions used by the worker's family. The main cells of health protection in the field of labor improvement, according to the Leningrad scheme, are the first aid points at enterprises. However, it should be noted that Moscow in recent time is also making efforts in the direction of closer integration of home care with the general system of D. measures. In the newly organized so-called unified dispensaries, outpatient physicians also carry out functions in providing home care. Due to the limited resources and medical forces and insufficient capacity of the health-prophylactic network in almost all places where D. is conducted, the latter extends primarily to workers in harmful and dangerous professions or to specific workshops with the greatest professional hazards, or to groups of workers most important for the production of the given district. Special attention everywhere is paid to the dispensary service of adolescent workers. In the field of D. of individual groups of workers exposed to different industrial hazards, dispensaries for combating occupational diseases play a major role. These dispensaries in their work are connected with the corresponding therapeutic and preventive institutions and guide their work in the fight against occupational diseases, which is an organic part of the work on D. For dispensarized workers, a special so-called sanitary journal is usually filled out, in which are entered not only the results of the initial examination but also all further changes in the health status and physical development of those under dispensary service, the results of current observations, detected both during repeat medical examinations and in the order of everyday attendance. The results of sanitary investigations of working and living conditions are also entered into it. Personal sanitary journals are usually kept in central outpatient clinics serving the corresponding enterprises. Commissions for labor and living conditions improvement - organs of worker self-activity, attached to the district association of health-prophylactic institutions - play a major role in carrying out dispensary service.

The commission includes members of the health section of the corresponding council, representatives of factory committees or labor protection commissions of the served enterprises and institutions, insurance funds, labor inspection, VLKSM, women's departments, the Medsantrud trade union, and in some places, Rabpros. This commission participates in the development and implementation of the D. plan, establishing the order of enterprises and population groups to be dispensarized, distributes the fund for medical-social assistance, assists in studying the sanitary condition of the area and its improvement, takes measures through appropriate organizations to improve housing and living conditions. Often the commission forms subcommittees on separate issues related to D. Through this commission, a close connection is established between institutions conducting D. and the served working population. Regarding dispensary care for the rural population, it must be noted that this work is in its initial stage due to the insufficient network of medical-sanitary districts and medical personnel. In those provinces and districts where D. is carried out in rural areas, certain population groups are usually selected for dispensary care based on different criteria: 1) by age - coverage of infants and older children, adolescents, organized children's collectives - children's institutions, schools, pioneer detachments, 2) by gender - care for pregnant women and nursing mothers, 3) by professional and social status - registration and dispensary observation of groups most susceptible to various diseases due to labor and living conditions and most important in their social significance - agricultural workers, farm laborers, collective farm members, artisans, etc., and 4) by the most prevalent diseases in the given area - syphilis, tbc, trachoma, malaria, etc. In the field of D., the main forms of work in rural areas are: proper registration and study of morbidity, and in particular professional, social-domestic, and infectious diseases; examination of labor and living conditions of the population to identify diseases that are significant for the given locality, with the aim of determining the causes of diseases, taking measures to eliminate them, and providing therapeutic-prophylactic and social-prophylactic assistance; study of the sanitary condition of the district (rural water supply, village improvement, housing issue, etc.) with the aim of identifying production and domestic factors of morbidity and for developing and implementing general health-improving and anti-epidemic measures; organization of special types of preventive care: protection of motherhood and infancy, protection of children's health (preschool, school ages, pioneers, VLKSM) and adolescents, and the fight against social, domestic, and professional diseases; organization of public initiative in the matter of improving labor and living conditions in the village. The center of all this work is the medical district, under whose direction all medical-sanitary institutions located on the territory of the district and serving it operate.

