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The 
Visiting Nurse Quarterly 
of Cleveland 


Vol 3 ()ctober, 191] No, 4 





Editorials 


It is a tribute to the activity and thoroughness of organ 
ized charity that so sharp an issue 1s being raised as to 
whether the social worker or the visiting nurse shall super 
vise the social relief in the homes of the sick poor. 

We regret to say that with few exceptions neither one 
of these workers seems to us as yet ideally fitted for this 
high service. 

The great mass of evidence collected by organized char 


ity, both medical and social, shows that sickness and ex 





are 


treme pov erty 


that 


in tuberculosi 


pression of this 


< 


the movement of 


well 


ve 


sad parti y 


pre ventiv¢ 





h inseparable companions, and 
perhaps the most perfect ex 
hip. Indeed, we believe that 


and worl 


constructive 


interest of public health had its origin in the practical re« 
enition of tuberculosis as a dual problem. 

Those who contend that the il worker is better fitted 
than the visiting nurse, to de th homes where there 1s 
tuberculosis, lay the str { cial side of the prob 
em. It on ( lat Nie the collaboration 
physician and ll work« uld fill the need, but nm most 
stances th an WV the time and the nec 

irv social training, and irker the nee 1 
nedical ti 1 to make the ibined « r iccesstu 

In the home bercul has gat 

thold, it ( » «le cl ‘ttor—the di ( 

h degen rate al eds the most kx d { 
ention, 1m lk escu mily from the condition 
we ha ( i mes ( le Ubi red, | weve 
Cc do 1} 1} LL al ! he 
nnot bx ( b ex th 1h l 
ren f fight o7 t thi 
ection must | e all thing 1 
the soundn f tl { in end \ 
the enemy 1 
The Sur lu re t1 nm the subye 
tates that t 1 nitas IS ¢ ( 
es not est nN rf the soc 1 
» deal li 1 ses us 1 11 
ee] that nu ) 1 Nn 
uestion ess 
We are a ( he majo { () 
ng nurses are ent ( exer the office of reli 
ent in the homes wher ( tuberculosis but we 
very nearl re th Miss tte when she says 

e realize tl 1 e pert equipped worker both sé 
of training are essential, the o1 question is which tl 
two shall supplement her tr by that which she lacl 











Shall the nurse add to her three years’ hospital experience, 
a course of six weeks or one year in a school of philan 
thropy, or shall the social worker supplement her school of 
philanthropy by three years in a training school for nurses? 
It is simply a question as to which of the two shall do it 
ell things being equal, it makes no difference which.” 

We have to dissent just a little in spirit from Miss La 
\lotte’s statement of the case because she does not include 


among the assets of the social worker the four years college 


course which, as a rule, precedes her social training, and 
which, in some respects, offsets the advantage of the three 


hospital training with which the nurse is equipped 


years’ 
Che nurse's training, we believe, is very much less often 


built upon the foundation of a college course 


lf nurse and social worker are to be fused in one agent 
in the service of the sick poor, that agent, ideally speaking, 
should have a college training with post graduate cours« 
in medical nursing, prophylactic nursing, an cial relief 
Such a combination would meet the very high requir 


ments now demanded by an increasingly enlightened pub 


(tne very signal advantage of such a mbined exercise 
‘f functions would be that the nursing sid the servi 
vould enable such an agent to perform actual manual service 
rr the family she is trying to rescue from the snare 
ickness and poverty. Such service 1s understood and ap 
‘reciated by the most ignorant and lowly people, and the 


ntaneous unburdening of the heart and mind to a person 


ho is taking the physical care of yourself or ur loved 

ones, would, we think, often direct one’s effo toward the 
wisest ends. 

he nurse always enters a home with a gift her hand 

the gift of manual service—which establishes at once, 11 

she so wills, a close human relationship between her and 


he members of the family. She can become almost inte 


erally a working member in the family group if she is great 
enough to see her opportunity and to use it. 


/ 








We realize that it will be some time before the college 


graduate, visiting nurse, and social worker can be fused 
into one individual, and in the meanwhile the only thing for 
the visiting nurse to do—if she is to keep abreast of her 
opportunities—is to supplement her hospital training by post 
graduate work in prophylactic dispensaries and’ by the study 
of social conditions. 

The key to the homes of the sick poor was first of all 
given into her keeping, and it is for her to see that the 
privacy of such homes is protected from all unnecessary in 
trusion and that the human side of the family problem meets 
with the reverence and sympathy which we accord to the 
misfortunes of those whom we personally know and love. 

The strictly impersonal attitude is we hold, a dangerous 
one and from this impersonal attitude the nurse is pre 


served by the nature of her ministration. 


IT. 


Since we are on the subject of the hygienic and economic 
reconstruction of the home which has fallen prey to disease 
and poverty, let us once again express our hope that at no 
distant time all district physicians—to whom municipalities 
entrust their sick poor—be provided with prophylactic and 
social training as a requirement for the exercise of their 
profession in families where disease and poverty are inex 
tricably enmeshed. The advisability of such post graduat 
experience for medically trained men who are to receive 
appointments as district physicians was strongly urged in 
the Visiting Nurse Quarterly January, 1911. Social dispens 
aries for the care of tuberculosis and of infant life, are now 
so well organized in many of our large cities that it ought 
not to be difficult for a municipality to insist that district 
physicians should conform to the same standards along these 
lines as are met by the agents who are salaried by private 
organizations. Indeed the obligation seems to us even great 


er, for the district physician’s salary is met by taxation, and 


the work of the private organization is a gift to the com 
munity. 











In Cleveland the men who chanced to have served in 
social dispensaries before receiving appointments as district 
physicians, together with the men who have remained in 
such dispensaries, have done work of such essential value 
to the city that it has forwarded in an extraordinary degree 


] 


the whole movement of public health work in Cleveland. 


ITT. 


The nurse in the field 1s of necessity more independent 
than her sister in the institution or in the private home where 
her services are directly paid for by the people whom she 
Serves. 

he Visiting Nurse is in a certain sense a public servant 
with a public servant's freedom and the increased persona 
responsibility which such freedom brings. She exercises her 
profession primarily to earn her own living, but the exercise 
of this profession among the poor leads her into the midst ot 
experiences which develop the altruistic side of her nature 
and broaden her interests. 

She nearly always finds herself giving and spending her 
self willingly in the service of real need, and “overtime” 
has a special and often sacred meaning to her. 

She does a great deal more voluntary service than anyone 
is aware of unless one watches the work closely. 

We speak of voluntary workers and of paid workers, but 
it is often difficult to realize how many hours of voluntary 
service are given, and given willingly, by visiting nurses 
to the care of “their families.” 

She loses something of her submissiveness or subser 
viency because she is no longer part of a strictly hierarchichal 
plan and because as her experience increases she must more 
often think and act for herself. 

She escapes the intensive influence of any one group of 
people because she goes in and out of many homes each day, 
and if she is deeply interested in her work for these per 
plexed human beings she will ponder over their troubles and 
such pondering will in time arouse within her the vague 


4) 











1 


rescience that only collectively can we be saved, and towarid 


‘ 


such salvation she does her part. 


IV. 


Beginning with the January number of the Quarterly the 
subscription price will be raised to a dollar a year. This in 
crease in price is made necessary by the increased size of 
the magazine. We hope that none of the subscribers will 
leave us and that on the contrary, they will each try to get 
a new subscriber to send in, as a token of their approval of 


this change. 


News notices referring exclusively to the Visiting Nurse 
\ssociation of Cleveland will be published in the Januat 
number of the Quarterly, which besides its usual material, 


embodies the Annual Report of the Cleveland Association. 








Tuberculosis Work in Cleveland 


HOW IT IS SUPPORTED, AND THE COST 


1—THE CITY. 
1 =Control and Direction of Department of Public Safet 
Safety. 

(a) Hospital for advanced cases, 102 beds. 

(b) Sanatorium for early stage cases, 87 beds 

\ new Sanatorium, costing $250,000, with a capacit 

»f 250, is being erected. 
No case is admitted to the Sanatorium without bein 


first examined in one of the tuberculosis dispen 


hwo 
he county pays the city $1.00 a di every cas 
taken care of in either institution 
ZA nd Direction of the Department | 
Division « Puberculosis in the Heal Departme 
the put ( registration es O 1 


5152 cases on record at present time 

ough the sanitary force the disinfe 
tion of all cases. 

c) The operation of three dispensaries. Each dispensary 


an q “s rt P } ‘ 
k to a definite district, and is 


confines its wot 
manned by a physician, 2 to 3 nurses and a clerl 
clinic. 

(d) City Laboratory, for free examination of sputum 


e) Supplies nurse in charge of Day Camp. 


Il—PRIVATE CHARITY. 


1 


1 The Anti-Tuberculosis League controls and support 
(a) One Dispensary, co-operating with the Board of 


Health: 1 volunteer pl 


1] 


ysician and + nurses 














(b) Nurse for Special Case Committee work. 
(c) Tent Colony for Tuberculosis children, open the year 
round ; capacity 31; 2 nurses. 
Open Air School in connection with the Camp ; teach 
er supplied by the Board of Education. 


(d) Day Camp; capacity 35; nurse supplied by the Board 
of Health. 


(e) Educational work—Lectures, distribution of litera 


ture; contributes to support of Neighborhood 
Health Campaign. 
(f) lurnishes limited amount of milk and eggs through 
the Associated Charities 
2 The Children’s fresh Air Camp. 
Preventorium for anaemic and predisposed children ; 


capacity 50 (will be in operation soon). 
3 The Associated Charities 
(a) Material relief, on recommendation of the tuberculo 


sis dispensaries. 


| a 


(b) Temporary lodging for homeless consumptives. 


[i—COMBINED MUNICIPAL AND PRIVATI 
CHARITY 

1 Five Open Air Schools under control and direction of 

joint committee from the Medical Inspection Depart 


ment of the Public Schools, the Anti-Tuberculosis 


League, the Federation of Women’s Clubs, the 
Fresh Air Camp Association, the 


I il, 


Board of Health. 
2 Neighborhood Health | 


ampaign, with the following 
twelve organizations interested in the health of the 


home co-operating in the building and placing of a 


combined exhibit, and the carrying on of intensive 
educational work in the various neighborhoods of 


the city ; 


The Visiting Nurse Association. 
The Anti-Tuberculosis League. 


12 


























The Babies’ Dispensary and [lospital. 
Vhe Board of Tlealth. 

Play and Recreation. 

Consumers’ League. 

Ilome Gardening. 

Society for Promoting the Interests of the Blind. 
Maternity Dispensary of Lakeside Hospital & W. R. | 
Department of Medical Inspection. 

Rainbow Cottage. 


Cleveland Maternity Dispensary Association 


SUMMARY: 


(ne Llospital for advanced cases............. 112 bed 

One Sanatorium for early cases................ 87 bed 

One Sanatorium for children ......4065sss80s00 31 beds 
One Day Camp, all stages, capacity.......... 35 
BORED 6.5% i005-cceie dae ad dowd ewe OO 

Nurses 

Supported by city iat RN a ace Soa ae Ge at Ie alee a SLR rl Neer Cag 2 

Supported by Anti-Tuberculosis League............... 7 

PORE ic i.4' @ Wdse dod Si aeeewdteumei aCe bees «rete 16 

Dispensaries- 

EE OE HOP 9.cks Dae eT RS OE ee ES 3 

Sate Tr LOR «so Se See eR ee ees l 

BOORe | a kewces ceeds Cee ee } 

Open Air Schools (five) 
Yearly amount spent by Board of Health ........$16,000 
Yearly amount spent by League ..............+% 14,000 


Yearly amount spent by Associated Charities ...... 2,500 
To the physicians in the City Dispensaries $50.00 a 
month is paid for five clinics, each averaging 1% to 2 hours. 
The nurses are paid from $60.00 to $100.00 per month. 


13 








THE HEALTH DEPARTMENT 


R. Hl. Bistop, Jr., M. D. 


1 


June 1, 1907, may rightly be said to mark the beginning 


of the Division of Tuberculosis under the Health Depart 


ment of the City of Cleveland, for on that date the notifica 
tion and registration of all cases of tuberculosis was made 
compulsory. lor a period of three and one-half years, the 
work of the department consisted merely in keeping a card 


catalog of the cases reported by private physicians, the City 


] 


Laboratory and the one Tuberculosis Dispensary then in 


1 
| 


operation. It was not until the fall of 1910 that sufficient 
funds were voted by the City Council to enable the estab 
lishment of a separate division, whose whole duty should by 
the development of tuberculosis work. 

With the establishment of this Division, with its director 
and an office force, and the subsequent development of 
three tuberculosis dispensaries with nurses and paid phy 
sicians, a big beginning has been made towards the centering 
of all of the tuberculosis work of the city in the Health 
Department. In no other city in the United States is the 
tuberculosis work so nearly centralized in the Health De 
partment as it is in Cleveland. 

The work up to the present time has been mainly in 
checking up and sifting out all the dead cases and out of 
town cases from the files, so that an active file, giving only 
the known cases in Cleveland at the present time may be 
had. As a help in this work a city census has been taken 
in which blanks were sent to all physicians and hospitals in 
the city, asking for a report of cases under their care. At 
the present time the Department has a record of 5,152 
known living cases. 

The principal sources of information in regard to 
tuberculosis cases is as follows, and the number of cases 
reported through each source since active work was begun 
is given: 


14 








SUMMARY OF REPORTS FOR JUNE, ji 
\UGUST AND SEPTEMBER 


June July \ug. S 
Number of cases reported by: 
Private physicians...... 37 2 . } 
Tuberculosis dispensaries .... i 39 ¢ 84 
Warrensville Sanatorium ... Serie ¢ 1s 
City THosoital < 25505 os fa 39 +] 
Private hospitals ...... te 2 
| eriological Labs tol 57 } } 
Other sources = 14 - 
Number of cases previously reported 
th soard of Health .. 48 69 ] »29 
Numb ( cases reported to 
( Hlealth 163 iz2 S 
mber of cases reported for disin 
fection 131 110 
Number of deaths from tuberculosis... 80 of 65 64 
Number of cases not previously re 
ed to Board of Health.....:.... 24 1s 28 18 
Number of cases having tuberculosis 
but having been reported as dying 
from Other Giseases x00 0.:6:0:0:< a0 0 1 0 ; 


1 
} 


\ttention is called to the large percentage of the dying 
cases that are being supervised either by private physicians 
or the dispensaries as shown by the fact that the case is on 
record at the Department. When a case is reported by a 
private physician, by postal card, telephone or laboratory 
opinion, an acknowledgement of the receipt of that report 
is always made, and with this acknowledgement literature 
is sent to be given to the patient, and a return card, with the 
name and address of the patient on it, to be returned to the 
department when the case leaves the physician’s care. 

On all report cards and sputum blanks is the statement 
that “All cases of tuberculosis reported to the Department 
of Health will be visited by a nurse from this department 
unless otherwise requested by the physician.” This puts the 
Department on the offensive rather than on the defensive in 
the handling of cases. In case, however, the physician has 


15 











had no opportunity to express his disapproval of a nurse 


calling, as would occur when the case is reported over the 
telephone, his permission is asked. With very few excep 
tions, the physicians are glad to have a nurse call, and every 


effort is made to co-operate with the physician in_ the 


1 


handling of the case 


One feature of the work which has met with the ver 


decided approval of the physicians, is the sending of a 


nurse to the home when a tuberculosis patient has died, t 
assist and instruct the family in the disinfection and renova 
tion of the home. A municipal fumigation plant 1s badly 
needed to aid in this work. 


\ll cases of tuberculosis discovered in the general dis 
pensaries in the city, are referred to the tuberculosis dis 
pensary in the district in which the patient lives and the 
Departinent is notified; the dispensary, in turn, is notified, 


and a nurse is sent to the home 


l‘actories, department stores, and business houses are 
coming to make use of the department by referring cases 
to the dispensaries for examination and diagnosis, and the 


P1VeC 


> 


evident willingness on the part of the management to 
financial assistance in the care of these cases, is a most 


hopeful sign and a field for great endeavor. 


The educational work up to the present time is limited, 
on account of funds, but it is hoped that this end of the 
work can be developed a very great deal. Tuberculosis and 
bad housing go hand-in-hand, and the establishment of a 
Tenement House Department under the Board of Health 
has aided greatly in increasing the thoroughness and effec 
tiveness of our work. 


The Board of Health, on the recommendation of the 
Division of Tuberculosis, recently ordered the forcible 
detention in the City Hospital of an unruly case. Such 
action must, necessarily, be taken with caution at this time, 
but it marks the beginning of the development of a phase of 
our work which will be far reaching in our end results. 


16 





























THE DISPENSARIES 


The plans for the establishment and development of the 
dispensary system is one of the most important parts of the 
Cleveland plan for the relief and control of tuberculosis. 

Since the municipality has come to the rescue and pro 
vided funds for the support of the work, this particular 
feature of the work has developed rapidly, and three new 
dispensaries have been opened during the past year. The 
district plan is being developed and the city has been car« 


fully divided into four districts, with a dispensary located 


in each one. Cases are only treated at the dispensary to 
which they belong. This plan prevents cases wandering 


from one clinic to another. It enables the nursing force to 
do more intensive work in each district, and the value of 
the dispensary from an educational standpoint is much en- 
hanced, because the people come to feel that the dispensary, 
with its corps of willing workers really belongs to them, and 
they depend upon it more than they did when there was 
but one central dispensary. 

The functions of the dispensary may be said to be: 

(1) To provide a place where all classes may come and 


be examined, and a diagnosis made. 


(2) To provide medical treatment for those who are 
too poor to afford a private physician. 
(3) To provide supervision of cases in their homes, and 


through co-operation with other charitable organi 
zations work out the problem of the home care of 
the cases which cannot go to a hospital or sanato 
rium. 
(4) To act as guardian of the health of the inmates of 
a home in which there has been tuberculosis. 
(5) To serve as a clearing house for sanatorium and 
hospital. 
(6) To educate the general public. 
Only those who are in direct contact with all phases 
of the work can realize how difficult it is to keep the di 


pensary work up to the highest point of efficiency. 


17 


The paying of physicians for their time in the clinics 
has been a big factor in improving the class of work done, 
and has enabled us to secure the services of men who are 
competent and interested in the work. A weekly meeting 
»f each separate dispensary force is held, and each case on 
the active list is carefully considered and planned for. In 
addition, a weekly meeting of the entire nursing force is 
held, and after a series of informal talks on tuberculosis, 
the work of allied organizations is studied; and speakers 
from the Associated Charities, the Department of Health, 
the Settlement Houses, and the many other social organiza 
tions have been the means of broadening the views of our 


nurses and have been instrumental in improving the charac 


ter of the work done. 

There is too great a tendency on the part of the nurs« 
to fall into a rut as the result of the necessary routine. In 
the rush of the clinic work it is impossible for the physician 
to consider evet phas of the home life of his patients 
which may have a bearing upon the handling of them, and 
heretofore the nurse has not been made to feel that she, 
more than anyone else, is responsible for the handling of 
the cases. 

