HX64074269 RA448 C59 Cleveland hospital a RECAP ■■" ; ' :V;: - 82x8 oBfa Bosh ill HI SBQKBBi HOC* Esssa ;■'■'■ ••■'•'■ Bm BB J3§ •'■^■■'- •■■'•■ BB88»wc 9fi 88$ " BEgppgv C ■ SKKR3 BBSS '■■■''' <&%?> Introduction General Environment Sanitation Part One Cleveland Hospijtal 'afivd Health Survey Copyright, 1920 by The Cleveland Hospital*Counctl Cleveland, Ohio Published by The Cleveland Hospital Council 308 Anisfield Bldg. Cleveland - Ohio Pref reiace The Hospital and Health Survey of Cleveland was made at the request of the Cleveland Hospital Council. The Survey Committee appointed to be directly responsible for the work and through whose hands this report has been received for publication consisted of the following: Malcolm L. McBride, Chairman Mrs. Alfred A. Brewster Thomas Couhlin Richard F. Grant Samuel H. Halle Otto Miller Dr. H. L. Rockwood Howell Wright, Secretary The staff responsible for the work were : Director — Haven Emerson, M. D. Assistant-Director — Gertrude E. Sturges, M. D. Cleveland Division of Health — Study in charge of Haven Emerson, M. D. [W. G. Moorehouse, M. D. Assisted by \G. B. Gascoigne \l. S. OSBORN Consultant in Orthopedics — Robert B. Osgood, M. D. Hospitals and Dispensaries in Cleveland — Study in charge of Michael M. Davis, Jr., Ph. D. (Anna M. Richardson, M. D. Mrs. Mary Strong Burns, R. N. [Miss H. L. Leete, R. N. Consultant in Hospital Administration — W. L. Babcock, M. D. Consultant in Convalescent Care — Frederic Brush, M. D. Nursing in Cleveland — Study in charge of Miss Josephine Goldmark, B. A. 'Miss Anne Strong, R. N. Mrs. Alice F. Piggott, R. N. Assisted by I Miss Elizabeth Fox, R. N. ] Miss Janet M. Geister, R. N. Miss A. H. Turner, A. B. (Mrs. Anna Staebler, R. N. Industry in Cleveland — Study in charge of Wade Wright, M. D. Assisted by /Mrs. Marie Wright "i Miss Florence V. Ball Venereal Disease in Cleveland — Study in charge of W. F. Snow, M. D. /-Alec Thomson, M. D. Assisted by j Allison French \ Mrs. M. P. Falconer [Bascomb Johnson Child Health Work in Cleveland — Consultant in Child Health — S. Josephine Baker, M. D., D. P. H. In charge of Sanitary Survey of Children's Institutions — Henry G. Mac Adam, M. D. Tuberculosis in Cleveland — Study in charge of Donald B. Armstrong, M. D. Mental Hygiene in Cleveland — Study in charge of Thomas W. Salmon, M. D. Assisted by Jesse M. W. Scott, M. D. Vital Statistics in Cleveland — Study in charge of Louis I. Dublin, Ph. D. Pharmacy in Cleveland — Study made by Edward Spease, B. S. The entire staff is under obligation to Miss Elizabeth R. Cummer and Miss Josephine Colegrove for secretarial work in assembling and pre- paring reports on individual hospitals, in proof-reading and in indexing the completed report. Bibliography of Surveys prepared by Miss Julia T. Emerson. Publicity for the Survey in Cleveland — In charge of Carlton Matson Assisted by Miss Georgia Bowen Special Reports were contributed by — National Committee for the Prevention of Blindness. Mrs. Winifred Hathaway, Executive Secretary. American Society for the Control of Cancer. F. J. Osborne, Executive Secretary. Association for the Prevention and Relief of Heart Disease. Miss M. E. Woughter, Executive Secretary. The expenses of the Survey and of the publication of the report have been met by appropriations received from the Community Chest through the Welfare Federation, of which the Hospital Council is a member. The report as a whole or by sections can be obtained from the Cleveland Hospital Council. A list of the parts will be found in the back of this volume, together with prices. Letters of Transmittal Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/clevelandhospitaOOclev Letters of Transmittal To the Cleveland Hospital Council: There is presented herewith the report of the Committee on the Hospital and Health Survey of Cleveland, appointed on October 1, 1919, as recorded in the minutes of the Cleveland Hospital Council: "Moved by Mr. Anisfield: "That the action of the President of the Cleveland Hospital Council in appointing a committee consisting of the following persons: Malcolm L. McBride, Chairman; Otto Miller, Richard Grant, Dr. H. L. Rockwood, Thomas L. Coughlin, Samuel H. Halle and Mrs. A. A. Brewster, to conduct a health survey of the City of Cleveland, be ratified and endorsed, and that the general outline of the Hospital and Health Survey as prepared by Mr. Wright and attached hereto be used as a guide by the committee in conduc- tion of the Survey, which outline shall be subject to modification as may be needed. "The Committee will have full power in the premises to engage per- sonnel and proceed with the Survey. It is emphasized that there should be specific and definite recommendations regarding the building programs and the character of the future work of the existing hospitals, such recommenda- tions to be made at as early a date as possible. "Throughout the whole investigation the committee is asked to be as specific as possible in its recommendations. "Seconded by Mr. Hildreth and carried unanimously." GENERAL OUTLINE For Hospital and Health Survey Hospital and health activities have a common purpose. It is better public health and fewer preventable deaths. There are four fundamental contributing factors to the efficient work of all hospital and health organizations working to this end. These are: Development of medical education, both post graduate and under graduate. Development of nursing education, both general and special. Advancement of public health and preventive medicine. Care of the individual sick. Due consideration must be given to each of these four factors in con- sidering the work of any individual hospital or health organization or group of such organizations or community hospital or health needs. The work of this committee may be divided into two parts: I. A survey and study of the existing hospital and health activities — public or pri- vate — of Cleveland. It should determine the contribution which is now being made to the common end by the different institutions individually and collectively, discover ways in which these institutions may be made to contribute more by reasonable changes either 8 Hospital and Health Survey in the division of labor with other institutions, the volume of work done or contemplated, or in the way of doing work. This involves a survey and study of: 1. Medical education in Cleveland as at present conducted. (a) Use of clinical material and facilities in Cleveland by the Medical School for under-graduate instruction, for post-graduate instruc- tion of young medical men, for instruction and development of the medical profession in general. 2. A study of nursing education as conducted at present in Cleveland. (a) Training Schools giving general nursing education. (b) Facilities for providing nurses with special education and training. 3. The Division of Health of the City of Cleveland and its relation to the hospitals, dispensaries and other medical institutions and the profession in general. Its activities in the care of contagious diseases and in preven- tive medicine. 4. A study of the existing hospitals and their plans for extension to determine: (a) The available and contemplated facilities for — Pay or private room patients, Part-pay and ward patients, Free patients. (b) The probable normal needs of the community for each of these classes of accommodations. 5. A study to determine the present and contemplated facilities as well as the probable normal needs of the city for the care of certain classes of sick: Contagious, including venereal diseases, Acute surgical, Acute medical, Chronic surgical and orthopedic, Chronic medical, Convalescent, The immediate development of facilities for chronic and con- valescent patients as a means of saving hospital space. Insane and mental diseases, Aged and infirm, Maternity, Babies and children, Accident and emergency. 6. Dispensaries. A study of their location as to their availability to all Cleveland citizens in need ; the type of cases receiving treatment therein ; the facilities of the various dispensaries to do properly theVork undertaken. II. The second part is a more extended study of the community to determine the ideal number, grouping, location, character and functions of the hospital, medical and health institutions which can best serve Cleveland at present and during the reasonable future development of the city. This entails the following: Letters of Transmittal 1. Morbidity, accident and mortality rates for the city, as a whole, and by dis- tricts, based on city statistics, questionnaires to doctors, hospital and dispensary records, Industrial Commission reports, U. S. Census figures on occupations, races and ages and morbidity census in other cities, per- haps house-to-house canvass of selected districts to learn amount of sick- ness, total and classified. 2. Care secured by the sick, economic ability to secure care. Home condi- tions affecting care. Knowledge or ignorance of existing facilities. Efforts of agencies to reach those needing their care. Constituencies of various hospitals or attraction of hospitals for various groups. Survey of ade- quacy of home care in typical neighborhoods. 3. Capacities and facilities of existing agencies for giving the amount of remedial care shown to be needed by studies of the amount and present care of all sickness, accidents, and by prospective increase of population. 4. The estimated reduction in sickness from extension of preventive medicine and health insurance, based on European experiences. 5. The Medical School's relation to present and future hospitals, dispensaries, sickness prevention and the health department. 6. The relation of nursing training schools to present and future hospitals, dispensaries, sickness prevention and the health department. On October 3, 1919, arrangements were made to undertake the study as proposed in the communication appointing this committee. The Survey staff was organized and began its work in Cleveland on November 9, 1919. The field studies, the public meetings and the con- ferences with representatives of the organizations and agencies, both public and private, concerned with the various aspects of the field of inquiry were completed early in July, 1920. The accompanying text, now printed and available for distribution, has been passed upon and approved by the committee. The subjects treated of include those specified at the time the committee was appointed and several others which it seemed desirable to add during the progress of the studies. It is recommended that the Cleveland Hospital Council use its influence in support of the proposals and conclusions of the report. Your committee requests its discharge with the completion of the serv- ices expected of it. (Signed) Malcolm L. McBride, Chairman, Mrs. Alfred A. Brewster, Thomas Coughlin, Richard F. Grant, Samuel H. Halle, Otto Miller, Dr. H. L. Rockwood, Howell Wright, Secretary. Cleveland, Ohio, September, 1920. 10 Hospital and Health Survey To the Hospital and Health Survey Committee of the Cleveland Hospital Council : Sirs: There is herewith presented to you in its completed form and prepared for publication the report of the several members of the Survey staff who have, under my direction, and with your approval, studied the Hospital Service, Education in the Medical and Allied Professions, and the Facilities for Health Protection in Cleveland. At the risk of criticism for failure to seize the opportunities presented to obtain and report all possible facts bearing upon the care of the sick and the protection or development of health, only such material has been collected and only such portions of the collected data have been prepared for publi- cation as appeared to contribute substantial force to the discussion of the problems and to the recommendations arrived at. Wherever information reliable in source and for all practical purposes comparable to what would be found in Cleveland was known of, it was accepted and used without attempt at duplication or repetition. From the beginning of our studies all of the investigators and consultants engaged in the work have acted upon the assumption that personal discus- sion, argument, demonstration and persuasion upon the spot with those directly concerned with administration or service in the health or hospital field, was sure to contribute more to change in method or improvement in results than could be expected from the reading of the printed page at a later date. There have been no pains spared to insure a broad and intimate contact with all groups of citizens concerned in any way in the multitude of services comprised in the hospital and health problem. Recognizing that Cleveland has been a generous contributor to each of the national movements now engaged in attacking the causes of ill health and in spreading knowledge of self-protection against disease and disability, it seemed reasonable to expect in return collaboration by these same national groups in Cleveland's effort at self-analysis and a share in the responsibility and privilege for providing a plan and program for so typical and aggressive an American municipality. Either through direct assumption of the entire cost of services obtained, or by sharing the cost of officers temporarily as- signed to the Cleveland Survey, or through the generous gift of time and attention at no expense to the Survey, we have been so fortunate as to obtain for incorporation into our report the studies and conclusions of representa- tives of: The National Tuberculosis Association, The American Social Hygiene Association, The National Committee for Mental Hygiene, The National Committee for the Control of Cancer, The Society for the Prevention and Relief of Heart Disease, The National Committee for the Prevention of Blindness, The National Committee for Study of Public Health Nursing Education. . Letters of Transmittal 11 The American College of Surgeons. Our investigators have been drawn also from the Harvard School of Industrial Hygiene, Boston Dispensary, New York City Department of Health, American Red Cross, American Child Hygiene Association. From Cleveland itself we have obtained continuous, helpful and devoted service, not only from those whose occupations, professional and lay, placed them in a position to assist or contribute to the volume and success of our study, but from that great group of well informed men and women who are ready to devote their time and capacities to any undertaking which offers assurance of improvement in the conditions of life of their fellow citizens. Among the most important sources of assistance have been the officers of the Division of Health, the Board of Education, the Welfare Federation, the Academy of Medicine, Western Reserve University, the Central Nursing Committee, the Visiting Nurse Association, the Associated Charities, the Consumers' League, Y. W. C. A., the Junior League and the Women's City Club. During the course of the Survey there was gj-mortunity to supplement and cooperate with: Y (a) A special committee on Social Hygiene whose work was drawing to a close about the time this Survey was begun. (b) The Welfare Federation, which undertook a study of the social, educational and recreational functions of the institutions for children, while the Survey analyzed the sanitary, medical and health services provided. (c) The Consumers' League in its study of the use of milk in Cleveland and in its recently inaugurated study of the employment of children. In submitting this report it is a pleasure to pay tribute to the breadth of vision and the public spirit shown in the objectives which the Cleveland Hospital Council set before you, its committee, for accomplishment. It seems reasonable to expect that such benefits as may accrue to Cleveland from the study of the local situation are not to be confined to this city alone, but will stimulate similar studies elsewhere and will prove of practical value to that large group of executives, trustees and their financial supporters throughout the country, who are carrying the responsibility for health de- velopment and its protection, for disease prevention and its treatment, for education in the field of medical services. For the support, encouragement and critical judgment of the committee I wish to express the gratitude of those engaged upon the Survey. There have been offered to us full freedom of opportunity and a spirit of coopera- tion and helpfulness without which our friendly contact with the institu- tions, agencies and branches of the civil government would have been diffi- cult to obtain. It must be apparent that in no single subject of our report has the field of study been exhausted. Our conclusions may well be modified in the future by what we trust will be undertaken in the way of further self -analysis 12 Hospital and Health Survey and research in the methods and results of medical social service which now- adays fills so important and costly a function in the structure of community life, safety and progress. The cost of the Survey has come within the amount originally set aside for this purpose: namely, $53,000, of which $3,000 had been spent on a study and report of social conditions which contribute to venereal disease incidence before the general plan of the hospital and health study was com- pleted. The total cost of the Survey, estimated at the time of going to press, including publicity service and publication of the report, has been $52,668.98, under the following functional headings : Direction and Administration $24,902.38 Tuberculosis 938.63 Hospital and Dispensary..... 5,117.54 Child Hygiene 1,026.27 Statistical _ 562.00 Venereal Disease 3,586.04 Nursing _ _ 3,829.85 Mental Disease and Mental Deficiency 385.00 Industrial Hygiene...- 4,429.68 Children's Institutions ._ 891.59 Publication 7,000.00 Total ...-. ...$52,668.98 In addition to the services paid for under the above headings there have been contributed, as indicated previously, the services of the representatives of a number of the national and local organizations interested in some aspect of health protection. It would have been impracticable to engage and pay for those directing and participating in these contributed services, but the following statement gives a very conservative estimate of the financial burden which has been borne by these organizations in the interest of the Survey of Cleveland: National Committee on Mental Hygiene _ $3,813.52 Committee for Study of Public Health Nursing Education 2,210.00 American Social Hygiene Association 1,500.00 The Welfare Federation, Cleveland 1,400.00 The Consumers' League of Ohio 800.00 American Red Cross Bureau of Public Health Nursing 250.00 American Society for Control of Cancer 100.00 National Society for the Prevention of Blindness 100.00 Association for Prevention and Relief of Heart Disease. 100.00 $10,273.52 Owing to the fact that the work of the Survey has extended over a con- siderable period of time, and since continuous progress in the development of services for the sick and facilities for disease prevention has occurred in Cleveland during the period of our study, it will be found that the present Letters of Transmittal 13 report, consisting as it does of contributions made by investigators at dif- ferent periods of time between November, 1919, and July, 1920, does not in all respects describe the conditions as they are on the date' of publication. Furthermore, it will be a matter of satisfaction to you, as well as a matter of interest to the reader, to know that many of the recommendations which are proposed in the various chapters of our report have already been adopted. It has been a privilege to be associated with the investigators who have shared the work and to have played the part of coordinator in the under- taking. Respectfully submitted by Haven Emerson, M. D., Director. Cleveland, Ohio, Hospital and Health Survey, September 22, 1920. Table of Contents PART I. Introduction — General Environment, Sanitation I. Introduction Page General Remarks on Report _ 25 Summary of Parts of Report 28 Summary of Recommendations of Report 35 II. Environment and Sanitation Population and Area.- 39 Topography and Climate „ 46 Housing 48 Water Supply 57 Sewage Disposal , 60 Street Cleaning and the Collection and Disposal of Garbage and Refuse.... 67 Flies and Mosquitoes - 83 Smoke and Its Prevention ___ _ 85 PART II. Health Services I. Introduction ;. .. 103 II. Public Health Services Division of Health^ — Administration 110 Bureaus 1 .. 122 New Activities Proposed..... 1 73 III. Private Health Agencies Anti-Tuberculosis League 193 Visiting Nurse Association 193 Day Nursery and Free Kindergarten Association 193 Hospital Council 193 Society for the Blind and a Program for the Prevention of Blindness 193 Associated Charities 196 Association for the Crippled and Disabled and the Program for the Care of Cripples _ 197 Proposed Agencies and Programs for — Prevention and Relief of Heart Disease 213 Prevention and Cure of Cancer _ 221 IV. Summary of Recommendations... 226 PART III. A Program for Child Health Work I. Present Organization _ „ 267 II. The Problem 269 III. Proposed Organization 270 16 Hospital and Health Survey Page IV. Functional Activities 273 V. Conclusions + 319 PART IV. Tuberculosis. I. The Story in Brief... 331 II. Objects and Methods 336 III. Statistical Record of Tuberculosis in Cleveland 338 IV. General Provisions for Attack and Defense against Tuberculosis 346 V. Special Provisions for Fighting Tuberculosis 355 VI. A Summary of Activities and Equipment.... 364 VII. Recommendations >. 370 PART V. Venereal Disease. I. General Statement 395 II. Medical Phases.. 398 III. Legal Aspects... 419 IV. Protective Social Measures. 429 V. Sex Education : 431 PART VI. Mental Diseases and Mental Deficiency. I. Introduction 443 II. City Facilities for Diagnosis and Treatment 446 III. State Facilities for Diagnosis and Treatment 467 IV. Courts and Correctional Agencies 476 V. Mentally Atypical Children 488 VI. Welfare Organizations t 497 VII. Prevention — -Mental Hygiene 501 VIII. Summary of Recommendations.. 503 PART VII. Health and Industry. I. Industrial Medical Service Introduction 525 The Industries of Cleveland 525 Medical Service in Industry..... 526 Medical Service in Non-Industrial Establishments 535 Medical Service Beyond the Plant 536 Industrial Medical Records 53 7 Absenteeism Due to Sickness 541 Physical Examinations : - 542 Special Services 544 The Small Establishment 550 Industrial Hospitals - 552 Table of Contents 1? Page The Training of Industrial Physicians and Nurses 552 Public Health Authorities and Industrial Hygiene - — 553 Recommendations - 554 II. Women and Industry Introduction _ — - 557 Conditions in Various Occupations Employing Women 558 General Discussion , . - - - 571 Recommendations — - — -.— 575 III. Children and Industry Introductory - - 579 Legal Provisions for Children 15 — 18 Going to Work - 581 Statistics for Children in Industry in Cleveland ._ 583 Where Children Work - — - 588 Health of Children at Work ... - - - 603 Education's Responsibility. : - - — 613 Junior Vocation Departments , -- - 615 Suggested Plan of Organization for a Vocational Guidance Bureau 617 Summary of Recommendations — - -- 619 PART VIII. Education and Practice in Medicine, Dentistry, Pharmacy. I. Medical Education and Practice in Cleveland Medical College of Western Reserve University 651 Classification of Cleveland Physicians by Specialties 663 Hospital Staff Service..... '- - : 664 Professional Organizations - — 664 Discussion of Autopsy Service. — ,. - - 667 Recommendations — 669 II. Quacks and Patent Medicines, in relation to the Foreign-Born of Cleveland The Picture The Immigrant... - — - 672 The Quack -■ 672 How the Quack Reaches the Immigrant..... —■- 674 The Objectives Means of Investigation and Prevention — — - 676 Recommendations - - 682 III. Dentistry in Cleveland Private Practice of Dentistry 683 Public Services 684 College of Dentistry 688 The Dental Hygienist 689 Recommendations 690 IV. Pharmacy in Cleveland Number and Education of Pharmacists 691 Laws Dealing with Pharmacy 691 Cooperation of Pharmacists with the Division of Health 694 School of Pharmacy of Western Reserve University 694 18 Hospital and Health Survey Page Proposed Manufacturing and Professional Service to Hospitals .*..._ 696 Recommendations 697 PART IX. Nursing. I. Nurses' Training in Cleveland Hospital Training Schools — 709 Post-graduate Courses 745 II. Public Health Nursing Central Nursing Committee _ 756 Division of Health _ 758 Visiting Nurse Association.... 1 773 Board of Education _ _ 782 University District '. 789 City- wide Prenatal and Maternity Service _ 797 Industrial Nursing , 803 III. Some Notes on Private Duty Nursing Unnecessary Employment of Full-time Graduate Nurses 808 Trained Attendants 809 PART X. Hospitals and Dispensaries. I. The Care of the Sick Resources for Care.. 819 Some Definitions ._.. 822 II. Hospitals Hospital Provision and Community Needs. 828 Organization for Service 838 The Human Problem of the Hospital Patient 849 The Medical Profession and the Hospitals 858 Finances and Administration... 868 Some Practical Points of Administration.. 877 III. Dispensaries Dispensaries in Cleveland - 890 The Public Health Dispensaries 901 Policies and Needs - 912 The Down-Town Dispensary.. 922 IV. Special Problems The Convalescent and the Hospital. — 926 A Community Program for Convalescent Care - 938 Chronic Illness and Its Care 944 Social Service in Hospitals and Dispensaries 952 The Ambulance Service of Cleveland 961 V. Hospital and Dispensary Planning Community Planning 966 Individual Hospital Planning... 973 Organization to Carry Out Plans — 979 Table of Contents 19 PART XI. Method, Bibliography, Index. I. Method of Survey Page Introduction : 1003 Preliminary Steps 1004 Scope... 1005 Aims and Methods... — 1 009 Conclusions 1016 II. Bibliography of Surveys 1038 III. Index 1061 TABLES Part II. Pages I. Number of births by sex, race and character of professional attendance, by health district 231 II. Analysis of all deaths by race, under one year, and for the diseases upon which the "sanitary index" is calculated 232 III. Communicable disease morbidity reports 233 IV. Endemic indices for Cleveland 234 V. Group of diseases included in the list upon which the sani- tary index is based 236 VI. Report of the work of the district physicians, 1919-1920 237 VII. Official record of raw milk in Cleveland during the past six years 238 VIII. Official record of pasteurized milk in Cleveland for the past six years 239 IX. Synopsis of classified report of bacteriological examination of Cleveland market milk 240 X.-XXXVIII. Outline of a complete system of vital statistics for the health department of a city of the size of Cleveland 242—255 XXXIX.-XLII. Summary of the survey of sanitary conditions in child car- ing institutions and of medical examinations of institu- tional and boarded-out children 255—258 Part IV. I.-V. Tuberculosis deaths by age, years, sex, occupation and forms 378-379 VI.-VII. Attendance at Health Centers 379 VIII.-XIII. Tabulation of Milk Consumption Study 380-382 Part VII. I. Classification of Industrial Organizations 622 II.-V. Analysis of Medical Service in Industry 622—623 20 Hospital and Health Survey Page VI. -VIII. Analysis of Accident Frequency and Severity Rates 624—625 IX. -X. Classification of Industrial Establishments Employing Women 626-627 XI. -XV. Classification of Conditions under Which Women Are Employed 628-630 XVI.-XIX. Employment of Children, by Age and Sex 631-632 XX.-XXII. Employment of Children, by Occupation 633-635 XXIII. Analysis of School and Physical Records of Newsboys 636 XXIV-XXVI. Tabulation of Examinations of Children Seeking Employment 637-639 Part X. I. Listing of Hospitals and Dispensaries 984 II. Percentage of Occupancy of Hospitals 986 III. -IV. Relationship of Hospital Locations and Admissions and Health Districts 987-988 V. Source of Request for Admission of Hospital Patients 988 VI. Expanses and Earnings of Hospitals 990 VII. Summary of Study of Convalescent Cases 991 VIII. Length of Stay of Hospital Patients 991 IX. Suggested Summary Report Form for Hospitals and Dispensaries 992 ILLUSTRATIONS Part I. Typical housing conditions in Cleveland's congested districts 50—51—52 Illustrations of failure of Street Cleaning and Garbage Disposal systems 69—70 Part IV. Where Tuberculosis comes from 358 Where Tuberculosis goes to 359 Part VI. Illustrations contrasting treatment of mental cases at the Cleveland City Hospital with their treatment elsewhere 448—457—459 Part VII. "Declaration of Dependence." Children and Industry 578 Part VIII. Typical patent medicine advertisements 680 Table of Contents . 21 DIAGRAMS AND MAPS Part I. Page Map showing population distribution and health districts — Facing page 38 Charts of Cleveland's comparative and expected growth of population 40 Map showing water supply, sewerage and sewage disposal developments 63 Part II. Diagram of Cleveland city government organization. Fig. I. 167 Map showing census tracts (sanitary areas). Fig. II. — Facing Page 114 Map showing location of facilities for prevention and treatment. Fig. III. 117 Map showing birth rate, stillbirth rate, infant death rates, estimated num- ber of mothers under prenatal care and number of children under care of prophylactic stations, by health districts. Fig. IV. 118 Graph showing the death rate of each of 25 cities in the United States. Fig. V. 120 Graph showing "Sanitary Index" for the years 1885-1920. Fig. VI. 128 Graph showing deaths in Cleveland from all causes for diseases on which the Sanitary Index rate is calculated. Fig. VII. 129 Graph showing death rates for eight important communicable diseases in Cleveland and in all cities included in the registration area, for the years 1913-17, and the death rates during 1917 for these same diseases in Cleve- land, the cities and the states of the registration area. Fig. VIII. 130 Graph illustrating the morbidity incidence of tuberculosis, four common acute communicable diseases of childhood and of venereal diseases, by health districts. Fig. IX. 131 Figure illustrating same data as Fig. IX. by health district map. Fig. X. 132 Graph illustrating the relative position of the health districts by registered births and deaths. Fig. XI. 133 Graph showing an analysis of death rates from all causes and from various communicable diseases, by health districts. Fig. XII. 134 Illustrating same data as Fig. XII. by health district map. Fig. XIII. 135 Graph representing suggested organization of services for boarded-out chil- dren. Fig. XIV. 179 Part III. Diagram showing organization of Proposed Central Child Hygiene Council 271 Graph showing incidence of defects in children by age and sex 304 Part IV. Map showing distribution of tuberculosis facilities 330 Graph showing death rates from pulmonary tuberculosis and non-tuberculous pulmonary diseases from 1852 to 1917 341 Part V. Map showing attendance at venereal disease clinics, by health districts 405 22 . Hospital, and Health Survey Part VII. Page Two maps showing location of industrial establishments 548—549 Part X. Map showing location of hospitals, dispensaries and health centers. Fig. I. 823 Chart showing provision and need for hospital beds. Fig. II. 836 Map showing residence of 2,500 dispensary patients by health districts. Fig. III. 891 Chart showing inter-relation between hospital and dispensary. Fig. IV. 898 Hospital and Health Survey of Cleveland, Ohio A Report Presented to the Committee on Survey of the Cleveland Hospital Council By Haven Emerson, M. D., Director, and the following collaborators: Gertrude E. Sturges, M. D., Assistant Director; Michael M. Davis, Jr., Ph. D., Director of the Hospital and Dispensary Survey; Josephine Goldmark, A. M., Director of the Nursing Survey; Wade Wright, M. D., Director of the Industrial Hygiene Survey; S. Josephine Baker, M. D., D. P. H., Director of the Infant and Maternity Survey; T. W. Salmon, M. D., Director of the Mental Hygiene Survey; W. F. Snow, M. D., Director of the Venereal Disease Survey; Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey. Introduction By Haven Emerson, M. D. "A few great points steadily reappear, alike in the poverty of the obscurest farm and in the miscellany of metropolitan life. * * * * . These few are alone to be regarded: the escape from all false ties; courage to be what we are; and love of what is simple and beautiful; independence, and cheerful relations, these are the essentials — these and the wish to serve — to add some- what to the well-being of men." THE habit of mind or of work which prevails in the United States is rather to move from the practical to the theoretical than in the reverse order. As is natural in a young nation free from the established pro- cedures and precedents of government and personal conduct which domi- nate the life of older countries, we see a need, we move to meet it, -we pres- ently suspect our method or results might be improved, we collect records, study, evolve a theory and perhaps then begin to apply the principles evolved to new undertakings in the same direction. We have not evolved a theory and principles of health development, of health protection, of disease preven- tion, of death postponement. It has been one of the illuminating educa- tional features of our contact with the keenly analytical, the intellectually honest minds of our French colleagues during the war that we have met a system of education and practice which begins with theory and principle, and gradually through individual and ultimately through government action arrives at application of theory to practical needs. This report is a contribution to the study of current facts, accomplish- ments, undertakings in the field of medico-social service. Theory is not within the plan of this presentation, but it is hoped that by the study of facts, by the application of recommendations, theory may be tested and the philosophy of social organization for the attainment of health and its main- tenance may be advanced. Those of us who have shared in this study are perforce enthusiasts, if you will, fanatics, crusaders in what we believe is to prove the greatest con- tribution of this generation to the success of a representative and demo- cratic social order : namely, civil and social organization for health. Neither forms of government nor systems of society will long endure unless the health, mental and physical, of the people is accepted as a matter of official and individual concern, in importance second only to the administration of jus- tice, provision of education, liberty of speech and of religious observance. This is not the place to press the argument. Personal experience and government documents in abundance provide the data from which students will decide the amount and distribution of wastage from sickness and pre- mature death. No expression, in terms of money equivalent of human labor, of this burden upon life, this deficit in happiness, adequately repre- sents the true total, but even to the so-called practical man, that much abused man-in-the-street who is supposed to be merely a mechanical adding machine without sympathies, emotions or imagination, the figures are im- pressive. Expressed for the population of Cleveland and its suburbs, roughly a 26 Hospital and Health Survey population of 1,000,000 within Cuyahoga County in 1920, and using the death and sick rates experience of 70 per cent of the total population of continental United States in 1916, and the sickness census in various cities, such as Pittsburgh, Boston and Rochester in recent years as appli- cable to the experience in Cleveland in 1920, we must picture about two per cent of all the people all the time too sick to work or be up and about, from causes of which one-half are certainly preventable. In 1919 the cost of illness and death from communicable diseases alone in Cleveland, based on the very conservative estimates of value of life and cost of sickness, burial, etc., used in a study in Illinois* must have been not less than $25,000,000. To this must be added, among other items, the cost of death and disease due to preventable but non-communicable forms of disease and the cost of $200 a year for each insane person and $160 a year for each feeble-minded person cared for in institutions. Further, we must recognize that not less than 35 per cent, and in some places as much as 75 per cent, of dependency seeking relief from public or private sources, is due to sickness. To say that dependency is in large meas- ure due to sickness is merely the corollary of the statement that the average of independence is everywhere lowered by sickness, and upon independence our whole social, family and labor structure is based. Three services we shall always need if we intend to provide the best that science affords to heal the sick and to guard the well against disease. Each service although indispensable by and for itself is, however, necessarily de- pendent upon the other two for its complete usefulness and application, and no one can be omitted without sacrifice of much of the value of the others. Diagnosis and Treatment of the sick comes first to mind as it was first to be provided, but first by a narrow margin of time before the Teaching of Medicine. These two led by many ages the third, the Prevention of Disease. We have won our way from an attitude of passive submission or accept- ance of disease and disability as inflictions of fate, of some evil genius, or by the gods or our own Divinity, through the self-respecting and upright posi- tion of self-defense against disease, using the weapons of science, until we are now moving aggressively forward attacking disease and determined to overcome it by all the resources of society as well as of science, by instilling into people the hope, the promise, the certainty of health, as well as by as- sembling, coordinating, directing with our knowledge of preventive medicine and organized government a continuous warfare upon all the physical, biological, economic and spiritual handicaps against which man and child cannot successfully make progress alone. First, and first by a long interval among the weapons of attack, comes education, not alone the training of the intelligence, the distribution of facts, but the development of the feelings, the emotions, the instinctive reactions which guide us chiefly in the emergencies and great decisions of life. The channels of this education are not alone the schools and colleges but the indi- vidual field workers, the physicians, the nurses, the public health officers, the social workers, the school teachers who make contact with the homes. Health, its attainment, its defense, its prolongation, cannot be taught all •Hemenway, American Journal of Public Health Vol. 10, Number 2, February, 1920. Introduction 27 the time to all the people, and to but few and for but short periods, through the public press or the distribution of so-called "literature" and propaganda by pictures, posters, etc. Rarely there comes the great teacher, one who compels attention by his knowledge or his art, a Franklin, a Pasteur, an Osier, but, in the main, health teaching, except to the few training for certain professions, will be given effectively only to those who are for one reason or another teachable. Children are teachable because youth is acquisitive and interested in itself and all that concerns its body and its playmates. Mothers are teachable for the sake of their babies. Perhaps one may include both parents some- times in this class, while their children are still dependent. The sick and suffering are generally teachable from self-interest, from hope, from humility. In the presence of epidemic disease of the kinds such as influenza and infantile paralysis, against which we have no reliable measures of defense, everyone can be taught the elements of personal hygiene and good health habits because of the fear of death. The first three groups include all the community at some periods of their lives and we owe them guarantee that the physicians, nurses, teachers and others whom they are beholden to at these periods for care and instruc- tion, themselves know what must be taught and furthermore practise what they preach. In this guarantee we fail at present. What can be done to protect those who are uninstructed must be done for people rather than by them, and here we come upon the functions of the public and private agencies for disease prevention. In this field we are emerging from the era when the health officer was a lawyer, a policeman, a scavenger, a mere clerk, to the concep- tion of the health officer as a leader in social organization, a student of dis- ease as it occurs in groups, an administrator of services which make life more secure and happier in every household, in reality the family physician of the community, its trusted advisor and protector. For those whom our education and our devices for prevention have been of no avail, the sick and injured of medical practice, the wastage resulting from our ineffectiveness in protection, we provide the physician, the visiting nurse, the dispensary, the hospital, the convalescent care. That there should be so much more needed to pay the cost of repair work than is thought suf- ficient to spend for prevention is a commentary upon our intelligence, a sharp reminder of our wastefulness, of our undeveloped business acumen. In the chapters which follow there will be given a description of the services provided in Cleveland for the prevention of disease and for the care of the sick, including description of the facilities for training those who contribute to this care. Where there are defects they will be pointed out, with, where possible, specific recommendations for their remedy. So a diagnosis and treatment for the city will be developed in a way similar to the method used in the physician's office or hospital. We were invited to Cleveland to learn and to state the facts and if more emphasis appears to be put upon shortcomings than upon excellencies it is not because the latter were not observed and admired, but that extensive 28 Hospital and Health Survey comment upon the bright eyes and rosy cheeks of the patient seems mal- apropos when there is a dressing to do for a broken arm. For convenience in distribution of the report to students and workers in the various special fields of hospital and health work the text is divided into eleven parts. Under General Environment and Sanitation, Part I, will be found de- scription of those elementary factors upon which are based an estimate of the standards of living attained by a community. The reader will wish to know the area and population, something of the geology and the nationali- ties, and what the history of growth predicts for future needs. As life and the success or failure we make of it is largely a matter of our ability to adapt ourselves to natural and artificial variations in environment, we are inter- ested in Nature's allotment of weather to this man-picked site for a great human aggregation. What man does to his fellow-men is certain to be more of a menace than what the elements dispense, and his home, where his chil- dren are reared, where he and his wife and the little ones spend the major part of their time, is found here as it is elsewhere in our cities commonly far below the limit either of our means or of our knowledge or of our legal requirements for healthy liviDg. The blessing of pure water is within his reach, and in the main there is good, provision for disposal of his wastes, for man, like bacteria, cannot live long in the midst of his own offal and dirt. With his air the Clevelander is not so fastidious and, although it is sup- posed to be the only remaining necessity of life still free for the humblest citizen, yet we find a filthiness of air which robs the child of its breath, the sun of its strength, the sky of its precious color, and simply because of habit and unneighborliness, the habit of ignoring coal smoke as a public nuisance and indifference to the inconvenience caused to the other fellow by your own belching chimney. In Part II. we deal with the dual machinery of public and private organ- ization for health protection. After outlining the basis in law and in local government administration for the powers and services of various depart- ments which contribute to health in Cleveland, the Division of Health and its bureaus are described and analyzed. The parsimony of public appro- priating bodies in matters of insurance against disease and death through investment in the services of doctors and nurses is in striking contrast with the liberal use of tax money to protect property against violence and fire. There are defects in personnel, organization and inadequacy of resources, but that there is a record of important and encouraging accomplishment cannot be doubted. Without a service for public education for legitimate civic advertising of needs and opportunities in health protection any health service is sadly crip- pled. This is the case in Cleveland. Official protection of industrial workers against health hazards is needed and would be welcomed, but it is not offered in the present health service. The childien of, the parochial schools, the children of pre-school age, the expectant mother, all lack the life saving service which is offered at public expense in some other cities. Introduction 29 As the family physician of the city the Commissioner of Health should be provided with physicians to maintain supervision over the health of those children whose lives are spent in the unnatural environment of institutions. This he cannot do at present. Among the existing bureaus there is none needing such a radical overhaul- ing as the Bureau of Vital