Dispensaryization. Dispensaryization in Moscow. Great practical work on dispensaryization in Moscow and in some districts of the Moscow province has been carried out by the Moscow Health Department, which, as indicated above, assigns dispensaryization to the so-called outpatient association. The organizational scheme of the outpatient association is as follows. 1. A central specialized outpatient clinic that conducts outpatient reception in all specialties, to which, in addition, clinics of the additional network and branches at enterprises refer patients for dispensary observation and treatment who require a more in-depth approach by specialists. 2. Clinics of the additional network with reception in the main specialties, on the one hand, taking workers under dispensary registration and dispensary observation, and on the other hand, conducting outpatient reception, referring those in need of special dispensary observation and special help to central outpatient clinics. 3. Branches of central outpatient clinics at enterprises, providing first aid at the workplace and at the same time conducting primary and repeated examinations within their specialty; connected with health subcommittees at enterprises (health cells), they carry out health work at enterprises, the fight against injuries and accidents. 4. Prophylactoria (dietary canteens, night sanatoriums, physical therapy sites), which, while part of outpatient associations, are simultaneously connected with the hospitals on whose territory they are often located. 5. Home care personnel, who at the request of patients provide assistance and care at home and at the same time conduct home observation for severe diseases among those taken under dispensary service, and upon completion of a severe disease they transfer their observations to the outpatient clinic where the patient is registered. 6. Sisters of social assistance, who are in close connection with home care, who, on the instructions of physicians conducting dispensary observation, investigate living conditions and carry out work to improve them. 7. Sanitary physicians for the fight against occupational diseases (since June 1928; before this time their work was carried out by senior sanitary physicians of outpatient associations together with district sanitary physicians); they study occupational disease based on materials from dispensary observations and outpatient clinics, carry out measures to improve working conditions through labor inspection, consult with physicians conducting dispensaryization on issues of etiology of diseases, etc. In close connection with outpatient associations are: 1. Hospitals, where patients are sent for inpatient treatment in the order of dispensary selection, and after completion of inpatient treatment with corresponding extracts from medical records, they are returned to outpatient associations for further observation and treatment. 2. Special dispensaries (tuberculosis, venereal, and narcodispensaries, consultations for pregnant women), which according to a pre-compiled plan participate in dispensary examinations of workers and subsequently take them under their special observation when indicated; after completion of observation in special dispensaries, patients with corresponding extracts from dispensary cards are returned under the observation of outpatient associations. 3. Sanatoriums, resorts, physical therapy clinics, etc., to which corresponding patients are sent on the basis of selection carried out by labor and living conditions improvement commissions. Dispensaryization of childhood is conducted in special institutions - children's preventive outpatient clinics, which have the task of providing therapeutic and preventive assistance to the organized child population and working adolescents on the basis of studying their psycho-physical development and conditions of their work and life; selection of children for children's playgrounds, forest schools, psychoneurological schools and sanatoriums and other therapeutic and preventive institutions; professional orientation of children and adolescents finishing labor school and professional selection into FZU schools; medical supervision over physical education, etc. The children's preventive outpatient clinic has offices for medical supervision over physical education, anthropometric, psychoneurological, and offices for clinical specialties, a pedological laboratory, a home investigation apparatus, and auxiliary institutions: day and night sanatoriums and a children's playground. In Moscow, dispensaryization of childhood is conducted only partially by children's preventive outpatient clinics, to a greater extent by general children's outpatient clinics, with children often being referred to general outpatient clinics for special assistance. Materials of examination are recorded in special cards. Filling in the personal health journal in the part concerning personal data and anamnesis, observation of children and their referral for dispensary examinations, communication with parents are assigned to physicians for child health protection. Dispensaryization of workers. To ensure unity and planning in dispensary service for adult workers in the outpatient associations of Moscow, each enterprise is attached to a specific outpatient clinic, which establishes the periods during which the person under dispensaryization must appear at the clinic for examination, and (through health cells) takes measures to ensure their timely appearance at these times; in Moscow the organization of examination is such that the composition of specialists examining a particular group is determined depending on the