We are holding our nurses responsible for the handling 
of every individual case which comes to our clinics. By 
thus making the nurse responsible, the interest in her work 
is increased and much better results are obtained. If the 
problem presented is one that will take more time and energy 
than the busy dispensary nurse can give, then it is referred 
to the Special Case Comn 

During the year July, 1910 to July, 1911, the ten nurses 
then doing tuberculosis work made 29,552 calls. 

But figures alone are misleading as to the actual amount 
of constructive work that is being done. A careful study 
is being made of the character of the work being done, and 
in another vear we will be in position to present figures 
which will show definite, tangible results for each visit. 

In addition to the following of the cases that are termed 
“dispensary cases,” all cases reported to the Board of Health 




















by private physicians or the City Bacteriological Laboratory 
are visited, unless the physician requests that no call le 
made. Homes, where a death from tuberculosis has oc 
curred, are immediately visited, with the consent of the at 
tending physician, and the family carefully instructed in 
regard to the disinfection, and a quiet search made for pos 
sible new cases. 

All dispensary families are visited at intervals of from 
two to three months over a period of two years after a 
death from tuberculosis, and the sociological history is not 
complete until every member of the family has a dispensary 
number after his name, showing he has been examined. 

The value of the dispensary as a clearing house for the 
hospital and sanatorium is unquestioned. At the present 
time no case can be admitted to the sanatorium unless it is 
first examined by the dispensary and found to be a suitable 
Case, 

\s in every large city, we have difficulty in obtaining 
hospital accommodations for our advanced cases. One thing 
is certain, and that is, that the accommodations and care 
eiven this class of case must be improved in order to insur 
our cases remaining there after they have once been admit 
ted. The large percentage of our ambulatory advanced 
cases would gladly spend their time in a hospital, 1f condi 
tions were attractive, and they felt that something was being 


done for them. 


The value of the dispensary, from an educational stand 
point, is hard to estimate. The following figures showing 
the number of cases examined and under the care of the 
dispensaries will give some idea of the educational work 


heing done. 


Year July, 1910-1911. 


Total number of Mew CASES... ... cc ccccccccccccucces 1807 
Total number of individual cases................00e- 312 
Total clinical attendance.......... eta ene ern 6832 








THE OPEN AIR SCHOOL 


Not until the past few vears was the child considered as 
a factor in the fight upon the great white plague. The possi 
bility of childhood being a period in the fight was not even 
thought of. Great sums of money and energy were expend 


ed in building sanatoria and in t 


. 
} 


he prevention of tuberculosis 
in the adult. It has taken a number of years for us to leart 
that by prevention, and by prevention alone, can we curb 
the onslaught of this disease which claims more victims 
than war or any other disease, and that this pre 
vention must start with the child from birth and be kept 
up until that child has reached adult life. The establishment 
of fresh air schools for the care of the tubercular child, and 
the so-called pre-tubercular, will mean an enormous strid 
toward checking the diseasé Heretofore only cases 


of bone, joint and gland tuberculosis were treated indi 
vidually as they arose. The possible reason for this wa 
the difficulty in eliciting the fine physical signs which existe 
and were necessary to find in order to establish a positive 
diagnosis of the disease. The work on the tuberculin re: 

tions has aided us considerably in determining an early diag 
nosis in the child. Autopsy reports have shown that th 
disease occurs more frequently in childhood than we at 
first supposed. Albrecht of Vienna found evidence of tu 
berculosis in 1060, or 33 per cent. in 3213 autopsies on chil 
dren under 12 years of age—the youngest case was a two 


weeks old baby. Steiner and Neurettes found in 320 autop 


sies on children lymph glands affected 299 times. Relliet 
and Barthez 249 times in 312 cases In 92 of my own 


autopsies evidences of tuberculosis were found in 65 cases 


These astonishing figures only prove to us that the child 
is frequently affected; its care during the childhood period 


should not be lost sight of. Careful and numerous routine 


examinations have shown that affected lungs and bronchial 




















glands are comparatively common in the child. The 
frequency of infection both latent and active at this 
period of life brings us face to face with the problem 
of how to handle these unfortunates and prevent the disease 
from becoming rapidly progressive in later life. 

Germany, like the pioneer she has been in many problems 
which concern humanity, was foremost in establishing the 
open air schools. The first school was established in the 
town of Charlottenburg, a suburb of Berlin, in 1904. A 
large number of backward children, who were about to be 
transferred to special classes, were carefully examined and 
were found to have anaemia and signs of incipient tuber 
culosis. This condition of affairs brought together the 
school physicians and educators, with the result that thes 
children were put into the open air and took the cure while 
they were being taught. The results of this experiment 
were so marvelous that very shortly numerous schools were 
established in different parts of Germany and the continent 
The fame of the open air schools of Charlottenburg spread 
to the United States, with the result that several schools 
were established in the East. 

The credit and honor of initiating the first open 


) 


] 


school in America belongs to Providence, Rhode Island. | 


January, 1908, the school authorities of that city remodeled 
one of their school rooms so as to convert the ordinat 

four-sided room into one of three sides, leaving one entir« 
ide open to the air. In this room, in the dead of winter, 
they began to teach a class of children selected by the school 
physicians. The class of children constituted the so-called 
type of “anaemic” or “pre-tuberculous.” The children wore 
their out door wraps, they sat in warm sitting-out bags, and 
on cold days had warm soap stones at their feet. They wert 
fed at intervals during the day and were allowed to rest 
at certain times between studies. The success of this ex 
periment can be judged by results obtained by examining the 
blood for the percent. of haemoglobin. After five months 
the haemoglobin average had increased from 74 per cent. t 
84 per cent. 


21 














CHOOL 


PhooR 


Ol 


HILI 


URRAY 














—* 








Similar results have been obtained in cities where the 


open air schools have been established; in every case weak, 
pale, poorly nourished and sickly children have been mad 
strong, healthy and better able to cope with the problems of 
life. One remarkable feature has been noticed, and that 
is that the child’s capacity for learning has been almost 


doubled. Li only for economic reasons, the open-ait 


, 1 
SCHOO 


would pay for itself many times over. Many children 
had previously been a drag to the other members of the cl 
and a tremendous strain upon the teacher, hay 
ahead, even surpassing their normal associates. The putti 
of these children in such physical condition and 
their resistance to such a high degree that their lat 


tion will never become an active one, is the end 


must strive for in this great problem. The preventior 
the child developing tuberculosis at the time when his 
her value to the community is the greatest, would nx 


saving to that community of a sum which would 


( 
far into the thousands of dollars. Better is it to spen 
few dollars in prevention in childhood rather than wait at 
spend thousands in its cure in adult life. 

The same problem which confronted the pione 
in establishing open air schools confronts us today in Cl 
land. Through the generosity of our Board o 
its Medical Inspection Board, Anti-Tuberculosis 
l-ederation of Women’s Clubs and several otl odie 
the open-air school in Cleveland has come to bi 
tion. That these schools are absolutely neces ( 
seen by passing through some of our school ro 

The same plan, with many minor changes, 
lowed here, as in other cities. Careful cl l be ke 
of those children who come of tuberculous ( 
who have been in contact with cases of tuberculosis, b 
peated examinations and weighing. The positive tubercu 


lous child will be excluded from school and referred to tl 
proper institutions for his care,—this will prevent any ini 
tion in the class room. Only those of the anaemic and pre 
tuberculous type will be cared for in the open-air sch 


23 








The nurse will follow these cases into the home and super 
vise their diet and give such instruction as may be neces 
sary to bring up their resistance and put forever a quietus 
upon the lurking infection. ‘The children saved from tuber 
culosis today add to the strength of our nation tomorrow. 
This is a worthy work, one in which all should ‘take part 
for the results which will be obtained will be most gratify 


ing. 


THE TENT COLONY—A SANATORIUM FOR 
CHILDREN 
\. fk. Mascuxe, M. D. 


With the advent of winter, the Tent Colony for tuber 
culous children had, year aiter year, been forced to close. 
he children were returned to their homes, most of them 
much improved as a result of the four or five months’ treat 
ment during the summer time, but a large percentage of 
them returning the following spring in bad physical condi 
tion. 

The fact that so many of the children were each spring 
applicants for re-entry convinced those in charge that the 
period of treatment was not long enough, and also that thx 
winter months were the very months that the child should 
have the care of an institution such as this. In fact, if the 
camp had to be closed at any season of the year, the time 
to close it was during the summer, for during that season, 
in spite of the hot weather in the city, the average child in 
our poor districts is under much better conditions than 
during the winter. There is better ventilation in the homes, 
windows and doors are kept constantly open, there are no 
hot, stuffy school rooms, and the child is, for the most part, 
out in the sunshine and air, even though it may be that the 


air is full of bad odors and smok 


\t any rate, it was decided one year ago to make an ex 
periment with winter work and to keep the camp open 
There was rejoicing on the part of the children. There 
were grave difficulties ahead though, in making a summer 


24 














equipment do service for winter work, and it was only the 
martyr-like devotion of the nurse in charge and the ready 
assistance of the employees of the Children’s I'resh Air 
Camp that made it possible. 

by the addition of a large play-room, which has a wide 
veranda, affording ample space for play, rest periods and 
school, a great many of the difficulties were overcome. But 
there were bound to be wet, rainy days, when the children 
must be kept from getting soaked. Then, too, the warm 


dressing room space was most limited, and the children 





“*“SUCH APPETITES AND SUCH RED WHOLESOME COMPLEXIONS COULD NOT 
BE DUPLICATED ANYWHERE. 


were forced to undress and prepare for bed in the warm 
bath rooms, then run through the cold and the wet and the 
snow to their tents and bed. but what, at first glance, 
seemed a hardship, turned out to be the greatest fun and 
amusement of all. And these youngsters throughout a long, 
cold winter, every night, crawled into beds, that were in 
tents, without heat, and they scorned such extras as hoods 
and felt slippers and mittens. Each bed was supplied with 


25 


4 





extra thickness of heavy brown paper, to keep the wind 
out, and there were plenty of blankets. Each child wore a 
suit of warm woolen underclothing under woolen pajamas, 
and there was no complaint at any time. 

During the day each child, boys and girls alike, wore the 
Mackinaw suits, no caps and no mittens. There was only 
one child who had a cold during the entire winter. Such 
appetites, and such red, wholesome complexions could not be 


duplicated anywhere. 


ee 





“THERE WAS ONLY ONE CHILD WHO HAD A COLD DURING THE ENTIRE WINTER) 


Of the 71 children who have been cared for at the camp 
since October 1, 1910, 20 have been discharged cured; 10 
discharged as improved, and 13 unimproved—these stayed 
such a very short time that no improvement was possible. 
Seventy-three per cent. of all those admitted were in the first 
stage of the disease, 20 per cent. were second stage cases, 
and 7 per cent. advanced or third stage cases. The average 
length of stay is 4% months. The greatest gain was 6% 
pounds in three weeks. It is usual that a big gain like this 


26 

















will take place in the first month and then the gain will be 
much slower. The gains during the winter months and the 
uminer months were about equal. l’or instance, during the 
six months from November to the latter part of April, the 
gain for 30 children was 152.5 pounds, an average, per child, 
of five pounds. During the balance of the year 41 children 
gamed 222!'> pounds, an average of 3.4 pounds. 

he cost of maintenance varies slightly from month t 
month, but has averaged about 47 cents a day, per child 
This includes every item of expense. 

It is to be hoped that the time is not far distant when 
we shall have a sanatorium which will accommodate 100 tu 
berculous children, and that we will have a preventorium 
for that great class of anaemic and predisposed children who 
will eventually develop tuberculosis unless something is 
done to help them increase their resistance. The work with 


children gives promise of the largest possible returns. 


THE CLEVELAND PLAN—THE SPECIAL CASE 
COMMITTEE 


BELLE SHERWIN 


Originally designed to relieve the Tuberculosis Dis 
pensary from the burden of cases which required an es 
ceptional expenditure of time and effort, this committe: 
has developed a less clearly forseen usefulness in connec 
tion with other institutional agencies in the anti-tuber 
culosis campaign. During the past year the most en 
couraging result of the work of the committee has been 
its ability to prepare patients to take advantage of the in 
stitutional care offered by the city or philanthropic or 
eanizations, and to conserve for other patients the bene 
fits of institutional care already received. It has thus be 
come an important link in the Cleveland plan, preventing 
waste of institutional effort, as well as saving the patient. 

The simplest form of its work in preparing a patient 
for entrance to an institution has been to offer to pay rent 


27 








upon condition that the wage-earning patient gives up 
his employment at once, and takes the first vacancy at 
the recommended sanatorium. More experience, skill and 
force is required to keep the patient at Sanatorium or Day 
Camp, satisfied that the standard of living in his home has 
not been lowered by his removal from it, ‘contented 
enough to get any real benefit from fresh air, new diet 


bits of rest and exercise. Just as often as this 


and new ha 
is done, economy is ensured to the institution and the 
probability of arresting disease increased. 

Mike Kohlsaat has been hardly prevailed upon to go 
steadily all summer to the Day Camp and take his pale 
little daughter, Lizzie, with him. Fear that the rest of 
the family would have too little to eat kept him uneasily 
on the point of going back to his job. Gradually the sum 
mers experience proved to him that he could rely upon 


1 


the nurses’ promises of food and clothing for Fritz and 


John and Ella, even when his wife’s earnings fluctuated 
[le is ready this fall to go to the Warrensville Sana 
torium. 

The committee's plan in his case was based on a goo 
prognosis and the first stage of tuberculosis. The report, 
“second stage, poor prognosis,” is usually met by a pre 
scription of good home care and isolation of the patient 
That was the recommendation when Big Mike Probek 
came to the committee in March. He seemed too sick 
to warrant any other plan even if there had been any plac« 
for him outside his home But in April he was improy 
ing week by week and before the last of May he was 1n 


condition to go with first stage cases to Warrensville. 


where he is still gaining Che committee 1s more than 
justified in undertaking a share in the support of his 
family for a few months more, now that a benefit fund 


has just expired. 
Unsuspected physical strength came to the rescue of 
Big Mike. In the case of Maude Harriat, youth and the 


serious interest of her church to help her, tempted the 

















committee to venture sending her to the country for two 
months, though “second stage” was written ominously 
on her chart. [-xcellent board and bedside care in a coun 


try home known to the committee did wonders for het 





No one could have proposed Warrensville for her in Jan 
uary, but early in April she was able to go there and be 
gin at once a history of continuous improvement. 
Opportunity to take a quick risk in the care of a Sp 
cial Case is less frequent than the necessity for persist 
ing-—-even months—-in urging patients to leave thei 
homes. “Weeping on” is the classic phrase of the con 
ittee and the cases whose records repeat it many time 
above such an entry as “closed October 21, 1911, becaus: 
the patients went to the Tent Colony to stay until they 
are well and their mother is satisfied now” are cast 
which the committee counts as milestones 
(novanm and Giaconda Sforza, who went to the Vent 
Colony the twenty-first of September, came to the care of 
the committee before Christmas,. both first stage cases 
both unquestionably candidates for the Colony, children 
of a tuberculous father dying at the City Hospital Sana 
torium, and a panic-stricken mother unable to give them 
proper care. For four months they waited for vacanci 
in the tents while their mother insisted upon work which 
left her children, four and six years old, uncared for at 
home. \Vhen Giovanni had bronchial pneumonia and 
later Giocanda a pleurisy, she tended each a few days. 
Vhen their father came home. [Before his numbered 
days were ended, the vacancies at the Tent C lony, long 
desired by the committee, were suddenly offered. Not 
unnaturally, the children’s mother refused to let them go 
just then, and struggled through a month of mourning 


for her husband before she consented to part with then 





Three weeks without them were all she could bear and 
one day she seized them with passionate affection and 
hurried them out of the breezy June sunshine back to the 
dark home, where the air hung stale and heavy and where 


29 














she grew less and less able to take care of them. Grief 
and dread of losing them preyed upon her. 

Once again, in July, Giovanni and Giaconda enjoyed 
a brief snatch of life in the hillside tents and once again 
were borne back home. Over and over again nurses and 
other good friends tried tenderly yet forcibly to help the 
exhausted mother help her children. Through misunder- 
standings and closed doors and finally through the inter 
vention of Judge Addams the desired goal was reached, 
nine months after the first steps were taken to ap 
proach it. 

Because these were children, we dare hope the nine 
months were not so perilous a loss of time as has proved 
to be the case in far less than nine weeks unavoidable 
delay in getting adults into fit surroundings. Time, large 
measures of it, has been required in the cure of some of 
the committee's children, but while they are children 
there is hope. In several instances in the past year, the 
committee has reason to hope with assurance for the fu 
ture of its little patients. 

Mary Companari, a rosebud of a girl, four years old, 
spent the summer of 1909 at the Tent Colony and when 
it was closed for the season became a ward of the Spe 
cial Case Committee in her own home—no fit place to live. 
Neither persuasion nor trips with the Special Case nurse 
to airier, brighter neighborhoods, nor offers of help to in 
crease the family’s earnings, won Mary’s father and 
mother to move. The next spring, however, they con 
sented to send her—their only child——back to the Colony, 
and more—let her stay there a full, round vear. In April, 
this year, the Colony physician pronounced her a cured 
case, and said she ought to go home, if the Special Case 
Committee could guarantee a good home environment. It 
could not then, but Mary’s return was absolutely con- 
ditioned upon moving to a really good location. The in 
ducement of the little daughter’s rosy companionship 


and one dollar a month to meet the increased rent——pre 


30 
































vailed. By the end of May the family was well estab- 
lished on a hill outside the city, the very spot for a rose 
to bloom, and this fall, the dollar for rent is no longer 
needed. 

The committee has had a longer history of responsibil- 
ity in the care of eleven-year-old Jim Nolan between Tent 
Colony seasons. \Vhen the nurse reported in April that 
Jim also could leave the Colony, the committee protested 
against allowing him to go to either of his uncles, his 
sole guardians. The court insisted. The nurse made the 
best possible arrangements with the most promising 
uncle and Jim went to live with him the middle of May. 
Instead of the promised sleeping porch, Jim slept in an 
inside room, only ventilated through another sleeping 
room. lis second uncle refused to do anything for him. 
Jim lost ground and became again an applicant for the 
Vent Colony. It was August before he could be read 
mitted, but in the meantime the committee said “TI told 
you so,” in the right place, and Jim went back with the 
assurance of the court that he should only leave the 
Colony when he was well, for a permanent good home in 
the country. 

If Jim’s case serves as a warning and a precedent, and 
children can be guarded from returning to dangerous 
home surroundings, a part of the problem of the commit- 
tee in caring for patients who have been dismissed from 
institutions will have been solved. Each Special Case is 
reported back to the committee when the patient leaves 
the institution to which he was sent by the committee. 
and every effort is made to adjust the patient to the life 
of the family or group to which he returns. 