Statistics. An adequate record of human liabili- ties and assets is indispensable to intelligent public health work. A concep- tion is presented of the possibilities, the necessities, the advantages of a true demographic office and reports for the city, a model for a municipality, an example which if followed would elevate the city, the state and the nation in the estimation of thoughtful people here and abroad. One of the archaisms of our civil government is disclosed in the per- sistence of the coroner's system. Until Cleveland follows the example of Boston and New York in establishing this function under non-political, competent pathologists there will be inefficiency, graft and the cloaking of crime under the forms and appearance of law. Everywhere we find private energy and sympathy organized to supple- ment public service. This is particularly the case in preventive and relief work for the sick. The crippled, the blind, the lame in heart and mind always will be sought out and assisted to such happiness and occupation as they can attain. Sooner or later the wish to prevent rises into effective effort and real health protection develops. There are in Cleveland as elsewhere special agencies for the care of the many handicapped, and the special merit of Cleveland is in the successful coordination of support and direction of many of these medical and social services maintained by private resources. These are described in some detail in the chapter on Private Health Services and the total of undertakings is certainly impressive, in spite of the gaps, which it is hoped will soon be filled. Although the subject matter of Part III. deals with many important functions and accomplishments of the Division of Health, and as well in- cludes description and discussion of auxiliary private agencies, the leading role of the child's health as the objective of the great majority of private and public health services made it seem wise to set apart this program in its entirety from the general field covered in Part II. Probably in no subject of public health work will the results of a logical and thorough integration of the public and private agencies bring such economies in cost and per- sonnel and such large returns. A good beginning has been made in pre- natal care of expectant mothers; a start upon service for the children be- tween two and six years, the pre-school child, is assured; important im- provements in public protection of the child in industry are under way. In the public schools, and more particularly in the parochial schools, there is need of thorough medical examination and home follow-up by nurses. Except for the defects of development, nutrition and exposures to infec- tion which result from the child's handicaps of home environment, the most serious defect in the provision made by the public for children during the years of compulsory school attendance is the quality of air permitted in the school rooms. In the majority of school rooms and in all those in the newer school buildings the systems of so-called mechanical ventilation are in con- trol of the child's vitality. Laws, more in the interest of building contrac- 30 Hospital and Health Survey tors and engineers than of children's health, impose a plan of so-called venti- lation which is really a kind of slow strangulation process. The open window has been shut by law. Children's health requires open window ventilation all the year round. The laws must be changed and school management be so arranged that the air in class rooms may be freely flowing, cool and fresh, with as nearly as practicable the relative humidity of outdoor air. Tuberculosis in Cleveland, which is dealt with in Part IV., is, first of all, a study of incidence and distribution, necessarily incomplete because of the inadequacy of the records of population, deaths and sickness, but sufficient to show the unfinished work, the need of renewed attack and the ways which have proved helpful elsewhere. In this subject, as in the following one of Venereal Diseases, we are face to face with a problem of social contacts. No mere medical knowledge, no public or private health organizations alone will accomplish the reduction or control of the spread of tuberculosis. As man's own habits, his customs, his environment artificially created, are the multitudinous contributory factors both to infection and to active expression of the disease, so it must be through a spread of knowledge, through intelli- gent, clean living, through the abatement of injustices which tax the nourish- ment, the rest, the peace of mind of those of modest means that we must look for diminution of tuberculosis, as well as through the greater skill of physicians in the early detection and in the arrest of active tuberculous disease. While tuberculosis remains the cause of something over 12 per cent of all deaths and responsible for the most costly of all sicknesses, and while we do not know the fact of sickness before death in at least 30 per cent of all persons dying of tuberculosis, there needs no elaborate exposition of our social and official shortcomings. The report upon the exact conditions in Cleveland will certainly lead to a stronger determination and a more generous support for medical and social agencies engaged on this problem. The so-called American Plan for the control of venereal disease is used in Part V. to measure Cleveland's accomplishment. From being a subject of technical discussion among specialists at medical society meetings the problem of control of syphilis and gonorrhea has aroused open discussion on the floor of Congress, has enlisted the joint action of three of the most power- ful departments of the Federal Government, is accorded earnest considera- tion and intelligent discussion in state legislatures and has been raised from shame and silence into the range of decent educational publicity. It is not for physicians, nurses, hospital superintendents and health officers that this subject is here dealt with. The origins of syphilis and gonorrhea are so intricately beset with social factors that although the scientific facts of etiology and diagnosis, the course of the diseases and their treatment have given the courage of knowledge in our campaigns, still by education in character, self-restraint, control of the brute in us by our better natures and by sparing our children the unfavorable contributory factors in employ- ment, conduct, recreation and opportunity which have generally prevailed until now, we can do as much through social organization as through health services. As the text of the chapters will show there is ample opportunity for advance along lines to suit the inclinations of the lay worker, as well as the practitioner or student in laboratory research. Introduction 31 Part VI. gives a picture which will develop humility in thinking people. With our vaunted humanity and practical efficiency we prove ourselves inhuman in our collection and treatment of the most pitiful of human wreck- age and inefficient in our indifference to the debt of feeble-mindedness and insanity we are permitting to be piled up for the next generation, by failure to provide for segregation and institutional care for the thousands now at large in the homes of the city. No more scathing comment upon civil administration could be made than the description of the kind of care provided for the mentally afflicted at City Hospital. Could this have occurred if there had been an active, alert, interested group of physicians and others organized to help the problems of mental hygiene, the interests of the mentally lame, the opportunities for prevention and education in Cleveland? Probably not, and certainly one of the results of the present brilliant statement of the situation should be the establishment of a local mental hygiene committee affiliated with the national body of this name. Part VII., the volume on the Medical Services in Industry, Women and Industry, and Children and Industry, represents the first effort in this country or, so far as we are aware, elsewhere, to see the broad landscape of this new professional country. Where are the workers? How distributed in large and small plants? What the quantity and quality of the profes- sional care provided for them? What is to be expected from reasonable care of the workers in terms of production and of producers? Such are questions that await answers. To quote from the first chapter of the report, "Cleve- land is an industrial community ; the greatest common interest of her people is her industries, and those of her people who labor therein are the life of the city. The future of Cleveland depends upon the well-being and the happiness of her industrial workers and to secure and safeguard their health is the vital task of industrial medical service." Such services are understood by the few leaders and the methods and results are matters of record for those who wish to learn. The city awaits and needs the advantages of these services, the results of which can be guaranteed. That there should be more than twenty-two thousand women occupied in industry may seem a small quota to take from the home makers of a city of 800,000 people, but as a unit exposed to varied and serious risks, as a great army of possible or prospective or present mothers, the interest of the state in their safety and continued health is large. That there are special physical disabilities acquired by women in apparently safe and reasonable work is well known. That fatigue plays a more serious part in the damage to women's health than is generally found among men, or at least expresses itself in a variety of troublesome nervous affections, is seen in some industries. That women should be excluded from night work is perhaps too obvious to argue. Now with .the facts before us, it is safe to say that with the increas- ing power of women in organization and self-determination it will not be long before remedies are found for the worst evils. The women of Ohio certainly need the rights of suffrage. How loosely we count our treasures, how careless we are of the strength of our men and women in the making, is told in the story of children in in- 32 Hospital and Health Survey dustry. Not a lurid tale of child slavery but an inventory of the pros and cons of this undesirable element in national wealth. The strengthening of laws will accomplish something, their better enforcement still more, but the final answer to the question of children in industry will be given only when parents see that in education and vocational training there is a greater return in maturity than the early earnings of children can provide. In Parts VIII. and IX. the profession of medicine and its associates, in service to the sick are dealt with, the training provided for them and the relations of their licensed practitioners to preventive and curative medicine. This involves a consideration of the University which mothers them all, her limitations, and wherein her children suffer from lack of educational pabu- lum. Much is asked of the University in the way of new undertakings in the educational field, all depending on the sinews of war — the state of the University treasury. Much is expected, however, by the injection of a more active leadership and initiative among trustees and teachers. The governing and teaching bodies need a generous dose of democracy and a sense of personal responsibility for a closer touch with the needs of the com- munity. The visions of a great installation will all in time come true, but even without fine structures, conditions can be provided which will attract and hold that quality of brains upon which alone great schools are built. In the practice of medicine certain characteristics are apparent which pertain more to the era of small town existence than to the service of physi- cians in a modern metropolis. Lack of use and consideration for the special- ties in medicine and surgery are striking to those familiar with practice farther east in the United States, and in European cities. Entertainment as well as cause for serious action will be found in the study of those harpies who fatten on the credulity and ignorance of our foreign tongue immigrants, the irresponsible and illegal practitioner, the advertising quacks. Dentistry and Pharmacy each present professional problems of impor- tance which cannot be ignored without loss of some measure of help to the public in the care of the sick. Their contributions to preventive medicine also are considerable and increasing in value. So extensive has the field of nursing become, so dependent are we in all directions of medical and public health practice upon this army of the trained sisterhood, that a study of their profession by a rarely well equipped group of their own graduates and leaders is particularly appropriate and most fortunate for this Survey. Nothing comparable to this has been done for the nursing profession before, and although studies of national extent are under way, Cleveland will now be in a particularly favorable condition to make good its present lead in strategic features of nursing education and practice, while waiting for the report of the National Committee from which we borrowed the director and several of the workers for our own study. Nurses training in the past and often still presenting a rather sorry pic- ture of mingled exploitation of willing labor and amateurish teaching, is worthily described. Practical means are proposed to meet the obligations of hospitals to both patients and nurse pupils. Introduction 33 Public Health Nursing includes thorough discussion of the services ren- dered in the many public and private organizations engaged in educational and bedside work through field nurses. Private nursing, too, though not a matter of chief importance from the point of view of the Survey has had an illuminating brief study put upon it. It was in the minds of the Trustees of the Cleveland Hospital Council that the conception of this Survey originated, and it was their declaration that the hospital is really a public service institution, responsible alike for prevention and for care of disease, that became the keynote of our program. Since pre- vention is the spirit of modern medicine the machinery for its accomplish- ment has had precedence in the order of chapters over the description of those services which have always been primarily devoted to cure, relief or post] o lenient of death amongst the seriously ill . In Part X. will be found not only a recital of the physical and profes- sional resources of the community in the shape of hospitals, dispensaries and their accessory services beyond their walls, but the spirit, the philosophy, the ideals which imbue the present-day executives of these centers of skill, tenderness and teaching. From cellar to garret the investigators have searched for the good and the poor in hospital management. From the admitting desk, or rather from the doorstep, of the hospital where the dis- appointed applicant is declined admission, to the report of complete conva- lescence by the patient at the dispensary or to the social service worker weeks and months later, the path of the patient has been followed and the quality of attention accorded him has been scrutinized. While estimates of the hospital needs of a community will vary with the education of people in the possibilities and advantages of hospital care for their own particular variety or for all varieties of ills, there is yet a basis of experience, a pragmatic test of adequacy to be offered. By this test Cleve- land's shortage of beds is manifest. The remedy is, in the first place, ade- quate buildings and personnel and disinterested administration of its great City Hospital, now a travesty upon hospital service. Private endowments and initiative will, as far as one can see into the future, always be required and generously supplied to meet the call for hos- pital beds, and as soon as the present apparent extravagance in cost of con- struction subsides there will certainly be undertaken great new hospital buildings and expansions of the present admirable ones, all justly held in affectionate regard by a grateful public. The shortage of dispensary service in Cleveland, as compared with service in other leading cities, constitutes another limitation of medical care for a considerable proportion of the popu- lation and for the facilities for consultation and diagnosis available to the medical profession. If one need beyond that of more beds for acute general hospital patients is to be mentioned, it must be the lack of convalescent facilities. This is a typical shortcoming of American cities the meeting of which will go far to abate many of the present troubles of hospital administrators and the pro- fessional staffs, and at the same time complete the now unfinished work so well begun in the hospitals themselves. 34 Hospital and Health Purvey There is no part of the present report which is so certain to appeal to a broad public as this section on Hospitals and Dispensaries. The public that is served, the public that contributes for the support of hospitals, the responsible trustees and their representatives, the hospital superintendents, the professions (medical, nursing, dental, pharmacy) in the field of education and service, the health officers and the private health agencies, all have an interest in the results of this study and the recommendations presented. Although individual reports to the trustees of the several hospitals have already been presented to them, the general hospital situation as described will add to the understanding of each in the solution of their separate and particular problems. What follows is for the convenience of students of sociology, a sketch of methods used, a list of analyses of kindred subjects made by other survey- ors, and the inevitable index of subjects to save the reader's time. Part XI. contains what may be likened to the description of technic in a physician's approach to his patient, the items to be included in his history and physical examination, etc. Although lists of publications dealing with surveys have been issued by libraries it has seemed wise to include here such as have been found useful to our present purpose or have in one way or another been levied upon for information or comparison. Introduction 35 Summary of Recommendations THE Cleveland Hospital Council specifically requested that detailed and definite recommendations for action be prepared by those responsible for the Survey. In the course of the following chapters the discovery of facts and the discussion of policies have been directed towards as definite a solution for each difficulty or inadequacy as was found practicable. At the end of each chapter there has been placed a summary of recommendations,, subject by subject. The full extent of the program which is conceived and the bearing that such a program of medical and social endeavor has upon the fabric of government and upon organized private effort can best be seen by an assembly of the various recommendations in certain main groups. An- alysis of those presented in the text shows that they fall logically under four headings. The first group deals with laws, both state and local (that is, as passed by the state legislature and affecting Cleveland, either directly or through charter provisions, and ordinances enacted by the legislative body of the city — the City Council). The variety of changes thought desirable to suggest is such that it is believed nothing short of an organized effort in the interest of this supplementary program of social legislation will suffice to obtain con- sideration by the state and local law makers. It is, therefore, recommended that the Welfare Federation request the volunteer services of a committee of lawyers and public officers of the State Legislature and the City Council to consider and act upon the recommendations of the Survey dealing with amendments or additions to the laws. A study of the recommendations under the various chapters shows that suggestions are made which affect the State Child Labor Law, the State School Code and the local city ordinance dealing with street trades, in the interest of the health of children; the Civil Code and Medical Practice Act in dealing with irresponsible and unlicensed medical and dental prac- titioners, the annual registry of dentists, the licensing of dental hygienists and nurse attendants and of various state statutes dealing with the sale of drugs elsewhere than in drug stores and the privilege of purchasing tax-free alcohol by retail druggists; the Injunction and Abatement Law, the laws dealing with prostitutes in the interest of control of venereal diseases; the laws covering the diagnosis and treatment of mentally defective persons who come in contact with the courts and the laws dealing with the licensing and supervision of hotels, both of which affect in some measure the social program for venereal disease control; a law providing for supervision and licensing of hospitals under the State Department of Health; the modification of the city charter to permit of the appointment of a Board of Trustees to be responsible for the administration of the City Hospital; the enactment of a revised Sanitary Code for the city of Cleveland. The second and very extensive group of recommendations deals with the manner of conduct of existing departments of state and city goverment and with the additional activities which it is thought suitable or necessary for them to undertake. Many of the recommendations presented have been discussed in detail with the administrative officers, particularly of the city 36 Hospital and Health Survey government, and in some instances with those of state departments within whose power it is to modify procedure or activities to meet the suggestions made. Many of the recommendations cannot, however, be carried out without generous increase of appropriations and some must wait for authority from elected executive officers by whom the administrators are appointed and from whom they have received their authority. It may be said in general that there is ample authority but insufficient appropriation and personnel to carry out the wishes which the voters and legislators evidently had in mind in framing the laws. The recommenda- tions, as they affect the state government, propose an adequate inspection service to protect the licensed practitioners of the various medical and associated professions; adequate inspection service for the institutions of the state hospitals, institutions for children and others; adequate inspection service to protect women and children in industry and to enforce the child labor law; and the transfer of the responsibility for supervision of food hand- lers in restaurants from the Department of the State Fire Marshal to the State Department of Health. General recommendations dealing with the city government include approval of the activities of the City Plan Commission; the investigation of sewage collection, treatment and disposal; investigation of the methods of collection and disposal of rubbish and garbage; a suggestion that the sum of $1,000,000 be provided annually for the next fifteen years for sewer construction. The departments of the city government which the recom- mendations particularly affect are the Department of Public Welfare, the Board of Education, the Department of Public Service and the Department of Public Safety, under all of which departments there are activities which deal more or less intimately with some or all phases of health protection and care of the sick. It is believed that the most effective way of obtaining im- provements of service or extensions of service as suggested in the recommenda- tions bearing upon the departments of city government will be by organizing a Public Health Association in the city of Cleveland, as proposed in the Introductory Chapter of Part II., and it is particularly suggested that one of the most important activities of such an association would be to maintain friendly and cooperative contact with the officers of the city government so that they may feel the support of the citizens, may get the benefit of criti- cal comment upon their activities and will be stimulated to their very best effort by the knowledge that their activities are being analyzed and tested by high standards. By those means of education properly included in the terms propaganda and publicity such an association would materially aid the officers of public departments to obtain adequate funds from the appro- priating body, the Board of Control, needed to carry on the activities recom- mended and desired by the tax-payers. The extent and detail of the recom- mendations are too great to lend themselves to any summary in this place and the reader is referred to the summaries of recommendations, especially at the ends of chapters dealing with public health services, child welfare, venereal diseases, tuberculosis and mental hygiene. The third group of recommendations deals with the private agencies. In almost all instances the recommendations as printed in the report have Introduction 37 been discussed with the officers or governing bodies of the private agencies which contribute to health protection and the care of the sick. In the case of all the hospitals, in addition to the recommendations here included, a special report, with detailed treatment of all the aspects of hospital work, has been prepared and submitted to the trustees of each of the hospitals in conference and by written statement. In the same way those matters bearing upon educational policies and practices in the various professional schools for medicine and the associated professions in Western Reserve University have been presented by word of mouth and in written report to the University authorities. The several coordinating agencies, such as the Welfare Federation, the Cleveland Hospital Council, the Academy of Medicine, the Association for the Crippled and Disabled, the Central Nursing Committee, the Kinder- garten and Day Nursery Association, have special responsibilities in further- ing the recommendations which deal with their component organizations or personnel. Similarly, the Chamber of Commerce, the Rotary Club and the Cleveland Advertising Club have very broad duties in support of all the movements which contribute to the well-being of the public. To these co- ordinating agencies, both those dealing with professional fields and those of a general business nature, are assigned certain obligations in the recom- mendations as presented. Upon industry a considerable burden is placed in suggestions that it meet the modern conception of responsibility to the employes by organizing for their protection against industrial hazards, and for their medical care, the professional and community resources which are mentioned in considerable detail in the section on industry in Cleveland. In addition to certain recom- mendations which deal with the activities of the Anti-Tuberculosis League the recommendation is made that a number of new and coordinated public health agencies, based on private initiative and support, should be established. Under the fourth heading would fall naturally the recommendations for new activities. Among these the most important is the Cleveland Public Health Association above referred to, planned as a parent and centralizing force in all private health activities for the city, with section activities to deal with child welfare and its subdivisions — prenatal, pre-school, school child and child labor features — venereal diseases, tuberculosis, cripples, obstetrical care, and so forth. Two of the fields of preventive medicine are not as yet occupied by any private effort in Cleveland; the first, the field of prevention and relief of heart disease, and the second the prevention and cure of cancer. Both the education and the technical professional sides of these two prob- lems need the same kind of organized support that has been provided to develop public services in the fields of tuberculosis, venereal disease and child hygiene. Two new institutional activities for which the sick of Cleveland are now really suffering are: a well organized central dispensary and provision for convalescent care outside of the general hospitals and under suitable con- ditions of space and occupation. 38 Hospital and Health Survey In offering such a series of comprehensive suggestions it is recognized that no community however willing, however wealthy, however well edu- cated in its social responsibilities could put into effect all the proposals, without a sacrifice of much that is good in the existing agencies and institu- tions, which must be used to build upon, and not be destroyed in the process of reconstruction. That all the recommendations can be made, even at the very considerable expense which this will involve, is the confident belief of the staff of the Survey, based upon its contact and experience with the citi- zens of Cleveland in all walks of life who have been a continuous, source of encouragement and inspiration to the investigators throughout the past year. When the program here presented has been carried out it will be found that, in terms of human lives ajid happiness, Cleveland has greatly increased vital assets although its financial liabilities may be found to have been increased beyond the point to which communities are now accustomed to spend the money of either the tax-payer or the private contributor. CITY OF CLEVELAND SHOWING STREET CAR TRAFFIC AND DISTRIBUTION OF POPULATION Courtesy Board of Rapid Transit Commissioner* WV "U ili l" \ " i v \'r>is Andes .alley Environment and Sanitation 51 1 4. Vacant Lot on Jerome Court The tearing down of buildings has been begun here but left unfinished. This lot and two others are the only play- ground space for many children living in this district. 5. A Backyard Playground in Hay- market District. 52 Hospital and Health Survea 6. Passageway up 'ihe Hill fkom ihe River Between Tenements. It is possible to icalk up from Canal Road I o Andes Alley on fin- streets through such pas- sages. No sunlight can reach the rooms which open of these passages. 7. Mencken and Hill Streets, Haymabket District This view shows how houses are built u p the East Ninth Street hill between Mencken and Hill Streets. JSoIhe of Ihe dwellings ore nothing more than burrows in the around. One can go into a tenement on Mencken Street and by means of rickety stairs wend his way across Jerome Court, Berg Street and out on Hill without seeing the light of day. Environment and Sanitation From observations made it would appear that Article III., Sections 53, 54, 55, 56- c 2 and 4, and 59, referring to buildings used as tenements before January 1, 1916, were violated on most of the premises inspected. Complaints and reports of the conditions as noted above had been made at intervals over a period of a year with no remedial action by the Bureau of Sanitation. In another section, where the excuse of impending demolition of premises couldnot be offered, quite similar conditions were found, as follows: Orange Avenue, opposite Depot Broken toilets, garbage accumulation which has been on premises since August, 1919. 2003 Orange Avenue Broken toilets, no lights in hall, alley with all winter accumulation of garbage. 2515 Orange Avenue Privy with leaky sewer outlet where bowl waste discharges into open pit, rotting boards on floor of shanty. Pile of manure in yard since August, 1919. 2515 Orange Avenue, Second Floor Toilet opening into the kitchen snd living room. No ventilation except through the kitchen. Dangerously loose flooiing. No lighting in halls. The worst conditions were found in lodging houses. With the exception of the lodging houses maintained by the Salvation Army, which complied with legal requirements and presented a picture of order and cleanliness, the lodging houses in Cleveland, including the one maintained by the New York Central Railroad in the basement of the Orange Avenue Freight depot, violated all reasonable provisions for sanitary living and disease prevention. Among the most important nuisances found were inadequate light and ventil- lation, old, soiled, stained bed covering, filthy floors, overcrowding, lack of space between bunks, etc. The licenses issued by the State Fire Marshal at Columbus, Ohio, are obtained without compliance with reasonable standards of cleanliness. There is no routine periodical inspection of lodging houses by state or city authorities. The cheapest lodging houses operated in the densest areas of New York's lower East Side shine by comparison with Cleveland's "flop-houses," which are a disgrace. In response to the frequent specific complaints by the district physicians of unsanitary conditions in lodging houses, the Bureau of Sanitation offers the excuse that there is no authority under the law to abate the nuisances described. The following extracts from notes of the investigator give a typical pic- ture of Cleveland's lodging houses, the clean and the filthy: 54 Hospital and Health Survey Salvation Army Citadel Has provision for 166 men, each in single partitioned rooms, the parti- tions going to within two feet of the ceiling, the space above being divided by an iron grill. Each room has 48 feet of floor space and 480 cubic feet of air s A ace. Toilet seats clogged and foul because of use oi toilet paper instead of towels for drying hands in the wash places. Premises otherwise clean, with clean linen on beds, clean towels supplied each night. License to operate obtained from the Department of State Fire Marshal, at Columbus, $15.00 a year. Original inspection of premises is made by representative from Columbus. No re-inspection. Occasionally visited by sanitary officer of Cleveland Health Division. Metropole Another Salvation Army lodging house where a license of $20.00 a year is paid, having accommodation for more than 200 men. Some single rooms as described above (Citadel), others large, well-ventilated, high-ceilinged dormitories, the beds being double-tier iron-spring bunks. Each separate room having a floor space of 40 square feet and air space of 400 cubic feet, the dormitory having 45 square feet of space per individual and 450 cubic feet air space per capita. Premises in clean condition. Shower baths in cellar. Laundry tubs for men to wash clothes and drying room for their use. Usual standards of simplicity and adequate cleanliness that one finds in Salvation Army quarters. Occasionally inspected by the Health Division, Charge of 50 cents per room and 35 cents per bed in dormintory. Palisades, 2146 Ontario Street One flight up to pool room, lunch counter, general lounging room and a few unlighted, unventilated cabins with semi-partitions, the ceiling of each being formed by wire gratings on which newspapers, rags and rubbish have accumulated almost to the exclusion of air. Two floors above this used for lodging purposes, the rooms being wholly inadequate as to light, floor space and cubic air space. The washrooms are filthy, the bedding old, the single sheet and so-called pillow case being grey and brown with dirt and discharges, the mattresses stained and torn, the coverlets filthy with stains of vermin and men. The per capita floor space allowed was 35 square feet and the air space 280 cubic feet. There was no light in the separate rooms and many of the rooms were pitch dark in the middle of a bright afternoon. Kerosene lamps were had by some of the men in the rooms and some of the rooms were furnished by the men with all kinds of personal belongings. Men were found who had lived in these rooms for months at a time at $2.00 a week. No proprietor or clerk on the premises and did not learn whether place was licensed. Neither as to cleanliness, air space, bedding or lighting does this building comply with what are recognized standards for even the cheapest lodging houses in New York City. 131 West Prospect Avenue Two-story building. First floor occupied by lunch counter, kitchen, lounge room and card room. Crowded with Negroes, Italians, Poles, etc. Eleven sleeping rooms on the second floor in rear; the proprietor occupying Environment and Sanitation 55 the front. These rooms are furnished with beds with filthy mattresses and bedding. Some beds double. Some rooms with two cots. Floor space 35 square feet per capita. The rooms with the exception of one had each an outside window. This place has no license because the inspector from Columbus said that with so small a number of rooms it was unnecessary to have a license. The serving of food in the restaurant on the ground floor was under the foulest imaginable conditions. Butter was picked out of the bowls with dirty hands. Food for serving was standing around on the floor in the kitchen and behind the lunch counter. No order, cleanliness or provision for decent washing of dishes or hands. The apparently total neglect of all provision for decent food preparation is one of the striking features observed on visiting a large number of eating houses and lunch counters feeding the transient or lodging-house public of the city. Lodging House maintained at the New York Central Freight Depot 132 men were in one cellar space entirely below ground excepting for a space of six inches which permits of partially open windows, looking out at street level on one side and on car tracks upon the other. Cubic space 240 feet per capita. Double-deck bunks, some for two people each; bunks two and three tiers deep, so close together that a sick man must be reached over the foot of the bed for examination and treatment. Only artificial light possible. Provision for toilets and wash basins excellent and. adequate. Another room for 72 men, 290 cubic feet per capita, with the same double- deck bunks in two and three rows, a place with insufficient ventilation and light to permit of the requirements of housing and unfit for human habitation according to the Building Code of almost any of the cities of the United States. Reported by district physician to be a constant source for medical care at the expense of the city through the winter, when the condition, due to lack of ventilation, was beyond belief. There was no medical care pro- vided by the company for this group of not less than 200 and frequently 250 to 300 men. One exhaust fan opening out at the level of the railroad tracks offers opportunity for change of air, but in winter the windows were kept shut constantly, and the intake of air must come in any event from the street level with all the dust of the large truck spaces of the freight yard. RECOMMENDA TIONS It is recommended that: The activities of the Chamber of Commerce in the interest of suitable housing in single or two-family buildings be continued, and that there be added to the present impor- tant financial undertaking to facilitate home building for wage earners, educational prop- aganda among householders as to proper and legal standards of construction, equipment and occupancy of living premises, so that those owning or renting homes may know their own duties and privileges or rights, as well as the degree and kind of protection they are entitled to at the hands of the city government for the protection of their health. 56 Hospital and Health Survey The undertaking of the City Plan Commission to establish a plan by zones for the construction and use of buildings be vigorously and continuously supported by all civic agencies such as the Chamber of Commerce, the Welfare Federation, the Consumers' League, etc., until the city government has enacted into law adequate restrictions and provisions for the future. The existing laws affecting the occupancy of premises, whether tenements, lodging houses or single-family houses now used for multiple family use, be enforced consistently, impartially and vigorously, to the end that the existing disgraceful conditions in and about living quarters of the poor in Cleveland be abated. The proposed Sanitary Code be enacted into law at the earliest possible date to give the Division of Health the necessary authority to take action in lodging houses and to enforce the abatement of nuisances. The authority to license, inspect, control and close lodging houses in Cleveland be vested in the office of the Commissioner of Health or the Director of Welfare of Cleveland,' if necessary, as the agent of the State Fire Marshal at Columbus. Environment and Sanitation . 57 Water Supply WITHOUT repeating the historical record of events, it may be briefly stated here that Cleveland has been through the same phases of in- difference, alarm, actual fear, confidence and now pride with regard to its municipal water supply which has been characteristic of many lake cities. Cleveland's water supply is now protected by the location of intake in the lake, by filtration and by chlorination, so that the citizens receive, except in a small part of the city for which filtered water cannot be obtained until construction already planned for is completed, a safe, potable water, attractive in appearance and suitable for all domestic and commercial uses. There is no reason to believe that communicable disease of any kind is now distributed by the public water supply. No one in Cleveland needs to buy bottled waters, except to satisfy some whim of taste or appearance. The source of supply is obviously adequate through the two intakes about four and one-half miles from the shore in Lake Erie. One crib is of the exposed, the other of the submerged type. Tunnels connect these cribs with the pumping stations at the foot of East 49th Street and on Divi- sion Avenue, at the foot of West 45th Street, 90 per cent of the pumpage being- done at present at the latter station, where the filtration plant is in operation, with a. daily capacity of about 150,000,000 gallons. Steel pipe lines carry the raw water to the chemical house whence it passes to the mixing chamber. Sulphate of iron (110-140 lbs. per million gallons) and lime (85-100 lbs. per million gallons) are supplied automatically in solution to the raw water in the steel pipe lines, according to the rate of flow and the condition of the water. Coagulation of removable matter is facilitated in the mixing chambers, and the settling out takes place between the mixing chambers and the filter build- ings. The filters are cleaned every 10 to 40 hours, according to the condition of the water, by reversing the flow through the beds. The filtered water is stored in a 20 million gallon reservoir, whence it is distributed by pumps through the city pipe system. The lake water carries but little suspended matter for most of the year and purification is needed chiefly to reduce the bacterial content of the water. There is a reservoir for surplus water. At the matter for most of the year and purification is needed chiefly to reduce bac- terial content of the water. There is a reservoir for surplus water. At the pumping station on the East Side the process is identical except that filtra- tion is not yet provided, though planned for. Most of the water distributed to the East Side of the city, as well as all that for the West Side, comes from the West Side station and has been filtered as well as chlorinated. Complaints of unpleasant taste in the water have been found justified at times, not because of excessive or irregular use of lime or chemicals applied at the pumping stations, but because of pollution of the water in the vicinity of the intake cribs by melting ice or obstructed flow from the Cuyahoga River, which occurs under certain conditions of wind and temperature, and always in the winter season. The water is tested daily both by the laboratory of the Water Division of the Department of Public Utilities and by the laboratory of the Division .58 Hospital and Health Survey of Health, sample; being taken regularly from points at the pumping station before and aftei filtration and chlorination, and at various police stations and other suitable points in the city. Tables giving the results of chemical and bacteriological tests made at the two laboratories show consistent find- ings in the effect of chlorine treatment (.271-. 