nature of pathological lesions characteristic of this profession. In the outpatient clinics, personal health journals of workers are kept; information from other treatment institutions where the patient is temporarily placed under observation is sent here. To ensure unity of observation over each worker, the so-called responsible dispensaryizers - therapists who conduct outpatient reception and at the same time, as an additional workload for special remuneration, have from 700 to 1,000 workers under dispensary registration, whom they observe within their specialty, referring them to other specialists or special institutions when appropriate diseases arise - keep personal health journals, recording in these journals data from periodic examinations and current observations, ensuring timely investigation of living conditions and provision of therapeutic and social assistance. Dispensary observation is carried out by a) periodic examinations and b) using current visits by the patient to treatment institutions for various diseases. In relation to persons whose primary examination establishes certain pathological lesions (see below), repeated examinations are conducted by using attendance for current diseases and at times depending on the nature of pathological involvement or current morbidity and working and living conditions. Only for persons found healthy at primary examination are special repeated examinations established: for adult workers and peasants not less than once a year, for adolescents and children not less than twice a year. The question of comprehensive registration in personal health journals of all detected morbidity is relatively simple under the district system of organization in the provinces and in small cities where the population is actually attached to one treatment institution that provides all types of assistance and which can therefore easily establish their registration in the personal health journal. In the conditions of large cities, however, where various treatment organizations - outpatient clinics, hospitals, home care, etc. - exist independently and where each patient can turn to various outpatient clinics, the question is much more complex and can be resolved a) by strict attachment of those taken under dispensary service for treatment to specific treatment institutions; b) by introducing a health passport for dispensaryized persons, which remains with the patient and to which every treatment institution makes entries about diseases and assistance provided; c) by systematic notifications about observed diseases sent by all treatment institutions to the outpatient clinic where the given person is under dispensary registration. As indicated, the Moscow Health Department has embarked on the path of partial attachment of dispensaryized persons for treatment to a specific institution and systematic notifications. In practice in Moscow, it has been established that, simultaneously with taking industrial workers under dispensary registration, sanitary physicians conduct a general examination of working and living conditions. The program of sanitary examination of enterprises contains general information about the nature and processes of production and work regime, its payment, vacations, organization of medical assistance, number and composition of workers by age, sex, family status, work and professional experience, sanitary topography of the enterprise, its water supply, sewerage, individual workshops (building material, area, cubic capacity, lighting, heating, ventilation); general data about the equipment of the enterprise; particularly harmful moments of production: harmful substances with which workers come into contact, gases, vapors, dust, temperature, humidity, noise, vibration, danger of injuries and measures to eliminate them.

In order to determine the etiology of diseases of individual groups of workers and even individual workers, it is necessary that the examination covers not only the enterprise as a whole and not only individual shops and workshops, but that as a result of it, characteristics of individual jobs, individual places in workshops that have certain sanitary peculiarities can be compiled. For these same purposes, sufficient attention is paid to describing the condition of workshops and facilities for individual hygiene: cluttering of workshops, their cleaning, care for heating, ventilation and other sanitary-technical facilities, washbasins, spittoons, work and special clothing, individual protective devices, showers, toilets, dressing rooms and places for storing clothing, rooms for rest, for eating, for feeding children, etc. Special attention is paid to the sanitary characteristics of detailed professions. Unlike the sanitary characteristics according to the scheme of the People's Commissariat of Labor, which contain only brief conclusions from studies of working conditions and the production process, according to the opinion of the Institute of Occupational Diseases named after Obukh (Moscow), the so-called sanitary-clinical characteristics should establish the connection between occupational hazards on the one hand and diseases on the other, using for this all methods—statistical, clinical, and experimental. Such sanitary-clinical characteristics according to the scheme of the Institute named after Obukh consist of 1) definition of the place of a given profession in the general course of production; 2) description of the external environment in which the work takes place and its hazards; 3) analysis of the work process itself with its division into separate moments and description of each of them; 4) physiological reaction of the