3ut nothing as difficult as providing proper living condi- 
tions and work for arrested and cured cases presents itself, 
now that it is possible to force the segregation of highly dan- 
gerous patients. For a man, now and then, light, outdoor 
work can be found and all goes well if he can live at home as 
he learned how to do at the sanatorium. For such as have 


31 











no home, where to live is a serious and may become a 
desperate question. For women and young girls there is 
less suitable work and certainly no less despair in se 
curing suitable places to live in. 

More understanding of these needs, more information 
about the means taken to meet them all over the country, 
more generous provision to meet them locally, must be 
had, if the work already done in this community is to be 


conserved, not lost. 


THE DAY CAMP 


EpNA B. PERKINS 


The Day Camp for tuberculous patients is by no means 
an original idea in Cleveland; it has been successfully car 
ried out in several cities, notably in Boston, where a large 
camp is maintained both summer and winter. The work is 
still in its infancy here, as our camp was first opened in an 
old house on the corner of Superior and Ansel avenues, in 
July, 1910. The project was started by a small committee 
of women to whom the Anti-Tuberculosis League suggested 
the idea and whose efforts it backed with both money and 
service. With so novel a notion as that of benefitting 
tuberculous patients by providing a place where they could 
spend the day out of doors, with medical attendance and 
nourishing food, but return to their homes at night, 
this committee had an educational campaign on its hands 
which made the raising of even a small part of the neces 
sary funds an uphill struggle. Nevertheless, so enthusiastic 
were all concerned over that brief and troublous first season 
that plans were soon made for the second, on a more pre 
tentious scale. The committee was enlarged, more money 
was raised—not much, for faith was still weak—and the 
Day Camp laid out as it now stands. 

The Camp is located on a beautiful piece of wooded land 
fronting the Lake, the use of which was given by Mr. R. 
R. Rhodes. Here stands a large house-tent (18x38 ft.) 


32 


























containing a kitchen, dining room and porch. This tent is 
set up on a wooden frame, with a door back and front, and 
windows at the sides. The dining-room is entirely open on 
both sides, from two feet above the floor to the roof. The 
whole is thoroughly screened and has proved in every way 
satisfactory. Back of the kitchen is a small tent for sup- 
plies, with a fly projecting over the large ice box, donated by 
Mr. Fred Snyder. Next to the supply tent is the wash tent, 
containing separate towels and basins for each patient, and 
an Allen Filter, with a water cooler. Another tent is appro 
priated for the use of Dr. A. N. Dawson, the attending 
physician. Here he examines the patients daily upon arrival, 
keeps records of the cases and has on hand all necessary 
medical supplies. An emergency tent, with two beds, is kept 
always in readiness in case of sudden sickness, or the 
possible contingency of some patient being unable to leave 
at night. Happily, this tent has, so far, never been needed. 
A phonograph, with many records, given by Mr. A. S. 
Nickels, occupies another tent, where are also kept games 
and such books and magazines as are given to the Camp by 
friends. Two other tents, connected by a large wooden plat- 
form, serve to shelter the patients in wet weather. Several 
of these small tents were donated by the Board of Health. 
The platform was built to provide a place for chairs off of 
the ground, which is sometimes damp. All these tents, and 
that set aside for the care-taker, are connected by board 
walks. The effect of the semi-circular arrangement among 
the trees is very attractive. 

Every effort has been made to have the Camp as sani- 
tary as possible, both for the instruction of the patients and 
for the protection of the neighborhood. There is running 
water in the kitchen and wash tent, brought 800 feet from 
the street, in inch pipe, laid over the ground. Drains made 
of loosely joined four-inch tiles, laid in a trench a foot deep, 
carry away the water from the two sinks. The outhouses 
are constructed on the model of the Marine Hospital sani- 
tary privy, so that no contamination is possible from them. 
The garbage is buried daily at some distance from the Camp, 


33 











NOONMALAV ON \ NINMOI HLOUW NOd.l UGALSISNE SI MIOH LSM V,, 
dIWVO AVA FHI 





























so that, with the exception of the wash water, nothing is 
discharged into the Lake. The washing is done on the place 
The paper napkins and sputum cups used by the patients are 
collected in a large wire basket and burned in that basket 
every night. These precautions, combined with cleanliness 
and care in the protection of food, have completely prevented 
the fly nuisance, so that even this source of infection, so 
difficult to regulate, has not been serious. 

The furniture, which is of the simplest, is partly left 
from last season, partly donated, and partly purchased. A 
gasoline range has done good service. Another one-burner 
gasoline stove, with a wash boiler on it, serves as a sterilizer 
for the dishes. Two long tables made of planks, and many 
stools, fill the dining room. A few chairs and tables, a 
locked cabinet for medicines, and the beds in the emergency 
tent, complete the general furnishing. In addition, each pa 

1 a collapsible 
drinking cup. Provision has been made for thirty patients 


tient has a reclining chair, a woolen blanket, an 
This entire equipment, including plumbing, lumber, hard 
ware, dishes, tents and telephone, cost $845.82. This sum 
cannot, however, be fairly counted against this one season, 
for it represents a permanent working capital for future 
vears. 

The Camp employs as cook, \nnie lekette, at $20 a 
month. She and her husband, a Warrensville patient, on the 
way to cure, live on the grounds, thus acting as care-takers. 
To Steve Fekette, an expert carpenter, the Committee owes 
many thanks for both time and money saved. The Camp is 
in charge of Mrs. M. FE. Jones, who has been a large factor 
in its success. Besides being an extremely efficient nurse, 
she has overseen the housekeeping, ordered supplies, en 
forced the rules, and maintained discipline among the pa 
tients. Patients, both men and women, are received only 
from the tuberculosis dispensaries. They come at eight 
o'clock, are examined, receive a meal of milk and eggs, and 
then rest in their chairs. A rest hour is insisted upon both 
morning and afternoon, during which no one is allowed to 
walk about, talk, or even read. Dinner is served at twelve 


> ~ 
Jw 








thirty. Iourteen menus were arranged at the beginning of 
the summer, with the assistance of Dr. Dawson, with a view 
to obtaining the most evenly balanced and nutritious diet. 
Irom these Mrs. Jones chooses, varying them slightly to suit 
the season. Meat, potatoes, one or two vegetables and desert 
are served. Another meal of milk and eggs is given late in 
the afternoon. The aim is, to feed the patients abundantly, 























THE EMERGENCY TENT. 


as that is an important part of their cure. A quart of mi'k 
and two eggs, besides the mid-day meal, is the usual ration. 
The cost per patient for food, including gasoline to cook it, 
and ice to cool it, has been about 25 cents a day. Reckoning 
in salaries, laundry, car fares (which are sometimes paid), 
napkins, etc., it amounts to 38 cents per patient per day. 

The time when the Camp must be closed is now ap- 


36 
































proaching. Already it is possible to know about what the 
summer has accomplished. The total patients up to Sep- 
tember Ist has been 82, with an average attendance of 18. 
The records show a marked improvement in all the cases; 
six patients, too ill to be admitted to Warrensville, can now 
go there. 

We have also made a beginning in preventive work, 
which we believe will prove to be the most useful aspect of 


the Camp. The dispensaries sent several patients who 





DINNER AT THE DAY CAMP. 


showed either an extremely mild type of the disease or who 
were merely suspected cases. After a short stay at the 
Camp these patients were all greatly benefited and able to 
return to their work. If such preventive work could be 
developed at the Camp it would be not only a great saving 
of suffering, but also a large economy to the city. 

Another result of the summer work is the education 
which the milder cases have received. It is impossible for 
them to be so great a menace to others, or so ignorant of 


y= 


I/ 











how to care for themselves as they were before coming to 
the Camp. The Day Camp is an expedient. It is a cheaj 
way to care for a few from among the thousands for whom 
Cleveland as yet makes no provision. With an equipment 
such as ours now is, a small additional expense can bring 
the capacity to 50 or more. With gradual additions, the 
Camp can grow. Perhaps, in time, it will become a year 
round camp. Then there can be no question, as there now 
appears to be in the minds of some, of its enormous use 
fulness. It is able to accommodate five times as many pa 
tients as a sanatorium, for the same maintenance, to say 
nothing of the first cost. There is no doubt that the patients 
improve and that they and the community learn much which 
makes for more healthful living. 


THE NEIGHBORHOOD HEALTH CAMPAIGN 


STARR CADWALLADER 


\ Committee, composed of representatives from twelve 
organizations dealing with matters of public health, was or 
ganized in the early part of this year which prepared an 
exhibit and placed it in six different sections of the city dur 
ing April and May. The object of the Committee was to 
conduct a systematic health campaign, emphasizing the im 
portance of community attention to the promotion of public 
health ; showing some of the relations which ordinary meth 
ods of living and working bear to health; giving information 
concerning the work of the various agencies represented in 
the exhibit, explaining how these agencies could be helped 
and used to best advantage. 

The organizations represented were: 

The Babies’ Dispensary and Hospital. 

The Visiting Nurse Association. 

The Anti-Tuberculosis League. 

The Board of Health. 

The Public School Medical Inspect mn. 

Rainbow Cottage. 


38 























Maternity Dispensary of Lakeside Hospital. 

Cleveland Maternity Dispensary Association, 

Society for Promoting the Interests of the blind. 

The Consumers’ League. 

The Home Gardening Association. 

I’lay and Recreation. 

The exhibit consisted of fifty wall panels and a number 
of floor models illustrating, simply and forcibly, the results 
of disease and bad sanitary conditions, together with sugges 
tions for overcoming the one and avoiding the other. [n 
each locality where the exhibit was shown it was explained 
to all visitors and was supplemented by lectures. 

The localities in which the exhibit was placed were: 

The Central Friendly Inn. 

Corner of Woodland and East Ninth street. 

\ntioch Baptist Church, Central avenue. 

Council Educational Alliance. 

Broadway and [ast lifty-fifth street. 

The Goodrich Cottages. 

In each locality interest was aroused through the co-op 
eration of neighborhood committees. During the six weeks 
of actual exhibition 9,000 people visited the exhibit and 
7 O00 attended the lectures. 

The results obtained were such that the committee was 
convinced the exhibition should be continued during the 
coming year. Plans have been made accordingly. The com 
mittee proposes to enlarge the exhibit itself and has provided 
for a more thorough explanation of its meaning. The com 
mittee also hopes to broaden the scope of its campaign so 
that it may further all the efforts for better health condi 
tions in the city, and afford a means of publicity on health 


and sanitary matters which shall be very generally helpful 
“THE MODEL HOUSE” 


ISABEL W. LowMAN 


\t the time of the Ideal Home exhibit in Cleveland the 
Anti-Tuberculosis League was given generous space for an 
exhibit which should engage itself to expose no unsightly 


39 











feature. The committee in charge accepted the space and 
met to consider some form of exhibit which should be at one 
and the same time useful and good looking. They decided 
to build a pretty little house and to equip it with all manner 
of furnishings and utensils which would keep the house clean 
and keep the dust down. 

A little white picket fence in front of the house was to 
give it just that touch of aloofness which would make people 
want to go into it. 

The “trap’’ was to be baited with flower boxes, growing 
vines, little green shutters, glass doors and other exterior 
charms. The architect on the committee most good natured- 
ly offered to see the scheme through, and the beauty side of 
the question was wisely left to him. 

‘our large mottoes—gilt letter on maroon colored board 

were prepared to hang on the exterior walls: “Build for 
Maximum Sunlight,” “Build for Maximum Air,” “Keep 
Your House Clean,” and over the doorway somewhat under 
the vine (for the beauty lovers sometimes got the upper 
hand), was the master sentence: “The Ideal Home Protects 
Its Inmates against Tuberculosis.” 

When the house was up and standing, all the furnishings 
were ready to place. 

The little house had a vestibule hall, with kitchen open- 
ing to right, bedroom straight ahead, and off the bedroom a 
sleeping porch for the member of the family who had tu- 
berculosis. Over this hypothetical personage the committee 
had much discussion. One faction contended that the ideal 
home must have lapsed considerably from hygienic rectitude 
in order to have an inmate suffering from tuberculosis. The 
other faction felt that the “tuberculosis house” (as we came 
to call it) missed its big opportunity if it did not show the 
public how you could “isolate the disease without isolating 
the person.” Finally the whole committee agreed to the 
creation of the tuberculous member of the family and with 
great zeal the beautiful screened porch was rimmed with ex- 
terior flower boxes. Awnings were put in place, a bed on 
wheels was procured; rubber blanket to protect bed from 


40 



































rain ; lying out wraps; paper bag for sputum napkins; and all 
the essentials by which the sputum could be destroyed while 
still moist, and without coming in contact with anybody or 
anything. The committee finally became enthusiastic over 
the porch, but when it was suggested that a lay figure be 
brought and put in bed the preventive measure faction re- 
volted, because they felt that, as the well members of the 





“THE IDEAL HOME PROTECTS ITS INMATES AGAINST TUBERCULOSIS.” 


family were to be imaginary, it was not fair to let the sick 
one get on top, as it were, and dominate the whole business. 

The bed-room was a charming little affair. 

Hygiene was not allowed to turn Beauty out, but then, 
Beauty had to be just as wholesome as possible. 

The mattresses and pillows were actually covered with 
washable cotton slips, though the beds were made up 
with the daintiest coverings in the daintiest coloring possible 
The fact that the washable slips were in place was announc- 
ed on a card standing over the bed. 

The floor and walls were finished in a way by which they 


41 











could be washed, the furniture was white, so that no dirt 
could lodge unnoticed on it; the rugs were washable. [very- 
thing was washable or “scrubable.” White cards painted 
with mottoes in large, clear black letters, warned one not 
to brush personal clothing or footwear in the house, but to 
take it out on a porch, on a fire escape, into the open air, so 
as not to send street dust (often contaminated dust) flying 
over walls, floors and furnishings. Other mottoes told one 
to keep windows open night and day, not to lay wraps or 
parcels on a bed, to brush teeth three times a day, ete. 

The room was always pretty, and every day fresh flowers 
were brought to add to the brightness and bloom of this 
pretty interior. 

The kitchen was “the laboratory where the health of the 
family was to be compounded.” 

Unfortunately the house space was too limited to allow 
a special place for general household utensils, so they had to 
stand around the kitchen. but the kitchen had a terrano 
Hoor, with rubber mats to relieve the strain of standing at 
sink and in front of ice box. The window was directly in 
front of the sink, so that the cook could look out, and, as 
often as possible, escape the sense of being house-bound. 
The committee hunted up the best filter it could find. 
Mural cards recommended the sterilizing of all milk not cer- 
tified. There was a fireless cooker to assure the proper 
cooking of cereals for early breakfast and for the protection 
of the housewife’s time. 

The peril of the fly was emphasized. Two large flies 
made of metal with isinglass wings, were put in conspicuous 
positions. An underground garbage receptacle and garbage 
receptacles with fly catchers, were exhibited. Dustless dust- 
ers, vacuum cleaners, soft brushes, preparations for laying 
the dust before sweeping, were put about. Tables with 
sanitary tops stood in convenient places. 

The House Committee wanted a lay figure to be sitting 
out shelling peas or paring potatoes, under a trellis, some- 
where outside, so as to visually suggest that all work which 
it is possible to do out doors should be done there. But of 


42 











, Fa NDOd WOOD SE MIINVA AHL JO HLVIVAH AHL AWAHM ANOLVA I AHL SI NAHOILIM AHL,, 


me Atty ey 
 MOGNiM y 























garden space there was none, and the cook could not be 
squeezed between the picket fence and the house wall, so 
she, too, had to remain in the limbo of dream figments. 
Last, but by no means least, wall cards proclaimed that 
no foods to be eaten uncooked should escape being washed. 
Attention was called to the fact that grocers, and confection- 
ers touch all manner of bread and cake stuffs, fruit and can- 
dies with their hands, and on these hands there are very fre- 
quently tubercle bacilli. It was urged that they be forced 





“HYGIENE WAS NOT ALLOWED TO TURN BEAUTY OUT, BUT THEN 


BEAUTY 
HAD TO BE JUST AS WHOLESOME AS POSSIBLE.” 


by public opinion to use tongs, pincers and shovels in pack- 
ing food into paper or box packages. Attention was called 
to the butcher who handles first meat, then money, turn 
about, or who handles chipped beef, sausage or meats to be 
eaten uncooked. 

Two trained nurses and two committee members were 
on duty all morning, afternoon and evening for two weeks, 
in the “Model House.” They had to serve in relays, for the 
house was crowded with visitors all the time. Thousands of 


44 




















people visited it and so many questions were asked that 
committee members and nurses alike were kept actively busy 
while on duty. 

When the Ideal Home Exhibit closed, such parts of the 
little house as could be moved—the glass windows, doors, 
window frames, little green shutters, window boxes and lit- 
tle white picket fence, were taken out to the Children’s 
Tuberculosis Tent Col ny and there set up, installed and 
equipped to accommodate five children and a nurse. This 
was done by the Ladies’ Club of Conneaut. The movable 
part of the exhibit was given to the Neighborhood Health 
Campaign. 

One rather important detail which I have failed to men- 
tion is that the little house had to be thoroughly cleaned 
every day, sometimes twice a day, in the morning and just 
before the evening session. [ood stuff had to be renewed, 
flowers in the inside changed and regular care given it in all 
its detail to preserve its cleanliness and attractiveness. 

It was a great care and a very great pleasure from first 
to last. 








Red Cross Christmas Seal Sale Campaign 
in Ohio—Results in 1910; Plans 
for 1911 


S. LIVINGSTON AMIATHER 


During the fall of 1910 a committee was organized in 
Cleveland, with the idea of enlarging and organizing the 
Red Cross Christmas Seal Campaign so that the funds 
collected could be concentrated under one management 
and some definite work started throughout the State as a 


whole. 

lleretofore the seal sale had been conducted through 
scattered agencies in various cities and the proceeds used 
to aid the local work, and in many instances the proceeds 
were so small that it was hard to see any tangible results. 

The plan was adopted of handling the State sales 
through the Ohio Society for the Prevention of Tuber 
culosis. It was then too late in the season to adopt 
the plan throughout the State, the National Red Cross 
having already appointed agents in a number of places, 
namely, Cleveland, Cincinnati, Columbus, Voledo, Mari 
etta, Mt. Vernon, Canton, and Delaware County, but the 
agency for the balance of the State was secured. 

The agreement with the National Red Cross at 
Washington was that 12!2 per cent. of the total receipts 
from the seal sale was to be remitted to it, and after de- 
fraying its expenses in connection with the printing and 
distributing of the seals and advertising matter, the bal- 
ance was to be given to the National Association for the 
Study and Prevention of Tuberculosis. The Ohio So- 
ciety, therefore, decided to handle the seal sale in two 


WaVs 


4 ) 























l. To give to city and county s« cicties the exclusive 
right to sell seals in their territory, they to retain 75 per 
cent of the proceeds for local work and remit the other 
25 per cent to the State S ciety, said society then remit 
ting 12'% per cent. to the National Headquarters, retaining 
the other 12'% per cent. for State work. 