454 parts per million) in dimin- ishing the occurrence of the presumptive test for fermentative organisms (according to standards proposed by the American Public Health Associa- tion), and also give evidence of the uniformity in tests made of water collected at widely distributed points on both sides of the city. One of the very considerable economies to the householder is the degree of softness of the public water supply provided by the method of treatment. The saving in soap alone to the people of Cleveland is worth many times the cost of chemical treatment of the water. When the plans already decided upon are completed there will be pumped and filtered water in abundance for one and a half to two million people. The city sells water to Lakewood, East Cleveland, Cleveland Heights, Shaker Heights and West Park. The city is metered and wasted water is paid for. Water is now furnished for a population of about one million people who reside in an area of about 110 square miles. The average rate of consumption is estimated at from 130 to 135 million gallons daily and the maximum rate of consumption at 200 million gallons daily. Nearly the entire pumpage is accounted for, a fact which would indicate that the dis- tribution system is in good condition. Improvements in the water supply and distribution have always been more than met by the water rates, which are not excessive. The growth of Cleveland and its vicinity is an assured fact, consequently, at intervals water facilities must be increased to meet the growing demand. With sewage treatment provided only to the extent of safeguarding bathing beach waters and minimizing the foul condition of the Cuyahoga River, the contamination of the lake shore waters will increase with the growth of the city. Therefore, in completing present plans and in making future ones the filtration of the city water should be considered of paramount importance. With two filtration plants, each with a capacity of 150 million gallons daily, it seems that pure and wholesome Avater will be furnished this com- munity for a number of years. However, recently a committee of Engin- eers, Messrs. Hoffman, Herron & Frazier, studied the future requirements of the Water Department and concluded that by the year 1940 two addi- tional filtration plants, one east and one west of the Cuyohoga River, would probably be necessary. There is no reason to believe that the water supply is responsible for any of the typhoid fever, dysentery or other diarrheal diseases reported and analyzed, since chlorination of the entire supply was established. The very low typhoid rate of Cleveland during the year 1919 is an excellent proof of the safely of the public water supply. With regard to private unauthorized and individual well supplies of water used in the outlying districts of the city and its suburbs not yet reached Environment and Sanitation 59 by the public supply, the situation is unsatisfactory. There is no map or census of these supplies, .and there is no system of inspection, or permit system controlling the use of other than public water supplies by the Division of Health. Some of the cases of enteric infection, for which the source has not been traced in the great majority of cases may well be due to individual ^ell supplies exposed to surface or other contamination regularly or occa- sionally. No one should be permitted to use water supply other than the public source unless the quality of water and the sanitary safety of its en- vironment and drainage area are known to the Division of Health and a permit or license for the use of such water is issued and only on the basis of bacteriological and sanitary control at frequent intervals. It is recommended that: The plans for filtration as prepared for the East 45th Street pumping station be carried to completion and that the present chemical and bacteriological standards for quality and purity of the water supply be maintained. The Division of Health make a careful survey to locate all sources of water supply in Cleveland other than the public supply and permit the use of only such as are found by chemical, bacteriological and sanitary standards to be continuously fit for human use. 60 Hospital and Health Survey Sewage Disposal WHERE, as in Cleveland, the drinking water is taken from the same natural source into which surface drainage and household and indus- trial sewage naturally empties by gravity, the collection, treatment and disposal of sewage becomes of almost as much importance as the purification of the water supply. Moreover, the use of the lake shore and beaches in and near the city for recreation purposes, boating, paddling, bathing, etc., is an added reason to exclude or reduce to a safe dilution the sewage effluent. Cleveland's present sewer system for collection, the facilities for treatment and the location of discharge outlets in deep water far from shore, as con- structed or planned for, and under contract, represent the best engineering opinion and the result of important practical experiments with a great variety of treatment and disposal methods. Until the city has so treated its own sewage from the areas which will contribute to the discharge into the upper part of the Cuyahoga River as to escape criticism and avoid nuisance, the industrial plants along the banks of the river cannot be required to abate the nuisances they are so obviously and so offensively guilty of at present. The opportunities for the great indus- tries of Cleveland to contribute to the cleanliness of air and water are so am- ple that one would think they might tempt the imagination of some engineer among them. The bird that fouls its own nest is a true "white-wing" in comparison with the collection of industrial plants upon the flats of the Cuyahoga River. The Cleveland program includes the controlling of the purity of the drink- ing water by treatment during the immediate future in two large filtration plants and the safeguarding of the bathing beach waters from sewage pollu- tion by treating the sewage in three large treatment plants. Treating the sewage is the first major step in eliminating the foul and objectionable con- ditions existing in the water of Cuyahoga River, while another benefit to be derived pertains to the prevention of the overtaxing or overloading the reason- able performance of the water purification plants. Another important bene- fit to be expected, although chiefly sentimental, is the meeting of the opposi- tion of the public to the use of a source of water for drinking purposes in which there exists even a suspicion of sewage pollution. The policy which has been adopted in Cleveland is similar to that in general use in this country and abroad, namely: controlling the purity of the water by filtration and treating the sewage only to a partial extent. Lake Erie waters near centers of population are becoming, year by year, less reliable as a source for a water supply without treatment. Filtration in conjunction with sterilizing agents will alone make the public water supply of this community satisfactory under existing conditions, and it is with this * The Survey is indebted to various officers in the employ of the city for most of the information regarding water supply and sewage in Cleveland, and in particular we wish to acknowledge the impor- tant statements of fact obtained from— Mr. George B. Gascoigne, Sanitary Engineer, Division of Engineering of the Department of Public Service, and Dr. Roger Perkins, Chief of the Eureau of Laboratories of the Division of Health and Prv, «ssor of Bacteriology and Hygiene at the Western Reserve University Medical School. Environment and Sanitation 61 viewpoint in mind that the problem of sewage treatment has been dealt with. With efficient operation of both water and sewage plants two bar- riers against the contamination of the water supply will be established. The program adopted is representative of the progressive spirit in the community and it should be consummated in its entirety. It demands the attention of the public until all of the contemplated structures are in use, and it should be stated that the efficient operation of the sewerage and sewage treatment works is just as important as the installation of the works. Sewerage The city of Cleveland is sewered upon the combined plan, i. e., one set of sewers cares for the storm water and sewage. Lake Erie is the ultimate dumping ground for all the sewage flowing through the city system, which may be described as a series of main sewers having outlets for excess storm water emptying either directly into the lake or into streams tributary thereto. The sanitary sewage, together with the first flush of storm water, is to be collected from the above-mentioned main sewers by means of a system of intercepting sewers which discharge at the selected points for treatment. These treatment sites are three in number, two on the lake front and one on the Cuyahoga River. The first sewers were built in Cleveland about 70 years ago, and today we find very few of these in use. The rapid growth of the city has made necessary the construction of many miles of sewers. However, the increase in sewer mileage apparently has not kept pace with the increase in street mileage. There are many factors governing this condition, principal among which is the inadequacy of financing. The demand for sewers includes projects for main sewers, some of which are partially completed, sewers for recently annexed portions of the city and sewers for undeveloped portions. Furthermore, there are many sewers needing rebuilding in advance of paving, and there are a number of streams which must be maintained as storm water channels which should be con- verted into storm sewers. The city now has about 17 miles of streets and only about 15 miles of sewers to the square mile. In order to make the sewer mileage equal to the street mileage, an additional sewer length of about 106 miles would be required. It is found that the city has been expending for sewer purposes about $1,000,000 each year. Mr. Robert Hoffman, Commissioner of Engineering and Construction, estimates that the city will need to expend about $1,000,000 each year for the next 10 to 15 years before it can provide sewerage facilities commensurate with the present and future demand. Available data tend to show that at the present time the city is about 88 per cent sewered, a ratio which compares favorably with that found in most of the larger cities. Under existing laws the city as a whole must pay the cost of sewers located within street intersections and at least two per cent of the remaining cost. Abutting property can not be assessed for more than would be required to pay the cost of a local sewer, so that the excess cost of any branch 62 Hospital and Health Survey or main sewer over or above what a local sewer would cost must be borne by the city as a whole. This portion of the cost is substantial and accounts in large measure for the amount the city must pay. The city's portion of the cost is usually financed through the sale of bonds issued for such purposes, but the amount of bonds which can be issued is limited in a number of ways. Sewage Treatment There is evidence that the bathing beach waters along the lake front are polluted by sewage now discharged at the main sewer outlets and at times by the storm-water emergency outlets discharging diluted sewage. Proof of the origin and spread of communicable diseases by sewage-polluted water used for bathing purposes, is difficult to obtain, but sufficient instances of typhoid fever, non-specific intestinal infections and of infectious conjunc- tivitis have been observed in New York City and* elsewhere as the result of unrestricted use of bathing beaches near sewer outfalls, justify our pro- tecting bathing waters against pollution or forbidding bathing when the pollution can be demonstrated. Bacteriological proof of the degree of sewage pollution is usually unnecessary, for sight and smell suffice to give warning and evidence. The locations for the sewage plants, together with the degree of treatment necessary and the type of sewage plants best suited to local conditions, were determined from tests on the sewage discharged at the East 140th Street and the West 58th Street outlets. The city, as may be seen from the accompanying map, has been divided into four main sewerage districts: the Westerly, Easterly, Southerly and Low Level. Each district, with the exception of the Low Level, has a main intercepting sewer to deliver sewage to the treatment site, and the population served in each district amounts to, approximately, 27 per cent, 50 per cent, 22 per cent and 1 per cent of the total population of the city, respectively. The sewage of the Westerly and Easterly districts will be treated at two lake-front plants, while the sewage from the remainder of the city will be treated at a plant located on the Cuyahoga River, about seven miles from its mouth. Since lake water is not available at this site, it appears that ulti- mately structures which provide a higher degree of treatment than at the lake-front sites will be necessary at this site. Since contemplated river and harbor improvements along the Cuyahoga River involve an extensive plan for straightening the river channel, the problem of sewage disposal for the Low Level district which bounds the river is rendered especially uncertain at this time. The primary results to be accomplished by sewage treatment works may be listed as follows: Preventing the pollution of bathing beach waters along the lake front. Kliininating the foul condition of the Cuyahoga River. At the Westerly site there has been constructed a submerged outfall, and a complete sew tge treatment plant is now under construction. It is expected that this will be completed and in continuous operation by the bathing sf>i-; channels, until the foul-smelling stream seeps away if the ground is dry or reaches Nottingham Creek if the clay soil cannot absorb it. Noth- ing can so successfully discourage attempts by the householder and the sanitary police to maintain decent surroundings for the little children of such regions as the absence of sewers while the public water supply is every- where available. A sewer is about as essential as a trolley line to develop suburbs and distribute families away from the packed tenements of the city. One particularly foul spot was found adjacent to the city filtration plant : namely, at Bentley Court, where a small area inhabited fairly densely by people of small means is entirely unsewered. Here the slops and privy vaults overflow and leakage from a row of houses has made a small swamp alongside of what serves as a roadway, where domestic animals and children find entertainment, and where the passerby holds his nose for the stench. It takes a high grade of intelligence, constant industry and real discipline to live at close quarters and not create nuisances, where sewers are lacking and water supply is provided. Summary The problem of safeguarding the health of any community by supplying a pure water and by removing the sewage pollution from bathing beach waters warrants considerable attention by the public. This is especially true in a large and growing community. During the past few years these problems have been studied actively and conscientiously in Cleveland, with the result that comprehensive plans for providing suitable water supply, 66 Hospital and Health Survey sewerage and sewage disposal facilities have been adopted and are being carried out with substantial progress to date.* The situation may be sum- marized as follows : 1. While the domestic supply of water in the City of Cleveland and vicinity can not be considered entirely satisfactory, physically and hygieni- cally, without treatment, excellent progress has been made to furnish a pure water supply by means of intakes suitably located off-shore and by adequate filtration and chlorination. 2. Progress is being made in providing sewerage facilities. However, the demand for sewers is extraordinary at this time, and this demand, because of the rapid expansion of the city, will continue during the immediate future. In order to meet this demand expenditures of large sums must be made for sewers. 3. The bathing beach waters along the lake front are subjected to con- tinuous pollution from sewage discharged at the outfalls, and to occasional pollution from diluted sewage discharged from storm water overflow outlets. The foul condition of the Cuyahoga River has long been a source of complaint. While correcting this condition may be considered partly a sentimental or comfort problem, sight should not be lost of the fact that this stream with its polluting materials is a direct menace to the water supply. 4. An investment of approximately $4,000,000 for sewage treatment devices will be rendered practically worthless unless funds are provided to operate and maintain such works in an efficient manner. The question of providing such funds should be given serious consideration in the imme- diate future. RECOMMENDA TJONS It is recommended that: The City persevere with its present excellent plan for sewage collection treatment and disposal. For sewer extensions the sum of $1,000,000 be provided annually for the next fifteen years, to permit of a wise and consistent development of the present plan and to permit of economies in construction. Cooperation be arranged for between the Park Department, the Public Service De- partment and the Division of Health to assure protection of the public against risk of infection from bathing at the public beaches in or near the city when there has been direct or emergency overflow contamination near the beaches, due to heavy rainfall in summer. Funds be provided to operate and maintain the sewage treatment works in the manner intended at the time of construction. * For those who wish to test th? standards Cleveland has set for itself in its present plans for proper collection and disposal of sewage, an excellent summary of standards methods and authoritative reference to the best present-day American practice can be found in the special article on this subject by Hommon, Hoskins, Streeter, Tarbett and Wagenhals in the U. S. Public Health Report (January 16, 1920,<]Vol. 35, No. 3). Environment and Sanitation < 67 Street Cleaning and the Collection and Disposal of Garbage and Refuse* o NE of the most important municipal problems in any city is the clean- ing of streets and the collection and disposal of garbage and other refuse. The streets may be efficiently lighted, well paved and sewered, but from a health standpoint how much more essential is it that they be well cleaned. Houses are constructed with all modern improvements, including provision for ventilation, with sewer connections, etc., but it is essential for the occu- pants that the refuse be speedily and systematically removed. We hear much at present in regard to parks and playgrounds for con- gested districts, in order to secure for the people who live and work in these districts better hygienic conditions. Dr. Peterson, former supervisor of playgrounds of Cleveland, estimated that the supervised playgrounds in Cleveland would accommodate 20,000 children; more than 105,000, he said, will have to play in the streets. In discussing parks and playgrounds how little we hear of keeping the streets, alleys, yards, courts and premises in a cleanly condition, to secure cleanliness of the streets for the people who live in the congested sections, to protect the air they breathe, the houses they live in, the shops they work in, their recreation grounds. Undoubtedly a large number of people spend their lives from beginning to end in an area, the healthfulness of which is controlled for good or bad, according to the method adopted for cleanliness. The work in connection with the cleanliness of the city, consisting in the cleaning of streets and the collection and disposal of refuse and garbage, is under the direction of the Director of Public Service, carried on by branches of the Service Department. Garbage Collection and Disposal Prior to 1897 there was no systematic method for collection and dis- posal of garbage — the garbage being collected by contractors, who made collections from all portions of the city and disposed of the material by taking it several miles out into the lake and there dumping it. The method of j disposal was not satisfactory on account of the excessive cost and the littering of the shores with floating debris. During the period previous to 1897 a portion of the garbage was disposed of by feeding to swine on farms inf the outlying districts. This method was not satisfactory and was finally condemned by the local health authorities. In 1897 a contract was awarded for collection and disposal for a period of five years, the contract being sublet to the Newburgh Reduction Com- pany, with a plant located at Willow, on the Baltimore & Ohio Railroad ♦This chapter was prepared from a report written for the Survey by Mr. I. S. Osborn, an engineer of Cleveland recently engaged by the city government to make an exhaustive study of the problem of municipal collection and disposal of wastes. The Survey is privileged to present this statement before the completion of the official report. 68 Hospital and Health Survey just south of Cleveland. At the expiration of the contract it was not x'e- newed but the contractor continued to perform the work until January 1, 1905, at the same price specified in the contract, $69,400 per year. On January 1, 1905, the entire equipment for collection and disposal of garbage was purchased by the city and since then has been operated by the municipality. . The methods of collection have remained, with few changes, the same as when the work was taken over by the municipality. The original horse- drawn wagons purchased by the city from the contractor had a removable box, which was removed from the wagon when filled and shipped to the disposal works, with an empty box returned and placed on the wagon for use in the next collection. In 1907, two years after the purchase of the equipment by the city, changes and improvements were made bj?" the purchase of new collection wagons and new steel garbage cars, as made necessary by improvements in the methods of handling the garbage at the disposal works. At present the garbage is collected from the various sections of the city in steel-body wagons, in which it is delivered to the central receiving stations where it is dumped into steel cars and shipped to the reduction works at Willow. The collection and disposal of garbage are supervised by two superin- tendents, one having charge of collection and the other of the final disposal. The superintendent of collection has general charge of the equipment and work of the collection department. Under him are employed 250 men, en- gaged in the work of collection and maintenance of equipment and stables. The superintendent of disposal is in charge of the reduction works. Under him are employed approximately 100 men, including foremen, mechanics, operators and laborers. Garbage is collected from all sections of the city, which has an area of 58.7 square miles, and a population of 796,836. The total area of the city is divided into 101 collection districts. The areas of the districts vary from a quarter square mile to one square mile or more, depending on the density of population and quantity of material to be collected. It is the intention in estpbMshinjr collection districts to limit the size so as to permit the making of regular collections on schedule. The collection equipment consists of the collecting wagons, horses, trucks and trailers, receiving stations, stables, railroad cars and miscellaneous minor equipment. The receiving station and stables are located near the geo- graj hical center of the city on Canal Road. The site comprises approximately one-third acre, on which the buildings are conveniently located as to railroad facilities on the Baltimore and Ohio Railroad, for shipment of garbage to the disposal plant. The property on which the buildings and loading platform are located, is leased for a short term, so that extensive improve- ments would not be warranted. The location is objectionable from the Environment and Sanitation 69 A winter's collection of garbage and rubbish under the kitchen window. Even the cat became used to it. This garbage has waited under the dining-room window for half tin 1 winter — for the collector Hospital and Health Survey This collection of old food was the winters decoration of a prominent corner in fl..„„l,.„,V i. nnrmpnipfl ( hstricf. Cleveland's congested district Just at the back door. Barrel nearly buried by pile of food and rubbish. Environment and Sanitation 71 standpoint of approach, due to the fact that it must be reached by steep grades by wagons arriving from all sections of the city, causing considerable trouble, especially in slippery weather. Most of the buildings are the same as formerly used by the contractor. The buildings are of frame construction and in a rather dilapidated condi- tion. The stable is of wooden construction, and in a poor state of repair. The size is not sufficient to accommodate the required number of horses, with a resulting crowding. The stables are poorly ventilated and lighted. One other stable is rented for service in the. western part of the city. The wagons are constructed with strong running gears, holding the steel tank body, having a capacity of 2^ cubic yards. The tank body is hinged to the rear axles and by means of a hoist the front end is elevated, dis- charging the material at the rear. The body is strengthened by arched ribs across the top, which supports a sectional canvas cover. In addition to the wagons, a number of trucks and trailers are used. The trailers are equipped so as to be drawn by either horses or tractors. The cars, sixteen in number, used for transportation of the garbage, are constructed entirely of steel and consist of a semi-cylindrical body supported upon trunnions. The cars have a capacity of 54 cubic yards or 35 to 40 tqns. The ordinances of the city require the provision by householders of suitable water-tight covered receptacles for garbage to be placed in accessible location for collectors. These ordinances are not enforced, especially among the poorer classes and in districts having foreign population, and in many cases boxes, buckets, baskets, etc., are used, which are not suitable recep- tacles. The Municipal Reduction Plant situated at Willow is about two miles south of the southerly corporation limits and nine miles from the garbage loading station. It occupies a tract of land 50 acres in area and is situated in the Cuyahoga River Valley. The buildings, comprising the present plant, consist of the Green Garbage Building, where the material is unloaded from the cars; the Main Building, which contains the digesters and dryers, to which is connected the building containing the grease-separating tanks and evaporators; the Percolating Building, containing the grease-extracting and separating machinery; and the Power House, containing boiler equipment and electric generating plant. The plant, as originally purchased from the contractor, was installed in 1898 and consisted of buildings of wood construction. The present buildings are constructed of brick and steel. The plant, as remodeled by the city, was increased in capacity at the same time that improved equipment was installed for making recoveries of by-products. The old method of unloading the garbage from tanks by cranes was abandoned, and is now replaced by the Green Garbage Building, where the garbage from the cars is emptied by direct dumping. The cars enter the building on an elevated track and are dumped by means of chain hoists. The car bodies rotate on roller bearings, and the garbage is dis- Hospital and Health Survey charged on the concrete floor underneath the tracks. The garbage in the unloading building is shoveled upon scraper conveyors and discharged through chutes into the digesters, of which there are 33. After digestion for a period of six hours, by using 70 to 80 pounds of steam, the steam pressure is applied at the top and the free liquor driven off through drains at the bottom to the settling basins, where the grease rises to the top and is skimmed off. The liquor from the bottom of the settling tanks is pumped to an evaporator for recovery of the solids in solution. The tankage in the digester is removed through a side outlet and dis- charged into a conveyor leading to the driers. The driers are of two types, known as the rotary direct-heat drier, through which the material is passed, eliminating approximately half of the moisture contained in the tankage. It is then passed through a combination steam and air drier to remove the remaining moisture. After drying, the dried material is conveyed to the extractor building, where it is placed in percolators and the grease remain- ing is recovered by percolation, using gasoline as a solvent. The combined grease and gasoline are then pumped to stills where the solvent is evaporated, leaving the grease ready for storage. The gasoline, driven off from the stills, is condensed and returned to storage for further use. The tankage, after percolation, is returned to the driers where the stick or concentrated solids which were in solution coming from the evaporator, are mixed with the fibrous materia], dried and then passed through the screening and grinding room before going to storage, awaiting sale of shipment. It has been shown by figures, based on reports of New York garbage- reduction results, that one ton of garbage yields the following products: from the grease enough glycerine is obtained to furnish high explosives for ten French 75-millimeter shells, and soap stock sufficient to make 125 pounds of laundry soap; from the tankage or fertilizer enough plant food in the form of nitrogen, phosphate and potash is secured to raise ten bushels of wheat. Many improvements have been made in the plant since it was originally purchased by the city, although very few changes have been made in the methods, or types of equipment used, during the past ten years. As the city has grown, surrounding the plant, there has been increasing objection raised to the odors given off by the processes which originate from the vents on the digesters and from the gases from the driers. To eliminate the odor, special treatment must be given to the gases carrying odors, which will eliminate the nuisance. Attempts have been made from time to time to deodorize the gases. Plans are under way at present for the condensa- tion of the gases or vapors given off by the digesters. The gases, which are of large volume, coming from the driers, are passed through a scrubber which consists of a horizontal brick chamber, where they are subjected to water sprays which wash and condense them. The efficiency of the scrubber is not sufficient to eliminate entirely the sweetish or caramel odor carried by these gases. It is realized by the city that steps are necessary to improve Environment and Sanitation 73 the present conditions at the plant, both from the standpoint of capacity and for the elimination of undesirable features and odors. The problem is under study at present. The collection and disposal of dead animals were formerly handled by the city, but at present are done by private rendering companies, who re- move and dispose of the large animals dying within the city. The small dead animals are disposed of with the garbage at the Reduction Plant. About 500 dead dogs are collected each month. The following table gives the quantity of garbage collected and disposed of during the past ten years; also the cost of collection, cost of disposal, receipts from sale of by-products and the net cost for collection and disposal. Table Giving Tons of Garbage Handled, Cost of Collection, Cost of Disposal, Receipts from By-Products and Net Cost per Ton for Collection and Disposal Year Tons Garbage Cost Collection Cost Disposal Gross Income Net Cost Collection, Disposal Net Cost Per Ton 1910 44,747 $124,701 $101,936 $190,652.00 $ 35.985 $0 804 1911 46,562 139,456 110,094 189.894 00 59,656 1 281 1912 43,550 139,379 107,015 151.162 00 95.232 2.187 1913 52,354 143,672 113,057 157,705 00 99.024 ! 891 1914 55,730 165,858 141,415 195,221 00 112,052 2.011 1915 62,357 181,556 151,503 224,691 00 108,368 1 738 1916 60,717 195,266 155,584 304,072.00 46.778 0.77 1917 56,121 236,035 191.001 292,745 00 134,291 2 393 1918 57,754 304,183 265,243 437,842 00 131,584 2.278 1919 60.932 355,175 238,202 295.361 00 297.016 4 874 Ashes and Rubbish Previous to 1906 ashes and rubbish were collected entirely by private scavengers, who were not licensed and only in a general way under the supervision of the Division of Health. The collections were not regular, the city was incompletely covered and the service very inefficient. The material was disposed of by dumping on vacant lots, side streets and road- ways, or in such places as it could be disposed of without causing immediate complaint. In 1906 the city undertook the collection of ashes and rubbish, in order to eliminate the nuisance caused by the littering of streets and alleys, also in order that the places of disposal could be controlled and more satis- factory results obtained. The work, in connection with the collection and disposal of rubbish and ashes, is under the direction of the Commissioner of Streets, whose superin- tendents and assistants have charge of the work. The work of collection is carried on by the same organization that performs such work as is done in cleaning the streets, and men and teams used in collection are also employed at times in street cleaning. For convenience the city is divided into six districts with a district super- intendent in charge of collection service as well as street cleaning. Collee- 74 Hospital, and Health Survey tion of ashes and rubbish is provided over the entire city. The frequency of collection varies and work is not regularly scheduled. In some sections there is a collection once in six weeks, in other sections more frequently. Collections are made by wagons or trucks. Additional trucks have been purchased for this service. The wagons are of the bottom dump type, having a capacity of four cubic yards. Rules and regulations have been adopted by the Department to facilitate the work, which require householders to provide suitable receptacles and the tying of loose refuse into bundles. The rules have been difficult to enforce and x in many cases are not complied with. In order to eliminate the dumping of waste paper and at the same time to realize upon its commercial value, the Department collects waste paper separately. This is baled and sold. This applies to street boxes and some of the larger producers of waste paper, but as a rule, the waste paper from residences is collected at the same time as the ashes, and is disposed of by dumping. The disposal of rubbish and ashes is made by dumping. The location of the dumps depends upon the land available for this purpose. In many cases dumps are made available by owners desiring their property filled. There are twelve principal dumping grounds now in use. The lake front, near East 9th Street, is the largest dump. It was first begun by dumping directly into the lake, after which a breakwater was constructed. There have been made over one hundred acres of land from dumped material at this point. The principal filling has been with ashes, street cleaning dirt and material from cellar excavations. At all the dumps the method is practically the same. The material is dropped from the wagons or trucks at the edge of the slope and then shoveled over the edge by hand. Considerable complaint is made of nuisance caused by the scattering of material, and the odors and smoke from fires in many of the dumps. These have generally been justified and their abatement is the duty of the Sanitary Bureau. The following table gives the quantity of ashes and rubbish as collected during the past five years, together with the cost for labor and teams for the service, as reported by the Division of Streets : Year Cubic Yards Collected Cost Cost Per Cubic Yard 1915 318,390 $181,296.13 $0.57 1916 356,336 209,920.85 0.59 1917 335,769 227,249.03 0.677 1918 477,967 277,650.03 0.58 1919 495,834 284,286.26 0.5734 The above cost includes only expenditures for teams and labor, and not any fixed charges, maintenance, overhead or allowance for use of trucks owned by the city. Environment and Sanitation 75 The Director of Public Service is now having a complete study and sur- vey made in order to determine what steps should be taken to remedy and improve the conditions of collection and disposal of garbage, ashes and rub- bish. This survey and study considers what steps can be taken to improve the collection service and at the same time reduce the cost for long hauls and the present expensive methods of handling. The investigation and report will cover the various methods necessary for collection, delivery and disposal of ashes, rubbish and garbage, including substantially the following subjects: 1. Analysis of data contained in the records of the Department of Public Service with reference to collection of garbage, ashes and rubbish. 2. Study of population and future growth of the city to provide for a comprehensive plan for future needs. 3. Comparison of various methods of collection and types of equipment suitable to systematize that service for the City of Cleveland. 4. Comparison of various methods of disposal for different classes of waste, adaptable to Cleveland's needs. 5. Outline of essential features necessary to produce a sanitary and economical collection and disposal of garbage, ashes and rubbish by various methods. 6. Quantities and plant capacities with proper allowance for future growth and local conditions. 7. The advisability of collection and disposal of waste in a central plant as compared with a number of plants. 8. Determination of and advisability of a number of transfer stations and methods of transfer and delivery of material to points of disposal. 9. Comparison of costs by various methods of collection and disposal, giving capital cost, annual operating and maintenance charges, also the total plant charges and revenues. 10. Recommendations. A discussion of the various projects adaptable to Cleveland, with recommendations covering the most feasible plan for the collection and disposal of waste from a sanitary and economical standpoint. The complete study, as outlined above, will take into account all prac- ticable plans that might be adopted, each developed so that the|most feas- ible plan can be recommended, taking into account the sanitary|and eco- nomical advantages to be gained to take care not only of present conditions but the future needs of the city. Hospital and Health Survey A "Front Door'' on a Cleveland Alley. The pile is made up of mixed gar- bage and rubbish. Stable rejvse on an alien in Cleveland's most congested quarter. In the Spring a natural lira ding place for millions of flies. Environment and Sanitation 77 Food and rubbish. The wintzr collection of a Clevel ind b ickyard. Next door to a grocery store in Cleveland's congested district. 78 Hospital and Health Survey Street Cleaning The work of cleaning the streets is under the direction of the Street Com- missioner and directly under one of the deputy commissioners. The work is carried on by district gangs, who are in charge of the collection and dis- posal of ashes and rubbish. Men and teams interchange for each class of work. The city is divided into six districts for refuse collection, with a foreman in charge of each district. The city is divided into three districts for street cleaning, by a "white wing" patrol, with a foreman of "white wings." The catch basin cleaning under the direction of a foreman, includes the whole city, except for parks and boulevards, which are under another de- partment. There is also a foreman in charge of equipment, including wagons, trucks and automobiles. In addition, there is the office force and a corps of inspec- tors and investigators of complaints. To each foreman is assigned such assistants, subforemen, laborers and teams as required. There are 609 miles of paved streets in the city, and the methods of clean- ing consist principally of "white wing" patrol, pickups and flushing. The cleaning of streets in the downtown section and the streets at more impor- tant intersections is done principally by "white wings." The patrol districts are not established, and the number of "white wings" employed varies with the funds available for cleaning work, with the result that the thoroughness of cleaning varies. No record is kept of the areas cleaned daily or left uncleaned, and the records are made up by assuming that each "white wing" has cleaned his allotted area at least once a day, irrespective of the work actually accomplished. The work is reported for "great squares," which contain 10,000 square feet each. The following table gives the work of the "white wing" patrol and the cost of it for the past five years, as given in reports of the Division of Streets. Year Squares Cleaned Total Cost Average Cost Per Square 1915 438,606 $119,421.15 $.2723 1916 448,387 104,327.78 0.2326 1917 300,083 135,389.83 0.4512 1918 312,094 105,358.34 0.3375 1919 313,497 139,055.72 0.4435 The above cost covers only labor and teaming, and does not include any fixed charges, maintenance or overhead. The method of pickups, in addition to flushing, is used on streets not included in the "white wing" areas. The men and equipment used in ash and rubbish collection are used largely in pickup work, which consists prin- Environment and Sanitation 79 cipally in cleaning gutters and picking up the accumulation of dirt on the streets. This method is used largely in outlying and residential streets. The following table gives the work by the pickup method as reported for the past five years, including the labor and teaming cost for the work. Year Squares Cleaned Cost Per Square Average 1915 93,993 $69,544.78 $0.74 1916 112,091 75,073.04 0.67 1917 75,342 78,497.82 1.04 1918 84,653 69 , 563 . 54 0.82 1919 85,624 75,967.96 89 One of the principal methods of cleaning is by flushing the streets, which is employed occasionally in the warm months of the year, on the main thoroughfares. The city has two motor driven flushers employed in this work and eleven street car flushers, rented from the street railway company. The motor driven flushers are used in the city as a whole, and assigned for work as needed. The street car flushers, when used, are operated on streets having trackage. Aside from the cleaning done by "white wing" patrols, the most effective work is done by flushing, although this is not extended so as to cover terri- tory outside the main thoroughfares. The following table gives the work and costs for flushing during the past five years. Year Squares Flushed Cost Average Cost Per Square 1915 329,319 $36,351.93 $0.11 1916 310,384 34,971.99 0.113 1917 163,168 20,250.47 0.124 1918 247,306 13,966.63 0.056 1919 336,340 18,165.68 0.054 During 1919 there was reported flushed by street car flushers 251,097 squares at a cost of $12,676.25, or an average cost of $0.0505 per square; and by motor flushers 85,243 at a cost of $5,489.43, or an average of $0.0644 per square. The above costs include the rental paid the Street Railway Company but do not include any fixed charges, maintenance, overhead or cost for water, which, if added to the total, would increase considerably the cost for motor flushers. The following table gives the direct expenses during the year 1919 for labor and team hire in the Street Cleaning Division, but not including fixed charges or replacements: 80 Hospital and Health Survey Expenditures of the Division of Street Cleaning During the Year 1919 Household refuse collection $284 , 286 . 26 White wing patrol... _ 139 , 055 . 72 Pickup gangs 75 , 967 . 96 Supervision and inspection 58, 734.08 Catch basin cleaning.. _ 39 , 994 . 38 Maintaining dumps 29 , 486 . 93 Mechanical repairs 2 7 , 233 . 90 Watchman 25 , 695 . 40 Market cleaning 15 , 786 . 56 Street car flushing 12 , 676 . 25 Waste paper.. _ 10 , 508 . 70 Motor flushing 5 , 489 . 43 Snow removal 2 , 599 99 Cinders _ _ 799.03 Total $728 , 314 . 59 Labor payroll 526 , 650 . 49 Team payroll _ 192 , 998 . 85 Rent of car flushers 8 , 665 . 25 $728,314.59 The insignificant suna charged to cost of snow removal in 1919 may be the explanation, it cannot be offered as the excuse for the intolerable filth and neglect of the streets during the winter of 1919-20. General The studies, now being made for the Director of Public Service, of the the city services for street cleaning and the collection of ashes, rubbish and garbage, will show where improvements can be made. One of the chief handicaps of the city has been the limited funds avail- able for conducting the work, with continually increasing cost for labor and equipment. If systematic and efficient work is to be carried on, the following requisites are necessary for success: 1. A sufficient appropriation. 2. An efficient organization. 