body to work and 5) its pathological reaction, determined on the basis of analysis of the morbidity of the corresponding professional group. Subsequently, the pathological involvement and morbidity identified during dispensary observation set tasks for sanitary organizations for further in-depth study of the enterprise. Examination and further study of the enterprise provides material for carrying out health-improving measures. In this direction, a great deal of work has been carried out jointly by the forces of sanitary doctors and sanitary inspection with the assistance of labor protection commissions and health subcommittees (health cells) in enterprises. Broad opportunities for such work are opened by the Resolution of the Council of People's Commissars on sanitary authorities of the Republic of 1927 and its supplement of March 22, 1928, which imposes on health authorities the study and struggle with occupational morbidity. Examination of living conditions of dispensarized workers for their general characterization is carried out by sanitary doctors on a selective basis (dwellings, nutrition, budget, daily routine, physical culture, etc.). Individual examinations of living conditions are carried out by social assistance sisters according to special instructions from attending physicians and have as their purpose the clarification of household etiology of diseases. Sisters of social assistance also carry out enormous work in instilling hygiene skills in the household and in improving household conditions. In the districts of Moscow province, Dispensaryization is carried out by district clinics; for special diagnosis and special treatment, the district clinic directs patients taken under dispensary care to district specialized clinics and special dispensaries. For work on examining and improving living conditions, the district clinic has sisters of social assistance. Participation of special dispensaries and consultations in Dispensaryization is carried out on approximately the same basis as in Moscow. Special work on examining the sanitary condition of villages, enterprises, handicraft industries and their improvement is carried out by the district sanitary doctor. Examination of villages in the case of rural population is carried out according to special settlement cards containing information on the sanitary topography of villages (location, terrain, soil), on vegetation, on land organization and land use, on auxiliary industries, on the number of inhabitants, on planning, construction, water supply, sewerage, nature of housing, nutrition, on enterprises and institutions, on local epidemiological data, etc. The settlement card is supplemented by examination of typical peasant farms, handicraft industries, etc., carried out according to a special program. Identifying not only those pathological conditions that are accompanied by more or less noticeable violations of functions, reduction of work capacity, violation of the patient's well-being, but also those that are not accompanied by these phenomena, dispensaryization obtains data that essentially differ from the usual morbidity data found in the course of the population's seeking medical help. S. M. Bogoslovsky introduced a special term for these data—'pathological involvement', as opposed to 'morbidity'. On the basis of data from dispensary examination of 115,349 workers and employees of the city of Moscow, he established that for every 100 male production workers there are 79.9 sick and 226.8 pathological marks; for every 100 female production workers—82.9 sick and 247.7 marks; for every 100 male auxiliary workers—76.3 sick and 214.8 marks; for every 100 female auxiliary workers—83.0 sick and 196.5 pathological marks; for every 100 male employees—82.6 sick and 220.9 pathological marks; for every 100 female employees—83.6 sick and 224.9 pathological marks. To give an idea of the scale in which medical-social assistance is provided to dispensarized people in Moscow, corresponding data for 1927/28 are given. Percentage of satisfied with various types of med.-soc. assistance in relation to the number in need of this assistance. Special treatment...........

26 Of the listed types of assistance, special importance is attached to prophylatoria (night sanatoriums, diet canteens, etc.), called into being precisely by the dispensary system and which initially received practical application in tuberculosis dispensaries. The purpose of prophylatoria 1) to give the patient, without removing him from ordinary work, the necessary conditions for restoring health in the form of appropriate premises, environment, regimen, nutrition and simplest therapeutic procedures, 2) to give him hygiene skills which he then transfers to his domestic household. Advantages of prophylatoria: 1) their cheapness (maintenance of a patient in a diet canteen in Moscow costs from 1 r. 20 k. to 1 r. 50 k. per day, in a night sanatorium from 2 r. to 2 r. 50 k.); 2) they are institutions for mass use; 3) due to the comparative simplicity of design and equipment they can be brought closer to enterprises; 4) prophylatoria possess great flexibility and are easily adapted to individual indications. The experience of three years of existence of prophylatoria in Moscow proves that they give good and sufficiently lasting results. Selection for prophylatoria, as well as for other types of special assistance, is carried out by labor and health improvement commissions on the basis of medical indications given by the leading Dispensaryization doctor and social ones established on the basis of statements from factory committees, health cells and other organizations.

Ya. Kats.