2. In such districts as were not covered by local so 
cieties, agents remitted the full proceeds to the State S 
ciety, which society remitted 1214 per cent. to the National 
lleadquarters. 


(Note: Some of these agents under this second 
heading had territory assigned to them 
and some were store-keepers or bankers 
who only sold the seals at their places of 


business ). 


The sale for 1910 in Ohio, throughout the territory 
not assigned to city agents direct from Washington, cov 
ered 769 towns and cities. Several of these cities, how 
ever, had surrounding territory assigned to them, and we 
have no detailed record of such sales. The total number 
of towns and cities in the State where the seals were sold 
we estiinate exceeded 325. The total receipts from the 
1910 seal sale throughout the State amounted — to 
$37,235.27, distributed as follows: 

Canton 92 O94 
Cincinnati 1,220,184 
Cleveland, including the proceeds from 


towns and cities which did not receive 


seals direct from Washington 2,020,295 
Columbus 220.000 
Delaware 18.066 
\arietta 23,363 
Steubenville 111,935 
‘Toledo 37 590 


The Ohio State S« ciety for the Prevention of Tuber 


culosis has been appointed agent for the entire State for 


47 











1911 and all applications for sub-agencies will be handled 
through it upon the following terms: 

1. Societies for the Prevention of Tuberculosis will 
be given the agency for their territory, with the privilege 
of retaining 75 per cent of the gross receipts for their lo 
cal work, the other 25 per cent going to the Ohio Society, 
which will, in turn, remit half, or 12% per cent of the to- 
tal, to the National Association for the Study and Preven 
tion of Tuberculosis. 

2. All other agents will remit their entire receipts to 
the Ohio State Society, which will retain 871% per cent for 
State work, remitting the other 12% per cent to the Na- 


1 


tional Society as usual. 

\pplications for agencies, and all orders for seals 
should be addressed to “S. Livingston Mather, Chairman, 
S01 St. Clair avenue, Cleveland, Ohio.” It is expected 
that the seals will be ready for delivery early in Noven 
ber, and applications for agencies should therefore be 
made at once. 

The Government postal authorities have found 
necessary to be very strict this year in their ruling that 
the seals be placed only on the backs of mail matter. The 
particular attention of all agents is called to this, and 
agents are urged to give this most important point wid 
publicity. 

The ultimate aim of the Ohio State Society is, to aid 
in organizing as many local societies for the prevention of 
tuberculosis as may be necessary to cover the State. Some 
of these will be city societies, some county societies, and 


a few covering two or more counties. 


48 

















Group Dangers in Tuberculosis 


Joun H. Lowman, M. D. 


It is now generally accepted that tuberculosis is a disease 
that results from the life and activity of a germ in the hu 
man body. Whether the disease is mild or severe depends 
on the virulence of the germ and the resistance of the body, 
hence we must always have in mind two things in the con 
sideration of the subject, viz: the germ and the body, or 
the seed and the soil. 

Until the tubercle bacillus was discovered by Robert 
Noch in 1882 all was confusion. Much was known, but the 
facts were not correlated and their interdependence and rela 
tionship not understood. Some diseased processes wet 
supposed not to be tuberculosis that are now known positive 
ly to be so because ot the presence ot the 9vern Phe in 
fectious character of the disease is understood, its degree 
of contagiousness 1s better known and it is also known in 
what part of the human family the seed is most abundant 
In fact all the conditions that surround the disease are bet 
ter appreciated now that the germ, which is the seed, can be 
seen, collected and studied. The life history of this germ 
has now become possible and our contemplation of it has 
poured a flood of light on the entire subject. 

The germ itself is microscopicaily small and when dry can 


be carried here and there on particles of dust with great 


facility. It has its origin in man, in whom it grows with 
great luxuriance. Hence the great source of infection is 
the man who has tuberculosis. Thus our study must be 
the consumptive, if we want to trace the trail of tubercu 
losis through a community. I cannot refrain, however, 
just here from digressing from the line of argument long 
enough to point out the fact that there are controllable con 
tagions and uncontrollable contagions from the standpoint 


* Address delivered at Engineer's Building, Cleveland, Ohio, Oct 
- ) 


10th, l fore Ohio State Federation of Labor in Annual Convention 


49 








of the infected individual. Smallpox, measles, scarlet fever, 
are uncontrollable contagions and those affected by these 
diseases must be absolutely isolated or their associates will 
in great numbers contract the disease. Typhoid fever and 
tuberculosis are controllable contagions. A fever patient by 
careful management is not dangerous to his attendants, and 
the consumptive who is well trained and careful in destroy- 
ing the sputum reduces the danger to his associates to a 
minimum. This we know from the conduct of the bacillus 
under restraint. 

Since the seed is the immediate cause of the disease and 
of the spread of the disease, we must control the seed and 
prevent its scattering itself broadcast over the land; if we do 
this we control tuberculosis. Naturally, therefore, much 
time has been given to this aspect of the question and many 
of the agencies used in the campaign against tuberculosis 
are means that prevent the scattering of the seed. 

Wherever the germ is there is a center of infection. The 
three main laws for the control of the disease are based 
upon this fact. These laws are, first, to discover the cen- 
ters of infection, second to stamp out these centers, and 
third, to prevent them from re-forming (Koch's laws). If 
these three laws could be enforced, tuberculosis would cease 
to exist upon the earth. It is well worth while, therefore, 
to consider how this can be accomplished. 

The enactment of a statute is much more easy than the 
enforcement, especially when this enforcement involves a 
disturbance of the customs, habits, rights and powers of a 
people. Unless one proceeds with caution the public will 
revolt and the statutes be null and void. 

A center of infection may be a single individual. <A 
group of infected individuals makes a larger center. The 
larger the group and the closer the association, directly 
or indirectly with the sound in health, the greater their dan- 
ger to the community. Two infected bakers who handled 
the bread as it came from the oven started an epidemic of 
tuberculosis in Berlin. The bacilli that gathered on their 
hands as they coughed, were transferred to the bread. Now, 


50 














all bread in that city must be wrapped in paper by machinery 
and never touched directly by hand. You will immediately 
make the natural inference regarding all foods that are 
not cooked. 

Hot water should be dashed over all fruits—oranges, 
lemons, apples, peaches that are to be handled and eaten un 
cooked. The skins of these are not eaten, but no one knows 
through whose hands they have passed. Confections and 
cakes should not be moved by the hands of the salesmen 
but by instruments. Thus this question becomes largely one 
of personal hygiene. [Everyone should think of these things 
and protect himself and his family wherever possible by per 
sonal care and cleanliness. It will be years before a nation 
will come to the consciousness of this and not regard it with 
amusement not a little akin to ridicule. But neverthele 
the race that has the highest sense of personal hygiene and 
follows most strictly sanitary laws will be freest from tu 
berculosis. 

Consumptives group themselves in different places. Cer 
tain sections of a city, certain wards, blocks, tenements, 
houses, flats, families are known to harbor more cases than 
other spots in the city. There may be other causes for this 
than contagion, but these are not necessary to dwell upon 
now. You will find more cases among certain groups of men 
and more in some classes of society than others, and more 
at certain ages than at other times of life, all of which shows 
that there are certain states and conditions of men in which 
the infecting centers are more numerous than in others 
Thus when you touch one group, say the stone cutters, or 
emery-grinders, you know that you will immediately come 
upon numerous centers of infection. We are thus led to 
study man in his various activities in order to find where 
lie the greatest dangers, and to protect him and abolish the 
centers whence proceeds the increasing infection. 

Irom 40 to 50 per cent. of the deaths among working 
men result from tuberculosis. This varies in different coun- 
tries. In Sweden it is 52 per cent. Some trades give 
a higher per cent. than others. Those trades where the men 


5] 




































are exposed to sharp dust, such as file-grinders, show a very 
high mortality. Those where there is crowding in small 
auarters, like cigarmakers, also give a high mortality. Those 
trades in which the men are exposed to irregular living and 
the temptations of alcohol, such as bartenders, also show a 
high mortality. \Wool-pickers and carders, brass polishers, 
also suffer. Seamstresses and housemaids show a great 
mortality, but probably from other causes than dust. rom 
families living in one room more cases of tuberculosis are 
reported than from families living in two rooms, and from 
families in two rooms more cases are reported than from 
those living in four or five rooms, and from those living in 
few rooms more are reported than from those living in their 


1° 


own house. This increase is explicable on the basis of ovet 
crowding. Tuberculosis is also associated with povert 
\s the scale of wages diminishes the mortality increases, and 


when poverty 1s reached many causes, such as lack of kn 


edge, absence of cleanliness, unhealthy living, under-feeding 
overcrowding, and only t often alcoholism, all b1 ( 

deadly influence to bear that in this lowest and most 
abandoned stratum of society there is a holocaust which 


carries off the great majo1 

\ll groups in which men form themselves, confer their 
own peculiar advantages and dangers upon their members, 
and when anyone enters a group he is immediately a partict 


pant in the favorable and unfavorable conditions of the 





group. 

Suppose a young man of twenty is a student and then 
becomes a stone-cutter, his risks of contracting tuberculosis 
are immediately increased 50 per cent. A woman, the head 
of a comfortable household, who by a reversal of fortune 
becomes a housemaid increases her risk of tuberculosis 50 
per cent. A young man who leaves a school at eighteen and 
becomes a plumber increases his risks of tuberculosis by 20 
per cent., and one who becomes a brass polisher increases 
his risks 30 or 40 per cent., and no matter what trade he 
enters he increases his risk on the whole 20 to 30 per cent. 

The reasons for these extraordinary facts do not lie in 


ep | 











the trade conditions alone, nor in the effort that the prose 
cuting of the trade demands, but in the opportunity which 
the assembling of the members of the group offers for the 
spread of the infection from one infecting center, i. e., one 
infected individual that has slipped into the group. This 
would be easier in some groups than others—glass blowers, 
for instance, or when the men were too closely crowded, or 
where the dust is too freely raised. 

In a good well-aired carpenter shop, containing many 
workmen, the men might work for years without coming in 
contact with a single case of tuberculosis, but if there should 
be introduced one infectious case who spat upon the floor, 
and if the dust should be raised occasionally by dry sweep 
ing, it would not be long before there were other cases. In 
a room in Paris where 20 clerks worked, 50 per cent. con 
tracted the disease, probably from one case. It is exceeding 
ly difficult to detect the infected members of the groups. The 
member does not know for many months that he is sick 
This makes a difficulty in enforcing our first law, viz: to 
discover the infecting center where the seed is first planted. 
The only method is by inspection. 

\ Harvester company in Chicago has recently introduced 
this system of inspection. It employed a visiting nurse and 
a physician to go through the factory. As the nurse would 
approach a foreman he would usually say that there were 
no sick men in his department. Intelligent questioning 
would, however, bring out the fact that certain good men 
were not as efficient as formerly, did not do as good or as 
much work as formerly, were occasionally absent, or had 
been given lighter jobs, possibly through favoritism or more 
cogent reasons, as age or time of service. The nurse, with 
her experienced eye, would see these men from a totally dif 
ferent standpoint from the foremen, and if she suspected 
their health to be the cause of their changed conduct or 
appearance, she would report them to the physician. In 
these particular Harvester works, 32 were examined, of 
whom 16 had tuberculosis. The company is now building a 
cottage with 10 beds at a sanatorium at Naperville, for the 


es 
Jd 








treatment of those in their employ who have tuberculosis. 
That is one way of detecting the infecting centers. Before 
any marked effect is made upon the mortality of a great city 
there must be general factory inspection. But the good ef- 
fect of efficient inspection of one factory only must be ap- 
parent to everyone. 

The great encouragement in this anti-tuberculosis work 
lies in the fact that the isolation of one case is sure to protect 
several of his associates. Although this may not show to 
advantage in statistics, one realizes that it must be true. The 
curve of mortality will not fall until this one case is multi- 
plied by hundreds, so vast are the numbers with which we 
have to deal. 

Another group of infections is among the children and 
youth of the country. The mortality among women has 
diminished very greatly, that of men also very much, but 
not so much as that of women. The mortality of children 
has remained unchanged and some think has even increased 
Why this is so is not perfectly clear except that the same 
consideration has not been given to children or the same 
special work done among them (except in [rance), until 
the last few years. The mortality among children increases 
rapidly at the school age and at the fifteenth year is about 
16 per cent. Association in larger groups than are found 
in the household must be one explanation of this. I would 
hold that the work and discipline of the school are not re 
sponsible for this but that some accidental condition in the 
grouping of the children is the cause. There is a great ten 
dency to uniformity, both mental and physical, in mass 
teaching. The tendency of the curriculum is to bring every 
one to a dead level, and the miscellaneous mixing of children 
of all physical conditions must have a similar tendency with 
their bodies. Until school inspectors watched very closely 
the acute eruptive diseases widespread epidemics of measles 
and scarletina were frequent \nd when we realize that 
these acute infections are the touchstone of the health of 
the children the average health of the child in the public 
school must have been lower. Whooping cough claims the 


54 




















most deaths in the first year of life, then measles and scar- 
let fever take the first place until the ninth year, when tu- 
Lerculosis has the greatest mortality. The school inspectors 
have never been able to detect early tuberculosis in children. 
This disease, although the most dangerous for the child 
from the ninth year on, has therefore, been practically neg- 
lected. Consequently many centers of infection in a place 
where they would be very productive of evil have not been 
recognized, but have been left to work their deadly leaven 
unrestrained, with the result that the mortality of the disease 
has gradually increased. This whole question of the child 
and school inspection is most involved and difficult of solu- 
tion. To exclude a delicate child from school is often to do 
him harm. The discipline, regular hours, school associations, 
airy rooms, and baths, and the aid of a sympathetic teacher, 
together with the mental growth and development which 
come from his school life, are of great value to him. To 
turn him on the street is to ruin him, or at least to retard 
his development. It certainly is a wise procedure to inves 
tigate the school children from the standpoint of tubercu- 
losis. What to do afterwards or coincidentally with this in- 
vestigation must be considered later on. 

It is the duty of the municipality to collect all the infor 
mation possible and register every case of tuberculosis that 
is discovered by the inspectors. Such information is confi 
dential and is used only by the health department in an off- 
cial manner. Notification of tuberculosis is becoming more 
and more general in the cities. Reports come from physi 
cians, hospitals, public institutions, dispensaries and city 
laboratories where sputum is examined. These reports are 
becoming more and more accurate, so that here in Cleveland 
80 to 85 per cent. of those dying of tuberculosis have been 
previously reported. 

The importance of these reports is very far-reaching. 
They show the various infected groups where the disease is 
increasing and indicate the strongholds against which the 
forces for diminishing the disease should be directed and 
where they can be directed to the best advantage. 


my | 








The same thing is done in any swift epidemic, like chol- 
era, smallpox or yellow fever. The rapid spread of the 
disease in such instances calls out the combined efforts of 
the hospital marine, quarantine and public health authori- 
ties. The principle, however, is the same as that advocated 
in tuberculosis. First, discover the cases, for from one 
case of contagion others will in all probability develop. 

The efficiency of compulsory notification is shown by the 
correspondence between the death certificates and the previ- 
ous notification of a: particular individual. If the notifica- 
tion fails in 15 to 20 per cent. of the cases, it is still effective. 
Leprosy was brought under complete control by supervising 
only 30 per cent. of the total number. The percentage of 
controlled cases varies with the virulence of the contagion. 
In a smallpox epidemic every case should be watched, but 
in the tuberculosis epidemic, control of 50 per cent. of the 
cases would probably cause a gradual reduction of the 
disease. It may, therefore, be stated that the conditions of 
Koch's first law have been reasonably well fulfilled in many 
places. The protected spots are, however, everywhere sur 
rounded by larger districts in which notification is not re 
quired by law, consequently new and unrecorded cases ate 
constantly slipping over the border. The failure to secure 
compulsory notification is usually due to faulty administra 
tion. There is no deep prejudice against it in America. In 
New York, where the pioneer work was done, it took seven 
years—from 1887 to 1894—for a vigorous health board to 
overcome the first opposition. Since then the New York 
plan has been the model for the world in health administra- 
tion. 


Having once discovered the cases, the second law, name- 


ly stamp them out, becomes operative. There is only one 


way to enforce the second law, and that is isolation. This 
is its real spirit. But isolation is manifestly impossible with 
a million human beings. That alone would seem to make 
it inoperative and merely an idealistic expression, without 


real meaning. [But isolation of course, means destroying the 


OO 


























case as an infecting center, that is making it non-contagious. 
This can be done by controlling the sputum. 

Thus since tuberculosis is a controllable contagion, you 
may have four classes of the disease: the advanced cases 
of the disease that cannot be managed, the early and arrested 
cases that can be taught, and the closed cases that are non 
contagi US. 

The first class, late, open, advanced, careless or irre 
sponsible non-controllable cases should be isolated in hos 
pitals, institutions or homes, according as they are in a po 
sition to affect others. A parent with several children should 
be in a hospital. 

Curable cases should be permitted to go to a sanatorium 
for four or six months. 

Arrested open cases, in fair health, should be taught how 
to render the sputum harmless, and thus isolate themselves 
as contagious by isolating the sputum. 

The closed cases, early and arrested, that are non-pro 
gressive, should be under inspection and care. 

You will see at once that there are many cases that can 
circulate among their fellows, many that can be taught t 
protect themselves and many others that should be in 
sanatorium, and, fourth, many that should be permanently) 
isolated in a hospital. 

In discussing this question of isolation, we must remem 
ber that isolation of every case, as I have already stated, 1s 
not necessary in tuberculosis in order to get a reduction of 
the mortality of the disease. The percentage lies between 
cholera, where every case and every suspect should be iso 
lated and leprosy, where only 25 per cent. of isolation, or 
even partial isolation, is needed. Probably an isolation of 
40 per cent. of the cases of tuberculosis would rapidly reduce 
the mortality rate. 

Of this 40 per cent. in America, 25 per cent., or 100,000, 
die every year. They must have immediate care; of the 
rest, 50 per cent. or 200,000, can be supervised by the State 
and private associations through the agency of the Visiting 


J/ 








Nurse. The remaining 25 per cent., or 100,000, are incip- 
ient, unrecognized or independent cases. 

That it is perfectly feasible to supervise this large num- 
ber is apparent from the local conditions here. In our Cleve- 
land municipal institutions there are places for 200 patients. 
With the new sanatorium at Warrensville, there will be 
places for 350. These 350 beds will care for 1,000 patients 
annually, for the average time of residence is four to. six 
months. The dispensaries supervise 2,000 walking cases. 
Thus there are 3,000 cases cared for here out of a possible 
6,000. Cleveland’s population is about one two-hundredth 
of the total population of the nation. Multiply 3,000, the 
number cared for here by 200, our fraction of the total, 
and we have 600,000. 