3. Sanitary and economical methods of work. 4. Cooperation on the part of the public. Appropriation is necessary to cover the cost of the work to be done, and the^quantity of work accomplished will depend on the fund available, pre- Environment and Sanitation 81 viding it is efficiently used. An efficient organization will develop effective and economical methods of work. Sanitary and economical methods of work will be obtained from study and application of studies, after compari- son of records and unit costs of the work by various methods. The cooperation of the public can be obtained by education and regula- tions consistently and uniformly enforced. Results will be more readily obtained when efficient and satisfactory service has been rendered. All four requisites are dependent on each other to obtain the maximum degree of success. From the investigation made it is evident that very little intensive study has ever been given the street cleaning work in the city. A comparison of the work done in Cleveland with that of other cities will show that less work is given here to effective street cleaning than in the other cities of comparable size; at the same time, the annual expenditure for the work is less than in other cities. The result is that many streets are seldom cleaned thoroughly, and many receive only such work as is given by the pickup method in cleaning gutters a very few times per year, a wholly in- adequate service. From the studies made it has developed that the records of the Street Cleaning Department are not complete as to the actual work performed, and unit costs for conducting the different parts of the work have never been developed. These are essential to permit the official in charge to obtain the information necessary for the proper work control and administration. The Director of Public Service is now planning for necessary changes in organization to provide assistants in the Street Cleaning Department. There will be systematic planning of work and a system for record and unit cost keeping of the several activities of the Department. These, when installed, should greatly assist in the direction of the Department. In one city, where studies were made, it was found that out of an annual expenditure of $350,000 at least one-third of the amount was wasted, due to inefficient work and inefficient methods. The city of Washington, by adoption of methods in planning and estab- lishment of complete record and unit cost keeping, was able to reduce the cost of street cleaning 30 per cent, and at the same time to do more effective work. Washington, during the summer months, washes each street on an average of once for each two and a half days. New York City has established methods and standardized the street cleaning work so that every important or congested thoroughfare is cleaned by flushing, by squeegee machine, or by sprinkling and sweeping, at least once in every 24 hours. With the shortage of funds for municipal work in Cleveland the establish- ment of the methods proposed should assist the officials in charge to accom- plish the greatest amount of work with the funds available. It is recommended that: The steps being taken by the city in having studies made to determine improvements 82 Hospital and Health Survey necessary for the collection and disposal of garbage, ashes and rubbish be approved. They should permit the adoption of improved methods equal to those found in any city. Special attention be given in studies now being made to eliminate so far as possible cause for complaint of nuisance, due to odors from dumps or disposal plants, either by more attention to control of dumps or by the adoption of other means for disposal. It is essential, in order to control properly and carry on efficiently the work of street cleaning to plan, schedule and keep records and unit costs of the work. The step being taken by the Director of Public Service to provide for an assistant to the Commissioner, who will develop, install, and keep records and unit costs of the several activities of the Department will be one of the most progressive steps taken since the organization of the Department. The work done should include studies of the work actually performed, to determine the advantages to be gained by making changes and improvements, and should furnish the Director and Commissioner with detailed information necessary for the work, the control and the management of the Department. The Collection of ashes and rubbish should be scheduled so that regular and syste- matic collections are made. Thus residents can plan on the time when collections will be made and have materials in proper condition for the collector. This will permit a better enforcement of regulations and will eliminate complaints. Environment and Sanitation 83 Flies and Mosquitoes THERE is no directory or list of stables and no census of horses or cattle stabled in Cleveland, kept at the Division of Health or otherwise avail- able. There are no regulations enforced dealing with the collection and disposal of animal manure so as to control fly breeding in Cleveland. Manure piles, fresh and of long standing, were found commonly in the resi- dential regions in the poorer quarters of town within common fly range of unscreened food stores and restaurants. Only one of several score of privies inspected on both West and East Sides of the city in the regions supplied or not supplied with sewers, was found to be so constructed as to give any reasonable expectation that flies could be kept away from access to freshly deposited human waste or to the privy vault itself. Only one privy above noted was found with seat covers, or if seat covers were provided, they were so made and used as to be of no use in excluding flies from the vault. Doors were open or cracked. Windows in privy closets not screened, fecal deposits on the seat, on the floor and overflowing from the pit on the ground without, were frequently found. Uncovered garbage cans and uncollected accumulations of garbage are common even in warm weather. Under these conditions for which the Sanitary Bureau of the Division of Health must be held responsible, it is unnecessary to go into any detail as to the fly nuisance in Cleveland. " Swat-the-fly " campaigns, or efforts to teach children and householders to kill flies and reduce disease are mere waste of time. Until breeding places of flies, that is, exposed fresh animal excreta are controlled attacks upon the fly upon the wing are vain. Screen- ing is necessary, and except in cheap eating and food stores, which seem to escape inspection, is fairly well accomplished. Control of water and milk and education of mothers are responsible for the low incidence of enteric disease in Cleveland, and not control of the fly. Neither mosquitoes nor malaria are sufficiently common to require any special attention. Mosquitoes breed more or less according to the character of the breeding season, but do not amount to a serious nuisance within the city limits. Only twelve cases of malaria were reported to the Division of Health in the years 1916-19 inclusive. RECOMMENDA TIONS It is recommended that: The Sanitary Bureau maintain supervision over the horse and cow stables in Cleve- land and with such authority as can be found in the Sanitary Code, require the protection and periodic removal of manure so that fly breeding may be reduced or largely prevented. All privies in Cleveland be so constructed and maintained after well-known methods as to prevent access of flies to human excreta. 84 Hospital and Health Survey The holding of garbage in covered tight metal containers and the removal of garbage at least twice a week from April to November be required throughout the city. An ordinance be passed and enforced forbidding such collections of water as are likely to permit the breeding of mosquitoes. (For model ordinance see U. S. Public Health Reports, 1920, April 2, page 829.) Environment and Sanitation 85 Smoke and Its Prevention ONE might honestly report after a careful survey of the city and its public and private agencies, that nothing of a practical nature is being done or even attempted in the field of smoke prevention. Cleveland enjoys an amazingly, and one would be tempted to say, an intolerably polluted air all the year round. The reason is not that such air pollution as Cleveland tolerates cannot be abated, or that similar disgraceful interference with health and the enjoyment of life has not been controlled elsewhere. "There is nothing impossible or wonderful about the smokeless combus- tion of even Pittsburgh coal, provided the proper methods are applied and the ordinary precautions taken." Such was the opinion expressed by the competent group of engineers responsible for Bulletin 8 of the Smoke Investigation of Pittsburgh in 1914. Another statement in the same publication is so directly applicable to Cleveland that it will bear quoting: "A small group of men control the plants which produce 80% of the smoke of the district. The solution of Pittsburgh's smoke problem lies in inducing these men to apply the best modern engineering practice to the combustion of fuel in their plants." If the Chamber of Commerce of Cleveland could convince the manu- facturing and commercial interests of the city that their indifference to the smoke nuisance is responsible for a very large amount of sickness in the city, and that the antiquated equipment and careless administration of their plants which cause this nuisance, cause them and the city each year a cash loss of several times the amount of the total annual Community Fund, or at a modest estimate about $20,000,000, action, civic and individual, would probably follow with gratifying rapidity. It needs no visiting surveyor to tell the people of Cleveland what their senses, sight, touch, smell and taste must convince them of daily, that the air of their city is unfit for human consumption just as their sewage-polluted water was a few years ago. Since no quantitative observations of air pollution in Cleveland could be discovered, a brief series of soot-fall studies was made during July and August, the months of the year when the degree of air pollution from soot is probably at its lowest. As compared with certain English cities and with Pittsburgh (Bulletin 8, Smoke Investigation, page 22) probably Cleveland's nearest former competitor in smoke production, in this country, Cleveland now deposits a few tons per square mile per annum less of combustion products than did the other cities (London and Pittsburgh) when they were at the height of their nuisance. In recent years both the English cities and Pitts- burgh have made improvements in this direction. Cleveland is supine in the face of increasing air pollution. 86 Hospital and Health Survey The following statement represents reports received from the firm of consulting engineers (The James H. Herron Co.) engaged to make soot-fall studies for the Survey. Purpose of Examination The purpose of the examination was to determine the amount of matter present in the atmosphere in samples taken from a number of stations throughout the city of Cleveland, also to get data which, if possible, may be compared with the work done in other communities on this same subject. Extent of Examination Observations were made at four stations situated as follows: 1. The roof of the Superior Peanut Co. building, situated adjacent to the Huron Road Hospital. This place was chosen owing to the fact that a roof position on the hospital was not available. 2. The roof of St. Alexis Hospital, Broadway and McBride Avenue. 3. The roof of the Babies' Dispensary, 2500 East 35th Street. 4. The roof of Mt. Sinai Hospital, 1800 East 105th Street. It was decided that the samples collected from these locations would be .sufficiently representative for general comparative purposes. Apparatus Used The apparatus used was composed of a gauge of four square feet in area and was similar to the standard gauge used in the investigation of atmos- pheric pollution in the city of London in the years of 1914 and 1915. This gauge was deemed most satisfactory for this purpose. The Analyses The deposit was collected at the end of each month and the analyses as reported made at the end of each of the two months, June 26 to July 26 and July 26 to August 26. The deposit was analyzed for tar, ash, fixed carbon and iron oxide. This followed the order in which the analyses were made in connection with the smoke investigation of the city of Pittsburgh, the result of which was published in Bulletin No. 8 of Smoke Investigation. The re- sults given in this analysis are comparable with the results obtained in Pitts burgh. Environment and Sanitation 87 Observations, June 26 to July 26, 1920 At Huron Road Hospital At Babies' Dispensary and Hospital At St. Alexis Hospital Soot Fall per Square Foot per Month 1.4940 Grams 1.5530 Grams 1.6514 Grams At Mt. Sina. Hospital .9436 Grams Per Cent Composition of Deposit Tar. 2.82 2.29 55 Fixed Carbon 32.65 31.26 34.19 Ash 64.55 66.45 65.26 Fe 2 O.s in Deposit ...... 6.67 11 04 10.82 Deposit in Tons Per Square Mile Per Year Total Deposit 550.94 592.70 608.98 Tar 13.55 13 .58 3 34 Fixed Carbon 178.59 185.40 208.24 Ash _. 355.80 393.72 397.40 Fe? O3 in Deposit 36.75 65.45 65.70 2.86 31.80 65.34 15.75 347.97 9.95 110.66 227.36 64.80 Observations, July 26 to August 26, 1920 At Huron Road Hospital At Babies' Dispensary and Hospital At St. Alexis Hospital Soot Fall per Square Foot per Month 3.7775 Grams 2.7259 Grams 1.9995 Grams At Mt. Sina Hospital .8421 Grams Per Cent Composition of Deposit (July 26 to August 26 1920) Tar... 3.33 3.61 3.76 4.43 Fixed Carbon 28.94 32.15 33.33 32.40 Ash 67.73 64.24 62.91 63.17 Fe 2 O3 in Deposit 23.00 17.90 13 38 16.58 Deposit in Tons per Square Mile per Year Total Deposit 1392.91 1005.15 737.31 310.52 Tar 46.39 36.32 27.66 13.75 Fixed Carbon.... 403.11 323.15 245.74 100 61 Ash..... 943.41 645.68 463.91 196.16 Fe 2 O3 in Deposit , 320 37 179 92 98.65 51.48 Average Deposit in Tons per Square Mile per Year Calculated on Observations June 26 to August 26, 1920 Total Deposit 971.73 798.93 673.15 329.50 Tar 29.97 24.95 27.50 11.85 Fixed Carbon 290.85 254.28 226.99 105.63 Ash „ 649.61 519.70 430.65 211.76 Fe* O3 in Deposit. 178 56 122.58 82.18 58.14 Hospital and Health Survey At times in the past in both Pittsburgh, Pennsylvania and London, England, deposits of more than 1,000 tons per square mile per year have been recorded for periods of a month or more. For details of relative pro- portions of the solid components of the deposits in Cleveland and in other cities here and abroad the reader is referred to original documents. There is a not inconsiderable volume of air pollution due to volatile sub- stances, the sulphurous acid and other fumes commonly found accompanying heavy soot fall, but precise information as to the extent of such harmful substances must await studies of greater extent than the Survey could under- take in the time and with the money at its disposal. Admitting, if only for the sake of argument, that Cleveland suffers from an extreme case of dirty air, and certainly the valuable reports of the Cleve- land Chamber of Commerce in recent years should leave one in no doubt as to the extent of financial loss to persons and property justly attributable to this public nuisance, it may reasonably be asked what is the interest of the Hospital and Health Survey in air pollution. Briefly, diseases of the upper respiratory tract are increased by the irri- tation of coal dust in the air, and pneumonia is to some degree increased in frequency and severity by pollution of the air with coal dust. Diminution of sunlight reduces the bactericidal action of this most sanitary free agent. A diminution of sunshine which is familiar to every Clevelander for all the cool and winter months of the year, can be shown to permit an increase of bacteria, both pathogenic and harmless, in the air. "When the air is dirty it is hard to get the streets, the yards, the clothes, the people clean," and certainly bodily, personal and home cleanliness are important safeguards to health. The baleful psychical effect of smoky, dark and dirty air on human health and happiness has been emphasized by observers in England and in Pittsburgh. In an ever wider radius from the main centers of smoke production, plant life, tree life and especially the life of evergreen trees and shrubs is being destroyed. The constant deposit on the ground of coal, tar, ash, cinder and unburned carbon destroys the scant fertility of grass plots in yards and parks in many parts of the city. It must be admitted that where the air contains such pollution as to make life unbearable for vegetation, we must look sharply to protect the lives and health of the human flowers, the children who for large numbers of the population, have no escape from the soot-laden air. True, there is a Commissioner of Smoke Prevention appointed by the Mayor. He has an office in the City Hall. He receives a salary of $2,000.00 a year. His preparation and education for this highly technical position has been that of a fireman on a locomotive. He has had no technical training, he has no books or laboratory or instruments of precision, or experience in the practices used elsewhere to measure the extent of smoke nuisance, to prepare strong cases and arguments in court, or to carry on effective educa- tion among plant owners, engineers, firemen, etc. One of his functions is to pass upon and issue licenses for plants for heating, power and other coal and oil consuming furnaces, all of which he does as a part of a purely formal Environment and Sanitation 89 clerical routine, without inquiry as to the adequacy of draft or other equip- ment, such as mechanical stokers, etc., which will render smoke nuisance at least less likely. There are four inspectors also appointed by the Mayor, and not through civil service examination, receiving $1,375.00 a year and a stenographer at $900. In the same office at a desk adjacent to that of the Commissioner of Smoke Prevention is an employe of eight of the railroads operating within the city limits. He receives $3,900.00 a year. His experi- ence was formerly locomotive fireman and later foreman responsible for locomotive equipment on one of the important railway systems. His func- tion is to serve the railroads which pay him, so that observations made by the field inspectors (or by himself) of wasteful smoke nuisance from loco- motives may be promptly reported to the company concerned, and the offending fireman may be reprimanded, suspended or dismissed. As a matter of fact, the saving to the railroads in fuel cost, as the result of disciplinary action directed against careless firemen, more than offset the expense of their smoke inspection service. There is probably some benefit to the city from this servant of railroad operating efficiency, but locomotive smoke plays but a small part in the general curtain of dirt which the plant chimneys throw over the city. Of the four inspectors in city employ, one is assigned to the east, one to the west, one to the downtown section of the city and one is on railroad duty to assist the railroad employe above referred to. Reports of smoke nuisance are based on duration and density as measured by the Pungleman chart. No action follows violation of the city ordinance. The reasons given for failure to prosecute (there have been no prosecutions for many months) are that there is not only no public opinion in support of vigorous action but that there is active opposition to any interference with industry in the interest of clean air, and further that cases are continued in the Municipal Court until all value of action is lost and there is lacking reasonable, judicial support for the objectives of the city officials. Conditions of smoke nuisance are reported by responsible observers both in and out of the city employ to be much worse than they were under the administration of Mayor Baker, when the Commissioner of Smoke Preven- tion, a trained civil engineer at a salary of $4,000.00, and with a force of com- petent inspectors, made an intelligent and effective attack on the problem. The resentment and opposition of prominent men against whose plants action was taken, resulted in the discontinuance of an efficient service by cutting off the appropriation. A complication which adds somewhat to the problem of the plant manager and engineer is that under the laws of Ohio a fireman must be licensed to run a fire room, and this operates largely to make him independent of the engineer in charge, so that criticism or complaint of the firing which is always in large measure the fault responsible for smoke nuisance, is withheld for fear of loss of the fireman in question. At present the returns from the city expenditure ($8,400.00 annually in salaries) for smoke abatement are negligible. 90 Hospital and Health Survey RECOMMEND A TIONS It is recommended that: A competent engineer familiar with the technical phases of cause and prevention of smoke nuisance, and with the harmful results to property and life from such other kinds of air pollution from combustion, refining, smelting and other industrial processes as are common in Cleveland, be employed as Commissioner of Smoke Prevention, and be paid a salary commensurate with his responsibility (not less than $6,000), and that he be provided with a budget which will permit him to employ through civil service com- petent inspectors (four would be sufficient). The Chamber of Commerce resume its activities in the public interest by developing among its members an intelligent activity for cleanliness of the air of Cleveland, by aiding and encouraging prosecution of violators, by publishing technical bulletins giving modern standard methods of mechanical stoking and hand firing, by serving its own members through an inspection service which will prevent any of its members from coming under criticism by the city inspectors. The Cleveland Betterment Council take an active part in obtaining proof of the damage done by air pollution to the health of people of the city, through regional studies of soot fall, etc., and by analysis of the distribution of sickness and death, in cooperation with the Division of Health and the public nursing agencies. THE CLEVELAND HOSPITAL AND HEALTH SURVEY REPORT List of Parts and Titles I. Introduction. General Environment. Sanitation. II. Public Health Services. Private Health Agencies. III. A Program for Child Health. IV. Tuberculosis. V. Venereal Disease. VI. Mental Diseases and Mental Deficiency. VII. Industrial Medical Service. Women and Industry. Children and Industry. VIII. Education and Practice in Medicine, Dentistry, Pharmacy. IX. Nursing X. Hospitals and Dispensaries. XI. Method of Survey. Bibliography of Surveys. Index. The complete set may be obtained at a cost of $5.50 plus the postage and single parts at 50 cents each plus the postage, from THE CLEVELAND HOSPITAL COUNCIL, 308 Anisfield Building, Cleveland, Ohio Public Health Services Private Health Agencies Part Two Cleveland Hospital and Health Survey Copyright, 1920 by The Cleveland Hospital Council Cleveland, Ohio Published by The Cleveland Hospital Council 308 Anisfield Bldg. Cleveland - Ohio Preface The Hospital and Health Survey of Cleveland was made at the request of the Cleveland Hospital Council. The Survey Committee appointed to be directly responsible for the work and through whose hands this report has been received for publica- tion consisted of the following : Malcolm L. McBride, Chairman; Mrs. Alfred A. Brewster, Thomas Coughlin, Richard F. Grant, Samuel H. Halle, Otto Miller, Dr. H. L. Rockwood, Howell Wright, Secretary} The staff responsible for the work were: Haven Emerson, M. D., Director and the following collaborators: Gertrude E. Sturges, M. D., Assistant Director; Michael M. Davis, Ph. D., Director of the Hospital and Dispensary Survey; Josephine Goldmark, 1$. A., Director of the Nursing Survey; Wade Wright, M. D., Director of the Industrial Hygiene Survey; Donald B. Armstrong, M. D., Director of Tuberculosis Survey; S. Josephine . Baker, M. D., D. P. H., Director of the Infant and Maternity Survey; T. W. Salmon, M. D., Director of the Mental Hygiene Survey; W. F. Snow, M. D., Director of the Venereal Disease Survey; Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey. The expenses of the Survey and of the publication of the report have been met by appropriations received from the Community Chest, through the Welfare Federation, of which the Hospital Council is a member. The report as a whole, or by sections, can be obtained from the Cleveland Hospital Council. A list of the parts will be found in the back of this volume, together with prices. TABLE OF CONTENTS Page I. Introduction _.__ 103 II. Public Health Services. Division of Health — Administration 110 Appointments _ 112 Appropriations 113 Administrative Districts _ ;.. 114 Bureaus — Communicable Disease 122 District Physicians 138 Tuberculosis 142 Child Hygiene 143 Sanitation.. _ 144 Food and Dairy Inspection _ 148 Milk Control...... 150 Laboratories , _ 155 Patent Medicines. 161 Vital Statistics '. 165 New Activities Proposed — Institutional Inspection 173 Industrial Hygiene 185 Medical Examination for City Employes 185 Public Health Education , __ 186 Control of Drug Addicts 189 Health Centers 190 Coroner Service 191 III. Private Health Agencies. Anti-Tuberculosis League 193 Visiting Nurse Association.. 193 Day Nursery and Free Kindergarten Association 193 Hospital Council 193 Society for the Blind and a Program for the Prevention of Blindness. 193 Associated Charities 196 TABLE OF CONTENTS— Continued Association for the Crippled and Disabled and a Program for the Care of Cripples. 197 Proposed Agencies and Programs for — Prevention and Relief of Heart Disease 213 Prevention and Cure of Cancer ..^221 IV. Summary of Recommendations __. 226 Appendix : Tables 231 Health Services By Haven Emerson, M. D. INTRODUCTORY "Public health is the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized com- munity efforts for the sanitation of the environment, the control of commun- ity infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will insure to every individual in the community a standard of living adequate for the maintenance of health." — C.-E. A. Winslow. PUBLIC Health Organization in the majority of the cities of the United States is more a vision than a reality, a hope of a few rather than a living, growing, democratic function of civil government and private endeavor. Cleveland has gone further than any city in the country in the marshaling of its voluntary community resources, both financial and organization for social service. It has created the spirit of Universal support for those activi- ties which are indispensable to human progress, and there has been capital- ized in Cleveland, as nowhere else, the conception that central direction, study, control and support are as necessary in private agencies created for the prevention and remedy of the evils resulting from social neglect as they are in private business or in the functions of civil government. We have in Cleveland the legal authority, the administrative skeleton for a public health service capable of including all the functions accepted as necessary or desir- able in the interest of health conservation, for the detection or arrest of in- cipient disease, and for education in the principles and practice of health development and protection. What we see in action is but a meager struc- ture, starved by scanty appropriations, occasionally hampered by party politics, only partially serving some of the elementary functions, and in- capable of undertaking others because of lack of heads and hands to plan and carry out the work. Supplementing the public health service of the city and serving many of the functions already assumed by the public authorities in many other places here and abroad we find the private agencies working under a community budget, receiving support by a voluntary self-taxation of the same people who pay the legal compulsory taxes of the city. Roughly speaking, about twice as much money is raised for the services included under health pres- ervation to be spent by private agencies annually in Cleveland as is appro- priated by the civil government for this group of functions. We have, as it were, a democracy within a democracy, an administrator selected by agents serving under unofficial direction, countless human needs, exercising many of the functions of Chief Executive of the city, as well as an elected Mayor. The Mayor of the city has his directors of departments, his technical advisors, his commissioners. 104 Hospital and Health Survey The Director of the Welfare Federation lacks any adequate permanent specialist in the field of health to advise him as to the relative necessities and probable results in preventive medical efforts of private agencies. On the part of the city we have a good plan for a machine, but lacking certain essential parts and without the power to produce results. In the Welfare Federation there is vision, imagination, insight into the needs and sufficient funds to supplement the public service for health, but without a trained officer, a professional student or administrator of health and without a plan for its own future in this field. In order to make the demonstration of voluntary community organiza- tion clear and brilliant Cleveland owes it to itself and to the other great municipalities of the country to assemble within one local public health association all the agencies which in innumerable ways apply the knowledge of modern science to develop health, to prolong life, to prevent disease, to secure in physical and mental happiness all we know normal child and man are capable of. It is recommended: That there be created a Cleveland Public Health Association, which shall include in its membership members of all medical and social agencies which contribute to public health protection, and the governing board of which shall be composed of officially designated repre- sentatives of each component agency or group of agencies. That there be created in the Welfare Federation the position of Secretary for Health, and that this position be filled by one who has had professional training or experience in public health work, preferably a doctor of public health or a physician, and that the functions of such a secretary be to advise the Director and through him the Board of Directors in all plans, expendi- tures, policies and undertakings of the Federation in the field of health and preventive medicine, to make studies of the results of public and private efforts in this field, to plan and carry out demonstrations of health services which it may be desirable to establish permanently under public or private auspices, to cooperate with and in every way to assist and supplement the service provided by the Division of Health of the city. It is believed that unless the above two recommendations are substan- tially met, in spirit if not in the precise form indicated, a large part of the value of the present critical inspection and analysis of Cleveland's hospital and health resources will be lost and the public interest aroused in the course of the very broad contact with many groups of citizens and officers of the city government will be dissipated before action is taken. In order to picture more definitely than we find it understood by many interested citizens of Cleveland, the history, evolution and present functions of the Welfare Federation, the following brief statement is included through the courtesy of the Director: "The Welfare Federation is an outgrowth of the community teamwork evidenced for many years in Cleveland. Public Health Services 105 In November, 1903, the Federation for Jewish Charities was incorporated to collect and apportion contributions for the maintenance of all Jewish charities, the promotion of education, science and art, and the interests of members of the Jewish faith and of humanity in general. The idea of federating all local civic and philanthropic work originated with the Chamber of Commerce. Mr. Martin A. Marks, interested in the Jewish Federation and Chairman of the Chamber of Commerce Endorsement Committee, with the members of that committee, visualized the strategic advantage of conducting an attack on Cleveland's social problems from the vantage point of the "Allied Council" principle. This step followed several years' work of the Endorsement Committee, through which it carefully worked out standards and practices which should govern the organization and adminis- tration of a philanthropic agency. The Federation for Charity and Philanthropy, as the organization was originally named, was formed in 1913 to aid the agencies in the most crucial part of their work — campaign-planning and money raising; to save them from going twice over the same ground, and to give each agency and Clevelanders in general a view of the city's social field and problems as a whole. By 1917 Cleveland had largely lost its small-town view of merely localized institu- tions to be cared for. It had seen how the work of the agencies and the Federation were related and how they must be coordinated if progress for the city were to be made without lost motion or waste energy. Recognition of this broadened vision was evidenced by an enlarged understanding of the social service field and by increased and popularized subscription of funds for social service work. During this time the Welfare Council, a voluntary combination of social agencies and civic bodies, with no budget or executive staff, had been formed to counsel and co- operate with the newly created Department of Public Welfare, as well as to promote social welfare measures and practices among private philanthropic organizations. The merger of the Federation for Charity and Philanthropy and the Welfare Council into the Welfare Federation of Cleveland, in 1917, was a recognition by all concerned that the functions of the two belonged together. Counsel and cooperation between public and private agencies and democratic representation of the social service bodies were thus secured for the benefit of the Welfare Federation and the good of the city when each mem- ber agency of the old Welfare Council was accorded representation by two delegates on the General Board of the new organization. This body, called the General Board, is composed of two delegates from each member agency of the Federation. It hears and discusses policies and plans for new movements, investigates problems, recommends action and elects the active Board of Trustees. The Welfare Federation office became the focal center for cooperation and planning among the social service agencies. It is the larger self of its constituent organizations and serves constituent agencies and the public along two general lines of activity: First: Budget-making and money raising. Second: Social planning, problem study and education. Under the impulse of the unifying motive growing out of the war, Cleveland, in common with many cities, built up a very strong organization which, through united 106 Hospital and Health Survey effort, gathered money for the various purposes connected with the war. This organiza- tion succeeded in securing more than one-third of all the population as subscribers and generous over-subscription on each effort and, greatest of all, these experiences revealed to the community itself a fuller measure of satisfaction and achievement in cooperative effort than the city had ever known before. All distinctions of creed, faith or political affiliation were forgotten in behalf of common ideals and a great collective purpose. Cleveland's habit of working together through its federations and in other civic ways, made it quite . natural that it should preserve this effective piece of machinery created during the war. Accordingly the war organization was continued under the name of the Community Fund, and in the fall of 1919 a campaign was conducted to take care of the current needs of all the social service agencies and to raise Cleveland's quota for un- finished war needs and for national and international organizations having a claim on the city's cooperation. A broad campaign of education and publicity, conducted through the press, the movies, the pulpit and lecture platform, window exhibits, parades and other graphic means of publicity, preceded the campaign. The number of subscribers usually contributing to peace-time enterprises was about twenty thousand. This campaign enrolled 160,000 givers, again more than reaching the goal, which was $3,425,000, the amount subscribed being $4,015,000, For nearly twenty years Cleveland has been studying its social service agencies. In turn it developed endorsing work, the Jewish Federation, the Welfare Council, the Welfare Federation, and finally the Community Fund. While this development had made much progress in the way of budget studies and in the planning of work, each year's experience has shown the need for more definite knowledge and for more intensive effort in the crea- tion of standards.* The city feels a responsibility for meeting the great future which is before it, with as much foresight and vision as is humanly possible for it to apply to these problems." CHARTER PROVISIONS The charter of the city of Cleveland, approved July 1, 1913, in section 69, provides for the election of a Mayor every two years. The City Council, now consisting of 26 members, one councilman from each ward, is elected at the same time. In the council is vested the legislative power of the city, except as reserved to the people by the charter. These are the only elective city officials provided under the charter. Section 78 of the charter provides for administrative functions to be carried out under several departments, the directors of which form the May- or's cabinet — Law, Public Service, Public Welfare, Public Safety, Finance, Public Utilities, Parks and Public Property. Section 82 of the charter provides that the Mayor and directors of the various departments shall constitute the Board of Control. No contracts involving an expenditure in excess of $1,000 can be awarded except on the *Plans for a hospital and health survey began here several years ago. A tentative plan was then drawn up and considered by the Cleveland Foundation. This was the beginning of agitation for a sur- vey. The thing that brought it to the forefront again last year was the number of hospital projects under consideration. As the result of a conference in Lakeside Hospital, the Community Fund wrote the Presi- dent of the Welfare Federation about it and he called a meeting of interested hospital and health workers at the time and out of this developed the Hospital and Health Survey under the auspices of the Cleveland Hospital Council. Public Health Services 107 approval of the Board of Control (Section 124). Section 189 gives the Board of Control authority to fix the number and salaries or compensation of all the officials and employes except the directors of the departments, members of the City Council and its employes, members of the Division, of Police and Fire under the immediate control of the chiefs thereof, and of t the members of boards or commissions in the unclassified service of the city. Section 41 states that the fiscal year begins on the first day of January. On or before the 15th day of November in each year the Mayor prepares an estimate of the expense of conducting the affairs of the city for the following year. This estimate is compiled from detailed information obtained from the various departments on uniform blanks prepared by the Director of 5 <■ sa a MO t) 1 00 |j 8f£"2 « p o a> o"co 3 H- I 2 M P. »" ^ o . ax m 3>x) C H- IB t-" p p 3 c & v. P < W co p a> c* H P p c* P O a* a> a" 3 o>ioit P O P H» c* M c*- O O O O P» 3W 4-!- : 108 Hospital and Health Survey Finance. This is submitted to the council, which, in accordance with Sec- tion 42, prepares an appropriation ordinance, using the Mayor's estimate as .a basis. Provisions are made for public hearings upon the appropriation ordinance before a committee of the council or before the entire council sitting in committee as a whole. These proceedings are public and are pub- lished. Section 83 provides that the director of a department, with the approval of the MayOr, may appoint a board composed of citizens qualified to act in an advisory capacity to the commissioner in any division under his super- vision. DEPARTMENT OF PUBLIC WELFARE A glance at the organization chart of the city government (Figure I) will make it plain that, with the exception of the health functions (educa- tional, protective and constructive) which are served by the Board of Edu- cation, all the public health services of the city of Cleveland fall within the Department of Public Welfare. Sections 81, 97, 98 and 99 of the charter concern us particularly here. Section 81 The Department of Public Welfare is the one to which is entrusted the administration of the public health activities in the city. General Powers and Duties. Section 97 The Director of Public Welfare shall manage and control all charitable, correctional and reformatory institutions and agencies belonging to the city; the use of all recreational facilities of the city, including parks, playgrounds, public gymnasiums, public bath houses, bathing beaches and social centers . He shall have charge of the inspection and supervision of all public amuse- ments and entertainments. He shall enforce all laws, ordinances and regula- tions relative to the preservation and promotion of the public health, the prevention and restriction of disease, the prevention, abatement and sup- pression of nuisances, and the sanitary inspection and supervision of the production, transportation, storage and sale of foods and food-stuffs. He shall cause a complete and accurate system of vital statistics to be kept. In time of epidemic he may enforce such quarantine and isolation regulations as are appropriate to the emergency. He shall have the supervision of the free employment office. The Commissioner of Charities and Corrections shall be the Deputy Director of Public Welfare. Publicity and Research. Section 98 The Commissioner of Publicity and Research shall provide for the study of and research into causes of poverty, delinquency, crime, disease and other similar problems in the community and shall by means of lectures, exhibits and in other proper ways promote the education and understanding of the community in those matters which concern the public health and welfare. Public Health Services 109 Health Commissioner. Section 99 The Commissioner of the Division of Health shall be the health officer of the city, and shall, under the direction and control of the Director of Public Welfare, enforce all ordinances and laws relating to health, and shall per- form all duties and have all the powers provided by general law relative to the public health to be exercised in municipalities by health officers; pro- vided that regulations affecting the public health, additional to those estab- lished by general law, and for the violation of which penalties are imposed, shall be enacted by the council and enforced as provided herein. Public Health Services* THE divisions of the Department of Public Welfare, as, outlined in the charter, are: Health, Charities and Corrections, Recreation, Research and Publicity and Employment. The Division of Recreation has been transferred from the Department of Public Welfare to the Department of Public Service. The Division of Housing has been transferred from the Department of Public Safety to that of Public Welfare. The Divisions now functioning are those of Health, Charities and Correction, Employment, and Housing. There is no Commissioner of Research and Publicity, although a brief experience with the service of the Division of Health shows clearly the sad lack of the functions which such a Commissioner might have been supposed to fill. Inquiry at the City Hall as to why this important charter position was left vacant elicited the reply that such a service would only create jealousy among the departments and commissioners because of the cer- tainty that the "advertisement" would always exploit one at the expense of the others. There seemed to be no conception of the idea that was obviously in the minds of the charter framers that a city government needs to test administrative, social and health measures and must, in honesty to its citi- zens, use systematic educational publicity to interpret its work, its needs, its difficulties'to the people, and to have an organized service free from com- mercial pressure or the warp of special interests. With the right man in such a place the community would double its return on its present investment in its Department of Welfare. The health interests of the city should demand that the position be filled. Among the obvious and desirable services to be rendered by educational publicity for the Division of Health are : (a) Advertising the services of nurses, clinics, dispensaries, health centers and hospitals. (b) Gaining the cooperation of special groups, as tenement dwellers, restaurant proprietors and storekeepers, so that the work of inspection may- be made easier and more effective. (c) Gaining the support of voters for legislative programs on public health and sanitation. (d) Developing a community sensitiveness and conscience in matters affecting the sanitation of environment and the maintenance of personal health. There is no Board of Health and no permanent advisory commission or board upon whom the Commissioner of Health relies for consideration of policies and programs, although Section 83 provides for such. *In the preparation of the following description of the powers, functions and accomplishments of the Division of Health the Survey has received, with the consent and approval of the Commissioner of Health, Dr. H. L. Rockwood, valuable original data from the unpublished records of the Division, collected and written out for the purposes of this publication by Dr. G. W. Moorehouse. Chief of the Bureau of Com- municable Disease, whose services as contributor to the Survey report have been of much value. Public Health Services 111 The Director of the Department of Public Welfare is appointed by the Mayor. The Commissioner of Health is supposed to be appointed and may be removed by the Director in conformity with the civil service pro- vision of the charter (Section 81). As a matter of fact the selection is a personal one and must in practice suit the Mayor. Health Commissioners are not selected on a civil service basis, although the present commissioner could easily qualify in any impartial examination. The commissioner is supposed to appoint all officers and employes of the division, but as a matter of fact he has to accept, in major official, as in the humble positions of inspec- tor or clerk, those sent by the office of the Mayor or by other city officials with the Mayor's sanction. Political interference with personnel in a service requiring so much tech- nical training, depending as it does upon carefully coordinated work of the bureaus and dealing with all the intimacies of disease detection and con- trol and the conditions of living of individuals, is certainly inimical to the best public interests. Just prior to elections and at other strategic moments the weight of political pressure by correspondence and personal notice is occasionally brought to bear upon the personnel of the division. This is an intolerable abuse of party politics. The Commissioner of Health is the executive officer of the division. His duties are to direct, control and supervise the work of the division. For this he receives a salary of $1,700. He is at the same time Medical Director of the Tuberculosis Sanitorium at Warrensville, for which he receives $3,300 a year. The latter position can be filled adequately by a part-time physician if he has the knowledge and experience possessed by the present commissioner. The position of Chief Executive of the Division of Health cannot possibly be filled by a part-time officer. Nothing less than full time, one might say over- time and all the time, can meet the needs of the situation with the insufficient staff and program as at present provided for the Health Division. Except on Sundays and holidays the office of the Division of Health is open from 8:30 a. m. to 4:30 p. m. with its full clerical force. At noon the members of the office staff have one hour off for lunch. From 4:30 to 7:30 p. m. on week days and from 9 a. m. to 12 noon on Sundays and holidays, a desk officer is present to receive calls for district physicians, reports of com- municable diseases, and to make out burial permits. In epidemic periods longer hours may be arranged. Supplies, maintenance, equipment and repairs needed by the Division of Health are secured by requisition and the system of checks and revisions appears adequate to protect the city in emergency, as well as in routine orders. The burden of the system falls upon the commissioner, who is really the bookkeeper of the Division. The divisional store room serves a useful purpose for the stock of standard supplies. An annual inventory, with state- ment of depreciation, is taken as of December 31st for the information and record of the Director of Public Welfare and the Commissioner of Health. 