What has been done here can be done everywhere. In 
some cities more is already done; in some less. The rural 
districts and small towns are less active in combatting the 
disease than the cities. Cleveland may be taken as a high 
average. But on this basis we have a factor of safety of 
200,000. These figures, all will understand, are estimates, 
but they are responsible estimates and should teach us that 
official contact with each individual patient is not only pos- 
sible, but highly probable. The chief discouragement in this 
whole movement has been its immensity. It has seemed to 
many to be impossible to do more than pass over the outside 
and leave the gnawing, fermenting kernel untouched. 

The machinery that is necessary includes municipal and 
private hospitals for advanced incurable cases, municipal and 
private sanatoria for curable, early and moderately advanced 
cases; and dispensaries for the supervision of the cases in 
their houses. Around the hospital, sanatorium and the dis- 
pensary many subsidiary philanthropies group themselves, 
such as clubs for assisting the family when the wage-earner 
is away; clubs to provide necessities of life, such as coal or 
food—principally milk; clubs to provide blankets and cloth- 
ing: children’s aid societies, to take the sound children in 
emergencies; fresh air parks, and many large co-operative 
agencies that are wise, large-hearted and indirectly anti-tu- 


58 














bercular in their aim. With a complete organization and 
effective administration of all these co-operating means, any 
community could elect to stamp out a large proportion of 
the tuberculosis that lurks in its midst. 

Our third law contemplates measures that will prevent 
the infection centers from reforming. It must concern itself 
largely with the soil, that is, with the predisposed, enfeebled 
body—with the insulted body, as our French colleagues 
put it. It also is concerned with the questions of preven 
tion and disinfection and the creation and enforcement of 
sound sanitary laws. Tuberculosis thrives in the feeble 
body. There is usually a period of weakness which precedes 
the final outbreak. The treatment consists mainly in a long 
period of rest in the open air, with good nutrition, and a 
fair climate with skilfully devised, graduated walks and ex- 
ercises during convalescence. This regime would build up 
almost anyone. There is no specific treatment of universal 
acceptance. The aim seems to be to change the soil to a 
degree that the seed will not grow in it. There have been 
many limited experiments on ways of living made among 
school children, students and factory operatives that prove 
this same proposition. When any one class of citizens can 
not specialize itself it should be assisted. This is especially 
true of the home. Cleveland is not a tenement house city, 
as is Cincinnati, for example. That probably accounts for 
the fact that the mortality from tuberculosis of the latter 
is more than twice that of the former town. The avarice 
of landlords and the desire of the foreign population to live 
in the center of the city makes the tenement house problem 
one of the greatest difficulties. Liverpool, England, has 
built 24,000 houses for the working class to replace a very 
vicious system of tenements. The public welfare movement 
of Liverpool has been very far-reaching, and this improve 
ment in the homes of a large class of citizens peculiarly af- 
fected by over-crowding, has been a great factor in the 
reduction of tuberculosis and also, in conjunction with a 
regulation of the milk supply, has brought about a great re- 
duction of infant mortality. Manchester, Sheffield, Cologne 


59 








and Copenhagen, have also built sanitary suburbs and in 
Copenhagen the new part is the most attractive and salubri- 
ous of the entire corporation. In New York this form of 
improvement has been attempted, but every effort has been 
forestalled by real estate speculators buying up the land and 
raising the price beyond the ability of the welfare pro- 
moters to meet. How far social and how far paternal ef- 
forts should go will always be a question. There is the in- 
dividual unit and there is the social unit. [ach has its own 
force and both are necessary. The true balance of the in- 
dividual force and the social force is what philosophers have 
always tried to determine. What the individual should do 
alone, and what he should do collectively, wiil be a never- 
ending problem. After the Greek thought lost its influence 
and the people grew tired of thinking, they literally turned 
themselves over, soul and body, to the princes of the Church 
and State, and accept ready-made codes of morals and 
government for their guidance. Everything was patriarchal. 
Governments controlled all great movements, then with the 
renaissance and the reformation, came the individual revolt 
and the development of the idea that the individual musi 
evolve from his inner consciousness his character and moral 
life, and this idea has persisted and grown. But there are 
many things that will never be done unless done collectively ; 
a mass movement against tuberculosis is one of these. but 
the enforcement of this third law—prevention—must come 
largely from individual effort, personal hygiene, personal 
regard for sanitary law, and orderly living. A government 
cannot change the habits of a people. This change is a 
matter of growth. 

Trades unions strive for shorter hours, an equalization 
of labor, as if the prosecution of the trade ‘was harmful to 
their members. Many parents and teachers even criticize 
the schools, as if the curriculum was too voluminous and 
fatiguing. The work alone does not harm the workman, 
nor does the school work hurt the scholar. It is the obsta- 
cles in the prosecution of the work, the accidents surround- 
ing it, that do the harm. If a consumptive did not slip into 


60 














a brass foundry and spit on the floor, the brass workers 
would not get tuberculosis. If the cigar makers would have 
larger, lighter, better ventillated quarters, and not sit oppo 
site one another when they work, their mortality and mor 
bidity, as well would be reduced, and this has already been 
proven by the cigar makers’ union. As a rule it is not the 
labor, but the unsanitary conditions in which the labor is fol 
lowed that reduces the vitality. If we pursue this course of 
reasoning along other than strictly physical lines we find the 
same laws operating. 

It is not the drama that degrades. It is the unholy asso 
ciations and surroundings which often accompany its pro 
duction which call forth the invectives of the pulpit. Th 
drama should elevate humanity. It was intended to ele 
vate it. 

It is sometimes difficult, so intricate are all the social 
questions, to analyze the situation and discover where the 
abuse is. [Dut so long as a portion of the communit 
prefer to vield to their appetites, emotions and passions, just 
so long will a large mass of humanity suffer bodily decay and 


a 


become predisposed to tuberculosis and be easy victims f 
it. .\ strong appeal should be made for public and personal! 
hygiene. 

In this connection a word regarding the psychic valu 
of beauty in cities is not amiss: 

We have not learned to make our cities beautiful and t 
provide museums and galleries, concerts and opera for the 
people. Those that live at the dead level of a sickening 
mediocrity need something to bring them out of their apathy. 
We beautify our suburbs with parks and lakes, but the city 
itself is becoming less and less wholesome and less and less 
attractive. The great mass must live in the city, and the 
masses need the psychical impulse that comes from seeing 
well-ordered and beautiful things. I have often felt that 
with many of the experiments made in groups of children 
that attempt to show that the regulation of the eye, the teeth, 
the exercise is the important thing in the life of the child, 
that it was the mental influence that came from specializing 


61 








the child that brought the benefit. He is put on a pedestal. 
Many observe, many are interested in him. He is given a 
special thing to do and does it and is rewarded. Many of these 
experiments become involved psychological processes. And so 
with a nation. It is not one thing that will lift them up to 
the level where they are safe against tuberculosis, but count- 
less things, and the great mass of them the individual must 
do for himself. In the great tuberculosis movement the first 
step, that is, the detection, must be an official one, but in- 
dividuals can assist. The next, the seclusion, must be a col- 
lective one, for large funds only build many sanatoria. The 
third step, health, must be largely individualistic. 

‘rom a survey of the whole matter it seems to me that 
we are approaching a solution of the problem. Its immens- 
ity will no longer paralyze, nor its confusion confound us. 
Order has come out of chaos, and it is clear what ought to he 
done and how it ought to be done, and it only remains to act. 
There will be mistakes, miscalculations and leakages as in 
any business, but experience will from year to year, dimin- 
ish them. The work will unquestionably progress until the 
mortality from tuberculosis has diminished to a point per- 
haps necessary in our modern civilization. 

There are well-defined grounds for the hope that tuber- 
culosis will ultimately be controlled, even though it may not 
vanish, for there is in mankind a vigorous immunity against 
it. 

Many scientists find at autopsy the remains of a cured 
tuberculosis in the human body. Some place the propor- 
tion very high and there is a great variation in the findings 
of various men, but a conservative estimate puts it at 60 per 
cent., that is 60 per cent. of those who die from non-tubercu- 
lous diseases show signs of having had tuberculosis that has 
been cured. Now, 10 per cent. of those who die, die of tu- 
berculosis. Consequently, 14 per cent. only of 70 per cent. 
that contract it perish and 86 per cent. recover. This is a 
more favorable record than pneumonia and also than ty- 
phoid fever in some hospitals. A disease with this high 
percentage of recoveries certainly can be circumvented. 


62 














The Past and Future of the Tuberculosis 
Nurse 


Kpna L. Forey, R. N. 


Supt. of Nurses, Chicago Tuberculosis Institute 


Seven years ago the first visiting tuberculosis nurse was 
engaged in Baltimore to hunt up “lost patients’ and bring 
them back to the dispensary. Her work was not clearly de- 
fined, but she was to carry the gospel of fresh air and sun- 
light into the homes of the tuberculous poor, whose mor 
tality, in spite of Koch’s discovery, was daily raising the 
cuestion as to the curability of tuberculosis. Education 
alone not sufficing, she was permitted to feed them, rather 
generously, a special diet combining the much needed fats 
and proteids. Instruction and diet-giving were only part of 
her work, however, for she investigated their home sut 
roundings, helped them arrange their sleeping quarters to 
better advantage, got them beds in sanatoria, forced them 
into hospitals for advanced cases, or got various relie’ 
organizations interested in their troubles, proving herself 
to be a veritable teacher, friend, councilor or special police, 
as the case seemed to demand. At the end of a year or two 
her enthusiasm wavered slightly, and the poor patient was 
denounced in no uncertain terms as unteachable, ignorant 
and careless. The milk, which he had sometimes shared 
with the rest of the family, and the eggs, which had been 
fried on both sides, or exchanged for food more suited to 
a proteid-wearied palate, were considered wasted and the 
last state of the patient was declared worse than the first. 

It was something, however, to have discovered that 
tuberculosis was a difficult subject to reduce to words of 
one syllable. It was also a good deal to have found that not 
one patient in five understood the carefully elaborated in- 
structions given him at a clinic, and that the few who did 


63 








understand were usually too poor to profit by the instruc- 
tion. Anda great big discovery was registered when nurses 
all over the country disclosed the utter inadequacy of insti- 
tutional care for hopeful and hopeless cases alike, and the 
fact that tuberculous children seemed to have been left 
entirely out of architechts’ or founders’ estimates. Open 
air schools, day camps, and even sanatoria have grown out 
of the insistent appeal of tuberculosis nurses for places to 
put their hopeful cases, and their work in the homes has 
demonstrated the wisdom of this extension of dispensary 
activity. 

‘rom a single nurse in the field in baltimore seven years 
ago, the ranks of the tuberculosis nurses have increased 
until we find them at work all over the United States, often 
in the employ of private Anti-Tuberculosis organizations, 
and, more frequently every year, in the employ of the state 
or municipality. The Health Dept. of New York City em- 
ploys 125 of these special nurses. Chicago, Boston and Cleve 
land have municipal tuberculosis nurses, and the Pennsyl 
vania Department of Health employs through the state 107, 
who assist at the state tuberculosis dispensaries and visit 


1 
| 


and nurse the patients in their homes. In spite of mistakes, 


duplications and unwarranted pessimism, the tuberculosis 


i 


1 


visiting nurse has earned her place as a not inconsiderable 
factor in the fight against tuberculosis; if other proof of 
this were wanting, the fact that the demand for her far 


ly of her would demonstrate public opinion 


exceeds the sup] 
in this regard. This lack of good nurses in public service 
is more serious than is generally appreciated. The fact that 
nurses are not sufficiently socially-trained should not 
trouble us nearly so much as the fact that the best technic 
ally-trained nurses are being attracted into other fields, 
institutional or social, leaving the tuberculosis and district 
nursing staffs in many towns to be made up of applicants 
whose training-schools were not up to standard and fitted 
them but inadequately for any field of work. Long hours, 


unreasonable demands and inadequate remuneration have 


64 





























kept many good nurses out of these fields. Any staff, mu 
nicipal or otherwise, that allows a nurse opportunity for 
growth, advancement and personal initiative gets and keeps 
L206 xd nurses. 

The work of the tuberculosis nurse in the dispensaries 
and homes is so well understood that I need not describe 
it in detail. Having been asked to present this paper 
because of my good fortune in serving in tubercu 
losis work under two municipalities and one very suc 


cessful private organization, | am going to confine the 


remainder of it to what | consider vitally important points 
in connection with this special branch of nursing. At the 
risk of disagreeing with many of you I am going to advocate 
free tuberculosis clinics in or near the low rent districts of 
all our cities, with tuberculosis nurses in attendance; bed 
side care by the visiting tuberculosis nurse of the tuber 
culous sick in their homes; special tuberculosis relief given 
at the request of the physician and nurse, after a conference 
with a Special Case Committee, not a local relief organiza 
tion; a simple, hygienic costume for every nurse; and a 
compulsory segregation ordinance that will be educational 
in its enactments and indeterminate in its sentences. It is 
absurd to expect some of our patients ever to become scien 
tifically discriminating after a few years of scattered 
instruction, but a few compulsory terms in a sanatorium 
would teach many of them respect for the law and for the 
health of others, as well. 

In regard to clinics, it should not be necessary to em 
phasize the need of them; nevertheless, it is true that 
a tuberculosis nurse is often asked to start visiting 
work in a town where there is no clinic and little or 
no provision for the medical care of her patients. To in 
struct or advise when an authoritative diagnosis is lacking, 
or when there is no free dispensary or tuberculosis clinic, 
and poor patients are being treated at long range by busy 
physicians, or not at all, as the case may be, makes con 
structive work almost an impossibility. All nurses appreciate 


65 








and value the good team work of physicians and nurses 
needed in this campaign, and a nurse who wants her work 
to succeed and her patients to be benefitted considers the 
clinic the foundation stone of her structure. 

To return to my second point, the greatest mistake made 
by the visiting tuberculosis nurse was not her pessimistic 
prognostications as to the outcome of tuberculosis work, 
unaccompanied by a shot-gun or by a drastic segregation 
law—every growing mortal has his Rubaiyat period—but 
her divorcing instructive from bedside nursing. To be sure, 
when workers were few and the fields large, it seemed better 
to devote her time to dispensary work and instruction of the 
hopeful cases, while the regular visiting nurse was sent in 


] Thi 
peless case. Ilhis arrangement 


to care for the bed-ridden, h 
might have been ideal if all nurses were born teachers, or 
if the tuberculosis nurses had remained members of the 
visiting nurses’ staff. A good nurse, however, considers 
that the work of her hands is quite 50% of her usefulness, 
and her patients doubtless put a higher valuation on it. 
Granting either premise, does it seem a logical conclusion of 
any particular case to turn it over to an unknown member 
of an entirely strange nursing staff just when the patient's 
confidence is won, when his need of a friend is greatest and 
when his dislike of strangers is most marked? If an afflict- 
ed household ever needs its own particular nurse, it is when 
the wage-earner or home-maker has lost out in the race and 
gone to bed, to be cared for and to spread infection among 
other members of the family, whose grief frequently blinds 
them to this danger. To leave such a family to its own 
devices, or to transfer it at the critical moment, causes un 
necessary mental suffering to the sick person, who has 
learned to look forward to the visits of his own nurse; 
introduces another element into an already demoralized 
household, (for sickness is always demoralizing) ; and may 
result in such strained after relations that the children do 
not get examined, nor are their minor complications attend- 
ed to until latent trouble becomes a positive reality. The 


OHO 


























nurse was trained in a hospital, not in a normal college, and 
she should “stick more to her last.” If concrete examples 
of the above were necessary all nurses could give plenty of 
them—for I believe we would all like to give nursing care. 
Perhaps this one will serve in lieu of many, however: 
Olive S., aged ten, possessed tonsils and adenoids that 
gave her wizened little face a most characteristic expression ; 
her father, in spite of his tuberculous condition, worked 
every day, had his own physician, and bitterly resented the 
fact that his wife should have taken his daughter to a 
“charity clinic.” Consequently, he was only politely skep 
tical when the nurse tried to convince him that Olive’s 
narrow chest and slight physique were handicaps enough 
without the added insult of frequent attacks of tonsilitis. 
lor this reason three months’ friendly visiting was seem 
ingly fruitless, and might have been actually so, were it not 
that on the last visit the child, with a temperature of 103, 
was found on the parlor sofa, after a wretched night, with 
her worn-out mother vainly endeavoring to give her some 
medicine left by the doctor. It did not take an hour to 
give the patient a bath, make up a comfortable bed on an 
otherwise respectable sofa, administer the medicine, spray 
her throat, and tie her neatly combed hair with Sunday 
ribbons, and the child went to sleep to waken refreshed, 
ready for the cooling drink, fixed and left by the nurse as 
a surprise. An attack of tonsilitis that usually remained a 
week and upset an entire household was thus aborted by 
medicine administered at the right time and a single hour’s 
work ; while, as a result, the operation was consented to, not 
because the father’s skepticism had decreased, but because 
his respect for the nurse’s opinion had increased. Follow 
ing this child’s uneventful recovery, a younger sister and 
three other children in the same block willingly lost their 
tonsils a few weeks later. In this case the instruction might 
have borne later results, but surely the personal service 
one mustard foot-bath against three months of friendly 
visiting—speaks volumes for combining nursing care with 


67 








instruction. Our patients are too much like the “man from 
Missouri; speech alone does not impress them. 

Then, too, it is almost inhuman to suggest that a nurse 
whose hands fairly ache to do the few little things that 
would make her patient so comfortable should confine her- 
self to oral instruction, when it would be so easy to give 
both at the same time were she suitably dressed for her 
work and had she a small nursing kit in her bag. As long 
as the average public institution retains its present character, 
there will be many patients of this class in need of home 
supervision, and it is a waste of effort to care for the 
incipient cases in these households, if we overlook the source 
of the infection and neglect the advanced cases by with- 
holding care that would increase their comfort and incident- 
ally their willingness to obey instructions. 

Now, as regards the giving of special tuberculosis, not 
family, relief: The nurse is not, nor should she be con- 
sidered by her patients, a relief giver. This does not mean 
that she should never give anything, for sick-bed diet is 
as essential as medicine or air and should be given when 
ordered, or needed. ‘Tuberculosis relief, especially in fam- 
ilies above the poverty line, where illness causes the need, 
should be given liberally if we are going to check, not merely 
prolong, the disease. A Special Case Committee will help 
meet these demands for two reasons: J irst, because its 
interest is primarily in the tuberculosis aspect of the family 
problem; and, secondly, because it will handle each case 
promptly, and possibly by its action and recommendation 
succeed in keeping down the number of investigators going 
into the family. The Anti-Tuberculosis League of Cleveland 
has worked this committee plan out splendidly. Regular 
weekly meetings are held. The directing physicians of the Tu- 
berculosis Dispensary and of the Babies’ Dispensary and 
Hospital, a representative from the Associated Charities, one 
from the Visiting Nurses’ Association, and the City Health 
Officer, are among the membership, which also includes 
several laymen possessing sympathies or influence which is 


68 




















of value to the committee and having in common with the 
others experience and sound judgment. A special nurse, 
whose salary is paid by the Committee, presents the cases 
and no case is considered closed unless a final disposition 
is made. If relief which cannot be given by the Associated 
Charities is needed, the Committee raises it; if the need be 
volunteer visiting for counsel, encouragement or friendship, 
one of the members is detailed to do it; if sanitary regula- 
tions are being openly defied, another member spends the 
time to go more closely into the matter; if children need 
dispensary care and the mother is too busy to take them, 
this is also arranged for by the Committee. In fact, a 
thousand and one little details, which are really very impor- 
tant but are frequently left undone, or bungled, because 
time to work them out intelligently or patiently is lacking, 
are assumed by this Committee. Then, when the special 
tuberculosis problem is worked out, the special nurse hands 
the case back to the visiting tuberculosis nurse who had it 
originally. Only those cases where the solution of the 
problem would mean robbing the other patients of their 
rightful time are given to the special case nurse. In this 
way, immediate help of various kinds is gained for worthy 
families, and sometimes representatives from half a dozen 
different organizations are kept away, or, if they must go, 
they visit as friends of the nurse. This Special Case Com 
mittee is not intended to replace the relief organization, nor 
to relieve it of all responsibility in regard to families where 
tuberculosis is the primary cause of poverty. Its relief is 
rather intended to supplement the relief work of such an 
organization, except in those cases where the society's pre 
vious rulings prevent their giving the needed assistance. But 
the giving of relief is in reality a very small part of this 
committee’s work and its gifts are not made without due 
regard for the opinion of the charity experts in its mem 
bership. The central registration bureau of the Associated 
Charities is always consulted, in order to avoid needless 
investigation. One of the difficulties of modern philanthropy 


69 








is this duplication of visits, until it seems to many of us 
as if the upbuilding of character by frequent investigation 
must include the destruction of a decent personal pride and 
sel f-res] ect. 

The social worker who cites endless tales of the tubercu 
losis nurse’s ill-directed alms giving, is met on every turn 
by the nurse who can cite equally true tales of the social 
worker's disastrous relief-withholding, whereas, the patients 
each desires to serve may be more simply and adequately 
reached by referring them to a court of special appeals, 
which is sufficiently nicely adjusted to weigh the social, 
medical, legal and economic aspects of the case before de 
ciding on its merits. For individual decisions are human, 
and therefore liable to error, and sometimes the mind of 
one type of an organization is human also, and it 1s con 
ceivable that even a relief organization might err occasion 
ally, but a committee composed of many minds from many 
interests can be to its patients a “City of Refuge,” as weil 
as a final tribunal. In Cleveland this Special Committee was 
formed by the Anti-Tuberculosis League, but there is no 
particular reason why it should not be an adjutant of the 
local relief organization. To be really effective, such a com- 
mittee must be composed of people very much in earnest 
and should be so strong in its membership that the implied 
co-operation would be limitless in its power for LOK vd. 

A nurse is trained to see the physical needs of her pa 
tients and to act quickly, she knows too that anxiety and 
avoidable worry are frequently as disastrous as the primary 
infection, and to her the payment of back rent is not a mor- 
tal sin, nor is food for anaemic children a crime against the 
sanctity of the home. A day-nursery for children, while 
the deserted mother of six or eight works by the day, does 
not strike her as logical, if those children are ever going 
to amount to anything, although a pension to that mother 
may be encouraging a worthless father in his idleness. Dis- 
cipline for the father of these children quite meets with her 
approval, while to let the innocent suffer with the guilty 
may be justice, but seems bad economics. Refusal to aid 

70 





























the large family where there are three cases of tuberculosis 
because their cottage with its yard and porch rents for 
$15.00 and they refuse to move into a $10.00 rent, without 
regard to room space, seems to her absolutely criminal; 
whereas, her insistence that the family is in every way 
worthy of aid may seem blind and unreasonable to the 
relief organization. ‘To cite special cases wastes time, and 
occasionally causes ill-will, The nurse understands _per- 
fectly that the solution of the tuberculosis problem is inex 

tricably interwoven with the big problems of housing re- 
form, standards of living, minimum wage, and the eight 

hour day, but she is placed in her district to act now, not 
in the millenium, and her patients are to her sick people, 
her ministry to serve them, not to classify them. A Special 
Case Committee, with time to consider her families, would 
be of inestimable service to a busy nurse. 

The responsibility of giving relief should not rest upon 
the individual nurse, but the power to relieve must be 
nearer than it is now, and to her technical training should 
be added a social training which must be given her in both 
field and class room, until she learns to discriminate in her 
service as well as in her sympathies. Academic theorizing 
is of little assistance to the woman whose daily work takes 
her in and out of homes where physical suffering, no mat- 
ter whose sin caused it, is present, and she needs a well 
balanced mind to keep her from becoming so depressed by 
the scenes in which she works that she is unable to retain 
her enthusiasm and her “open mind.” Nurses engaged by 
private societies have, perhaps, more opportunity of keep- 
ing a future vision ever before them, but, on the other hand, 
the problem is too tremendous to remain in private hands 
long, and the municipality that shirks its responsibility, or 
engages indifferently trained women to do its tuberculosis 
nursing, will lose in the long run, for its tuberculosis situa- 
tion will remain unchanged if its people are ill-taught. In 
some places a stigma attaches itself to women in public 
service, and this can only be dispelled when people realize 


7\ 





that the field needs intelligence as well as training, and to 
get and keep both qualities in its service a city must grant 
its workers unrestricted opportunities for growth and ad- 
vancement. 

A uniform for the tuberculosis nurse is a much mooted 
question. Personally, I believe that there should be a stand- 
ard, 1f not uniform, costume,—simple hat, washable dress 
and plain, long coat, purchased after consultation with the 
supervisor. In small towns, or until tuberculosis becomes 
less of a bug-bear than it is now, a striking uniform serves 
only to make landlords uneasy and patients more so. On 
the other hand, to those of us accustomed to, and fond of 
the trig neatness of a nurse’s uniform, a roomful of nurses 
on duty, in all kinds of raiment, is as distressing as an or 
phanage of children all dressed in brown gingham is to a 
real lover of little people. In large cities where there are 
many public nurses, a compromise might be effected by hav 
ing a common uniform for all nurses, selected by a commit 
tee composed of their superintendents. No uniform should 
make the wearer needlessly conspicuous, but a not-striking 
uniform, plus a simple hat, would be willingly worn by any 
nurse who felt that she thus identified herself with others 
in a good work. <A nurse’s uniform should mean to her 
what a soldier’s does to him,—a constant reminder of the 
cause she serves—and, though she need not wear it to 
Grand Opera, she should wear it on duty. 

Lastly, | would plead for segregation of open cases of 
tuberculosi Voluntary segregation is, of course, more 
ideal and will not interfere at all with a democratic belief 
in personal liberty. This, in a large number of cases, would 
be possible, were the institutions provided, properly built, 
equipped and managed. buildings and equipment cannot 
be expected to do ev erything, the spirit of the places is a 
direct index to its management. If a diet suited to day 
laborers is provided for patients whose digestive powers are 
seriously impaired by disease, or if medical attention and 


nursing service are negligible quantities, no patient is going 


Ki he 




















to be sufficiently altruistic to die in discomfort when home, 
no matter how poor, means an attempt at least at better 
food and care. Nor would the public at large, nor the 
special workers, wish to consign a patient to perpetual sen- 
tence in such an institution simply because his disease, not 
his crime, made him an unwelcome member of society. 
People who are going to die, whether in two months or two 
years, need to be helped to forget that the sentence of death 
is hanging over them. It is not necessary to have our hos 
pitals for advanced cases so badly managed that patients 
refuse to remain in them. The Boston Consumptives’ Hos 
pital is intended for moderately advanced and advanced 
cases, and it has become such a comparatively simple mat 
ter to send patients there and to keep them there that the 
nursing care given in the homes by the Visiting Tubercu 
losis Nurses 1s done more in cases of emergency than as a 
part of the regular routine. A recent visitor at the Mary 
land State Sanatorium, where hopeful cases and others are 
treated, remarked that he felt as if he were leaving a happy 
summer colony, rather than a hospital. If Boston and 
Maryland can obtain voluntary segregation in a large num 
ber of cases, the plan is not Utopian. On the other hand, 
there are a few patients whose warped mentalities make 
them take an almost malicious delight in exposing their 
families to infection. Such patients should be restrained 
from spreading the disease further, and as long as a patient 
remains unwilling to take the simple precautions necessary 
he should be made to feel that his refusal to do so is a mis 
demeanor and should be punished accordingly. 

Many of our patients, whether from above or below the 
poverty line, are strangely ignorant of the laws of hygiene; 
and the unseen presence and rapid reproduction of the 
tubercle bacilli are to them inconceivable. They cannot be 
ordered, they must be taught. It is not good sense to ask 
that these poor souls comprehend in a few brief instruc 
tions, facts that opened a new world to us; or to ask them, 
for reasons they cannot possibly understand, to change 


ar hee | 
49 











habits of a lifetime,—nay, of generations—without taking 
into consideration their racial characteristics and supersti- 
tions, their religious beliefs, or their inherited tendencies. 
We have asked the German to exchange his beer for milk, 
the Italian to open his window at night, the Irishman to 
give up his “wakes” and tobacco, the Hebrew to make radi- 
cal changes in his diet, and the American citizen of every 
descent to refrain from nickel shows, crowded meeting 
places and dance halls, which to him make life worth living. 
We have taught a crude eugenics to mothers absolutely un- 
able to carry out our instructions. We have sometimes 
foolishly taken work from a patient and then offered him 
a stone. We have asked patients to sacrifice time, tradition 
and family ties even, for that wil-o’-the-wisp, health. For 
some we have gained health, others have fallen by the way- 
side, or given up the struggle in disgust and despair, and 
the mass of the people, because of circumstances over which 
they have no control, are as yet unimpressed. The nurse’s 
educational attempts must extend beyond her present hori- 
ZOn. 

By patient endeavor and ceaseless example she must 
teach and nurse the patients who look to her for relief. By a 
close co-operation with all the agencies in the city, she can, 
by her observations, aid the workers whose field lies in re- 
lief-giving, housing reform, and what not. She must win 
from the public, by an intelligent discrimination, sympathy 
for the many deserving, or compulsory segregation for the 
comparatively few wilfully careless patients. Her work 
with the physicians at the clinics must enable her to carry 
their instructions to the patients and to bring back the so- 
cial diagnosis that will best assist in their treatment of each 
particular case. By her work with the children of the tu- 
berculous, she must help school boards to realize how easy 
it is to teach hygiene to children before they grow into 
skeptical and slow-reasoning adults; and, finally, by her 
service to her people and all these other agencies, she will 


74 























create in the work a new spirit and in herself a new per 
sonality, for, after all, a chain is only as strong as its weak 
est link, and on the nurse, as the logical go-between for 
public and patients alike, rests a tremendous responsibility 
and the promise of a great future. 


75 





‘The Nurse as a Social Worker 
ELLEN La Morte, R. N. 


Nurse-in-Chief, Tuberculosis Division, Health Department of 


Baltimore 


During the past fifteen years, but more especially dur- 
ing the past ten years, a new field has opened to nurses- 
the field of social work. When the first district nurse went 
on duty many years ago, she went on primarily in the 
capacity of nurse; when the first tuberculosis nurse went 
on duty some eight years ago, she also went in the capacity 
of nurse, but now with the evolvement of social work, a 
social as well as a medical problem, we also see the evolve- 
ment of the nurse. In order to keep pace with it, she is now 
becoming a social as well as a medical agent. 

This evolvement of the nurse is a perfectly logical one. 
Sickness and poverty go hand in hand, with sometimes one, 
sometimes the other, in the lead. It is impossible to dis- 
associate the two. Therefore in order to deal properly with 
the situation, we must either have two sets of agents, medi- 
cal and social, or else one set of workers so thoroughly 
equipped that they are able to combine understanding of 
both medical and social service. To have two sets of work- 
ers, Where one would suffice, is an economic waste. 

Let us look over the field very briefly and see what 1s 
meant by medical service, and what is meant by social sery 
ice, and why it is that we must either have two sets of 
workers, or one very highly equipped set of workers, able 
to perform both kinds of service. Let us first consider the 
duties of the nurse—and as a concrete example, let us con- 
sider the work of the special tuberculosis nurse. 

The work of the tuberculosis nurse, from the purely 
medical view point, consists of actual nursing care given to 
ill or bedridden patients, and of supervision, instruction and 


40 
































advice given to incipient or ambulatory cases. In each 
case, the nurse is the go-between of the physician and the pa- 
tient, and she sees that the doctor’s orders are carried out, 
and that the patient follows, as well as may be, a mode of 
life which conduces to his recovery and at the same time 
lessens his danger to the community. If we follow the 
nurse in her rounds from house to house within a geo 
graphic area, we shall see her deal with all sorts of cases, 
and give to each the exact sort of attention that he requires 
Thus, the first case may be an incipient one, who is taking 
the sanatorium treatment at home, and all that he requires 
is supervision and encouragement, and a new supply of fill- 
ers; the next case, who was doing well the week before, is 
in bed with a fresh cold, and needs a bath, clean linen and 
general attention; the next is a last stage case, requiring 
daily care, including dressing of bedsores; the next may be 
a suspicious case, in which the diagnosis is not positive, but 
where the patient needs all possible advice and suggestion 
as to living a hygienic life; the next case is to go to a sana 
torium, and details have to be arranged for; and the last 
case is one of empyema, which requires surgical dressing 
and attention. Now all this is nursing work—medical un 
derstanding of one sort or another, and one nurse is capa 
ble of doing all of it. To have two sets of nurses at work 
in the same district or geographic area, one to care for ad 
vanced cases, one for the ambulatory ones, would be a 
senseless waste of time and money. By this arrangement 
we should often see two nurses at work in the same house 
hold—one giving a bed-bath to an advanced case, and one 
teaching some other member of the family how to become 
a “careful consumptive who is not a menace.” The tuber- 
culosis nurse cannot separate her patients, and the com 
munity that wishes to separate the sort of workers that deal 
with these patients is a community that has small economic 
sense, and which by reason of this defect employs two peo- 
ple where one would do. 

Let us now look at the tuberculosis problem from its 
complicated social side. We find that it is almost entirely 


—— 


4/4 








a class disease—a disease of the exploited classes. but 
that phase, of course, is one that the discreet social worker 
will not bring forward too prominently. Therefore social 
work among the tuberculous poor consists largely of pallia- 
tive efforts, wise giving of relief in the way of coal, grocer- 
ies, bedding, and so forth. Knowledge of economic condi- 
tions, the predisposing causes of tuberculosis, is the knowl- 
edge that the social worker must possess. In nearly every 
home in which there is tuberculosis, there arises sooner or 
later the need for social interference. The problem of deal- 
ing with the patient himself is usually a medical one; the 
problem of dealing with his family is a social one. It 1s 
impossible to treat the patient from the purely medical view 
point, and it is impossible to treat the family without special 
training and experience in social work. It is this experi 
ence therefore, that the nurse must have in order to become 
a really effective agent in the community. She must im 
peratively have this social training, in addition to her medi 
cal training, or there must be two sets of agents at work, 
a medical and a social agent. We have seen that two sets 
of workers is wasteful policy, therefore we must train the 
murse in social work, since she is the logical agent in the 
homes of the tuberculous poor. 

Probably no other agent comes so closely in touch with 
the people as the district nurse. She so readily wins the 
confidence of the family, and her intimate contact with them 
enables her to see clearly the conditions that hamper and 
destroy them. By reason of this close insight she is in a 
position to understand, to analyze and to draw intelligent 
conclusions as to their needs, weaknesses, and failings. And 
having arrived at certain conclusions as to their needs, the 
socially trained nurse is in a position to apply for relief to 
the proper sources. It does not need a Charity Organiza- 
tion agent to discover that the reason a patient cannot sleep 
out of doors is because he has no blankets. It does not 
need a volunteer worker to discover that a family of ten, 
with one bed among them, is a family that should be given 
an extra bed—perhaps even two. It does not need a friend- 


— 


78 


























ly visitor to come to the conclusion that a man who earns 
$15 a week and who spends it all on drink, is hardly one for 
whom it is wise to pay rent and grocer’s bills. And the 
nurse as well as the lay worker, is able to see which children 
in a family need special attention—which are truant and 


possibly feeble minded; which should be sent to fresh air 
farms; which boys or girls should be brought into touch 
with the settlement—in short, the nurse should be so social 
ly trained that she should feel on entering a household, that 
it is not only the sick member of it who demands her atten 
tion, but that her responsibility extends to all its members, 
one and all are her special concern and interest. 

This social training is perfectly possible to acquire, and 
it must be acquired if the nurse is ever to become more 
than the doctor’s hand-maiden, with no greater expression 
of responsibility than a “yes, doctor” and ‘no, doctor.” 
Nurses of that type are useless in the social field. Very 
excellent they may be as nurses, but they will not do as 
effective social agents. So extensive is the field of social 
work, so wide open are the gates that lead to it, and so 
great are the demands for adequately equipped workers of 
the highest type and fullest training, that the nurse who 
goes in for social work today must add to her hospital train- 
ing this other requisite—social training and experience. 
This special knowledge may be had in one of two ways 
Either by a course in one of the schools of philanthropy, 
or by extensive experience in field work under the guidance 
of a socially trained nurse. The reason that we believe 
that this experience should be had under a socially trained 
nurse rather than under a trained social worker, is because 
of the medical aspect of the situation, which a layman is 
powerless to fully appreciate. 

It is this medical aspect of relief work—an aspect which 
is nearly constant—which makes us feel strongly that it 
is the socially trained nurse who must in the end supplant 
the social worker, as the more practical agent of the two. 
No relief problem is free from the complication of physical 
disability, and no physical disability but which is bound up 


79 











with the need for social interference. And the person who 
understands both points of view is the one who is of most 
value to the community. 

The question, therefore, arises, since it is wasteful pol- 
icy to have two sets of people working at the same thing, 
which of the two shall survive? Are we to have two 
agencies—are we to have the social worker doing to the 
extent of her ability, and then calling in the nurse when the 
medical situation gets beyond her? Or are we to have the 
socially trained nurse who in her work is able to combine 
knowledge and experience of both sorts? If we realize 
that in the perfectly equipped worker both sorts of training 
are essential—the only question is—which of the two shall 
supplement her training by that which she lacks? Shall 
the nurse add to her three years’ hospital experience a 
course of six weeks or one year in a school of philanthropy ? 
Or shall the social worker supplement her school of phil- 
anthropy training by three years in a training school for 
nurses? It is simply a question as to which shall do it 
all things being equal, it makes no difference which. 