112 Hospital and Health Survey There are, in addition to the Bureau of Administration, which consists of the commissioner and two clerical assistants, the following bureaus: Communicable Disease Tuberculosis, Child Hygiene, Sanitation, Food and Dairy Inspection, Laboratory, Vital Statistics. Under the previous Commissioner of Health a valuable publicity service by a monthly educational leaflet and a question and answer service in the newspapers, was provided by private funds. Budgetary requests for public health education have been struck out of the appropriation ordinances each year. The service of the Bureau of Communicable Diseases for venereal disease control is dependent upon outside support. The Bureau of Child Hygiene does not include prenatal and maternity services, or school medical inspection for parochial schools. There is no housing or institutional inspection service provided, although these functions might be served by an expansion of the bureaus of sanitation and of child hygiene. There is no service for industrial hygiene. Appointments The Civil Service Commission states that the Commissioner of Health and all employes of the Division of Health are under the classified civil serv- ice and in the class known as competitors. (See Amendments to the Char- ter, Sec. 131). However, examinations for physicians and nurses have never been given, and the commission, after investigation, concludes that competi- tive examinations for these positions are not entirely practical. As a result of this decision the clerical positions in the Division of Health and those of sanitary officers are the only ones for which examinations have been given. When a vacancy exists, the list of applicants who have taken the examina- tion is consulted and an appointment is made from this list. Should there be no such list, a condition which often occurs, a vacancy may be filled temporarily, but such appointee must take the examination as soon -as an opportunity offers. Should the applicant fail in the examination and there be still no list from which an appointment may be made, the applicant may be continued in the position. Applications for the position of field nurse must pass through the hands of the Central Committee on Public Health Nurses, a private organization, and be acted upon by this body. This committee consists of a lay and a pro- Public Health Services 113 fessional representative of the Visiting Nurse Association, school nurses from the Board of Education and field nurses of the Division of Health. This procedure is in no way provided for in the city charter or by ordinance. It is entirely extra-legal. The same end would be attained within the law if the Civil Service Commission designated the Central Nursing Committee as examiners of nurses applying for positions in the classified service. The recommendations of this committee are needed in the appointment of visit- ing and school nurses as well as the field nurses of the Division of Health. In this way an excellent type of nurse for these positions is secured. There is no probationary period for employes of the Division of Health and there are no formal reports on efficiency. There is no physical examina- tion given for physical fitness before employment and none are provided thereafter. Except for the sanitary police, who share in the rights of the police pension fund, no employes of the Division of Health have any rights in any city pension fund. All sanitary police receive a complete physical examination, including a Wassermann test. The appropriation for the Division of Health for 1920 is: Bureaus General Administration $ 6 , 650 of which $ 5 , 990 is for salaries. Communicable Diseases 57,010 " Tuberculosis 79,368 " Child Hygiene 80,304 " Sanitation 60,170 " Food and Dairy Inspection 49 , 994 " Laboratories _ 34,468 " Vital Statistics 7 , 029 " 37,800 « it « 74,670 « M U 76 , 774 « it a 51,857 a « (I 48,436 U It (( 31,409 (i (( it 7,029 a U M $374,993 $333,965 or a total appropriation of 47c per capita of the population'of^Cleveland as of January, 1920 (796,836). The per capita cost of the Division of Health varied between 10 and 13.6 cents per capita (usually about 12^ cents) from 1884 to 1898; from 1899 to 1901, 30 to 37 cents; 1902 about 60 cents, the high years 1899-1902 being due to smallpox. The appropriations for smallpox in these years built a smallpox hospital on the City Hospital grounds, a frame building, which was later renovated for advanced cases of tuberculosis. From 1903 to 1910 the expenditures averaged somewhat more than 20 cents per capita. In 1909 smallpox again threatened to become serious and the health office received an appropriation of $50,000. $12,000 of this was used to combat the disease and the remainder to complete the contagious disease building at the City Hospital. In 1913-1919 the per capita cost rose from 38 to 41 cents. The per capita cost in 1915 was 35.7 cents. When it is recalled that a dol- lar in 1920 will buy in terms of service and supplies little more than half what it would in 1915, the absolute increase to 47 cents per capita of the 114 Hospital and Health Survey appropriation really means a decided reduction in public health service as compared with the appropriations before the war which were even then less than half the amount spent by some progressive communities. The city of Detroit has appropriated for the current year's health budget a total of $709,570, or 71.4 cents per capita. This appropriation includes the same services as are provided for in Cleveland's budget above specified with the exception that school medical inspection for all the schools is pro- vided for within the health department in Detroit. If this deduction is made the per capita allowance for functions essentially identical with those provided for in the Cleveland Division of Health will cost Detroit 60 cents per capita. There is a total of 250 employes provided for, of whom 37 are physicians, 45 are from other professions or are technicians, veterinarians, bacteriologists, chemists, etc. 85 are nurses, 31 are sanitary police officers, 40 are clerical assistants, stenographers, typists, etc. 12 are laborers, cleaners, messengers, etc. The eight-hour day is the rule, except for the part-time employes, and for the district physicians who are on call day and night. One day's vacation for each month of service up to a maximum of two weeks' vacation each year is allowed. Sick leave with pay up to two weeks in a year is provided for. Organized care, medical and nursing, for sick employes is not provided, but the district physicians visit sanitary officers for illness, and nurses visit nurses reporting ill. Keeping track of the payroll and absences from work is adequately pro- vided for in the commissioner's office. Administrative Districts There are districts for sanitary inspection, districts for the city (district) physicians, and so-called Health Center districts, none of which coincide with any unit for which complete population data are available. If it is found desirable to continue the use of the three sets of districts as at present, they should be so outlined as to include multiples of the census tracts or sani- tary areas for which population data can readily be made available. As it is at present neither the Commissioner of Health nor his officers know the population, the rates of births, deaths or morbidity for the areas of the dif- ferent districts, although a beginning has been made to collect and tabulate information according to Health Center districts. These are shown in Fig. HI. It is recommended that the city government and private agencies operat- ing field services or serving community needs adopt as the basis for all ad- ministrative districts the. so-called census tracts, or as they are called in Fig. II. Census Tract or Sanitary Area Public Health Services 115 certain cities, sanitary areas. These sanitary areas, of which there are 131 officially designated and used by the Census Bureau for the collection of population data, are sufficiently small to make it possible by assembling such areas to outline administrative districts suitable for all varieties of medical, social and public administration work (see map of city, giving these sanitary areas, Fig. II.). When it is appreciated that all the important data which are used to measure the results of health work, the distribution and shifting of population and the results of all varieties of social effort for the community, are collected and made available through the Federal Census for each of these small districts, the value of operating public and private medico-social utili- ties, according to districts for which all this important information will be easily available for comparison decade by decade, can readily be seen. The administration of the Division of Health is centralized, the main office and the laboratories being at the City Hall. The district physicians receive calls through the City Hall and through the police stations in their district and at night at their homes. The work of the Bureaus of Child Hygiene and Tuberculosis is done largely from and in district offices called Health Centers, which are really branch offices for the convenience of provid- ing diagnostic, educational, nursing and follow-up care, in locations easily accessible to the homes of the majority to be served. Detailed description of the functions and administraton of these centers will be found under the chapters and Dispensaries, Public Health Nursing and Child Hygiene (Parts X., IX. and III.) Although the use of these district centers for tuberculosis and infant wel- fare work was an innovation in the administration of the Cleveland Division of Health, neither the principle nor the methods constitute an important step in health administration except in the feature of having the nurses from the two bureaus serve all public health functions in their districts regardless of the bureau to which they are credited on the payroll. Concerning this im- portant and controversial type of public health nursing service, detailed discussion will be found in the appropriate chapter on public health nursing. (Part IX.). For the work of the Bureaus of Tuberculosis and Child Hygiene the city is divided into seven districts with "Health Centers." These are housed in dwellings, apartments or ground floor store rooms. Historically these were originally tuberculosis dispensaries, each with its staff of a doctor, a super- visor and a group of nurses. At present each has in addition a baby's prophylactic dispensary with its dispensary physician, five have offices for a district physician, and three have dental equipment. The nursing service is generalized. There are eight baby's prophylactic dispensaries, in addition to the seven in Health Centers, or a total of fifteen. A portion of District 2 is set off from the remainder as a teaching center for Public Health Nursing, under the direction and supervision of Western Reserve University. There is no district physician or tuberculosis dispensary assigned exclusively to this territory, a baby's dispensary is located in it, however. The nursing service for this territory, containing about 9% of the 116 Hospital and Health Survey city's population, is given by the staff of instructors and pupils of the Uni- versity at no cost to the city. It is commonly referred to as "University District," or District 8. Fig. HI. shows the location of the offices and dispensaries in each health district which provide for prevention of disease or for treatment of the sick. (The area omitted at the east end of District 6 does not contain any of the facilities considered.) Fig. IV. shows for each health district: 1. The estimated number of expectant mothers under prenatal care per 1,000 births. 2. The birth rate per 1,000 population. 3. The rate of still-births per 1,000 registered births. 4 and 5. The death rate of infants under one month and under one year per 1,000 registered births. 6. The number of babies reported for the first time at the baby stations per 1,000 children under two years. All these figures are for a period of twelve months in 1919-20. Table I. in the appendix gives by health districts for the year 1919-20 important information concerning births, by sex, nativity and character of professional attendance at the birth. Table II. gives for each health district for the year 1919-20 an analysis of all deaths by race, under one year, and for the diseases upon which the so- called sanitary index is calculated. Conferences The Commissioner calls an advisory committee occasionally, usually in the presence of emergencies. The Commissioner has obtained valuable assistance from conference with a committee of druggists in determining policies and action in the control of sale of patent medicines. The Commissioner holds no regular conferences with the chiefs of the bureaus of his division. There have been a few conferences held by the Commissioner during the past year with the physicians on tuberculosis clinic duty, and with the directors and supervisors of field nurses engaged in this work. There are weekly meetings held by the Director of Public Health Nursing of the Division which all the nurses are expected to attend. They discuss their work and occasionally have professional matters presented to them by speakers from outside the division. Library There is no library or collection of public health literature or reports or professional publications kept in the Division of Health. The Municipal Public Health Services 117 118 Hospital and Health Survey Public Health Services 119 Reference Library, which is situated on the fourth floor of the City Hall, contains considerable public health literature, however, and is available for reference. Legal Action Each bureau of the Division of Health from which prosecutions originate handles these prosecutions without any uniform method of reference to the Commissioner. The number of convictions or the failure to secure convic- tions is not indicated in the report of the bureau chief to the Commissioner. All legal action taken as a result of the activities of any bureau might well be handled by a single officer or through a centralized service in the Bureau of Administration rather than in the present way. Sanitary Code In March, 1908, a sanitary code was adopted and published covering many of the important provisions of law necessary to permit control of nui- sances, of communicable diseases, of meats, milk, dairy and other food products and food stores, of housing, of disposal of the dead, ice, public conveyances, spitting, barber shops, etc. Recently a revised and modern sanitary code has been adopted which gives authority and defines sanitary standards in substantial agreement with modern practice. During the past several years (since 1913) there has been an interval since the former code became inoperable under the law and until the recent enactment of the revised code there has been great and at times insuperable difficulty met by the Division of Health in enforcing the essential requirements for sanitation and disease control. As long as the rules and regulations under which the Division of Health must operate and which are the basis for its legal action to abate nuisances, require reports of births or registry of midwives, or to control the persons or premises where com- municable disease is found, are passed or enacted only by the council of the city, there will be much waste of time and effort in persuading these rela- tively uninformed and uninterested laymen of the essential needs for good public health administration. A charter change should be made which would permit of the writing by the Commissioner of Health, assisted, by an advisory commission of physicians and sanitarians, of rules and regulations dealing with protection of public health, such regulations to have the force and effect of city ordinances as do those now enacted by the council. Filing Each Bureau of the Division of Health maintains its own filing system; that of the Commissioner and those of communicable disease, tuberculosis and vital statistics being kept at the central office. Each health center has a record of all families for whom work has been done by the nurses and a medical history with nurse's notes of those patients who have visited the tuberculosis dispensary. 120 Hospital and Health Survey 1917 — Death Rate per 1,000 Population. Figures based on population as estimated by the Bureau of Census for the year 1917. NEW ORLEANS DETROIT PITTSBURGH WASHINGTON TOLEDO NEW HAVEN PHILADELPHIA BOSTON CINCINNATI BUFFALO LOUISVILLE DAYTON PROVIDENCE ROCHESTER SAN FRANCISCO ST LOUIS CHICAGO JERSEY CITY COLUMBUS NEWARK NEW YORK LOS ANGELES DENVER MINNEAPOLIS 19.9 19.0 J18.2 Fig. V. Public Health Services 121 Morale In spite of the handicaps indicated in the brief description above there is evident, particularly among the physicians, nurses, inspectors and laboratory workers of the Division of Health a spirit of devotion and enthusiasm, a true morale which speaks well for the unselfishness in the leadership and direc- tion of the work. Although more could be done with improved organization and additional personnel there is being given to Cleveland by those consti- tuting the modest force of the Division of Health a quality of service out of proportion to the remuneration and public support accorded them. There is herewith presented in Fig. V. in graphic form the death rate for each of 25 cities in the United States for the year 1917 from the figures of the Bureau of the Census, the last available. Cleveland will doubtless wish and undertake to attain a higher relative position. No municipality wants to be merely in the middle of such a series. To be number thirteen when there are twelve better places to fill is a chal- lenge to the energy and capacity of the city's Division of Health. 122 Hospital and Health Survey The Bureau of Communicable Disease Authority and Scope ORDINANCE No. 32846-B, passed by the council July 13, 1914, and amended chiefly with respect to influenza and influenza-pneumonia, September 5, 1919, provides: that there be created in the Division of Health a Bureau of Communicable Disease. The function of the bureau shall be to prevent the transmission of communicable diseases, perform disin- fection, establish and maintain quarantine, and to perform such other duties as shall be deemed necessary for the prevention and control of epidemics. The Chief of the Bureau of Communicable Disease shall be a graduate of medicine, shall act as the medical consultant of the Division of Health, and shall direct the activities of the bureau. Under the direction of the Com- missioner of Health the work of the Bureau of Communicable Disease is carried on by the following: a chief physician (Chief of the Bureau), seven senior physicians (district physicians), with the assistance of a sergeant and five sanitary officers, nurses and typists. The Chief of the Bureau supervises the activities of the Division of Health in the control of communicable dis- ease, examines for diagnosis suspected cases and makes personal investiga- tion when difficulty arises in the establishment of quarantine. In the past smallpox has very frequently demanded a large part of the time of the Chief of the Bureau. In epidemic periods he has commonly investigated all cases of cerebro-spinal meningitis or infantile paralysis or assigned the same to others for investigation. The revised Sanitary Code gives adequate authority for the control of the acute communicable disease within the City of Cleveland and on vessels arriving in the harbor of the city. There is no subdivision for venereal diseases, but one is under considera- tion and provision is made for such a division in the budget prepared for next year. For details of the needs and suggested organization and functions of such a subdivision of venereal diseases see the report on venereal disease, Part V. The control of communicable diseases in animals is vested at present in the Bureau of Food and Dairy Inspection, because there are veterinarians included only in the personnel of this bureau. It would be in the interest of good organization to have the veterinary work in connection with communi- cable diseases as well as the care and treatment of human rabies included within the Bureau of Communicable Diseases. It is probable that, with the expansion of the scope and usefulness of the Division of Health, preventable diseases of occupation or industry, prevent- able diseases of habit, such as narcotic addiction, and the control of pre- ventable mental diseases will all be included together with tuberculosis and venereal disease, under a Bureau of Preventable Diseases, each large sub- group being dealt with in a special subdivision. All the group diseases, the communicable in man and animals, as well as the non-communicable which Public Health Services 123 come under the term preventable, require the study of experts in epidemi- ology and the constant research of trained technicians in the laboratory sciences. The kind of high grade research and direction needed in this field can be obtained or justified only if there is a consolidation of the services coming under a bureau dealing with all preventable diseases. Of the list of diseases for which report is required impetigo contagiosa, pemphigus neonatorum, tinea and scabies, might be omitted without any loss of service to the public. It is believed that there should be enforcement, with penalties for failure to report, until there is something approaching com- plete reporting of the more important diseases. No additions to the list are suggested. To forbid those infested with scabies or afflicted with impetigo or tinea to mingle in any way with the public has about the same effect as good advice given in doctors' offices, but unless there is an attempt to enforce such regulations they are better omitted from the body of the law. The following provision of the Sanitary Code is extreme and its enforce- ment is not justified without liberal qualifications. It is often disregarded and should be modified. "No superintendent, principal or teacher of any public, parochial or private school or other institution, nor any parent, or other person shall permit any child having any communicable disease or any child living in a family where such a disease exists, or has recently existed, to attend school until the Division of Health shall certify in writing that danger from infection has been removed by recovery, removal or death of the patient, and disinfection has been made according to the requirements of the Division of Health." Control of undertakers by license and regulations governing their pro- cedure in the case of deaths resulting from certain communicable diseases Would be better than requiring the presence of a sanitary officer at the burial. Such extreme precaution applied to bodies after death is out of proportion to the risk. "Every undertaker receiving notice or being called upon to prepare for burial the body of any person who has died from smallpox, scarlet fever, diphtheria, membranous croup, infantile paralysis, or cerebro-spinal meningitis, shall within twelve hours after receiving such notice or call, notify the Division of Health of the time of burial, and such burial shall not take place without the presence of a sanitary officer." It is not the corpse but the undetected, the early, the carrier case about on his feet, who spreads disease. The following requirement is superfluous if the casket is tight, as required in another section : "No undertaker shall use any vehicle other than a hearse for conveying the body of any person who died from any of the following diseases: Acute Poliomyelitis (infantile paralysis), Cerebrospinal Menginitis, Asiatic Cholera, Diphtheria, Influenza or Influenzal Pneumonia, Dysentery (Amoebic or Bacillary), Plague, Scarlet Fever, Smallpox, Yellow Fever." The regulations for the isolation period for the various diseases are in process of revision to correspond with the standards recommended by the American Public Health Association. These regulations will make some 124 Hospital and Health Survey changes in procedure, the most important of which are : placarding solely by the sanitary officers; instruction, the granting of permits and the lifting of quarantine solely by the nurses acting as quarantine officers. Reporting of Communicable Diseases Cleveland physicians have for many years been furnished stamped postal cards for reporting communicable diseases to the Division of Health, but under the Griswold Act they have recently received books of franked cards (with stub) for this purpose. By far the largest number of physicians' cases are reported by telephone. Before quarantine is instituted in reported cases of smallpox or of chickenpox in adults (over 13) the case is investigated for correctness of diagnosis by the physician of the Division of Health acting in the capacity of diagnostician. The following cards are used at, or turned in at the Communicable Dis- ease desk: The "telephone ticLef'is for immediate entry of all reported cases. It provides for the disease, the date reported, how reported, the address and name of patient, the physician and his address, the officer carding, the date carded and remarks. The "quarantine officer's report" provides for a report on all the data mentioned above with several additional items, as: date of onset, names of other members of the family if found sick, milk supply, library books, water supply, number of children and adults in family, number attending school, what schools, where carded, where adults are employed, the number of rooms in house, etc. The "street file" provides for the name of the disease, the case number, the address, name of patient, occupation of parents, name of attending physician, name of officer who imposes quarantine and who later releases from quarantine, number of school permits granted, removal to hospital. Dates : of report, of quarantine, of receipt of convalescent slip, of commencing convalescence, of death, of release from quarantine and of disinfection. The "nurse's card" provides for a report of essentially the same facts as those asked for on the quarantine officer's report card. All homes quaran- tined for diphtheria and scarlet fever are visited by public health nurses and this card is made out for each. The "convalescent ticket" is left in the home so that the attending physician may give the Division of Health the date of beginning convales- cence. The "convalescent card" is made out upon the receipt of the convalescent ticket and filed under the street address. The work and school permits are given to adults and children released from quarantined premises during quarantine and to the patient and others at the end of quarantine. Public Health Services 125 The report of the sanitary officer of various types of work performed: Disinfection, attendance upon private funerals, spraying, enforcing quaran- tine, etc. The record of eye cases received. • The cards described are used as follows in the quarantined diseases: all telephone tickets are taken by the sergeant in charge of sanitary officers assigned to the bureau and given out to the officers for placarding. The name of the officer having the assignment and the date the case was carded is entered upon the ticket. The officer cards the house, front and rear entrances, or if an apartment or hotel, the entrance of the apartment, tells the family the precautions to be used in keeping quarantine, grants or withholds work permits as circumstances require, and fills out the quarantine officers' report. The sanitary officers receive their work at 8 a. m. at the office. They call in from their districts at noon and again at 4 p. m. for work which comes in later in the day. In District No. 1 and in the University District the nurses act as quaran- tine officers, placard houses, give permits and make out officers' reports. In all districts the nurses visit all cases of diphtheria and scarlet fever to give instructions in the care of the patient in quarantine and for diphtheria to take cultures of all who may be released from quarantine. The quarantine officer's report having been returned to the desk is matched with the telephone ticket to verify the completeness of the work and from them the street file is made out. The telephone ticket is preserved; the quarantine officers' reports for each disease are numbered consecutively for each month, putting two or more numbers on a card, provided more than one case is found in the home; the street file cards are filed by address, a separate file being kept for diph- theria. The results of all cultures taken to release from quarantine in diph- theria are entered on the backs of these cards. The work and school permits need little explanation. They are given to adults and children who may be permitted to work or to go to school during the period of quarantine, and, school permits particularly, to the patient and others who have been kept under quarantine until its termina- tion. Convalescent tickets are not used in diphtheria, the patient being released on culture. When a physician reports a case of diphtheria he is asked if he desires to have nurses take the release cultures, and almost invariably replies in the affirmative. When his consent has been secured the health center in which this patient is located is notified and eight days from the reported onset of the disease culturing is begun. In measles the date of appearance of rash is noted by the officer and the ticket returned to the desk; in scarlet fever the ticket is not left in the home but is mailed to the physician; for other quarantined diseases it is left in the home for the signa- ture of the physician. 126 Hospital and Health Survey The public and parochial schools and the public library receive daily notice of the names and addresses of all cases of diphtheria, scarlet fever, smallpox, epidemic cerebro spinal meningitis and acute poliomyelitis. Any library books found in the homes in which one of the above diseases is quarantined are brought by the sanitary officer to the city laboratory, disinfected and returned to the library . The physician in charge of the contagious wards at City Hospital, having reported that many cases of diphtheria admitted to the hospital indicate by their history an entirely inadequate use of antitoxin, a slip giving suggestions for the administration of antitoxin in cases of diphtheria is inserted in all physicians' culture outfits. Within the past two years an attempt has been made to determine the susceptibility of children in institutions to diphtheria by the Schick test and to provide immunization of those found susceptible, by the use of toxin- antitoxin in three injections at intervals of one week. This has been done on several thousand children with satisfactory results. By preference the institution is "Schicked" when the disease is not present. However, if con- sent has not been secured before this, study of the children is made on the occurrence of cases. Plans for making this procedure available to all Cleveland children are under consideration. S:yiallpox Cleveland has a large unvaccinated population and as a consequence smallpox is a problem much of the time, as indicated by the number of cases handled in the past five years— 1915, 45; 1916, 204; 1917, 661; 1918, 1,120; 1919, 232. Fortunately the disease has been present in the very mild form and has caused no deaths. In a thoroughly vaccinated population there would be no smallpox problem, but the only time when Cleveland has had a practically vaccinated population was eighteen years ago, when the presence of the disease in a severe form led the Chamber of Commerce, the Board of Education and the other groups of laymen to get solidly behind the Commis- sioner of Health in this matter. Notwithstanding the provision of the communicable disease ordinance that no unvaccinated child may be in school, our children are not completely vaccinated. Out of 105,000 unvaccinated children in the public schools in the year 1917-18, 101,000 were vaccinated by school physicians; 3,600 were permitted to attend school on receipt of a sworn statement from the parents that they were opposed to vaccination, 400 on doctors' certificates and 14 were excluded. The parochial schools, having no medical supervision, have presented greater difficulties than the public schools. Within the past year the bureau has vaccinated in about half the parochial schools, including most of the largest of these, and this work will be pushed the coming fall. The district physicians report 12,629 vaccinations in the year 1919. Public Health Services 127 On the occurrence of a case of smallpox all exposures in the household are vaccinated, all contacts in shops and factories, if the patient had been at work after the onset of his illness and all pupils and teachers in schools for either direct or indirect exposure. The influx of Southern Negroes accounts to a very considerable degree for the recent cases of smallpox in Cleveland. Arrangements have been made to reach certain of these who enter the city in groups and vaccinate them before they begin their work So much for the authority, the system, the method, and all based in the main upon sound medical opinion, except that so-called disinfection by gaseous fumigation is probably valueless and an unnecessary expense. In cases of smallpox, and where deaths from tuberculosis have occurred in tene- ments, disinfection to precede thorough cleansing and renovation of walls and painted surfaces is probably a wise precaution. Results What of the results? To what extent is reporting uniform and observed conscientiously? Are isolation and placards respected? What is the effect on the incidence of the reportable diseases? Table III. in the Appendix, studied in connection with the reports of deaths in the table of so-called endemic indices, Table IV., discloses the obvious and general incompleteness of morbidity reports. The results of administrative measures directed to the control of the communicable diseases should be shown in a reduction in the number of cases and in the percentage of deaths among the cases that do occur. The incompleteness of reporting of cases,the margin of error in diagnosis and in statements of cause of death make any conclusions as to the numerical in- crease or decrease in communicable diseases and deaths from them of doubt- ful value. However, in the absence of any particular change in the attitude of physicians with regard to reporting and of new or unusual efforts by the Division of Health to enforce reporting by physicians, we may assume that the fluctuations in numbers of cases reported represent bona ride variations in incidence, but not the total incidence. Similarly in the absence of any specific or new and accurate criteria for establishing diagnosis among these diseases, the reports of deaths in this group of diseases in which the clinical picture is fairly typical, probably may be considered quite reliable. No at- tempt will be made here to calculate the case mortality percentage of com- municable diseases in Cleveland, as such studies would extend the report out of all relation to its particular object and immediate uses. Such infor- mation should be presented in the annual report of the Commissioner of Health. For those who are professionally trained to read and understand the significance of and the relative merit in the use of the so-called Sanitary Index and of the Endemic Index a chart and table are prepared from data obtained from the Chief of the Bureau of Communicable Disease. (Fig. VI. and Table IV.) 128 Hospital axd Health Survey n w C O a z <■ a Hi E > !§, N hJ *> U 3 i 8 a £ B i— i S ►< < £ < c J. El, 1 ■ w~ * J y 3 ^ 1 / c / / / I t \ 1 % * \ » 1 4 / ' / 1 1 \ \ / 1 1 f * k N / / 9 / / • 1 • \ / k fl & +» / CO © \ 3 rH © * \ OS to / / / E-f 1 1 \ 1 1 1 • / 1 . / i /* /' 1* / / f * C *. %. 4 n» 1 1 *N. / — * i i e e Public Health Services 129 DEATHS IN CLEVELAND FROM ALL CAUSES AND FOR DISEASES ON WHICH THE SANITARY INDEX RATE IS CALCULATED, PER 10,000 POPULATION (Rates corrected according to population estimates based on 1920 census returns) Year. 1910 Population 564 , 066 Total Deaths 8,703 Sanitary Index Deaths 3,414 Year... 1915 Population 683 , 416 Total Deaths 9,534 Sanitary Index Deaths 3 , 280 1911 1912 1913 1914 587,936 611,806 635,676 659,546 8,545 8,769 9,454 8,980 3,204 3,032 3,503 3,193 1916 1917 1918 1919 707,286 731,156 755,026 778,896 10,719 11,623 13,882 10,616 3,425 3,956 3,496 3,105 143 135.5 134.3 139 125 129.5 141 148.5 173 127.5 lllllllllB Year 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 Year Fig. VII. The proportion of total deaths due to the group of communicable diseases and causes of death under one year upon which the so-called sanitary index is calculated, is represented by^the shaded lower portion of the column for each year. 130 Hospital and Health Survey ID G u rt O & 13 C 3 & a. c Oh H3 nt ^ C- H rH ^ to O Z> O H O r-H o a> O Oi O rH »H ***w^ O o O 1 O CO H rH CD to •H Sn rH Sh-P © «H ftH PhO © © *& P *X5 p> © CO £ OS rM K as c« © rH +3 £ © .d ra -P > -P -H 05 © as bO © rH © © PO PCS < PQ pq S fr-39lf"~ 9' 0*1 I 8'SSll S'9 PQ e-sn •oi[] PQ 9*6i S'6I Jg CQ 6*091 I t> t- r-\ rH o> a> rH r* o O 1 o o O ra o ra o O © o © * *»iH •^■p o O P O OS o O >H O-P rH • rH O r-i ra J> U H h'O wa © CT» © © © © &rH OiJh P.Sh . © © © ' © -P ©■p •P 'd ■P ra -p ra 05 fj a5 -h as tH ft; as K bO K bO rH © © & © si U ^t r. •p > •P ■P cfl © 05 H as r-\ © r-\ © t-A © rH PO P«* P CQ «l H* CD CO o CD CD p* ea CD 09 CO CD CDH3 Pi CD CD 05 u CD p p* m pi CD O CD CD rr g pj CD o CD CO c+ CD CD >d Di CD CD o CD Pi CO c+ H» \-> CDg° tO 1 i v£» 95.5 1 92.2 5.2 cn 8 |, 79.5 .6 01 1 67 -* 150.4 00 ^^ 1 43.2 w 1 39. ft *■ 1-37.5 H 137.0 Cn 34.5 31.8 CD CDfiotO | 4i.i h 1 40.6 o> J 36.0 Cn 32.2 c 1 28.1 27.0 23 • 8 Fig. XI. - 1: ^ 120.0 134 Hospital and Health Survey tco 9 o O © Mc* £ M H» HO J» O ffl « C 4 c+ p"o tr o » ® o 4 • w » OO O < oa £ o HCF5 ►* (5 p*% H- OOl » O Offl c* 9 Om p* • <— 'W B <-* O Q a <5 ►d 4 e+p P He* HHOpT CD Op (A H» O »"> OH- oofrio 1 -a J 119. M J118.2 u\ 1 101.8 a> J 92.5 W 83.7 *. 83.6 ] 143.4 Fig. XII. Public Health Services 135 Fig. XIII. *The narrow eastern portion of District Six has been omitted. A— Deaths from scarlet fever, whooping cough, measles and diphtheria per 100,000 population. B— Deaths from pulmonary tuberculosis per 100,000 population. C— Deaths from pneumonia (all forms) per 100,000 population. D— Deaths from diarrhea under 2 years per 100,000 population. 136 Hospital and Health Survey Fig. XL illustrates the relative position of the health districts as measured by registered births and deaths. Fig. XII. shows an analysis of death rates from all causes and from vari- ous communicable diseases, by health districts. Most of the same data are presented on Fig. XIII. , a map of the city divided into health districts. The reader is referred to parts IV. and V. for complete discussion of the incidence and sufficiency of methods for control, and the results of public health service in tuberculosis, syphilis and gonorrhea. The accompanying table, quoted from the annual report upon typhoid fever in the large cities of the United States, published in the Journal of the American Medical Association, Vol. 74, No. 10, page 673, shows Cleveland's enviable position resulting in all probability more from the chlorination after filtration of its water supply and the general pasteurization of its milk supply than from other causes. Death Rates from Typhoid in Cities of Group One {More than 500,000 Population) DEATHS FROM TYPHOID PER 100,000 POPULATION Average Average Average 1919 1918 1916-1919 1911-1915 1906-1910 Chicago 1.2 1.4 2.7 8.2 15.8 New York 2.0 2.2 3.7 2.5 3.4 2.8 8.0 8.0 13.5 Boston 16.0 Cleveland.. 2.4 4.7 4.9 10.0 15.7 Philadelphia 4.4 3.0 5.3 11.2 41.7 Detroit 5.3 10.0 12.0 18.1 21.1 St. Louis 5.8 7.2 7.5 12.1 14.7 Pittsburgh. 