However, in place of the difficult and arduous hospital 
training which is demanded of all properly qualified nurses, 
it has been suggested that the “social relief agents of organ- 
ized charities should have some hospital experience.” This 
attempt to substitute adequate training by a mere smatter- 
ing of “experience” would be a most dangerous proceeding. 
In one of the foremost hospitals of the country the proba- 
tioners are not allowed to enter the wards until after a pre- 
liminary training of six months; accepting this as a stand- 
ard, what sort of “experience” would it be possible to give 
the social worker in a few weeks or months in an institu- 
tion? And what sort of an institution would it be that 
would lend itself to training of this kind? Let us be quite 
honest about this matter and look facts in the face. If this 
medical experience is so valuable a factor in social relief 
work as we all believe it to be, then let it be acquired thor- 
oughly and carefully, in the way that all first-class hospi- 
tals demand. It cannot be obtained by a few weeks in an 
80 








institution, nor by a course in nursing obtained through a 
correspondence school. We should have as much respect 
for that sort of nursing training as we would have for the 


physician who had acquired his medical degree by mail. 


So what are we to do? Are we to have two sets of 
workers in the field, the one supplementing and comple- 
menting the work of the other? Or are we to have one 
set, able to combine adequate knowledge of medical and 
social service. We are reasonable beings. Doubtless we 


shall come to reasonable conclusions. 








Tuberculosis as a State Problem 
Ropert G. PATTERSON, PH. D. 


Executive Secretary of the Ohio Society for the Prevention of 


Tuberculosis 


Ohio was one of the first states in this country to or- 
ganize a society for the express purpose of combating tu- 
berculosis on a state-wide basis. 


At a meeting of the State Board of Health, held in 
June, 1901, the question of forming such a society was first 
considered. [ive months later, on November 14th, 1901, 
the Ohio Society for the Prevention of Tuberculosis was 
formally organized with more than three hundred members, 
from all parts of the state. Membership dues were the only 
source of revenue, and these never increased sufficiently to 
warrant an extended campaign. Some literature was pre- 
pared and printed through the co-operation of the State 
Board of Health. In one of the pamphlets issued soon 
after the organization of the Society, the objects are stated 
to be, first, a well-directed campaign of education; and sec- 
ond, advocating and aiding to establish state and municipal 
hospitals for the cure of tuberculosis. 

The educational campaign was conducted in a more or 
less desultory fashion, much of the publicity work being 
done in connection with the agitation for a State Sanato- 
rium. As a result of this activity and the efforts of the 
State Board of Health, the Legislature passed an act in 
1902, creating a State Tuberculosis Commission, consisting 
of seven members, appointed by the Governor, to investi- 
gate the feasibility of establishing sanatoria in the state. 
An appropriation of $500.00 was provided and the Com- 
mission was directed to report to the Governor by May, 
1903. 


82 

















Following the report of this Commission, the Legis- 
lature passed an act in 1904, providing for the creation of 
another Commission, consisting of five members, to pur- 
chase lands and to erect a State Sanatorium for Tubercu- 
losis and to make provision for the appointment of a man 
aging board. The appropriation for this work was $35,- 
000.00. After consideration of a number of sites the Com- 
mission purchased three hundred and fifty-five acres of 
land about two miles from the city of Mt. Vernon and pro- 
ceeded to push forward the work entrusted to it. On Oc 
tober 27th, 1909, the State Sanatorium was formally dedi 
cated, the ceremonies in connection with which were con- 
ducted under the auspices of the Ohio Society for the Pre- 
vention of Tuberculosis. An effort was made at this time to 
adequately finance the Society in order to secure the services 
of a paid secretary. Meeting with but little response, the 
Society lapsed into a paper organization. 

At present the State Sanatorium has a capacity for one 
hundred and thirty patients, but it is ultimately planned to 
provide for treatment for two hundred. Incipient cases of 
tuberculosis only are admitted, as this institution is designed 
as an educational agent to instruct the tubercular how to 
properly care for himself. The rates charged are five dol 
lars a week, but cases up to 2 per cent. of the available 
capacity may be admitted for a sum less than five dollars, 
as determined by the Board of Trustees. Admission is 
secured through application to the Superintendent. On 
\ugust 15th, 1911, the complete report of the Commission 
was filed with the State Auditor and showed that $678,599.26 
had been expended on the Sanatorium up to date. 

The Legislature passed an act in 1908 which provided 
that: “to keep any person suffering from pulmonary tuber- 
culosis in any county infirmary, except in separate build 
ings, to be provided and used for that purpose only, shall 
be unlawful.” The act provides for the erection by coun- 
ties of suitable sanatoria or for the boarding of tuberculous 
patients from one county in sanatoria in another. This 
act was amended in 1909, so that it became mandatory upon 


83 





County Commissioners to provide separate hospitals for 
tuberculous cases before January Ist, 1911. A_ further 
amendment made it possible for any two or more counties, 
not to exceed five, to combine and erect a district hospital 
to be maintained jointly by the several counties. 

At present the equipment of the state for fighting the 
disease consists of the State Sanatorium, with one hundred 
and thirty beds, for incipient cases; two municipal hos- 
pitals at Cleveland, with eighty and one hundred beds, re- 
spectively, for cases of tuberculosis in the first and second 
stages of the disease; one at Cincinnati, with provisions for 
three hundred beds and taking all classes of cases; three 
county hospitals, with sixty-two beds in al! for all classes 
of cases; three district hospitals, with one hundred and two 
beds, for all classes of cases; special provision for tubercu 
losis cases is made at two of the State Hospitals for the 
Insane, with provision for one hundred and sixty beds in 
all; and at Dayton, in the National Military Home, provi- 
sion is made for thirty beds in a tuberculosis ward. A total 
of eight hundred and thirty-four beds for the treatment of 
a disease which last year carried off 7,208 of our people! 
Authorities on tuberculosis statistics estimate at least three 
living cases of tuberculosis present in the community for 
every death recorded as a result of the disease. On that 
basis, we have eight hundred and thirty-four beds to place 
at the service of 21,624 cases of tuberculosis that are now 
in the homes of our state. 

However, there are many more hospitals projected, but 
they are still on paper. Jealousy as to location, injunction 
proceedings arising out of real or feigned differences as to 
legal procedure and wrangling among county officials, have 
delayed the work of giving proper treatment to the people 
who are suffering with tuberculosis. 

The last act of the Legislature touching this disease was 
passed in the session of 1910. It gives permission to boards 
of education in any city schools to establish open air schools 
for tuberculous children and to exclude such children from 
the regular public schools. Seven such schools have been 


84 





Bs 


as 
2 
& 
; 
Fi 


es 





projected in Ohio; five in Cleveland, where four are already 
in operation, one in Cincinnati, where the school board 
in January, 1911, began the construction of a “roof-room” 
on one of the public schools, for the open air treatment of 
children predisposed to tuberculosis ; and, one in Columbus, 
for children with incipient tuberculosis or predisposed to the 
disease. Neither have been in actual operation up to this 
time. 

On November 22nd, 1910, a meeting of the State Society 
was held to discuss ways and means for financing the or 
ganization. After consideration, the Cleveland branch of 
the National Red Cross Society was authorized to conduct 
the sale of seals in all unoccupied territory throughout Ohio. 
The money derived from the sale went to the support of 
the State Society. In the cities where there were local anti- 
tuberculosis organizations which were authorized to sell 
seals, the societies were asked to contribute at least 12'% 
per cent. of their proceeds to the support of the State So- 
ciety, and the entire proceeds from the sale outside of their 
own city. At a subsequent meeting Mr. S. Livingston 
Mather of Cleveland, Chairman of the Committee in charge 
of the sale, reported a net receipt of $4,288.46 for the State 
Society and a balance on hand by the State Treasurer of 
$326.46, making a total of $4,614.92, available for use by 
the State Society. 

The services of a paid secretary were secured, and on 
May Ist, 1911, he began working on the problem as to how 
to secure for Ohio the most efficient and adequate tubercu- 
losis equipment and treatment obtainable. At the annual 
meeting of the Society, held early in September, amend- 
ments were made to the Constitution, changing the form of 
the Society completely. The chief innovation was the se- 
lection of a board of 30 trustees, the members to serve from 
one to five years. The organization will be incorporated this 
year. Officers of the Society for the coming year are, Dr. 
John H. Lowman, of Cleveland, President; Dr. W. W. 
Brand, of Toledo, First Vice President; Dr. Frank Warner, 


85 





of Columbus, Second Vice President; Dr. Henry Baldwin, 
of Springfield, Secretary; Mr. Foster Copeland, of Colum- 
bus, Treasurer. 

Definite plans are being made for the sale of Red Cross 
Seals in Ohio again, under the supervision of Mr. S. Liv- 
ingston Mather. An endeavor will be made to hold the local 
Red Cross Seal Committees together after the Seal sale, and 
to continue them as local committees, to work for the pre- 
vention of tuberculosis in their own communities. 

The State Society will institute a vigorous campaign to 
teach the people generally, the nature and symptoms of tu- 
berculosis ; to strongly urge upon the medical profession the 
necessity for reporting cases of tuberculosis to the Board of 
Health (the state does not require compulsory notifica- 
tion of tuberculosis) ; to place before the people in every 
city and considerable village in the state, the need for free 
dispensaries, at which any person can secure an expert and 
thorough diagnosis of his condition and adequate instruc- 
tions as to what he must do; to show the necessity for V1s- 
iting Nurses to visit the patients in their homes and in- 
struct them, not once, but many times, in the protection of 
their households; to bring the proper officials to see the 
absolute need of hospitals—municipal, county and district. 

But in the final analysis, it is only the effort of the 
public-spirited men and women in every city and village 
which can provide the necessary force to accomplish such a 
program. A State Society can only hope to stimulate such 
people into a realization of the magnitude of the problem. 
and aid in converting that realization into action directed 
to solving it. 


SO 

















News Notes 


The Anti-Tuberculosis League of King County, 
Seattle, began its crusade only two and a half years ago. 
At that time, i. e., May Ist, 1908, it had only one visiting 
nurse and twenty advanced consumptives on its list. In 
December of the same year a second nurse was added; 
and in May, 1910, a third nurse was engaged. Later, 
however, owing to the opening of the “Henry Sana- 
torium,” it was considered advisable to retain only two 
for this branch of the work. 

The Out Patient Department of the work was opened 
only one year ago, for daily treatment and examination 
of patients. Up to date 347 cases have been examined. 

In the beginning all financial aid was secured by vol- 
untary contributions, but for the past year the city has 
given $333.33 per month for the care of the city cases, and 
during the past six months the county has done likewise. 
The county has also given $4000.00 in bonds to build 
the pavilions and cottages of the “Henry Sanatorium,” 
which stands on ground given by Mr. H. C. Henry, the 
lLeague’s president. A large portion of the stock of the 
Alaska-Yukon-Pacific Exposition was donated to the 
league which, when dividends were declared, brought 
in a substantial sum. 


In Seattle, Wash., has been formed a Catholic Social 
Settlement League, whose work is to a great extent based 
on the nursing of the sick poor. Its principal purpose is 
to study the conditions of the sick and unfortunate, and 
to discover if possible the causes which have led to exist- 
ing distress, and to remedy them, not so much by the giv 
ing of charity as by assistance toward health, employ 
ment, reform if necessary, and general self-respect. There 
is no other organization of its kind on the Pacific coast. 
Miss Alice Kershaw, the Visiting Nurse in charge of the 


87 











work, says, in a paper read at a meeting of the King 
County Nurses’ Association. “I have accomplished my 
best work where | started in with a sick patient. Through 
care and kindness to the sick | have won the hearts of 
mothers, fathers, sisters and brothers, and even of the 
neighbors.” 


In Chicago three Open Air Schools for anaeinic chil- 
dren were made possible this summer by the co-opera 
tion of the following agencies: The Board of Education, 
which supplies teachers, tents, and janitor service; the 
School Extension Committee, which takes general man- 
agement and particularly the support of the Libby and 
William Penn Schools; the Chicago Tuberculosis Insti- 
tute, which supports the Lake View Open Air School 
and has the selection and complete medical direction of 
all children; and the Municipal Tuberculosis Sanatorium. 
whose graduate nurse daily watches the physical condi 
tion of every boy and girl. The steadily improved physical 
condition as evidenced by the testimony of the three 
physicians in charge and the gain in weight shows that 
the improvement of these 100 children, if extended to the 
3,000 needing similar treatment, would result in the sav 
ing of many young lives and in enabling scores to return 
to the less expensive regular public school. 


The Anti-Tuberculosis League of Cincinnati has is- 
sued 65,000 booklets for distribution among the future 
citizens of that city. The booklet is called “The A B C’s 
of Health,” and contains much valuable information, 
couched in such simple and attractive language as to 
interest a child. It is also copiously illustrated with pic- 
tures which carry a lesson without the need of words. 


Prof. Winslow, in his address given at the American 
Nurses’ Association Convention held in Boston June last, 
said: “The Visiting Nurse is the most important figure 
in the modern movement for the protection of the public 
health.” 

88 

















The Ohio State Association of Graduate Nurses 
held its eighth annual meeting in Cleveland, October 17th 
and 18th, with headquarters at the Young Women’s Chris- 
tian Association. A very interesting program included, 
besides the official transaction of regular business, a Red 
Cross session, a Social Welfare session, and an evening ses- 
sion for Superintendents of Nurses. We reprint below the 
Social Welfare session program. Tea was served at the 
I‘lora Stone Mather residence for nurses at Lakeside Hos- 
pital, on Wednesday, the 17th, and at the Babies’ Dispens- 
ary and Hospital on Thursday afternoon. On Wednesday 
evening an organ recital at Trinity Cathedral was given in 
honor of the Red Cross nurses, and was largely attended 
by nurses and by those who had been invited to meet them. 
After the recital the audience passed through the beautiful 
stone cloister of the church, into the parish house, which 
was decorated with plants, flowers, American flags, Red 
Cross insignia and standards representing the different 
countries. Miss Laura Hilliard, honorary president of the 
Cleveland Visiting Nurse Association, was the hostess on 
this occasion. Receiving with her were Miss Jane A. 
Delano, Chairman National Committee, American Red 
Cross; Miss Mary E. Gladwyn, President Ohio State As- 
sociation of Graduate Nurses; Miss Mary A. Samuels, 
Superintendent of Nurses at Lakeside Hospital; and Miss 
Alma Hoyle, President Graduate Nurses’ Association of 
Cleveland. The clergy of Trinity Cathedral, members of the 
local Red Cross Chapter, and members of the Executive 
Board of the Anti-Tuberculosis League, as well as prom- 
inent members of Trinity Cathedral, were also active in 
serving and entertaining the guests. The Graduate Nurses 
of Cleveland gave a very beautiful luncheon at the Young 
Women’s Christian Association on Thursday, to the con- 
vention. To this luncheon were invited various women 
from the Boards of Trustees of organizations co-operating 
with the nurse, and also a few of the trustees and staff of 
the Young Women’s Christian Association, whose hospi- 
tality had been so graciously extended. 


89 











PROGRAM OF SOCIAL WELFARE SESSION. 


Miss ABBIE ROBERTS 


Chairman, Cincinnati Visiting Nurse Assoc’n 


“The Nurse in the Reduction of Infant Mortality” 
Dr. H. J. GERSTENBERGER 
Assistant Professor Pediatrics, W. R. U. 
Med. Director Babies’ Dispensary and Hospital 
“Report of Investigation of Practice of Midwifery ‘in 
Cincinnati” 
Miss MALINDA NITSCHIKE 
“Report of Investigation of Practice of Midwifery in 
Cleveland” 
Miss GERTRUDE BARNES 


Cleveland Society for Promoting the Interest of the Blind 


“Social Training for Nurses” 
HANNA BUCHANAN 


Cleveland Visiting Nurse Association 


Oj) 





























Stories Told by Nurses 


Little Sarah 


Mi_tprep M. PALMER 


Many strange things had happened in the life of little 
Sarah Berkovitch. First there was the ambulance that 
rang its bell fiercely in front of the little candy store one 
cold, December day. A great crowd gathered round and 
she gazed, open-eyed, with the rest. Suddenly, to her 
amazement, the store door opened and two men brought 
out her father on a bed and shoved him into the ambu- 
lance. She ran after him, screaming, but he motioned her 
back feebly, struggling with a paroxysm of coughing; 
the door banged and he was gone. 

Then were the sad days in the tiny room back of the 
candy store. Her older sisters forgot to laugh, and her 
mother always cried with her shawl over her face; for, 
mystery of mysteries, her father never came back! Many 
times she watched for him, straining her eyes into the 
early winter darkness. But he forgot to come. 

A short time after this her sisters went away. \hen 
she asked where they were, her mother sobbed aloud 
and wrung her hands, saying, “To de Orphans—de Or- 
phans!”’ And when Sarah demanded where “Orphans” 
was, her mother wailed so violently, rocking herself to 
and fro and muttering such strange things to herself in 
Yiddish, that Sarah was frightened and asked no more. 

Then, one day, Sarah’s mother told her that she was 
going to the hospital, but that she would surely come 
back and that she must stay with Mrs. Schwartz and be 
a 20 d eirl, 


Sarah never expected to see her mother again. But, 


so inversely does happiness sometimes come, not only 


91 








her mother came back, but brought with her a little, red, 
gasping piece of humanity—a new baby! Now, indeed, 
was Sarah's cup of joy brim full. She laughed and sang 
and played with the baby till even her mother forgot to 
cry. A curious sense of responsibility rested upon Sarah. 
She learned the name and price of everything in the 
store. With the air of a connoisseur she offered the fat, 
brown cigars in the show case. She learned to mix a 
soda, and, with conscious ease, handed out the all-day 
suckers and slabs of licorice and chocolate to the neigh- 
bor children. 

In these little stores that cater to the penny trade, the 
hours are long, and it was always midnight or after when 
the store was locked for the night. Then weary Sarah 
would go fast asleep in the tiny, closed, windowless room. 

As spring came on Sarah lost her vivacity. She was 
always tired, her head ached and she could not eat. Her 
mother watched her with sinking heart till she could 
stand it no longer. She went over to the Settlement 
house and asked for a nurse. The nurse came and took 
Sarah to the Tuberculosis Dispensary, where it was found 
that she was an “incipient case.” 

Many times the nurse from the Dispensary called on 
Mrs. Berkovitch trying to impress upon her the neces- 
sity of fresh air and good food for Sarah. As to the food, 
she was more than willing to save enough money to buy 
milk and eggs, but the air—TIt was so lonesome, she would 
say shiveringly. She was afraid to leave even the tran 
som open because of rough men in the neighborhood. 

Then the nurse asked if she would let Sarah go to the 
Tent Colony, promising that she would find a little girl 
to keep in the store while Sarah was gone. 

After many days of indecision, Mrs. Berkovitch con 
sented, and Sarah spent the summer in the country with 
other little children who had lived in close, windowless 
rooms. 

Here Sarah alternately ate and rested and played and 


9? 

















drank long draughts of sweet milk and slept soundly 
through the cool, wonderful nights. 

\t last October came and she was well enough to be 
discharged. Then the old problem presented itself. Mani- 
festly she could not go back to the conditions that had 
contributed to her illness and undo all that had been done 

The nurse called again on Mrs. Berkovitch and told 
her that Sarah could not come home unless a proper place 
was provided for her to sleep in. To her surprise, the 
mother needed no persuasion. She had seen Sarah getting 
fatter and rosier all the summer and realized the value 
of fresh air and right living. She rented a room from 
her neighbor upstairs, and a little bed was gotten and 
placed by the open window. 

llere Sarah sleeps from eight o’clock till six in the 
morning, and forgetting the noise of Woodland Avenue, 


dreams that she is back at the Tent Colony again. 


The Last Resort 


Lucy Hitrcu 


\What can be more heart-breaking and pitiful than to 
be brought from your native country to a strange land 
by vour husband, and then to be deserted and left to 
battle and struggle on alone and finally become dependent 
upon charity? Such is the story I am about to tell of 
Mrs. Susie Blank of Main street. 

[t was in the month of April that she first came to our 
dispensary but, as in many other cases, in such a late 
stage of the disease that there was positively no hope 
for her. 

When I first visited her she lived alone, in three 
rooms, in one of those dilapidated old houses on Main 
street. She stayed in these rooms until her funds were 
exhausted and she was compelled to move. Then a neigh- 
bor took pity on her and offered her a room in her house. 
Poor Susie had been put on the list for the City Hospital, 


93 








but for some unknown reason, when she was admitted at 
the hospital she stayed but one day. 

The next best place for Susie was the Tuberculosis 
Day Camp. She spent many a pleasant day there, and 
would have enjoyed many more if her strength had per- 
mitted, but she gradually became so ill that she finally 
came to the dispensary and begged to be sent to the hos- 
pital again. Susie spent some anxious moments waiting 
for her turn, but it was not long before word came for her 
to goimmediately. I quickly wrapped some sputum cups 
and paper napkins together, and made my way toward 
Main street. What surprised me most was that this very 
sick woman was caring for three babies. She finally 
found someone to care for her charges, and before long 
the patient and I were on our way to the hospital. 

She has now learned to appreciate the tender care of 
the nurses, and is willing that someone wait upon her, in 
place of her doing for others. She has also learned that 
a clean sheet stretched smoothly over a mattress makes 
a better bed than numerous feather beds, and that a well 
ventilated ward makes a better sleeping place than a 
small room with closed windows,—but the lesson has 
been learned too late! 


An Allegory 


Mary M. Taytor 


As you enter the house, you are shown into a cheery 
room with a pleasant outlook, flowers blooming in the 
window and the song of the mocking bird in the air; and 
as you look into the face of the one to whom this room 
has long been home, you feel at once that you are in no 
ordinary sick room atmosphere. Yet those who know 
her well tell you that thirteen long years ago Mrs. R 
through the development of a strangely baffling malady 
to which medical science could afford but little relief, and 


for which the physician could scarcely find a name—re 


94 

















luctantly laid down, one by one, the daily tasks, hoping, 
through the months, to take them up again; but as the 
years slowly passed and disease made greater inroad on 
the frail body, she realized that the active work, in which 
she had played a large part, must be done by others. 


Cared for, at first, by strange hands, somewhat awk- 
ward, because unaccustomed, but soon made gentle and 
skillful by the love toward her unto whom they minis- 
tered so tenderly, she suffered in silence with untiring 
patience, ever seeking new ways in which to do for others. 

Taking a keen interest in the ‘“World’s Work,” and 
retaining a sympathetic understanding of others’ lives, 
her room became a place where people brought their per 
plexities, their joys and sorrows, always finding, as they 
did so, that the joys grew more and more, and the per 
plexities ever less, for she seemed to impart to them some 
of her own wonderful insight and to give a new aspect to 
common things. 

Many come, the rich and poor, the young and old, the 
educated and the ignorant, and all are made welcome 
the gladest greeting, perhaps, for those who bring with 
them the gift of music or of song. 

Whatever struggles come when 

“The waiting hours are weary to bear 
And the courage is hard to keep” 
are carefully hidden in her own heart, and she gives to 
the world only the brave smile and the kindly word. 

A young girl, little more than a child, rowed a tiny 
home-made raft out into a pond to gather water lilies. 
The desirable ones were difficult to reach, because they 
grew just the other side of some rank yellow weeds. As 
she picked up the flowers, her childish, questioning mind 
wondered what power was inherent in the lily that en- 
abled it to reject the poisons, and to draw unto itself, from 
out the mud and slime at the bottom of the greenish 
water, only the elements that made for sweetness of 
fragrance and beauty and purity of form and color while 


95 











growing in the same water the weed had drawn to itself, 
from out the same mud and slime only the elements that 
made it ugly and obnoxious. 

The Visiting Nurse (the young girl older grown) has 
called on Mrs. R week after week for two years, and 
she is often reminded of the day she rowed her little boat 
out into the pond to get the lilies, and asks what power 
it is in the woman that has enabled her to gather from 
out the pain and loneliness, the weakness and helplessness 
of years, the things that make for sweetness and strength 
of character, and that have made of life a blessing and a 
rarely beautiful thing; while not far away live others who, 
out of a more favorable environment have drawn only 
things which make of life a weariness and a burden. 


The Black Sheep 


[pA Harris 

[ turned into a dismal little side street, mounted the 
steps of one of the many lodging houses, and gave the 
bell a vigorous ring. “Is Mr. S. in?” I asked of the 
frowning, sharp-faced woman, who opened the door a 
fraction of an inch, in answer to my summons. “Very 
well, I'll go right up and see him.” The woman grunted 
something that might have been taken for an assent, 
opened the deor wider, and I went up three dark flights 
of stairs and tapped on the door at the head of them. 
Then without waiting for a response, I pushed open the 
door and entered the room. 

It was very dark and dingy. A lighted, sputtering 
gas jet served as both light and sunshine, and the odor of 
countless cigarettes made it choking and stuffy after the 
fresh morning air, out of doors. In an old plush chair 
by one window, | found Mr. S., a lank young man, with 
a face of pasty whiteness and cheeks that began to look 
hollow, sitting with his feet propped up on the window- 
sill, staring out at the littered dirty alley, which ran its 
length behind the houses. 


96 








After opening the window, [ sat down on an old creak 
ing chair, asking Mr. S. meanwhile how he felt. “line, 
more fine,” came the answer, but even while he spoke he 
was racked with a spasm of violent coughing. “Your 
cough doesn’t seem much better,” I ventured. “Aw, that 
aint ‘nut’ns, don't let that worry ver.” Eyeing him very 
closely, I said, “Mr. S., this is no place for you. You 
ought to be out in the country and breathe the fresh air.” 
“That’s where you're wrong, ma’am,” he replied, ‘nix 
on anything of that kind, and don’t come here for that 
agin.” 

\nother paroxvsm of coughing seized him, which 
brought a flush to his cheeks—-a flush which only ac 
centuated the usual pallor. I soon saw that my visit was 
irritating him, and could do no good as lone as he wa 
in such ill humor, so saying that I would call again the 
next day, and leaving my morning paper with him, [ said 
“oood by "a 

[ descended the dark stairs with the sound of Mr. S.’s 
racking cough still ringing in my ears. After I had gone 
Mr. S. carefully and painstakingly brushed his clothes 
and started out for a certain place, not far distant, where 
for a very small sum, he could get a glass of beer and a 
free lunch, which would serve as his dinner. Down the 
dark flight he made his way, but stopped in the lower 
hall, by an old rickety hat-rack. His eves fell upon an 
envelope, which bore his name, among the waiting mail 
With pathetic eagerness, he tore it open and began to 
read. Suddenly his brows knit and his lips began to 
quiver. If was from home! By the time he had finished 
his letter, his lunch was forgotten, and, instead of going 
out, he returned to his forlorn room and seated himself 
by the window, with his head buried in his hands, in deep 
meditation. 

On the following day, I returned as I had promised, but 
before I had time to urge him to return to the country, 


he told me about the letter and its meaning. Ile began 


97 








by saying, “Listen to me! I got folks away out in the 


country——imiles away—good folks too! Do you get it? 
Well, I was the Black Sheep-—I was always wild—that’s 
how I come to be what Iam. [| could not stand the quiet 
country life, so I left. They didn’t want anything to do 
with me and | thought they wished me everything bad 
They're straight and honest, see?) They plod along with 
just enough to live on——but they're honest. I never heard 
from any of them since | left, except one sister whi 
writes, when she knows where I am.” 

Ilere he broke into a fit of weeping, which wound up 
in a violent coughing spell and then, between sobs, he 


~ I ! 


continued, “today | got a letter from mother, who says 
‘Come home, my boy, come home, vour father is on hi 


death-bed and is willing to forgive you'—and I’m going 


home.” 


\GNES \ LOGAN, 


\fternoon clinic had begun at the Tuberculosis [is 
pensary. Several patients had been examined and had 
received their directio1 s, when an elderly ladv came 
slowly up the stairs, and one could see at a glance that 
she was not one to accept charity without a good cause 

\WWhile her face wore a kindly, sweet expression, it 
also showed a certain fine pride, and a self will, which the 
nurse realized later in her dealings with the woman. 

The patient seated herself in a vacant chair near the 
table and the nurse proceeded to take a history of her 


case. In filling out the history blank it is necessary to 


know something about the patient’s physical condition, 
also whether tuberculosis is hereditary. In completing 
the history the nurse found that the patient’s father had 
died of typhoid fever, her mother had been bedridden for 
three vears suffering from a complication of diseases, 
and two brothers had died of tuberculosis. The woman 


OR 





RAR Sow, 


had nursed them all faithfully until God had called them 
to the Great Beyond and left her, at the advanced age of 
seventy years, alone. She had no relatives living, and 
her only friend had moved away. 

The woman's case was diagnosed pulmonary tuberculo 
sis third stage, so she was sent to the Tuberculosis Day 
Camp. This she appreciated. She said it was the only place 
where she felt at rest; the camp was so clean; they fur 
nished such good nourishing food, and it was so well cooked ; 
and then the air, she said, was so pure and fresh, for the 
camp was situated on the shore of old Lake Erie. 

Later it was found that all this woman had left of this 
world’s goods was an old silver watch which her brother 
had given her, telling her to sell it when it became necessary, 
and a sewing machine, which she sold for eight dollars. 
\ kind family had given her a room, and had told her she 
could stay with them as long as she wished. But fate 
seemed to follow, for the kind friend was taken to the 
hospital to undergo an operation and was compelled to 
remain there about six weeks. Then the friend’s household 
goods were taken, as there were several payments due on 
them which could not be met. Now our dear old lady's only 
iriend had been taken away, and she was left without a 
place to rest her weary head. 

Through an agent of the .\ssociated Charities, she se 
cured a few night lodgings at the Wayfayer’s Lodge. 

In the meantime, the nurse found her a small room with 
a very nice family for three dollars a month. The money 
she received for the sewing machine, paid for the first two 
months rent in advance and the nurse assured her that after 
two months there would be a new supply of money—even 
though there is no evidence of it at present. 

Two different associations are trying to secure the Rose 
Pension for her which would make her comfortable and 
happy. This woman certainly deserves it, for she is one of 
our most worthy and self-respecting patients. She told me 
that she never failed to pray fervently that God would send 


OO 








her her daily needs, and that she would not have to be 
buried in a pauper’s grave, and all that know her will surely 


utter the same prayer. 


Her Hardest Lesson 
CHRISTIN \SKELAND. 


l‘lorence was young, inexperienced and very ambitious, 
and did not realize that her strength would give out. She 
had a beautiful character, but she was headstrong, and as 
her parents were dead there was no one who could advise 
her proper] Hler work she did well for whatever she 
undertook had her whole mind and energy. The money 
that had been left by her parents was not enough to give 
I‘lorence a very extensive education, so she took a business 
course at one of the colleges, and secured a position with a 
firm where competent work was required. 


Poor Florence did not spare herself, but worked so hard 


and did her work so well, that she soon became very val 
uable. But she was not of a disposition to be satisfied with 
this. .\fter a time she started to take up several studies at 
1 
' 


night school. She went o1 long time working at the office 


all day, and at school over her books at night. The smal) 
hours of the morning were often coming on before she 
would retire Phen her strength began to fail \t last 
she was compelled to seek medical advice. She was told 
she had tuberculosis, must give up work of all kinds and 
have complete rest it Sa heavy blow but it must be 
met. She was examined for entrance to Mt. Vernon, but 
ull had to wait some time for her 
turn. In the meantime she was taken to the Tent Colony 

\t last the time came to go to Mt. Vernon. On arriving 
Ilorence was ordered complete rest. Oh, ves, she would 
like that, for she really felt tired. At 10:30 p. m. the nurse 
saw a light in Florence’s room. “Why, Ilorence,” she 
complete rest.” “I am resting,” 
replied Florence. This was true for Florence had not often 


100 


written her letters as early in the evening as this. “but, 
l‘lorence, you must write no letters the first week you are 
here, or rather till your temperature becomes normal.’ 
I‘lerence could not see it this way, and rested only when 
she was exhausted. It took a long time before she could 
be taught how to rest, and she had many a struggle learning 
this, her hardest lesson, but at last she learned and under 
stood. 

When first starting the cure [Florence felt it a great 
waste of time—she had made so many plans for her life, 
and there was so much to do! But as time went on sh« 
began to see that this period of rest was as full of results as 
the more active period—that the calm, peaceful out-of-door 
life was giving her beautiful thoughts and broader sym 
pathies, and might help to make her a better, nobler woman 


A Family from Poland 
Mary KLEMA 


In the spring of 1902, on board of a ship leaving Europe 
for America, was a young Polish married couple. They had 
heard of the luxuries of our great country and were coming 
to share them. Soon after landing they came to Cleveland 
where they rented a few rooms and went to housekeeping 

John soon found employment in the wire mills and Julia 
went out working whenever she could. Everything went 
along smoothly until little Bruno came, then Julia was un 
able to help John make money; but she was still John’s 
helper, for being a good housekeeper they were able to save 


the sum of seven hundred dollars, which seemed to them a 


small fortune. The world looked very bright for they 
could soon buy that longed for home. 

Then suddenly everything was changed. John’s health 
began to fail and a physician’s care was needed. The 


months dragged on and John was still unable to work and 
was getting weaker every day. As there was no income the 
family had to draw upon their small fortune. There were 
five to be provided for by this time, and the seven hundred 
dollars were soon gone. 


101 





Light again came to the family when they heard of the 
free Tuberculosis Dispensary, where so many were cared 
for. But, alas! the doctor found John was suffering from 
tuberculosis, and too far gone to be cured. 

He was sent to the Tuberculosis hospital, but was too 


lonesome away from his family, so he returned home to 


have Julia take care of him. The nurse called upon the 


family and gave instructions, which Julia, being an apt 
pupil, carefully carried out. 

In August John died leaving Julia to care for the three 
small children. They have all been examined at the dis 
pensary and through Julia’s care in carrying out the nurse's 
instructions fortunately no one has the dreaded disease. 

The family has now moved into better quarters and is 
getting along fairly well, as Julia is now able to go out anid 


work. 


























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Contents 
Editorials 
Tuberculosis Work in Cleveland 


The Health Department 


The | yispensat 1es 


The (open \ir Sch 


J ( P M. D 

The Tent Colony——A Sanatorium for Childr 
\ | [ac \ ) 

The Cleveland Plat lhe Special Cas« 
Committe 
B S 

The Day ( amp 
| “Pp Pry 

Phe Ne ehborhood He h ( paign 
S ( 

wall Bs \lode LH Is¢ 
| \ \\ | 

Red Cross Chris 5. Si S Campaign in Oh 


Results in 1910; Plans for 1911 
7 Nn M 
Group Dangers in Tuberculosis 
JouNn H. Lowman, M. D 


The Past and Future the Tuberculosis Nur 


Ss ¢ 
| Se EY, R 
The Nurse as a Social Worke 
ELLEN La Mo RR 


Tuberculosis as a State Problem 
Rorert G. | Ph. D 
News Notes 
Stories Told by Nurses 
Little Sarah ; 
Miu M. Pa 
The Last Resort 
Lucy Hitcu 
An \llegory 
Mary M. Taytor 
The Black Sheep 
IpA Harris 
Fate , ‘ ; , 
AGNES A. CocAN 
Her Hardest lLesson 
CHRISTINE ASKELANI 
A Family from Poland 
Mary Kiema 


Q4 


OO 


100 


101 





EN —— 


The Babies’ Dispensary 
and Hospital 


is in close co-operation with 
eal The Visiting Nurse Associa- 

J“ tion. It’s Work is to bring 
life, health, happiness to the 
babies of Cleveland. 


A contribution, little or big, 
will help. 








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Made of wood—handsomely finished— and fitted to you window with 


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We will gladly send demonstrator, without any obligation on your part, 
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The Modern Ventilating Co. 


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Ventilating appliances to suit all conditions 


Office: 210 Electric Bldg., CLEVELAND 
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EVERY NURSE 


Needs Pattee’s 
PRACTICAL 


] DIETETICS PRACTICAL DIETETICS 


| WITH REFERENCE TO 


DIET in DISEASE with reference to 


DIET IN DISEASE 


This manual, by Alida Frances Pattee, late in 
structor of Dietetics at Bellevue, Mt. Sinai, Hahne 
1 and Flower Hospital Training School for 
Nurses, New York City, should find a place in the 


Alida Frances Pattee 














handbag equipment of every nurse. It is of prac- 
the nursing of any case; it suggests 
appropriate food for every disease, and tells what 





ilso gives the proper diet for infants and 
nd the preparation of same. 





Adopted by the United States and Canadian governments, recommended by 
th evarious State Boards of Examiners of Nurses, and used asa 
text-l 


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Sixth Edition just published. Price $1.50. By Mail, $1.60 


Special Rates on Quantities to Training Schools, etc. 


A. F. PATTEE, Publisher MT. VERNON, N. Y. 




















TUBERCULOSIS- The Pines ee North Carolina 


The Pines is aq ly Tuberculo of the Lung 
and Throat It also receive care perative treatment, suc surgical cases a € 
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Che climate of t Mi nt 1 ot Westet Nort Carolina is stimulating and invigorating 
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Use Bulgarian Lactic Buttermilk containing the 


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FORSAVINGS July 31st,:911—- . seeemeenne 


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Prescription and Manufacturing Optician 























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Our rapid growth has in no Mail Orders promptly filled 
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LINOTYPE COMPOSITION FOR THE TRA 

















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glish, German and Italian speaking nurses. Special 
training in infants-teeding and social-service desirable. Eight-hour day. 
Salaries, $60—$80. State training and experience. 


Address M. B. H. A. care Visiting Nurse Quarterly