6.2 9.8 8.9 15.9 65.0 Baltimore 8.9 12.2 13.6 23.7 35.1 Cleveland's relatively high death rate from diphtheria (Fig. VIII.) as compared with other cities and states may in part be attributed to the lack of any services of a skilled intubator for patients coming to the care of the district physicians and the unusual indifference of the general practitioner to the importance of early and adequate use of diphtheria antitoxin for therapeutic purposes, on clinical diagnosis or on reasonable suspicion with- out awaiting positive laboratory confirmation. The experience of the City Hospital contagious service and of the consultants in pediatrics in the city are full of instances where lives were sacrificed by the inexcusable delay in the use of this specific therapy. It is recommended that a physician skilled in intubation be employed by the Division of Health to be available on call for emergencies in diphtheria, and that the Division of Health undertake, through Public Health Services 137 the Academy of Medicine and directly with the practising physicians, edu- cation in the advantages of diphtheria antitoxin and the dangers commonly resulting from delay in its administration. With the exception of rabies none of the animal diseases require par- ticular mention here, since tuberculosis in cattle is guarded against by ade- quate meat inspection and by the compulsory pasteurization of milk. The situation of rabies control is bad, owing to the lack of an ordinance requiring muzzling, and the lack of enforcement of the state dog licensing law. The most valuable agency in controlling rabies in Cleveland is the Animal Pro- tective League which maintains an active collection service for the removal of stray dogs. The diagnosis of rabies in animals and man and the protective treatment of those bitten by rabid animals are provided according to good modern standards by the Bureau of Food and Dairy Inspection. The cost of treat- ment is provided by the county commissioners. Inadequate Supervision of Quarantine In Cleveland as in many municipalities there is frank criticism of the futility of official attempts at quarantine. Responsible physicians and nurses report that keeping of quarantine in Cleveland is so unusual that a family who does keep it is cause for much comment and no little surprise. Instances of inadequate supervision and a lack of firmness or conviction in enforcing regulations are quoted from case reports obtained by the Survey. E. G., Portland Avenue, was quarantined for diphtheria August 23, 1919. This report was telephoned to the Division of Health the same day, "Patient ill in room off kitchen. Comes into kitchen frequently. Family upstairs come and go through this kitchen whenever entering or leaving house. Patient's mother refuses to keep quarantine." Division of Health promised to force child into hospital, but did not. The first release culture was taken September 8th, and as the child was a diphtheria carrier, quarantine was continued for a long period of time; the sign finally being removed Septem- ber 23rd. During this period the woman tore down the sign and went out. This was reported to the Division of Health. The woman and child with positive culture went to market and were absent when the nurse went to culture. A report of this was made to the Division of Health and as far as results were concerned, the nurse might just as well have saved the time she spent in telephoning. Mrs. P., Scovill Avenue, was quarantined for diphtheria September 17, 1919, and family was cultured on same date. She herself had a positive culture which held so for some time. The sign was taken down October 3rd. On the 25th of September the nurse went to culture and found patient with positive culture at church. The nurse returned in the afternoon and was told by patient that as she was not sick there was "no need of such a fuss." This was reported to the Division of Health with the result that on the 29th, when the nurse returned for another culture, the house was closed 138 Hospital and Health Survey and the door was padlocked on the outside. This, too, was reported to the Division of Health with such good effect that the woman was out again on the 30th and neighbors said she was at the store and not expected back for some time. A diphtheria sign was put up September 19th on the house of Mrs. F., Scovill Avenue. The sign did not come down until October 8th, as the child here was a carrier also. The family made no pretense of keeping quarantine and the Division of Health was informed. The next time the nurse saw the woman she was selling fruit from a stand in front of the house and the child, with a positive culture, was with her. This was reported to the Division of Health and the child remained in the home. The following notes from a nurse's record indicate some of the reasons for lack of confidence in quarantine. "These cases of diphtheria are typical of our present system. One and all of these families said nonchalantly, when found breaking isolation, 'Nobody does any different,' or 'Mrs. So and So had a sign on her house and she didn't do any different, so why should I?' And when one discovers that in a tiny section, with a popula- tion of 12,000, between the months of September and December there were twenty-seven families (under so-called quarantine for diphtheria) who ran wild with no more serious result than a visit from a sanitary officer, can one wonder either at the unconcern of the families or the prevalence of the disease this winter?" And why must there be such a delay in getting orders to remove diph- theria signs when the cultures have proved satisfactory? In at least a third of these cases the report of the culture comes to the nurse two or three days before it reaches the authority in the Division of Health whose business it is to order the signs removed. Verified instances of failure to observe quarantine were obtained in a brief period in January, 1920, in the case of the following diseases: Diphtheria 14 instances Whooping cough 15 " Mumps 5 Chickenpox 1 " Scarlet fever 1 " The district physicians of the Division of Health find the situation very unsatisfactory, the warnings or threats of sanitary police and nurses failing to produce any substantial results. Firmness, tact and a consistent policy should remedy this. SERVICE OF DISTRICT PHYSICIANS Organization There are seven full-time district physicians employed by the Cleveland Division of Health under the Bureau of Communicable Disease. One of them acts as Assistant Chief of the Bureau and one handles only cases Public Health Services 139 of drug addiction, leaving five to cover the district work. These physi- cians receive $3,300.00 a year and are required to provide their own auto- mobiles, telephone service and physicians' bags. They are furnished with drugs and surgical dressings by the Division of Health. Each physician is assigned to one of the following five districts : District One is the entire West Side, exclusive of a small portion of the so-called South Side east of West 14th. District Two is the East Side, from the river to East 71st Street, north of Euclid Avenue; District Three extends from Euclid Avenue, on the north, to the city limits, and from East 55th Street to West 14th Street. This district includes the congested area of the city. District Four extends from East 71st Street, on the west, to the city limits in Collinwood (East 200th Street), to the south side of Euclid Avenue west to East 55th Street, from there to Quincy Avenue and east to the city limits. District Five extends from Quincy Avenue and East 55th Street south and east to the city limits. These districts have different boundaries from those of any other administrative districts used in public or private health work. Duties The duties of the district physicians are to care for the sick poor, investi- gate suspected cases of communicable disease and to make vaccinations, etc., under the direction of the chief of the bureau. They are not permitted to do any obstetrical work or any major surgery. They are, further, not expected to treat in their homes the more serious diseases, such as pneu- monia, typhoid fever, heart disease or nephritis, but to refer such cases to hospitals when possible. Many ambulatory cases are properly referred to the dispensaries of such hospitals as Lakeside, Mt. Sinai and Charity, where the facilities for diagnosis and treatment are better than those at the command of the district physicians. Method of Receiving Calls Calls for the services of the district physicians come to them in a variety of ways; their names and addresses are known to the police of the city, and the number of calls which they receive from this source is considerable. This applies particularly to night calls. They are reached by people needing their services in exactly the same way that private physicians receive their calls, through the advice of friends and neighbors who give their names and addresses. They are also called by public health nurses, by the Visiting Nurse Association and by other agencies. The greatest single source of calls, however, is to be found in the call book kept for district physicians at the Division of Health. It is impossible to determine exactly the relative num- ber of calls from the different sources. As fair an estimate as can be made is that about one-third are received from other sources than the call book. Offices Each physician is provided with an office at the health center in his dis- trict, where he keeps supplies and where patients may go to see him. The office work of the district physician is, however, comparatively small. 140 Hospital and Health Survey Records The Division of Health has never required district physicians to keep histories of their cases. Monthly summaries are required and these are made up from records kept in a pocket note book. From these entries the physicians are expected to be able to tell their diagnoses and the disposition of the cases assigned to them. As a test of their ability to report such essen- tial facts they have been asked from time to time in their conferences to report upon cases selected at random from the call book, and the chief of the bureau has found them able to do so. Supervision The work of the district physicians is under the general direction of the Chief of the Bureau of Communicable Disease, although in actual practice there is very little supervision of their work in the homes. Weekly staff meetings are held, except during the summer months, and at these meetings matters of seasonal interest are discussed, and the district physicians are free to bring up special cases for conference. Volume of Work A table showing the volume of the activities of the different district physi- cians for the year 1919 will be found in the Appendix (Table VI.) It is obvious that the amount of work of the different physicians varies greatly. This may be accounted for partially by the character of the dis- tricts themselves (for example, District Three, which shows the highest* num- ber of calls, includes the most congested and poorest area in the city), par- tially by the distances necessary to cover in making calls, and partially, no doubt, by the diligence of the individual physicians. The average of calls per case varies from one in District Five to 3.8 in District One. If an average of two calls per patient be accepted as a stand- ard, two districts (Three and Five) fall below, two districts (Two and Four) are practically equal and one district (number One) is well above the stand- ard. The number of vaccinations varied greatly, District Five having reported over ten times as many as District Two. It is interesting to note that the highest number of vaccinations was recorded in the district where the aver- age number of calls per case was the lowest. According to the records the physicians vary greatly in referring cases to agencies. The physician in District Two reports no use of agencies other than hospitals and dispensaries. The physicians in Districts Three and Five show good cooperation with the nursing agencies. The variation in the amount of work reported raises the question of the desirability of redistricting the city. Public Health Services 141 Summary of Complaints of Service By various social and charitable agencies: 1. There were seven sources of complaints because service was not prompt. One agency stated that delays of two days or more occurred; another that calls were sometimes never answered. Five agencies stated that the service was prompt. The difference in localities could easily ac- count for this discrepancy. 2. Six agencies complained of the lack of continuity of care, the general consensus of opinion being that calls were not repeated sufficiently often unless pressure was brought to bear on the physicians. 3. There were two complaints of brutality; one of superficial work; three of difficulty in getting in touch with physicians; one of lack of physi- cian's understanding of foreign language; one of lack of sufficient home instruction being given. 4. All agencies joined in saying that the district physicians were willing to give medical information to cooperating agencies, although one complained that the physicians' records were so inadequate that details of cases were not available. By district physicians themselves: The district physicians themselves seemed to feel a lack of thorough supervision of their work and a failure of cooperation by the Health Divi- sion. They expressed a need for standard instruction; for more systematic information as to changes in procedures or policies of the Division of Health, City Hospital and other agencies ; and in general a lack of sympathetic rela- tionship with the chief of their bureau and the Commissioner of Health. Other needs brought out by the physicians themselves were: for a con- sultant on their cases; more adequate case histories; a more comprehensive drug formulary; provision of bottles for dispensing drugs; smaller districts or a redistricting of the city. One physician felt that his work was hampered by the fact that he had no command of foreign languages; another felt a great lack of appreciation among the foreign population. RECOMMEND A TIONS It is recommended that: District physicians be appointed for a definite term of service, with a limit to the number of terms permitted on re -appointment. Appointments be made after examination, written and oral, by a special committee of physicians appointed for this purpose (from the Academy of Medicine if possible). 142 Hospital and Health Survey There be a special night service rotating through the staff or assigned to the junior members for certain periods. Ambulatory cases be excluded from care, such cases to be referred to the appropriate dispensary, and not treated at the offices of the district physicians. The visiting nurses be used as a routine for all cases except those discharged at the first visit or referred to a hospital for care at once. Each district physician be assigned for part of his time to dispensary work and to sani- tary inspection work. The latter function should include reports upon the sanitary con- dition of the physician's district and special investigations on request of the Commissioner. Each district physician should be assigned to duty to a particular clinic for dispensary service for several months each year. There be added three more physicians to the staff to cover the special night service and the extra work that cannot now be done, or be done well. The city be redistricted on the basis of multiples of the sanitary areas as used by the Bureau of the Census. Staff meetings be held monthly for consideration of a definite program arranged by the Chief of the Bureau. Each physician should be expected in turn to present a report and take the leading part in one meeting each year. Time for discussion of administra- tive matters and technical medical questions should be arranged for at each staff meeting. The district physicians should report by simple forms to the central office by mail daily. These reports, which should be brief, should be tabulated and analyzed at the central office. BUREAU OF TUBERCULOSIS The Bureau of Tuberculosis has been discussed under Part IV. and hence a description of it has been omitted here. Public Health Services 143 The Bureau of Child Hygiene THE Bureau of Child Hygiene deals with matters of such importance to the entire health and welfare programs, both public and private, that Part III. of the report is devoted exclusively to these subjects, including consideration of the organizations and functions of this bureau in the Division of Health. Furthermore, in the Survey of Nursing (Part IX.), the nursing service of the Division of Health is analyzed in detail, including a special study of the follow-up of infant welfare work from the health centers. In Part IX. in the chapter on Prenatal and Maternity Care, there is discussion of the relation of the Bureau of Child Hygiene to this activity. In Part X. there will be found consideration of the health centers which serve many purposes under the direct control of the Bureau of Child Hygiene. Treat- ment here of the official public health services for children would be a mere repetition of what is more appropriately dealt with in other chapters. 144 Hospital and Health Survey The Bureau of Sanitation FOR several years this division lias had no chief and the results are obvious. The scant attention which the commissioner, from the midst of his multifarious duties, can give as the acting chief is insufficient to develop the proper functions of the force at his disposal. The sergeant and the 16 patrolmen under him, with two clerks, no more than keep abreast of the citizens' complaints, which flood their office. Five more patrolmen are assigned to placarding and enforcement of quarantine, and another five are on duty with the Bureau of Food and Dairy Inspection. Both of these services would be better done by other employes if such were available, than by men brought up with the ordinary police point of view. Nurses are being used more and more for carrying out isolation require- ments, and trained food inspectors would be more appropriate for the ed- ucational supervision of the food and dairy industries than police. When enforcement, summons or arrest are needed patrolmen can be easily obtained. Complaints come to the office by wire, mail, by word of mouth and re- ferred from the central complaint bureau of the City Hall. The records of complaints, of action taken and of disposition are simple and adequate. A series studied at the office and in the hands of inspectors showed that entries were made at the time of or on the day of inspection. The office is open from 8 a. m. to 7:30 p. m., and there are often times when the sergeant, in order to get out into the field, must assign a patrolman of the squad to desk duty. The squad is wholly used in satisfying complaints and enforcement of notices or orders issued. There is no constructive work going on in the office. They have no lists of premises, such as stables, offen- sive trade factories and other city nuisances, and they have no house files for various lots or premises in the city against which complaints have been lodged. They have no census of private water supplies and only a partial census of privies in the city. There is no supervision of the field force with the exception of what the sergeant can do in the few hours each day, two or three, when he is free from office duties. There are no meetings held at which instructions or ad- vice is given to the squad. Neither the sergeant nor those under him have had any technical education in sanitation. Various members of the squad find it a stepping stone to the practice of law, for which they study at night school while working for the city. The Sanitary Bureau cooperates with other city departments directly, in accomplishing abatement of nuisances, in such matters as engineering serv- ice, sewage, water supply and street cleaning problems. They cooperate with the Associated Charities and other private agencies, where the difficulty is economic and a poor family cannot comply with orders. There is no spirit or readiness to cooperate with departments of the Ohio state govern- ment, and as a result premises, such as licensed lodging houses, are wholly neglected by the Sanitary Bureau. Public Health Services . 145 Although many records were found showing prompt follow-up with action through the City Prosecutor, there were a considerable number in which action to abate serious housing nuisances and violations had been held for three years and more because of expected construction work which would obviate need of further attention, particularly in regard to premises in the "Hill" region. Plenty of cause for action was found in the much neglected region bounded by West 25th Street, Lorain, Trowbridge and Fulton to the river, where open and trough sewers and offensive privies were found and where housing conditions were very bad. No such thing as a sanitary survey has been attempted. There is no preventive work under way. Simply satisfying citizens' complaints appears to be the objective of the bureau at present, although a few years ago, under a chief, an aggressive and successful attack was made against violations of occupancy regulations. In studying the work in the field with two of the sanitary patrolmen, both a member of the squad who had been in the work for 12 years and a younger officer who had been on duty for but a few months, showed the best possible side of the bureau work. They were considerate, tactful, quiet, and evidently obtained excellent cooperation through persuasion. They have a good general understanding of their duties and powers and are looked upon as friends and advisers by the people. They have evidently never been taught what a sanitary privy is and they have no standards of enforcement. All privies were in a shockingly neglected condition, and although orders were placed, many months, and in some in- stances more than a year, had passed since the issuance of orders and nothing practical had been accomplished. Much harmless advice was given by the patrolmen on the basis of common sense, but their information as to con- tagious diseases was quite elementary and the calls they were observed to make for this purpose carried no intelligible advice or help to the families. The most offensive condition found was in the Collinwood region, where a veritable scandal results in the matter of removal of night soil from the privy vaults. The householder is forbidden to excavate or remove vault contents himself. The Park Department is responsible for this service. The householder is expected to pay beforehand at a charge arbitrarily set by the contractor. There are much discrimination and mjustice in the charges. Deposits accumulate over six to eight months and service is denied the people except at extravagant rates. The householders being people of small means, chiefly of foreign birth and unorganized, have not made their complaints heard at City Hall. They should not need to, as this is distinctly a serv- ice the Division of Health owes them through pressure upon the Park Department. The tenement house code (March 8, 1915) or so much of it as it is the duty of the Sanitary Bureau to enforce, is very generally ignored in its essential requirements for health protection, and yet a large amount of work appears to have been accomplished. The entire force of twenty-six patrolmen should be assigned to sanitary work proper. The sixteen officers assigned to 146 Hospital and Health Survey the work of the Bureau of Sanitation have each a definite district, consisting of from one to several of the twenty-six wards into which the city is divided. It is difficult to visualize the actual work of the Bureau on the basis of the annual report, but some idea of the work can be obtained from the fol- lowing statement: in 1919, 73,859 inspections were made, 7,073 on com- plaints. Of the latter 86 are noted as wrong addresses and 40 as no cause for complaint. 44,982 is the number of first inspections made by the men on their regular rounds. As a result of the 73,859 inspections, 13,969 notices were served, 11,456 directly by the officer on his rounds and 2,513 mailed from the office. The reinspections totaled 27,393 and the second (third, etc.) notices, 4,506. As a result of the notices sent out interviews were sought by those against whom orders had been issued, to the number of 4,344, of which 3,505 were personal interviews, chiefly with the officer on his rounds but in part interviews in the office. 839 were interviews by telephone. After two or more reinspections, when orders are not complied with, at the request of the bureau, the police prosecutor issues a letter calling upon the person against whom the order has been served to appear before him. In most instances, instead of the police prosecutor or his assistant seeing these people when they appear in his office they are interviewed by a sanitary officer detailed for this purpose. Ordinarily the party concerned is allowed a few days to comply with the order issued by the bureau. At the expiration of this time the officer again reinspects and re-reinspects. In some instances great delay occurs before the order is complied with, prosecutor's letters being sent at frequent intervals. In 1919 prosecutor's letters numbered 2,708, the party called appearing in all but 492 instances. Fifty-five warrants were requested during the year. So far as can be ascertained none were issued, no trials were undertaken or convictions secured. 14,525 orders issued were complied with. In addition to such inspections as affected tenement houses and other dwellings we find lodging houses, laun- dries, picture shows and theaters, workshops, barber shops and taxicabs dealt with. Forty-five dwellings and tenements were vacated and 86 were razed as unfit for habitation. More than 3,000 interior and exterior repairs and altera- tions were secured. Lights and ventilation were secured for 322 public halls or rooms and 148 overcrowded rooms vacated. 1,696 rooms were cleaned by tenants. Twenty-four permits were issued for privies and cesspools, 265 were abandoned and 13 repaired; 139 sewer vaults and sewer crocks were aban- doned and 62 repaired. Hopper closets are permitted but not recommended; of these 105 were installed, 288 repaired and 51 removed. Sanitary closets, 742 installed, 601 repaired. The following activities were also part of the bureau's work: orders for installation of city water, repairs of sinks, etc., 1,699; wells and cisterns con- demned, 6; vacant lots cleaned, drained, etc., 901; yards cleaned, drained and graded, 6,654; receptacles ordered for garbage or rubbish, 8,320; sheds Public Health Services 147 and barns vacated, cleaned, water-tight flooring provided, sewer connections made, city water installed, etc., 1,481. It is said that the sanitary inspection of public baths, bathing beaches and summer camps is thorough and entirely creditable to the bureau. The field investigations of the Survey did not include the season of the year when these recreational activities were in operation. 148 Hospital and Health Survey Bureau of Food and Dairy Inspection The work of the Bureau of Food and Dairy Inspection is carried on by- three graduates in veterinary medicine: one who is chief of the bureau, another who supervises nieat inspection in city slaughter houses, and a third who inspects the carcasses of all animals killed in out-of-town slaughter houses and has charge of the work of the bureau with respect to rabies in animals. In addition to the veterinarians there are 25 lay inspectors, one of whom supervises dairy inspection, the others being assigned to the inspection of slaughter houses, cold storage plants, ice cream factories, stores where milk and dairy products are sold, meat markets, etc. The clerical work of the bureau is carried on by a clerk and a typist. The following is a summary of the work of the Food and Dairy Bureau for the year 1919: total number of dairies visited and scored, 3,986; total num- ber of visits, 4,633; number of dairies excluded, 407. Nearly three-fourths of these exclusions were for the following causes in the order mentioned: not white-washing stable, unsanitary conditions, plank floor in stable. Milk houses not used, milk houses not in proper condition or farms without milk houses, constitute another important reason for exclusion. Of the 407 ex- cluded, 283 were re-admitted. The number of cows in this territory is 43,703, an average of eleven cows per dairy. The dairies are scored by the inspectors annually. The maximum score given was 100, the minimum 52, the average 65. Special visits were made in 124 instances to investigate changes and altera- tions, and in 13 instances to investigate contagious diseases. 42 visits to country milk-collecting stations were made during the year and these led to 34 notices to improve conditions. The work of the bureau which has to do with the milk depots of the city, those places where milk and milk products alone are handled, numbers 11,689 visits. The number of milk depots is 269. In addition, 1,379 visits were made to the 3,000 stores handling milk. There is a total of 3,341 milk depots and stores to which permits were granted. 107 permits were refused. 153 visits were made to investigate changes and alterations and 19 for con- tagious diseases. Two hundred and sixty visits were made to 17 milk platforms. Within the past year quite a change has taken place in the shipment of milk into the city. Formerly the greater part of it came in over interurban and steam railroads, and was discharged at loading platforms. During the past winter, trucks, which run straight to the distributor, have been more and more extensively used until now it is estimated that 80 per cent of all milk comes in on trucks. The chief work that is done at the platform is to note unwashed and untagged cans, the taking of the temperature of milk and the collection of samples for examination. Similar samples are taken of the milk on trucks at their entrance to the city or at least before they have discharged their load. 2,205 milk temperatures were taken and 11,950 samples collected. These visits to the platforms and the trucks resulted in the rejection of 1,329 gal- lons of milk, the most common cause for rejection being the shipment from Public Health Services 149 excluded dairies. Other causes were: untagged or dirty cans, shipment from known tuberculosis herds and selling without a license. There are in the city of Cleveland three wholesale ice cream plants, two of which, however, have been consolidated. To other plants which produce ice cream for their own retail trade, totaling about 60, 3,050 visits were made during the year. There are seven butter factories in the city. To these seven, forty visits of inspection were made. Four slaughter houses in the city of Cleveland are under inspection by this bureau, and eight are under federal inspection. 35 slaughter houses outside of the city slaughter on definite days and postmortem examinations of all carcasses are made before shipment. In inspection work before slaughter the following numbers of food ani- mals have come under the eye of the bureau: 135,317 cattle, 942,659 hogs, 359,095 sheep, 115,377 calves. Of these there were rejected: 1,534 cattle (more than 50 per cent for tuberculosis, more than 25 per cent for actinomy- cosis), 471 hogs (nearly 60 per cent for cholera, none for tuberculosis), 359 sheep (emaciation and crippling the most prominent causes, actual disease about 10 per cent), 308 calves (immaturity, emaciation and crippling the most common causes, actual disease less than 15 per cent — 3 per cent for tuber- culosis). Meat animals inspected after slaughter: 27,881 cattle, 35,303 hogs, 48,294 sheep, 54,465 calves. Rejections: 143 cattle (more than 67 per cent for tuberculosis), 249 hogs (83 per cent for cholera, 6 per cent for tubercu- losis), 203 sheep, 58 calves. In addition to the entire animals condemned before and after slaughter, parts of 2,029 cattle, 2,607 hogs, 1,603 sheep and 142 calves were rejected at the slaughter houses. The market and commission house confiscation of meat totaled 63,822 pounds. There are approximately 1,150 meat markets in Cleveland. 598 complaints in regard to meat markets were investigated and a total of 7,308 visits to markets made. There are 190 poultry dressing rooms, to which 1,100 visits were made. At all slaughter houses and most meat markets sausage is made. There are eight, or fewer, factories making sausages exclusively. The visits to sausage factories totaled 501. Arrests for violating the meat ordinance during the year were 8, arrests for violations of the milk and bottle ordinance 4, summons to prosecutor's office 5. The number who were brought to trial and who were convicted is not stated. The control of rabies is handled jointly with the Bureau of Communicable Disease but chiefly by the Bureau of Milk and Dairy Inspection. Of 1,000 dogs which were reported in 1919 to have bitten one or more human beings in Cleveland, 110 dogs were actually rabid, as shown by observation, or the finding of Negri bodies, or by both observation and examination. 196 per- 150 Hospital and Health Survey sons were bitten by these dogs and received Pasteur treatment. 39 examina- tions were made in the laboratory and of these examinations 17, or 43.5 per cent of the total, were positive for rabies. The history of some of the re- maining 22 dogs was so suggestive of rabies that treatment was given to the persons bitten. Forty-three dogs not found, either dead or alive, were considered rabid on their history and the 74 persons bitten by them were treated. In addition to the dogs, four cats were found to be rabid on examination and one was considered to be so on the history. 14 persons were bitten by these cats, 12 by those with known rabies. One rabid horse bit one person, and rats were reported as having bitten two people. If the animal is found alive it is placed under observation; if killed or found dead, its brain is examined for the presence of Negri bodies. Pasteur treatment is given on the positive diagnosis of rabies on either of the grounds. If the animal cannot be found or the presence of Negri bodies cannot be demonstrated, the circumstances surrounding the biting are considered and the person bitten is given the benefit of the doubt and Pasteur treatment is offered. The quality of supervision of the slaughtering and sale of meat appears to be excellent, the standards being those of the Federal Bureau of Animal Industry. All slaughter houses must be under federal or city license and inspection systems. The regulations as enforced cover all the usual precau- tions and requirements. Slaughter house and food factory inspection is made for the non-federal inspected houses in the city and the 28 outside of the city. About 25 per cent of the city killed meat is slaughtered in other than federal inspected houses. No uninspected meat is permitted for sale in the city. MILK CONTROL The handling of milk control in Cleveland, in spite of the up-to-date regula- tions, suffers from several radical defects in principle and method which are probably responsible for the high percentage of dangerously polluted milk samples found on the bacterial counts of samples examined at the request of the Survey by the Bureau of Laboratories in February and June, 1920. The ordinances do not cover the question of sterilization of containers. There is dangerous neglect of this important point in the technic of milk distribution by many dealers. Exclusion of milk supplies is based on the condition of the dairy, and the results of inspection of the premises where milk is handled and pasteurized. The routine use of bacterial counts is not a basis of milk control. The chief of the bureau agreed that reliance placed upon inspection of dairies, the amount of dirt by the clarifying test, and the standard method of pasteurizing and recording by temperature and duration of exposure, cannot be relied upon to guarantee a safe milk to the consumer as long as unstcrilized containers are used, which make the milk unreliable even after Public Health Services 151 pasteurization. Little attention is paid to bacteriological counts for exclu- sion of milk. At present, with the apparently limited force, the division could with advantage gradually change its policy from field inspection to laboratory control of the delivered milk. Milk inspection is carried out in the country within a radius of 200 miles and at the pasteurizing plants outside and inside the city. Chemical tests are made by the inspectors themselves at the Division of Health laboratory. Bacteriological tests are made by the bac- teriological laboratory under the director of laboratories. The following is quoted from field notes made by the investigator for the Survey on accompanying a dairy inspector on his rounds in the country: "The inspector stated that he covered his old route once a year and that he tried to cover new territory more often. During the winter the inspectors do very little work in the country and in the summer are often called out to do other work. He had 900 dairies last year under his care and will have about 1,200 this year. When he is on the road he sees from 10 to 15 dairies a day. Dairies which make butter do not have to come up to the standard : in fact, he told of several very poor dairies to which he had suggested that they make butter instead of shipping milk. This is certainly a dangerous policy. There are no bacteriological tests to determine the cleanliness of utensils. No search is made for the cause of a high bacteriological count, where the milk is brought in, with a notice to the inspectors to follow up the high counts. The score card shows that more emphasis is put on technic than construction. The inspector observed really seemed interested in the cleanliness of the process, although he scored dairies without seeing the process of milking or handling of milk. The inspector was primarily interested in clean utensils and provisions for cooling. The emphasis is evidently correctly placed. The previous score card is not taken with him when he goes to make a second inspection. He carries the facts as to previous conditions in his head." Firmness and an entirely consistent policy of exclusion for specified defects does not prevail. "Many dairies were using milking machines, which are exceedingly dangerous unless cared for immaculately. Many of the machines seen were dirty. They cannot be sterilized. In one dairy an elaborate sterilizing plant was found with all utensils sterilized, but 12 dirty milking machines." Tables VII. and VIII. in the Appendix represent the official record of raw (certified) and pasteurized market milk in Cleveland during the past six years. The following reports were received by the Survey from the bacterio- logical laboratory of the Division of Health : March 19, 1920 "Enclosed herewith are the results of the bacteriological examinations of the Cleve- land Milk Supply made recently for the Cleveland Hospital Survey. "From these we have made the following notations: There were 103 samples ex- amined. Of those containing 50,000 or less bacteria colonies per c. c. there were 43, or 41.7';. From 51,000 to 100,000, inclusive, there were nine samples, or 8.7%. Of those 152 Hospital and Health Survey from 100 and 1,000 to 500,000, inclusive, there were 21 samples, or 20.3%. 30 samples, or 29.1% contained over 500,000 colonies per c.c. "The presence of gas producers in lactose broth was found in 52 samples, or 50.5%. Six of these samples showed the presence of gas formers in all five dilutions and one of these showed the presence in all tests of all dilutions. Five samples showed the presence of gas formers in four of the five dilutions. "Of the 92 samples examined in triplicate for the presence of spore forming gas pro- ducers 36 samples (39%) gave positive results. Fermentations Spore Formers Positive Samples Positive Tests Positive Samples Positive Tests No. Per No. Per No. Per No. Per Colonies per c.c. Cent Cent Cent Cent Under 50,000 21 50. 75 11.6 12 23. 24 21.6 51,000 to 100,000 4 44.4 8 6. 3 33.3 4 19.1 100,000 to 500,000 12 57.1 44 14. 5 23.8 9 15.8 Over 500,000 16 53.3 99 22. 12 40. 29 33.3 "The methods pursued in the examination of Cleveland Market Milk for the Hospital Survey were as follows: COLLECTION OF SAMPLES "Samples were collected from the various milk plants, milk wagons and grocery stores by the writer and other laboratory employes. The milk was brought direct to the labora- tory in the original package and examined immediately. Owing to the low temperature of the weather the samples were not iced in transit. Although the temperature was not taken, it is safe to say that the milk did not reach a temperature of more than three or four degrees above, and in most cases was several degrees below the temperature at which it was received, by the time plating was begun. Both quart and pint bottles were collected. METHODS OF EXAMINATION "Agar plates were made, using plain standard agar in triplicate dilutions of 1:100 and 1:1000. Fermentations were made in triplicate in lactose broth in quantities of 10 c.c, 1 c.c, 0.1 c.c, 0.01 c.c. and 0.001 c.c. The plates were counted after 24 hours incuba- tion at 37 degrees C. and the average taken for record. Where the count was high it was recorded as an estimate; for example, 'Over 500,000.' If fermentation occurred, a trans- plant was made from the fermentation tube (showing gas) to eosin-methylen blue agar, the organism isolated in a pure culture for further study. Fermentations incubated for at least 72 hours. "Triplicate specimens of 10 c.c of milk each were placed in test tubes with a few drops of azolitmin solution and heated in the water bath at 80 degrees C. for 30 minutes, and then incubated at 37 degrees C. for 72 hours or until gas production was indicated. It was then transplanted to lactose fermentation tubes and reincubated, as a control on the presence of gas production. These cultures were then plated on plain agar and incubated anaero- bically for isolation in pure culture for further examination. "This covers in general the methods of procedure with the Hospital Survey samples. Some other examinations were originally planned, but either the necessary material and Public Health Services 153 equipment were not at hand, or other immediate facilities were lacking, so that the work could not be consistently carried out and was therefore discontinued." A series of samples examined in June were analyzed in a somewhat more detailed manner, as shown in the accompanying report from the same source. "July 8, 1920. "Enclosed herewith is a classified report of the bacteriological examination of Cleve- land market milk. "Bacteriological Examination — Counts were made in duplicate on plain agar with dilutions of 1:1000 in sterile tap water incubated at 37 degrees C. for 24 hours. The aver- age of the duplicates was recorded. Fermentation tests for the presence of gas producers was made in dilutions of 1:1000, 1:100, 1:10, 1 and 10 c.c, respectively, in triplicates, using 1 % lactose broth Dunham tubes. The figures in the corresponding columns in the report indicate the number of triplicates showing the presence of gas. Triplicate tests for spore bearing gas formers were made by placing 10 c.c. of milk in a 6-inch test tube with a couple of drops of sterile azolitmin solution, and heating in the water bath at 80 degrees C. for at least 30 minutes. These were then incubated at 37 degrees C. for 72 hours or until gas formation was indicated, and then transferred to 1% lactose broth in Dunham tubes. The column "Ana," in the report indicates the number of these showing the presence of gas." CLASSIFICATION OF DEALERS AND RESULTS At a conference with the four city dairy inspectors who are familiar with the dairy premises and personnel, the dealers were placed in three groups: Group 1 — Dealers whose premises, equipment and methods are of the best, equipped with bottle sterilizers, coolers, automatic filler and capper, etc. Group 2 — Those whose methods may be satisfactory but who are not equipped with the most "up-to-date" apparatus, such as sterilizers, auto- matic fillers, cappers, etc. Group 3 — Those whose premises, equipment and methods are the cause of more or less dissatisfaction. Classes — The groups are sub-divided into three classes, according to the bacterio- logical results. Class A — Contains those whose bacteria count does not exceed 50,000 colonies per c.c. nor have gas formation in more than 50% of the fermenta- tion tests. Class B — Includes all that do not belong to Class A, but which do not have a bacteria count of over 500,000 colonies per c.c. Class C — Includes all with a bacteria count of over 500,000 colonies per c.c. A classification of the patrons is suggested by indicating the so-called better residence sections by "X," the medium sections by "Y," and the poorer sections, factory districts and congested portions of the city by "Z." 154 Hospital and Health Survey In Table IX. will be found the detailed results of this study. It is easy to see froni the reports that intelligent, consistent, economical and constructive work through bacterial counts of milk is needed to clean up the milk supply by tracing the dirty supplies to their source, by testing the pasteurized product as delivered to the consumer, and then following back to the production point to discover the place and cause of the con- tamination. Among the reasons to which the unsatisfactory condition of the milk must be attributed are the holding of pasteurized milk without prompt cool- ing, in the containers used in the process of pasteurizing before bottling; the use of unsterilized containers for distribution to the consumer; the ab- sence of any prosecution based on bacteriological tests; and the emphasis in prosecution of farmers solely upon the sediment test and butter fat con- tent. The system of milk control does not put any effective check by bac- teriological methods upon the cleanliness of the milk before pasteurization. The dealers are prosecuted for failure to meet the requirements in butter fat and sediment test, for use of bottles not their own, for the condition of their premises and for the processes used in pasteurizing and bottling. The milk bottle caps do not show the grade or date or anything except advertising and trade terms, to indicate the quality and age of the milk. An official and uniform text on caps would better protect the consumer. It is recommended that bacterial count control largely replace the present diffuse and unproductive system of milk and dairy inspection, and that auto- mobile transportation sufficient to save the time of field inspectors be pro- vided. In this bureau, as elsewhere in the Division of Health, we find workers with sufficient knowledge but hampered by lack of sound policies, and lack- ing in the educational facilities upon which good preventive health work is usually done. The staff meets for conference on Saturday mornings to discuss policies and the service. There would seem to be no good reason for keeping this bureau separate from the other food inspection service now carried on under the city chemist. The chemical laboratory should not have inspectional functions but should be used as a source for facts, upon which records, prosecutions and exclusion of food should be determined. The personnel of the bureau, except the director, comes from the civil service eligible lists. Applicants have no medical examination, since they are not eligible for any pension fund. They are supposed to pass a mental examination on some of the technical information required in dairy and meat inspection. This eligible list has been eliminated for the past two years as there have been no examinations held by the Civil Service Com- mission. Inspectors are taken as they come, without examination. They receive for the first year $1,500 salary; for the second year $1,650, and for the third year $1,800; supervising lay inspector $2,000; the two assistants $2,400; and the chief $3,800. Public Health Services 155 Bureau of Laboratories THE work of the Bureau of Laboratories is carried on under the super- vision of the Chief of the Bureau, known as the Director of Laboratories, at present a part-time employe, also occupying the chair of bacteriology and hygiene at Western Reserve University Medical School. Two laborator- ies are maintained, one the bacteriological laboratory for the examination of cultures, smears, blood specimens and pathological specimens for the diag- nosis of disease, and the examination of water, milk and other substances for their safety and purity as foods. The second laboratory is a chemical labora- tory and is charged with the analysis of food and drugs, the sanitary super- vision of stores, restaurants, bake shops and the like. The ordinance authorizing the bureau provides that the function of the laboratory shall be to assist in the diagnosis of communicable disease, to fix the period of quarantine, to determine the quality of the milk, food and water supply of Cleveland, and to perform such chemical and bacteriological analyses as are related to public welfare. The functions of the laboratories are similar to those of other municipal health laboratories: i. e., diagnosis, analysis, production, research. The out- fits supplied for diagnostic uses are assembled but not manufactured at the laboratory and there are no biological products produced as a routine by the city. The Chief of the Bureau of Laboratories, under the direction of the Com- missioner of Health, has charge of all employes of the bureau, assigns their duties and enforces the laws relating to the functions of the bureau. The bureau supplies outfits for the collection of material from suspected cases of diphtheria, typhoid fever, tuberculosis, rabies, and such other com- municable diseases as the Commissioner of Health and the Chief of the Bureau of Communicable Diseases may decide. No diagnostic services are provided for meningococcus or other organisms causing meningitis or for pathological changes in the spinal fluid. No type determinations are offered for pneumococcus or meningococcus. No tetanus antitoxin, antipneumococcus vaccine or antimeningococcus serum are avail- able through the laboratory or any bureau of the Division of Health. Viru- lence tests for persistent diphtheria carrier organisms are rarely made (in per- haps 10 to 12 cases a year) and then by the lethal test instead of by the more economical and quite as reliable intradermal test in guinea pigs. The bureau examines and reports on samples of milk and dairy products submitted by the Bureau of Food and Dairy Inspection, and such samples from other sources as may be approved by the Commissioner and the Chief of the Bureau of Laboratories. The laboratory's activities in milk examinations were as follows: There were 12,245 milk samples examined; 10,016 shipper's samples and 2,229 dealer's samples. Four per cent of all were below the lactometer 156 Hospital and Health Survey standard; 5.5 per cent below the fat standard; 27.5 per cent below the total solid standard and 19.7 per cent below the standard of cleanliness by the sedi- ment test. When shipper's samples are found to fall below the legal standards, written notices are sent to the producer calling his attention to these facts. Later, averaging perhaps two months from the time the notice was first sent, an effort is made to secure samples of milk from the same producer to see whether or not the fault complained of has been corrected. This is poor follow-up and leaves too much to chance and the good will of the shipper. No bacterial counts were made of the shipper's samples of milk, but it is stated that 50 per cent of the dealer's samples had more than 50,000 bac- teria to the c. c. (It should be remembered that the milk ordinance speci- fies 500,000 as the bacterial standard for milk which may be sold in the city of Cleveland.) The bureau makes chemical and bacteriological examinations of the municipal water supply (including samples from springs in parks) at approved intervals, as well as sanitary examinations of water used by citizens of Cleve- land at their homes in the city or country. It also examines from time to time such water as is offered for sale. The bureau makes such chemical, bacteriological and pathological examinations of samples of foods submitted by the Bureau of Food and Dairy Inspection as may be necessary. It makes tests as to the bactericidal efficiency of disinfectants and germicides. The work of the bacteriological laboratory is carried on by a staff con- sisting of a director on part-time, and four other persons, two of whom are listed as bacteriologists, one as a physician, the other as serologist. One of the four named above has, under the director of the bureau, general super- vision of the laboratory. There are four laboratory assistants, one who cleans glassware, being classified as laborer, one messenger and two typists as clerical assistants. The following summary of the work of the bacteriological laboratory indi- cates the types of examinations made and their number in 1919. 45,711 specimens were examined, an increase of more than 50 per cent over the num- ber examined in the previous year. Specimens of sputum, blood for Widal tests and the heads of animals for the diagnosis of rabies, showed a decrease in number. The decided increase in total specimens was due to an 83 per cent increase in throat cultures and the increase in the number of blood specimens sent in for Wassermann tests and of smears for gonococcus. Diph- theria having shown a low incidence in the three years previous to 1919, became more prevalent during that year, and this increased prevalence accounts largely for the increased number of cultures. It is not unlikely, however, that more exposure cultures were taken than has been usual in the past since this procedure was made very extensive whenever diphtheria oc- curred in schools or institutions. The probable truth of this inference is indicated by the fact that while diagnosis cultures increased 66 per cent, exposure cultures more than doubled in number. There was a diminution in sputum specimens from 3,216 in 1918 to 3,101 in 1919, and from 764 in which the tubercle bacillus was found in 1918, to 630 in 1919. Public Health Services 157 Increasing interest in venereal disease control may well explain the in- creased number of examinations for their diagnosis. Wassermann speci- mens presented for examination increased from 5,807 in 1918 to 8,070 in 1919 and the positive findings from 1,498 to 2,658. An approximate estimate of the cost per specimen is 33 cents for all diagnostic tests. The chief criticisms of the laboratory which have been heard relate to the dependability of its reports in laboratory diagnoses and upon the maintenance at the distributing stations of a proper supply of outfits for the collection of material for diagnosis, and of diphtheria antitoxin for use in immunization and treatment of diphtheria patients and those exposed to diphtheria. In general, according to the judgment of physicians having experience in this matter, it appears that the Wassermann work of the city laboratory is of high character. A similar statement would undoubtedly be made of the morphological differentiation of the pseudo-forms from the true forms of the diphtheria bacillus. In diphtheria particularly it is probably true that a doubtful specimen is rarely passed as positive or negative on the judgment of any one person; it is the rule of the laboratory that such specimens shall always be seen and confirmed by more than one bacteriologist. Collection of Specimens for Diagnosis The main distributing stations for outfits of all kinds and for diphtheria antitoxin are the police stations of the city; a few of the larger drug stores as well, have these supplies for the convenience of physicians in the downtown office buildings. In each police station a small incubator heated by an elec- tric lamp is to be found, and the physician, after making a culture, is thus enabled to get it promptly under a suitable temperature, so that when taken to the laboratory it is usually ready for immediate examination. Last sum- mer a number of these incubators were out of order for some time through a difficulty experienced in getting the lamps. This difficulty was corrected before the cooler weather set in last fall. Frequent criticisms are received of the failure to find outfits or anti- toxin in these stations and of the bad condition of these outfits. Much, but not all, of this difficulty is avoided when the laboratory has a reliable mes- senger, but the man who can qualify as such usually soon finds a better paying job and leaves the city's employ. He collects daily from each sta- tion and is supposed to assure himself at each visit that an adequate supply of outfits in perfect condition and a sufficient supply of antitoxin are on hand and that the incubator is operating properly. ^^L^ One cause of the difficulties met in keeping the stations properly supplied is the fact that physicians at times take more Outfits or more antitoxin than they need for immediate use, leaving nothing for those who may follow. Further, it is quite certainly known that Cleveland antitoxin is occasionally used for patients who are not residents of Cleveland but of the suburbs. 158 Hospital and Health Survey Twelve of the police precinct stations were visited by our investigator with the collector on one of his routine collecting trips. This collector had been in the service for six months. He has a good Ford car at his disposal and makes a daily trip covering all the police stations, beginning at 6 a. m. and finishing about 10 a. m. Three times a week he also includes the health centers. On Sunday each police precinct is telephoned, and visits are made only where there is material to be collected. In the afternoon his work con- sists of answering telephone orders, getting supplies from bath houses, ice wagons, etc., and also doing odd jobs around the laboratory. He is supposed to keep the police stations supplied with the following: 4 to 8 diphtheria culture tubes, 6 to 10 sputum bottles, antitoxin in units of 1,000, 5,000 and 10,000, about 4 or 5 each; 6 to 8 Wassermann outfits, Neisser outfits, where there is demand, and Widal outfits. Each precinct has an electric incubator. Diphtheria cultures are sup- posed to be kept in this; sputum and Wassermann outside. Sometimes mistakes are made, and occasionally the doors are left open. Supplies in some stations are kept in cupboards which are unlocked. No supplies are kept on ice. It is impossible to ascertain how long supplies are kept with- out replacement. The collector says that he has instructions to examine the diphtheria culture tubes at least every week and bring in all defective media. "Police Precinct No. 2 — No material to be collected. Supplies kept in a locked closet. Material on hand: four diphtheria; ten Widal ; three Wassermann ; three sputum ; four antitoxin, two each 1,000 and 5,000, no 10,000 units. "Police Precinct No. 3 — Material collected: two Wassermann, one Neisser, one diphtheria. Material kept in locked closet. Material on hand: four diphtheria; one Wassermann; eleven sputum; seven Widal; antitoxin, no 5,000, two 10,000, four 1,000 units. "Police Precinct No. 4 — Material collected: one sputum, one Wassermann, three diphtheria. Material kept in closet without lock. Material on hand: one diphtheria; six antitoxin, two of which were 5,000, four 10,000 and no 1,000 units; three sputum; nine Widal. "Police Precinct No. 5 — Material collected: one Wassermann, one diphtheria, one sputum. Supplies kept in closet without a lock. Material on hand: seven diphtheria; seven Wassermann; eight Widal; five sputum; antitoxin, three 5,000, two 1,000 and four 10,000 units. "Police Precinct No. 6 — Material collected: two Neisser, one Wassermann, five diphtheria. Material kept in cupboard without a lock. Material on hand: three diph- theria; six Wassermann; three sputum; antitoxin, three 5,000, one 10,000, five 1,000 units. "Police Precinct No. 7 — Material collected: none. Supplies kept in safe. Material on hand: eight diphtheria; four Wassermann; five typhoid; antitoxin, five 1,000, no 5,000 or 10,000 units. "Police Precinct No. 9 — Material collected: three diphtheria, one sputum Sup- plies kept in a closet with no lock. Material on hand: nine diphtheria tubes, two of which were dry; nine antitoxin; nine sputum; eight Widal; twelve Wassermann outfits. Public Health Services 159 "Police Precinct No. 10 — Material collected: one sputum, two diphtheria. Sup- plies kept in locked cupboard. Material on hand: five diphtheria cultures, two of which were dry ; thirteen antitoxin ; eight Neisser ; nine Widal ; three Wassermann ; two sputum outfits. "Police Precinct No. 11 — Material collected: three Wassermann, five diphtheria, three sputum. Supplies kept in closet without lock. Material on hand: one diphtheria; thirteen antitoxin, three 1,000, four 5,000, six 10,000; seven sputum ; six Wassermann ; five Widal outfits. "Police Precinct No. 12 — Nothing to collect. Supplies kept in office in unlocked cupboard. Material on hand: seven diphtheria cultures, two of which were dry; eleven antitoxin; three sputum; one dozen Widal; one dozen Wassermann. "Police Precinct No. 13 — Material collected: three diphtheria, six Wassermann, one sputum. Material kept in closet with no lock. Material on hand: no diphtheria; two Wasserman u ; three sputum; two antitoxin, one each 1,000 and 10,000; three typhoid ; one Neisser outfit. "Police Precinct No. 14 — Material collected: one sputum, one diphtheria. Sup- plies kept in a closet without a lock. Material on hand: three diphtheria; five Wassermann, ten antitoxin, three 1,000, three 5,000 and four 10,000; three sputum; two Widal outfits. "The police captains and lieutenants said that they had had a great many complaints because of lack of material and also because the diphtheria culture material was not in good shape. "There have been a great many recent complaints because the Wassermann outfits do not now include a needle. The collector explained the complaints about lack of material by saying that recently the department shipments of antitoxin and diphtheria culture material had been delayed by freight strikes, etc , and that for some time they had prac- tically no material on hand. "The collector appeared to be intelligent, alert and interested in his job and could im- prove the service if not hampered by lack of supplies at the central office." Ever since it began its work the laboratory has interested itself particu- larly in the water supply of the city. The amount of chlorine used from day to day is based mainly upon bacteriological examinations of the water and these are now made by the Division of Water under the Department of Public Service. The continuance of the examinations by the bacteriological laboratory constitute, however, a valuable check upon those of the division directly responsible. As a summary of the results of the examinations of the city water for the year 1919 in the bacteriological laboratory it may be said first, that the raw water shows great pollution; second, that the chlorinated water shows con- siderable variation, that it is apt to be fairly or entirely free from evidences of pollution in the summer and winter, while in the spring and fall, particu- larly the former, it shows traces of pollution varying from slight to decided in a month; third, that the blend of ■ filtered chlorinated and unfiltered chlorinated water, as used on the East Side of the city, shows some improve- ment over the chlorinated water previously in use; fourth, occasional colon colonies are found in the filtered chlorinated water. 160 Hospital and Health Survey The work of the chemical laboratory under the director of the bureau is performed by a staff consisting of three chemists, one a chief chemist who supervises the work of the bureau and performs some slight services for the medical school in demonstrating points of sanitary interest in the city to medical students; six assistant chemists, six sanitary officers assigned to the laboratory, and two typists. The laboratory has charge of all food, drug and liquor analyses, miscellaneous chemical analyses, the inspection of drug stores and of stores, restaurants and other places where food, except milk or meat, are produced, sold or stored. One out of the seven chemists in this laboratory obtained his position as a result of competitive civil service examination. The last examination was held in 1917. The Bureau of Food and Dairy Inspection is charged with the control of the milk and meat supply of the city of Cleveland and this responsibility extends from production to delivery to the ultimate consumer. The con- trol of all other food is lodged in the chemical laboratory of the Bureau of Laboratories. Here, again, the bureau is charged with the sanitary super- vision of the production, storage and sale of these products. All stores handling food, except those which limit themselves to the sale of milk or meat, and all bakeries, confectionery stores, groceries, restaurants, bottling works and the like are under their supervision. The state permits for res- taurants, etc., are issued only after inspection and approval by the city chemist as to methods and equipment. Much attention has been paid in the past to the sanitary condition of bakeries and by cooperation with the local organizations maintained by bakeries the conditions in the bake-shops have become quite satisfactory. Recently more attention has been paid to the proper distribution of the products of these shops to stores and the care with which they are handled at these places. The inspection work of the chemical laboratory is performed by sanitary patrolmen assigned to the laboratory. During the year 1918 five sanitary patrolmen and three inspectors were so assigned. The positions of inspec- tors were abolished in the year 1919 and six patrolmen were assigned to this duty. The total number of inspections are represented by the following figures: inspections, 7,552; reinspections, 7,801; warning letters, 340; sum- mons before the police prosecutor, 382; stores closed, 54; arrests, 15; con- victions, 13; and cases pending on appeal by the city, 2. No case is brought into court unless all other means have been exhausted. Food stores are inspected about six times a year, bakeries and restaurants three to four times a year; candy factories about three times a year; bottling establishments according to season. This laboratory also does work for the State Medical Board for violations of the medical practice act and for the State Board of Pharmacy and for the Engineers Board of the city (who provide one chemist and an assistant for the laboratory) and for the Depart- ment of Public Service. From an inspection of the small restaurants and food stores made by an investigator for the Survey, it is obvious that there are constant violations of ordinary sanitary decency in these places, which could be checked if more Public Health Services 161 time were spent on actual inspection, and less of the appropriation for this division were used in doing non-health work. The six inspectors, of whom one works always at the railroad terminals, cover the entire city and spend a large part of their time in traveling from place to place in the city. Good administration would suggest that the sanitary inspection force be combined instead of being split into the three groups, so that each patrolman would have a small district within which he would fulfill the functions of sanitary inspector, food and drug inspector and quarantine officer. At present the minimum of actual service in the field for the maximum expense is accom- plished. The Bureau of Laboratories cooperates with other departments of the city government in inspection work of all descriptions, with reference to bacterio- logical and chemical standards. The bacteriological laboratory makes any examination of milk and meat that comes within its province, for the Bureau of Food and Dairy Inspections. The chemical laboratory does the same, and in addition examines chemically, food products other than milk and meat for their identity and sanitary condition. In the past many samples have been taken from retail stores, but recently much effort has been made to secure samples of food as it enters the city in carload lots or smaller shipments, and to determine its quality before it has left the jobber. The laboratory works in close cooperation with the Bureau of Chemistry of the United States Department of Agriculture in this matter. As a result of this work in 1919 four warning letters were sent; there were 26 summons to appear before the police prosecutor, 14 arrests, 9 con- victions, 4 cases discharged and one case pending on the appeal of the de- fendant: One hundred and twenty-nine car lot shipments and 355 less than car lot shipments were inspected. The confiscations cover such articles as baked goods, baking powder, cereals, candy, fruits, nuts, olives and pickles. A considerable number of fruits and vegetables were ordered sorted. The inspection of drug stores is a function of the chemical laboratory. A special duty has been placed upon the inspector of drug stores by the narcotic ordinance of the city. The Division of Health some years ago established close relations with the Druggists' Association of Cleveland and through the cooperation thus at- tained has been able to secure the voluntary removal of a considerable number of the more objectionable types of patent medicines from the shelves of Cleveland druggists. Aside from patent medicines and narcotics the laboratory has been especially interested in fraudulent or adulterated preparations and has suc- ceeded in keeping from sale a considerable number and variety of drugs of a type similar to aspirin and phenacetin which were misbranded or adulter- ated. THE "PATENT MEDICINE" IN CLEVELAND This is a subject that must be approached in a tactful manner because of the large amount of capital invested in the manufacture and sale of these 162 Hospital, and Health Survey substances, and likewise because many individuals of more than average intelligence believe in patent medicines and practise self -medication. It is not true that these remedies are used only by the foreigners and the ignorant. To pass over this subject without mentioning it would be to overlook a very important item affecting public health. The United States Government report shows about $90,000,000 to be invested in the production of proprietary remedies. It does not classify these remedies to show which ones are entirely non-secret in nature, stating their entire formula on the label, or in an otherwise public manner. It does not say which ones are based upon preparations whose formulas are incorporated in the United States Pharmacopoeia and National Formulary. It does not say which ones are mainly alcoholic in nature. It does not say which ones are entirely secret in their composition, nor does it say how many may be entirely "rank fakes." A need for such a classification cer- tainly exists. In this enlightened age no one should be permitted to buy anv combination of drugs upon the open market labeled merely as a "cure- all." The discussion of this subject is often avoided by those who should dis- cuss it, for fear of controversy with those interested in the business. These remedies are manufactured on their own account by large pharma- ceutical houses, and are put up under fancy proprietary names, but often carrying the full formula on the label or in accompanying literature. These same houses also have what they call their private formula department where they fill formulae submitted to them by physicians, by combinations of physicians and laity, and by druggists or by people who think they have a formula that is the only specific for a certain disease. These remedies are also made by small concerns who do only a "private formula" business. Again they are made in a small way by druggists or, indeed, contrary to the idea of the statutes, by persons whose knowledge of drugs and medicines is absolutely nil. They are likewise made and offered to the public under coined names that sound to the uninitated like the names of drugs or chemicals. In this way the public is advised to treat a certain malady by mixing this drug with something well known, such as glycerin, alcohol, etc., and then by using it in a specified manner. These are usually advertised as prescrip- tions or in answer to letters or supposed letters to the firm asking for medical advice. Distribution and Sale The non-secret proprietaries are sold by agents of pharmaceutical houses who rail directly upon physicians and hospitals. Other non-secret remedies are found in the drug stores and purport to be the "Best Ever" line of reme- dies, or some similar line, and whose formulae are usually on the bottle or are given directly to the druggist. Among the secret and semi-secret remedies are those most often adver- tised. The demand is created entirely by newspaper advertising, or by maga- Public Health Services 163 zines, periodicals, calendars, almanacs and other literature placed directly in the hands of the public. They are then sold by the druggist or by the mail house. Others are made and sold by wagon vendors or by house-to-house can- vassers who take orders and deliver or sell direct. One method of the house- to-house canvasser is to represent that the profit, or part of it, goes to a hospital for children, thus trying to sell the remedy on a sympathy basis. Many are sold in grocery stores, general stores, restaurants, barber shops and by anyone who can create a volume of sales satisfactory to the manufacturer. The drug store is supposed to sell the major portion of them because it is in a fixed place of business, although it is very doubtful if the drug store handles fifty per cent of the proprietary remedies sold. The newspaper advertising which creates the demand is the most potent factor in the distribution of these remedies. The manufacturer prefers the names "package remedies," "home remedies," "proprietary remedies," and, of course, abhors the epithets "fake" and "patents." One feature that must not be overlooked is the form of counter prescrib- ing in some drug stores, happily few of them, where the unsuspecting victim asks for a remedy and has a well known proprietary, such as "Mother's Friend," transferred to a plain bottle and sold for $10. The law does not limit the price to be charged, nor does it limit the sale to any set of responsible and trained hands. All the law says is that the label must not claim to cure, nor may it carry false and fraudulent claims nor may the medicine contain certain harmful drugs. The Pure Food and Drugs Act only applies to the above, when these remedies enter interstate commerce. Situation in Cleveland Important steps have been taken to purify the- traffic, but these steps have only scratched the surface. Here the Northern Ohio Druggists' Association has appointed an Ad- visory Board who, with certain members of the Medical and Pharmacy School faculties, meet from time to time with the city chemist and pass upon the legitimacy of a proprietary remedy in so far as existing law permits action to be taken. The druggists have also agreed that any new "proprietary" must pass the city chemist as to label and claims before they will stock it. In this way a large number of new preparations have been excluded from the market, many on the market have been removed and many labels and much litera- ture have been revised. Some little cooperation has been had from newspapers relative to the changing of form of advertisement. It is needless to state that a newspaper always endeavors to protect its advertisers against steps that tend to injure distribution of their wares. 164 Hospital and Health Survey During the past three years there have been about two dozen patent medicines excluded from sale in Cleveland and about three dozen the claims of which have been modified under pressure or threat from this division. Revision of labels is required in many cases. A misbranding order is held as a threat over those who resist demand for toning down their advertise- ments. On looking over the files and correspondence on fraudulent patent medi- cine claims, it was found that the standards of the Bureau of Chemistry at Washington are followed, but that an amazing patience and tolerance is displayed in dealing with mischievous and frankly misleading advertising claims. Correspondence in one flagrant case of misbranding continued for twelve months before any result was obtained. This brings discredit on public law and service. The city chemist has apparently found it necessary to abate his efforts when he finds the newspapers of the city objecting to the reduction of income which the withdrawal of false advertising claims of proprietary remedies incurs. RECOMMENDA TIONS That a committee of physicians, hospital men, druggists, the City Health Commissioner, the City Chemist, the Cleveland Advertising Club, and newspaper men, with a representa- tive from the Chamber of Commerce or other Civic body, study the question of newspaper advertising of medicines to determine if it is essential to the success: of the newspaper adver- tising department; if not, to recommend it be discontinued; if it is, find some manner of furnishing the same space to the newspaper for the advertising of real commodities. It cannot be conceded that any drug should be advertised to the public. The opinion that anyone may select his own treatment of disease after reading an advertisement is only based upon monetary gain, either directly or indirectly, and this factor should be consid- ered secondary in dealing with the protection of public health. It is recommended that the same committee, or a similar one, take steps to draft such city or state legislation as will place the dispensing of all medicines in the hands of those qualified to do so, and with such safeguards that the unscrupulous ones may be reached; (as, for instance, Regulation 10 of the Sanitary Code of the Village of Athens, New York, which forbids the sale of medicines or medical appliances otherwise than by licensed pharmacists or by physicians, without the approval of the health officer;) or a re- quirement that all medicines not issued on physician's prescriptions be rgistered with the names and amounts of physiologically active ingredients, upon which claims of therapeutic results are based, and a copy of all text used in advertising. It is recommended that if any such ordinance or regulation is passed, it be made ap- plicable at first and enforced only within the city of Cleveland, and later that an attempt be made to have the matter adequately and similarly dealt with under state law. Public Health Services 165 Bureau of Vital Statistics SINCE the whole structure, plan, program, estimate of results and basis for current work, as well as the science of municipal demography de- pend upon the system and organization of vital statistics, this subject is treated in a special manner by an authority in this field, an executive, an author and a student of social problems. REPORT AND SUGGESTIONS ON CONDITION OF VITAL STATISTICS IN THE DIVISION OF HEALTH, CITY OF CLEVELAND By Louis I. Dublin, Ph. D. Vital statistics, that is, the essential facts, the rates and percentages dealing with population, births, deaths and the incidence of disease, by which the result of work for health protection is measured, upon which plans for improvement as well as sanitary and administrative policies are based or determined, are to all intents and purposes non-existent in the Division of Health of the city of Cleveland. On April 8, 1920, there was not yet available- for the use of the Health Commissioner of the city the crude or general death rate for the year 1919, nor even the record of the number of deaths from all causes which occurred in Cleveland in 1919. The birth rate for 1919 was out of the question; for, if any figure was quoted, it would obviously be unreliable, since non-reporting of births is very frequent among the rank and file of physicians and midwives in Cleve- land. In other words, the health authorities of this city have not at hand the most vital facts as to their community. They do not know what effect their work has on the community; in what respects it is effective and in what respects it is not. Except through conjecture, they cannot know the dis- tricts and sections of the city in which their work is most necessary and those in which it is not quite so necessary. Nor can they estimate the per- sonnel required to do a specific amount of work nor the probable cost of such work. Cleveland is today conducting its health work in a manner typical of American cities twenty years ago. It has apparently not yet learned the very obvious lesson that both economy and efficiency require a system of record keeping which will at once permit the development of a scientific health program and at the same time make possible such supervision and control of the service rendered as to indicate its effect and its value. Such, then, is the present status of this very important branch of the health work of the city of Cleveland. The picture does not well become a city of close to eight hundred thousand people, ranking fifth among the municipalities of America; a city justly priding herself on her vast resources and her unquestioned prosperity; on the variety and extent of her industries; on her favorable and healthy location and on the right-mindedness of her officials and her people. Cleveland is rightfully a proud and progressive city. In few cities of America does one meet more forward-looking citizens. 166 Hospital and Health Survey But, these citizens, it seems, have not heard of the necessity of applying arithmetic to the problems of their public health, or to those other aspects of municipal government which closely affect the general welfare. It is at this time almost impossible to present a demographic picture of this city. It must not be supposed from the above that the city of Cleveland is niggardly in providing the means for work so essential to its health activities and general welfare. About $7,000 is to be spent in 1920 in salaries alone to carry on the vital statistics of the Division of Health. In addition, there is the cost of the equipment of tabulating machinery, of records and files, of furniture and office space. But proper and necessary results are not obtained from this expenditure. There is a registrar at a salary of $1,750. He is a practising physician whose duties are, as far as could be determined, limited to countersigning birth and death certificates. These duties occupy about an hour a day. A young lady, designated statistician, at a salary of $1,520, is untrained, but is interested and conscientious. She does what she can undirected. She runs the little division that exists in the depart- ment, tabulates the records and has general supervision. But she is com- pletely out of touch with her superiors and has no experience of her own to fall back on. Several other clerks, varying in number from four to eight, prepare transcripts of birth and death certificates, file these and carry out the simple routine required by the law. Under such direction it is obvious that the $7,000 provided for the vital statistics work is almost completely wasted. Yet, it is important to recog- nize what is being done. Certificates of birth and death are received. These are copied for the local files and the originals sent to the State Department of Health. The copies that are kept locally are bound into permanent volumes. An alphabetical index is also made to facilitate finding certificates which are arranged numerically. Gross carelessness in the acceptance of illegal and incomplete birth and death certificates, and errors in names, addresses and dates of copies left in Cleveland files f6r reference are of fre- quent occurrence. Occasionally, as implied above, an attempt is made to count certificates and to report to the Health Officer the total number of births and deaths for certain periods; but such effort is always belated. At no point is there any evidence that those who work at this material have the training necessary to do so. The important item of cause of death is, for example, assigned by a clerk whose decisions with reference to joint causes or otherwise complicated statements have no value as to their authen- ticity or agreement with the rules of practice of the Census Bureau. No effort is made to check the most important fact, the completeness of registration. No list of physicians and midwives is used in this department, although one is available in the office of the Health Commissioner. No tabulations are made of the numbers of reports received from each physician and midwife. No correspondence is had with any one of these when no certifi- cates are received for long periods of time. No check of any kind is carried on to determine whether birth or death certification is complete. Checks that have been made by other agencies (voluntary and official) indicate that the birth registration may be from 60 to 80 per cent complete, the figures varying during recent years. Public Health Services 167 The following check made by the Survey will serve to gauge to some de- gree the extent of incompleteness: The records of 614 children under two years of age who were bornlin Cleveland were obtained through the Division of Health nurses, and the Visiting Nurse Association. These records were checked at the Bureau f of Vital Statistics and only 383 or 62% were found registered under the same date, spelling of name, etc. These same cases and 55 others, a total of 669, were re-checked and a search made under every probable spelling and under the records for several months, and 522 or 78% were found registered. No monthly records of births, deaths, or of cases of reportable disease are made available to the citizens of Cleveland. No bulletins are issued by the Division of Health and, as far as could be ascertained, no printed annual statement has been prepared for several years. The city of Cleveland presents a rare opportunity among the larger cities of the country to begin de novo in fashioning a system for its record keeping. A system of vital statistics can readily be instituted which shall reflect the tone of the reorganized health service. It must be part and parcel of such a health service; an integral part of a comprehensive effort to conserve the vital resources of the city to the utmost. Such a service will be embraced under three heads: 1. Registration of births, deaths and cases of sickness. 2. Tabulations and reports. 3. Investigation, research and health information. 1. The first subdivision is basic to all the rest, for without the primary registered facts, tabulations, reports or investigations cannot be made. The state law requires that every birth and death in the city shall be reported within ten days. It is the duty of the Registrar to see that this requirement of the law is enforced. The first step in such enforcement is to have a complete list of physicians and midwives available. At regular intervals reports of births should be credited to the certifying physicians and midwives. Those from whom there are no reports or only a very small number should be questioned to determine whether they are negligent in reporting. Reports of births should also be checked against lists of baptisms, newspaper notices and similar sources of information. Records of deaths of infants under one year of age should, as a matter of routine, go through the Registry Room to determine whether they had been previously registered as births. Records of stillbirths should figure equally among births and deaths. The names of those physicians and midwives who are particularly negligent in their duties of registration would soon be available. An effort could then be concentrated on them to mend their ways. It will be necessary in some cases to prosecute physicians and midwives according to law as a lesson to others that the authorities are determined to make birth registration complete. It will be necessary in this connection to obtain the cooperation of the State Registrar and of the State local prosecuting authorities who share in the responsibility for enforcing the vital statistics law. 168 Hospital and Health Survey Death registration in Cleveland is probably in a satisfactory condition, although no effort has as yet been made to determine the comoleteness of registration. Physicians uniformly take more seriously the requirements of death registration. It would, nevertheless, be useful at certain intervals if an effort "were made to check the list in the registry office with lists of deaths obtained from independent sources, such as hospitals and institutions for the aged and dependent, newspaper lists of decedents, etc. It is conceiv- able that through these means physicians who neglect occasionally to report a death or who unduly delay their reports will be discovered. Once received, the certificates of births and deaths must be transcribed, the originals sent to the State Registrar, and the certified copies bound and made available for easy access and future reference. This necessitates the preparation of additional index volumes or card records of births and deaths, arranged alphabetically by name with a corresponding registry number of the original certificates. It goes without saying that such indices and the transcripts themselves should be legibly written and checked as to accuracy. The transcripts must be bound at regular intervals in consecutive order of the file number and placed where they can be easily accessible and safe from mishandling or destruction by fire. At the present time the file room of the Division of Health is in bad condition. It is a general storeroom as well as file room and it is altogether too small and too dark to permit good work to be done. Batches of birth and death certificates are in constant danger of being misplaced under present conditions. In addition to the registration of births and deaths, the Bureau of Vital Statistics should serve the Bureau of Communicable Diseases of the Division as the repository of the records of cases of communicable disease reported as required by law. While these records are primarily intended for the guidance of the Bureau of Communicable Diseases for administrative health work, it would be economical if the cases were communicated to the Registrar for tabulation to show from week to week, and at other longer intervals, the condition of the city with reference to infectious and other reportable diseases. It is also recommended that this division cooperate with the Cleveland Hospital Council with a view to recording the number and character of patients receiving care, together with a statement of the diagnosis, and the other basic facts for the sick in each of the several wards or preferably in the sanitary areas of the city. This phase of hospital statistics will be treated in another section of this report and will not, therefore, require further dis- cussion at this point. The present clerical force is quite adequate to insure the performance of the registration work of the Vital Statistics Bureau. All that is needed is intelli- gent supervision and leadership. If the registration of communicable disease and hospital cases is desired as an added activity of the division, an addi- tion of one or, at most, two clerks will be necessary. 2. Once the certificates of birth and death are received and the number certi- fied as correct, it is the function of the Registrar to tabulate the result at re- gular interval.s A weekly report of the number of births and deaths registered should be available. The health officer should receive on Monday of each Public Health Services 169 week a statement from the Registrar covering the number of births and deaths reported during the preceding week. Both births and deaths should be tabulated by sanitary areas and by Health Districts and the numbers compared with those for the corresponding week of the previous year. Deaths should be further subdivided as to broad age periods and by the principal causes to show the current mortality among infants, and, especially from the infectious diseases. At the close of each month a more detailed monthly statement should be prepared and, at the close of the year, a full annual report should be prepared. A series of tables are given in the appendix which are designed to show the facts required for each year for a city of the size and importance of Cleveland. The Registrar should also tabulate and report on the cases of sickness in the community so far as records for such cases are available. Under this head two important activities may be distinguished: (a) The Statistics of Infectious and Notifiable Diseases. Under the first head the Registrar will cooperate with the Director of the Bureau of Communicable Diseases. It should be the duty of the Regis- trar to make pin maps for the cases indicating the incidence of disease by sanitary areas or by Health Districts of the city. He should weekly, monthly, quarterly and annually compile the figures showing the prevalence of the several diseases for the sanitary areas. He should make comparisons with the incidence of such diseases in previous years and keep the Health Com- missioner and the others of the Administrative Staff informed of impending epidemics and of the distribution of cases in the several areas of the city. Such work, it is true, is rarely done by registrars in American cities. It is carried on usually, when at all, by the Director of the Bureau of Communi- cable Diseases; but the work is essentially statistical and could be more economically performed by the Statistical Bureau. There is no statistical work that will produce greater dividends than the careful compilation of records of disease, intelligently interpreted with reference to distribution by health districts, sanitary areas or by wards, and by age, color and nativity of the population. When properly correlated with the registration of deaths from these same diseases, it should be possible to prepare tables showing, in addition to the attack or morbidity rate, the lethal or ease-fatality rate, which would indicate the severity of the epidemic at any particular time. (b) Hospital Statistics. Cleveland finds itself exactly in the same position as do all cities in the United States with reference to a knowledge of the work of its hospitals. In no American city of any size is it possible to give the total number of cases admitted to hospitals, both public and private, the diseases for which entrance was sought, the age and sex distribution of the patients, the duration of treatment and the result of the treatment. It is a blemish on the excellent work done by hospitals that this phase of their activities has been left un- developed almost without exception in the United States. For Cleveland this represents an opportunity. For, should this city organize an effective bureau in its health division under the direction of a competent vital statis- 170 Hospital and Health Survey tician, it would be a relatively simple matter to put into operation a plan which will result in the compilation of just such data with reference to hos- pitalization in this city. The necessity of such records of hospital care is never questioned; but nowhere have the necessary steps been taken to assure the receipt of the facts. In the matter of organization, it would be necessary only to establish a central office, preferably in the Bureau of Vital Statistics of the city, where uniform reports would be received from each of the hospitals of the city for each case on its discharge. Such a standard form would include such basic items as age of the patient, sex, color, nativity, occu- pation, duration of residence in Cleveland, address, diagnosis on admission and at discharge, a brief summary of the treatment, duration of the treat- ment, the date of discharge and condition on discharge; a statement of the social service work done or contemplated would make a valuable addition. It would be necessary only for the hospitals of the city to agree upon a simple blank including such items as these, and to send them as completed to the central record office immediately upon the discharge of the patient. A nomen- clature and classification of diseases and of conditions or states of the patients on discharge should also be agreed upon. In the central office these records would be edited and otherwise prepared for transfer to perforated cards which would then be sorted and tabulated by mechanical devices. At comparatively low cost, it should be possible at the end of each quarter and at the end of the year to have available a series of tables showing for each hospital and for all hospitals combined, the essential facts for the cases discharged during the period. From the point of view of the city such information would be of the greatest value in indicating the adequacy of hospital care then available and the need for additional hospitals and their location. It is conceivable that hospitals are now improperly placed with reference to the outlying sec- tions of the city. A study of the wards in which patients are located as compared with the location of the hospitals in which they have been cared for, would indicate opportunities for greater service through more effective location of hospital structures. Causes for undue competition between hos- pitals could be removed through this means. But, more important, will be the effect upon the management of hospitals in the city in standardizing record keeping, in bringing them together for mutual conference to learn why certain types of cases are better cared for in one hospital than in another, why, at any rate, one hospital has a lower lethality rate for certain diseases or surgical conditions than another. Comparisons could also be made be- tween the duration of stay in certain hospitals in treating like cases. The opportunity for constructive criticism is unlimited. Such a plan as this could be operated tactfully with the cooperation of the hospital authorities. The cost for such an activity should very properly be met by the Hospital Council, but the maximum will not be more than a small item for each of the hospitals. The Division of Health would supply only the use of its machinery and the directing care of its statistician. For the city, however, and for the Health Division especially, this will mean that, for the first time, it will have a knowledge of morbidity in the population which is cared for through the agencies of the hospitals. This is certainly an important phase of the health problem of the city. The patients cared for by the Public Health Services 171 Visiting Nurse Association should on discharge be reported in a similar man- ner to the Bureau of Vital Statistics through the central office of the Asso- ciation. The nursing service is practically a great extra-mural hospital. 3. The above outline of the work of the Bureau of Vital Statistics is a con- servative statement of what such work may profitably include. It will prob- ably be all that an efficient registrar or statistician with a limited staff will be able to undertake during the first few years of his incumbency. It is conceivable, however, that if the Registrar is carefully chosen and is sup- ported by the Health Commissioner and by the private and other official agencies, his department will gradually absorb other work along the lines of investigation and research which it can efficiently perform. Such work should lie directly in the field of public health and social welfare. It should be the duty of the Registrar to conduct statistical investigations into the effectiveness of the various experiments undertaken by the Division of Health, be it in organizing the health service along district rather than central lines, or in determining the efficiency of generalized as against specialized visiting nursing of the sick, or the best method of caring for certain diseases, such as pneumonia and the communicable diseases of children whether in hospitals or at home under proper medical and nursing care. The Registrar may also well undertake to prepare, in cooperation with other official and semi-private agencies, annually or biennially, a Year-Book for the City of Cleveland in which the chief facts of the population should form the central items. This report would include data covering the city and its resources. The Registrar would, in this sense, be a compiler and editor of materials received from the several heads of divisions of the city administra- tion. From the Commissioner of Streets he will receive annually a statement covering miles of streets now paved and cleaned and otherwise; from the Commissioner of Engineering and Construction and from the Commissioner of Water, the essential facts concerning those departments; from the judges and District Attorney facts concerning crime; from the school commissioners, facts for the educational system; from the Commissioner of Internal Revenue, located in Cleveland, items related to incomes and the value of manufacturing products. The result would be a Year Book which would reflect the greatest credit upon the city because it would show in narrow compass the true greatness of the community. It would present briefly a summary of the major activities of the population, its resources in men, the value of its products, the source of its revenue. It should be a most valuable reference guide for the administration of the city toward new projects and an expression of the progressive spirit of its citizens. Such a plan as this looks into the future, but it is not at all chimerical. \11 of it can be accomplished if only the first step be taken; namely, to obtain or the Division of Health a man properly qualified to do the immediate statistical work of that department but with sufficient wisdom and capacity :o assure his assumption of larger responsibilities in the future. Everything ncluded above will ultimately reflect favorably upon the health of the people md justifies the inclusion of this scheme under the activities of the Division >f Health. 172 Hospital and Health Survey Introduction to Cleveland Tables Tables X. -XXXVIII. (Appendix) present an outline of a complete system of vital statistics for the health department of a city of the size of Cleve- land. It will not be necessary to prepare all these tables each year. The first seven will be valuable, primarily, for census years when detailed and accurate data for the population are available. Other tables have special bearing on certain diseases and conditions and need appear only occasionally as it is desired to arouse interest in them. Much will depend on the facilities, both in funds and personnel, available to the registrar. With gen- erous support he may give a fairly complete presentation of the vital resources and activities of the population from year to year. But with limited support it will be necessary for him to use only those tables which give the more essential facts. RECOMMENDA TIONS It is recommended that: 1. A competent statistician be put in charge of the Bureau of Vital Statistics with sufficient support to carry through a comprehensive program of record keeping for the Division of Health. 2. Birth registration, which is now very defective, be made complete. This may be accom- plished through the following steps: (a) A complete list of physicians and midwives. (b) A check-back at regular intervals of all births reported to th^ physicians and midwives reporting them. (c) A follow-up of those physicians doing obstetrical work and of all mid- wives who do not make any or a small number of reports. (d) A check-back of all infant deaths to the birth registration list, and if no record of birth, the case to be followed up to determine the negligent physician or midwife. (e) The prosecution of persons persistently violating the law. 3. The cooperation of the local and State Medical Society be obtained as a preliminary to subsequent enforcement of the law. 4. Provision be made for the editing, tabulating and analyzing of certificates of death. 5. More care be taken to file birth and death certificates to' provide against their loss or misplacement. 6. The Division of Health consider the problem of morbidity statistics and make pro- vision for the study of records of communicable disease, and of hospital and Visiting Nurse Association dis<*harge certificates. 7. Provision be made for such investigation and research work in the Division of Health as will keep the Commissioner informed as to the effectiveness of the various activities of the department and of such experimental work as is undertaken. 8. The Registrar compile a year-book covering the health as well as the social and economic data of the city. ' Public Health Services 173 New Activities Proposed for the Division of Health EACH of the existing bureaus of the Division of Health is called upon by public demand, by appeal or pressure of private agencies or by the initiative of its own officers and the Commissioner of Health to add here and there a temporary or permanent function or service. This will go on and should go on to the end of time. At the moment there are a few functions which our study and the force of circumstances seem to impose upon the Division of Health. We refer to: 1. Inspection and supervision of sanitation and medical services in institutions where public and private charges are harbored temporarily or for life. 2. Inspection, technical advice and protection, for the industries and commercial establishments of the city, to diminish the hazards to health, in occupations. 3. Medical examination service for the city employes. 4. Public health education. 5. Supervision of and provision for the victims of habit-forming drugs and protection of the public against the illicit introduction of these drugs in trade. A brief statement on each of these needs follows: INSTITUTIONAL INSPECTION The Griswold Act of the last legislature recognizes the need for institu- tional inspection as a public health measure, and in Section 1261-31 author- izes frequent inspection of infirmaries, children's homes, workhouses, jails, or other charitable, benevolent or penal institutions, including physical ex- amination of the inmates whenever necessary by representatives of health departments. As a safeguard against communicable disease alone, such an activity is justified and sooner or later the Division of Health must deal with this important subject in an organized way. Owing to the nature of the problem most of this work must be done by physicians. By adding to the present number of district physicians a partial inspection of institutions can be begun in much the same way that the division has begun school inspec- tion in parochial schools, through the public health nurse. Since no information was available as to the sanitary conditions which prevail in institutions or as to medical service, a special study was made of these aspects of the institutional life of children, in cooperation with the investigator of the Welfare Federation who studied the social, economic, educational, recreational and spiritual environment of the institutional chil- dren. The results of the combined study have been presented to the superin- tendents and boards of managers of the various institutions studied, in much :he same way in which the reports of the Survey on hospitals were made available directly to hospital trustees and administrators. 174 Hospital and Health Survey The study of the institutions fell under three headings: Child Caring Institutions proper, Boarding Homes for Children, Day Nurseries. Dr. Henry G. McAdam, the chief of the division of institutional inspection of the New York City Department of Health aided by inspectors of the Board of State Charities and physicians of Cleveland engaged to make medical examinations of children, did the field work. The following reports were prepared by Dr. McAdam. Report ox Child Caring Institutions in Cleveland Objects 1 . A complete physical examination of at least 1 5 % of the inmates of Child Caring Institutions. 2. A Sanitary Survey of the building or buildings housing these inmates. So far as was possible the children examined were actually divided among those who had been in the institution only a short time, and those who had been resident for from six months to a number of years. The analysis of these findings is divided according to whether the child's length of stay in the institution was under or over six months. The children were examined for defects under eleven headings, viz.: (1) Vision, (2) Hearing, (3) Defective Teeth, (4) Defective Nasal Breathing, (5) Hypertrophied Tonsils, (6) Defective Nutrition, (7) Cardiac Disease, (8) Pulmonary Disease, (9) Orthopedic Defects, (10) Nervous Disease, (11) Miscellaneous. Under the heading, Miscellaneous, the following diseases, defects and conditions found during the examinations were noted: Enlarged cervical glands Enlarged Thyroid glands Enlarged axillary glands Adenoid facies Conjunctivitis Protruding abdomen Redundant foreskin Acne High arch palate Impetigo Enuresis Furunculosis No Uvula Scabies Ringworm Infection of legs Infection of back Infection of right heel Infection of buttocks General pallor Infection behind ear Pasty complexion Puffmess under eyes Chronic Otitis Representatives of the Board of State Charities, under direction, use the outline that is used in inspection of similar institutions in the City of New York, on which to base their reports. . Public Health Services 175 We were impressed by the number of Homes for Children that had in contemplation new buildings or new locations, or both. Among those where definite plans have been perfected, are the following: 1. Cleveland Protestant Orphan Asylum — Land has been pur- chased and plans are ready for a new structure. 2. Cleveland Christian Orphanage — It is almost certain that this institution will be in a new building within a year. 3. Jewish Infant Orphan Asylum — Property has been purchased and plans completed for removing from the present location to the new quarters within a year. 4. St. Vincent's Orphan Asylum — Plans have been perfected and this institution will move into new buildings inside of a year. 5. Jewish Orphan Asylum — Plans have been perfected for the new buildings, but it will probably be three years before a change is made. $25,000 have been expended in necessary alterations of the present place, and con- tracts for $25,000 additional expenditures have been passed by the com- mittee in charge of the budget. The admission procedures followed and the physical condition of the in- mates and buildings, varied within very wide limits, and individual reports in detail have been prepared for each institution. Summaries of the examinations of the inmates, of medical service pro- vided for them, and of the results of the sanitary inspections of the nineteen institutions studied, are to be found in Tables XXXIX. -XLI. in the Ap- pendix. Summary of Medical Service 1. Only three child-caring institutions out of the total of 19 investi- gated, provide an entrance physical examination. 2. Only three institutions out of the total of 19 have an admission quarantine to prevent new inmates from bringing contagion into the institu- tion. 3. Eleven institutions have ample isolation facilities, and eight do not. 4. Thirteen institutions have adequate hospital facilities, while six have none, or inadequate facilities. 5. Not a single institution of the 19 investigated conducts periodic physical re-examinations of the inmates. 6. Thirteen of the Homes investigated have Hospital and Dispensary affiliations, while six maintain no relationship of this nature. 7. Children are allowed as visitors in 17 of the institutions investigated. In only two is this prohibited. 176 Hospital and Health Survey There was no way to determine what percentage of the children examined had had corrective work done during their stay in the institution, in as much as none of the institutions conduct re-examinations of the children. Without records, the value of the work cannot be determined. In some of the institutions visited, information on loose pieces of scrap paper were the only records kept. Only three Child Caring Institutions give a complete physical examination on admission and keep records of the findings. In one of these (The Deten- tion Home) a trained nurse conducts the examinations. The other two are the Cleveland Christian Orphanage and the Cleveland Protestant Orphan Asylum. Adequate admission quarantine is of great importance as an administra- tive feature in Child Caring Institutions. If every child on admission to an institution is placed in quarantine for the incubation periods of contagious diseases, before being allowed to mingle with the other children he or she cannot spread communicable diseases in that institution and the only source of contagion must be from the outside. Furthermore, if children (who are more prone to contract the ordinary contagious diseases than adults) are excluded as visitors to institutions, contagion will be reduced to a minimum. During our investigation no special effort was devoted to the subject of venereal diseases. We found, however, with reference to penal institutions particularly, that this subject received the attention it deserved. Theo- retically, Wassermann tests should be made on all new admission sand vaginal smears made of all females. For practical purposes it would prob- ably be sufficient to perform Wassermann tests where indicated by clinica signs or symptoms, and to make vaginal smears in the presence of vaginal discharges. RECOMMEND A TIONS 1. No child-caring institution should be allowed to operate without a permit. 2. Prior to the issuance of a permit the applicant should show: (a) The necessity for the institution. (b) That there is a proper plant in which to conduct the proposed institution. (c) The financial ability to maintain the institution for which the per- mit is asked properly in all respects. (d) Capability for efficient management. 3. Permits should be issued only after compliance with certain equipment and serv- ice standards which should include the following: (a) Protection against fire hazards. (b) Protection against accidents due to unguarded machinery. (c) Type of building should be fire-proof if in excess of 20 feet in height. (d) No over-crowding. A minimum of 600 cubic feet of air space should be allowed to each child, except when very young infants only are housed, when 300 cubic feet should be allowed for each child. Public Health Services 177 (e) Proper heat, light, ventilation, refrigeration and screening of building. (f) Adequate toilet and bathing facilities. (g) Adequate laundry facilities. (h) Adequate isolation and quarantine facilities. (i) Provision for regular physical examinations and re-examinations of the children, either by: 1. The attending physician of the institution, or 2. The clinics of the Division of Health, or 3. A special corps of, physicians employed by the city. 4. Regular and adequate inspection and supervision by the municipal government. Boarding Homes for Children No sanitary survey was made of the boarding homes for children under the care of the Humane Society, but 57 "boarded out" children received physical examinations. The results are given in the Appendix, Table XLII. A description of the present procedures for the medical supervision of these children follows:* "The medical care of children in boarding homes in general is provided by the Division of Health and the Babies' Dispensary as follows: Children under three years of age, when received by the Humane Society are examined at the Babies' Dispensary and are tested for venereal disease and tuberculosis; the children are brought back for reading of tests and re-examination at the time that the dispensary specifies. Medical care for the children is provided at the dispensary as long as the doctors advise. The diet for the children is prescribed at this dispensary as long as the children are brought there. Milk for babies under fifteen months of age is ordered and provided by the dispensary and is free for children whose parents are unable to pay. "After the children are discharged from the Babies' Dispensary they are taken by the boarding mother to the prophylactic dispensaries of the Division of Health in the district in which the boarding home is located. They are taken to these dispensaries once in two weeks and are cared for by the doctors and nurses in these dispensaries. All medical charts for children are kept at the Babies' Dispensary or at the prophylactic dispensary which the child attends. "Sick children who are too ill to go to the dispensary are attended by the district Dhysicians. The boarding women are instructed to notify the district doctor of their dis- :ricts in case of such illness. The doctor arranges for the child to go to the hospital if lecessary. "Children over three years of age when received by the society have medical examina- ions made by the doctors at the prophylactic dispensaries, the examinations being made n the district in which the boarding home is located. Medical treatment for these chil- lren is provided at the dispensaries of the various hospitals. If the children are placed n boarding homes outside of the city limits the family physician of the boarding mother *This description was prepared for the Survey by the Director of the Cleveland Humane Society. 178 Hospital and Health Survey is generally called. Dental work for these children is done at the Western Reserve Uni- versity Dental School, the society paying for the material used. "Supervision — The nurses of the Division of Health supervise all boarding homes within the city limits. Each nurse visits weekly the children in boarding homes in her respective district and each week makes a report of her visits to the Division of Health. A copy of this report is sent to the society. The visitors of the society also supervise children in boarding homes. The matters pertaining to the health of the children, however, are left to the nurses and to the dispensaries. "Homes — The children are placed in family homes which have been investigated by the society and licensed by the Division of Health. Applications for licenses are con- sidered by a committee consisting of representatives of the Division of Health and the Humane Society before a recommendation for license is made to the Board of State Chari- ties. It is the policy of the society not to place more than one child in a home unless the children are related. The society has five subsidized homes, having five beds in each home, where children are cared for temporarily while arrangements are being made to place them in other boarding homes. The society has no special homes for the care of convalescent children or diseased children." Suggested Procedure All activities relative to the placing out of children in foster homes should radiate from a central institution or place, which we will tentatively call a Children's Placement Bureau of the Division of Health. Before a child is listed in the Children's Placement Bureau an investiga- tion by the Humane Society should be made to see that the child is one requiring, and suitable for, placement. It having been decided that the child is to be placed out, he is taken to the Children's Placement Bureau, and the parent or legal guardian should sign, at that time, a release, permit- ting the Placement Bureau to relieve, by proper treatment, physical condi- tions from which the child may suffer, along the lines indicated below: Date 1920. I hereby agree and consent that if my child,... , while under the control of the Children's Placement Bureau, shall be found to have: 1 . Defective Vision, 2. Defective Hearing, 3. Defective Teeth, 4. Defective Nasal Breathing, 5. Hypertrophied Tonsils, ^ 6. Orthopedic Defects, these defects may be corrected under the direction of the authorities of said Children's Placement Bureau, without further action on my part. Name Address Relationship Public Health Services 179 The child should be kept under the control of the Placement Bureau either in its own building or buildings or in specially subsidized homes until these defects have been corrected, if it is probable that they can be corrected within a short period, say two to four weeks. If a defect is chronic in nature, the child having the chronic defect should be released to a specially graded foster home, and kept only in such specially graded home until the defect has been corrected. In making recommendation that a child be sent to a specially graded foster home, unsatisfactory condition of the teeth alone should^not ordinarily be considered as a chronic defect. SOARD L 0F HEALTH/ fOISTiRICT 1 [PHYSCIANS/ BABIES IDJSPENSAKY". CHI [All OTHff IHOSpiTAlSJ :N5 EMENT, EAtf /cleveland) -Humane )CIETY> nee iDFpAPJf-W rOSTER HOMES original Home Fig. XIV. While in the Children's Placement Bureau, in addition to the regular physical examination which may be made at the Babies' Dispensary or other institution, as decided upon by the Children's Placement Bureau, the chil- dren should be Schick tested and a culture should be taken from both nose and throat. If the case is suitable, toxin — antitoxin, for immunization- should be given. They should be tested for tuberculosis and Wassermann 180 Hospital and Health Survey test should be made. In the case of females, vaginal smears should be taken. Vaccinations should be done where indicated. No child should be sent to a foster home while defects are being corrected, unless the defects are of a chronic nature. The foster homes should be graded "A" and k 'B." The "A" homes should be those conducted by women who have proved themselves to be specially qualified to care for children, und the grade "B" to include all other licensed homes. The foster mothers having grade "A" homes should receive the children with chronic defects, and should be paid a larger compensation than those having grade "B" licenses, in view of the fact that they have superior training, and that a child with a chronic defect is harder to manage, and so the grade "A" foster mother is entitled to a larger sum. By this method any child with a readily remediable defect would remain in the Placement Bureau until in good general health, and the children with chronic defects would receive special care until their defects, if correctable, are cured. The effect on foster mothers of having two grades of license would be to spur the grade "B" foster mothers on to do good work in order that they might get a grade "A" license, with its increased income, and those who already have a grade "A" license, to exert themselves in order that they may continue to hold that grade. • After the children have been placed in foster homes the Division of Health should supervise the home, and pay particular attention to the sanitary con- dition of the home and the health of the foster mother and of the children; the Humane Society at the same time making stated visits to supervise the moral and financial conditions surrounding the child in the boarding home. It should be the aim of the Central Placement Bureau to have as few children as possible in each home. Whenever the number of children in a home exceeds three in number, whether subsidized or not, there should be, in addition to the preliminary investigations made by the Humane Society and the Division of Health, an investigation of the premises made by the Fire Department to determine whether the building is reasonably safe to house the number of children for which a permit is to be issued. While the children are under the care of the foster mothers, they should be taken from time to time to the Babies' Dispensary or the prophylactic dispensaries of the Division of Health for re-examination, observation, regulation of diet, etc., and when ill and unable to go to the dispensaries should be cared for by the district physician or be sent by him to the ap- propriate hospital. A diagram illustrating the contacts between the various services as sug- gested above follows: Fig. XIV. Day Nurseries in Cleveland There are seven day nurseries in Cleveland, five of which, the Mather, Louise, Lend-a-Hand, Perkins and Wade, are branches of the Cleveland Day Nursey and Free Kindergarten Association; one, Merrick House, is conducted in connection with that Settlement House; and one, Joseph & Public Health Services 181 Feiss, is maintained by that industrial plant for the children of its employes. Three of these day nurseries, Louise, Perkins and Wade, are in the same building with kindergartens. Joseph & Feiss are thinking of conducting a kindergarten during the summer, but no definite plans have been made. The Cleveland Day Nursery and Free Kindergarten Association, which maintains five nurseries, four kindergartens and a Kindergarten Training School, is a voluntary organization included in the Welfare Federation. The Association employs an executive secretary, who has charge of administra- tion and who also acts on authority delegated by the Division of Health as the official investigator of day nurseries in Cleveland. At the instigation of the Day Nursery and Free Kindergarten Association, City Ordinance No. 47591 was passed in October, 1918, to regulate the day nurseries in Cleveland. This ordinance was based upon the ordinances in New York City and Chicago and its provisions for equipment and operation of day nurseries are excellent. This ordinance makes specifications as to medical service (including initial and periodic physical examinations); plant and equipment; ventila- tion; light; heat; air space (300 cubic feet per child) ; playground; cleanli- ness; methods of cleaning; provision of individual beds; care of children's clothing; provision of individual washcloths, towels, bed linen, combs, tooth brushes, hairbrushes and drinking cups; toilet facilities; isolation; food and care thereof, and sanitation, etc. All-day nurseries in Cleveland must be licensed and permits are issued by the Commissioner of Assessments and Licenses upon recommendation of the Commissioner of Health, after an investigation of the premises has been made by the Bureau of Child Hygiene. These permits are issued annually. The Division of Health having no adequate personnel for supervision of day nurseries, delegated the authority for such supervision to the executive secretary of the Day Nursery and Free Kindergarten Association, who, be- cause of the pressure of other duties, has little time to spend in the sanitary supervision of nurseries. Excellent results have been accomplished, how- ever, by the Day Nursery Association in suppressing various "mushroom" nurseries that have sprung up from time to time and which did not meet the standards provided for in the ordinance. The aggregate attendance at the nurseries for 1919 was 47,085 child- days, and the average daily •attendance of children was 184.75. The num- ber of rejections of applicants for nursery care from August, 1919, to Janu- ary, 1920, was 131, of which ten only were due to lack of room in the nur- series. The Day Nursery Association formerly had an investigator to pass on all admissions as to social or economic necessity of providing care for the child. Now admissions are made by the superintendents. Children who have only one parent, usually a widowed or deserted mother, are admitted to the day nurseries. In rare instances children with two parents are cared for if the father is ill or incapacitated. In some cases 182 Hospital and Health Survey children are admitted when the mother goes to work as well as the father. The age of admission is from six months to fourteen years, nursing children being admitted only on special recommendation of the examining physician. At the time this investigation was made very few nursing children were regis- tered in the nurseries. If the economic status of the family warrants, a charge of fifty cents per day is made. The estimated cost per day for each child to the Day Nur- sery Association is about $1.00. A study of the admission procedure at the day nurseries and of the eco- nomic question involved in providing day nurseries for the care of children of women in industry, will be made by the Welfare Federation in connection with their study of children's institutions. Medical Service The Day Nursery and Free Kindergarten Association employs a physi- cian on part time to give medical service to the five day nurseries under its care. Before being admitted to the nursery, the children receive a physical examination either by the day nursery physician or at a nearby dispensary. The examination consists of the following: History of — Chickenpox, measles, mumps, scarlet fever, whooping cough, vaccination. Examination of — Glands, skin, eyes, ears, nose, teeth, throat, tonsils, heart, lungs, abdomen and weight. The examiner gives special attention to the nutrition and development of the child, and looks for any evidences of anemia. This examination is made with the children's clothes loosened or removed. No laboratory tests are made at the day nurseries, but any such necessary work is referred to the various dispensaries or to the Division of Health. No diphtheria culture tubes are kept at the nurseries, the physician having[a supply of these with him when calling at the nurseries^ ' Each superintendent interviewed stated that there was a daily inspection of the children on admission, either by herself or by a nurse, for symptoms of contagious disease. The last sentence of regulation 21, "each child admitted to or cared for in any day nursery shall be examined at least once every three months," did not seem to be thoroughly understood or adequately carried out by the day nurseries. No superintendent interviewed stated that there was a periodical re-examination of children every three months, and a number of cards of children who had been in the nurseries four months and over, did not show any record of re-examinations. Children who have been absent from the nursery for a week or more are examined either by the nursery physician or at a nearby dispensary before readmission. Public Health Services 183 The children in* the nurseries are weighed either every two weeks or every month, the procedure varying in the different nurseries. Excellent weight charts are kept. Opposite each child's name a star is placed, a blue star indicating loss or stationary weight, and a red star a gain. These charts have proved of great educational value to both mothers and children. Two of the nurseries have trained nurses as superintendents. For nurs- ing service the other nurseries can avail themselves of the service of the nurses of the Division of Health or of the Visiting Nurse Association, but the superintendents do not seem to be taking advantage of these opportunities as fully as could be desired. The follow-up to correct defects is carried on under the direction of the superintendents. A study of the records of the five day nurseries under the control of the association gives the following results: of 197 children who had been under the care of the day nurseries over four months, there were four cases of defective vision, three of which had been corrected and one of which was under parental care. There were eighty cases of defective teeth, on which fifty-two, or 65 per cent, of the corrections had been made. Be- sides these corrections one case was under parental care and three were over school age. Sixty-six cases of diseased or hypertrophied tonsils were noted, of which forty-one, or 62.1. per cent, had been corrected. Also there were three under parental care, one "unwilling" and one "improved." According to these figures which were furnished by the Day Nursery Association, the follow-up work of the nurseries seems to be adequate. Vaccinations are made by the nursery physician on all children who have not been vaccinated. Merrick House: The medical service at Merrick House is practically the same as that furnished to the nurseries under the Day Nursery Association, with the ex- ception that the physician visits twice a week. Joseph & Feiss: The medical service is given by the physician in charge of the factory, who is on call at any time and who always responds quickly. According to the facts furnished by the superintendent, the service given comes up to the standards of the ordinance. The children are examined on admission, re- examined after absence, etc. The superintendent of the nursery is a trained nurse. 184 Hospital and Health Survey Summary of Conditions Found in the Seven Nurseries by the Investigator Number of Nurseries Sleeping room not provided with the minimum cubic air capacity required by the city ordinance 2- Children sleeping together.... _ L 1 Drinking cups used in common _ _. 4 Combs used in common or incompletely sterilized after use 5 No ventilation in room in which children were playing 2 Poor ventilation of toilets . 2 Dry dusting and sweeping done..... 4 Clothing hung too closely to permit of clothing ventilation... 2 Wash cloths, towels and tooth brushes hung so closely that in some in- stances they touched 4 Beds not identified 2 Aprons not identified 1 Bibs not identified and piled together after each use. 1 Rubber sheets not provided for all beds of infants 1 1 RECOMMEND A TIONS 1. Supervision: That the responsibility for the enforcement of the requirements of the day nursery ordinance be assumed by the Division of Health, and inspection of the day nurseries be made by a trained inspector under the Bureau of Child Hygiene in the Division of Health. That monthly inspections of the day nurseries be made. That the provisions of the city ordinance in regard to individual beds, isolation rooms, adequate ventilation and air space and other necessities for satisfactory sanitation in the day nurseries, which are violated at the present time, be observed and enforced. 2. Medical and Nursing Service: That the regulation which has produced good results in other cities and which requires a vaginal smear of all girls before admission, might be found of value in giving additional protection against infection. That there be an increase of the home nursing service given to the children attending the day nurseries and that, for this service, the day nurseries call upon the Division of Health or the Visiting Nurse Association nurses in the district. 3. General: That a further study into the admission procedure and organization of day nurseries be made by the Welfare Federation in connection with their study of children's institu- tions. In this investigation special attention should be given to the economic question involved in providing day nursery care for the children of women in industry. Public Health Services 185 From the numerous defects of equipment and management and professional services discovered, among the institutions, homes and nurseries above described, and from the serious extent, to which physical defects prevail among the dependent children examined it would appear plain that all precautions for these otherwise helpless public wards are not being taken for their present and future health. It is recommended that institutional inspection be recognized as a legitimate activity of the Division of Health and that an organization adequate to look after the institutions and homes for children be created there. INDUSTRIAL HYGIENE Although the complete argument for better protection of industrial workers, based on an extensive study of the existing conditions in industrv in Cleveland, will be found in Part VII. of this report it is worth noting here that whatever may be done voluntarily and in response to the human and economic interests of individual employers and corporations, there will surely be industries and individual plants where only so much is done for the health and sanitary safety of the employes as labor organizations and officers of public departments force the employers to do. Even in the brief period of the Survey a number of instances of flagrant violation of human health rights in Cleveland industries came to notice, which could not have endured and should not have developed at all if it were known that capable inspection and swift action were ready for the protection of employes. Not only are the employes but the employers entitled to the kind of guidance which those trained in the science of industrial hygiene can give them, in the manner of using human labor so that undue risks and perma- nent health liability may not be incurred. It is recommended that a bureau or sub-division of an existing bureau be established to detect and correct health hazards in industry. If there were a trained sanitarian at the head of the bureau of sanitation, industrial hygiene might. at first be included there, but it is believed that a separate bureau for this purpose should be created with a chief trained in the investi- gation and remedy of injurious processes and conditions affecting industrial employes. MEDICAL EXAMINATION FOR CITY EMPLOYES The city of Cleveland employs more people than any organization of industry or commerce within the city or near it. The city payroll varies from 6,500 in winter to 8,000 in summer. This varied personnel is entirely without any organized medical service. In a few departments physical ex- amination may or may not be offered or required at the time of employment, but most of the city employes enter public service without any medical observation as to fitness for their work. In a few departments medical care is available in case of sickness. In no department is there an annual medi- cal survey and examination of each employe. From records of many thousands of examinations throughout this coun- try we can prophesy that from 130 to 160 (i. e., 2%) of the city employes 186 Hospital and Health Survey have active pulmonary tuberculosis and that most of them are unaware of it until too late; from 4,850 to 6,000 (i.e., 75%) are in need of medical or dental advice or treatment for serious or minor defects and diseases, most of which (64%) could be prevented or permanent damage avoided by early recognition. It is recommended that: The Division of Health be authorized to employ physicians and organize a service for the medical examination of all applicants or appointees to positions in the city service and for an annual re-examination of every one on the city payroll from the mayor down. Provision be made for the privacy of records. Treatment for defects be not undertaken at present as a charge upon the taxpayer. If there were to be one service established by the city in the interest of health protection it is believed that that should be free diagnostic service: that is, medical examination of the apparently healthy of all ages and con- ditions of the people. Prevention of disease depends on its recognition. Medical practice for treatment of diseases alone will never meet the needs. What we need in the interest of public welfare is a universal habit of applying once a year to a physician so that he may serve his most important function; namely, match his diagnostic skill against the insidious evidences of impaired structure and function in man. The administration and provision of medical services by the city, free to all who can be taught to apply, would be the best health investment the city could make and nothing would so stimulate physicians to the best they are capable of. Private patients should now establish the practice of calling in their family physician for a health examination annually, and should learn from him what they may expect or what they must do to preserve or attain health. For infants and school children such services are developing but are not yet complete. For industries such services are becoming the rule. The custom should become universal. PUBLIC HEALTH EDUCATION At the beginning of the chapter on Public Health Services reference is made to the unfortunate lack of such a necessary public service as was evi- dently conceived by the framers of the city charter when they provided for a Commissioner of Research and Publicity within the Department of Public Welfare. In order to picture more concretely the present assets of Cleveland in this field a brief report of existing health education resources in Cleveland has been prepared. It would be difficult, indeed, to make a comprehensive summary of public health education in Cleveland for, undoubtedly, all social agencies and agents strive— whenever an opening is presented — to inform their bene- ficiaries in regard to health rules and their observance. Only the principal channels through which this kind of education is directed will be mentioned. Public Health Services 187 The primary sources of health information are, of course, the practitioners of medicine and the nurses who see all classes of people and all types of disease. Of the private agencies those which offer nursing service probably have the best chance of bringing home, with telling effect, their lessons in health education. The contacts of the nurses from the Visiting Nurse Association and the University District are with families where there is sickness and their opportunities for instruction along health lines are only limited by the num- ber of cases under their care. Nurses of the prenatal stations of Maternity Hospital and the nurses of the Babies' Dispensary and Hospital carry the "word" on special health topics (hygiene of pregnancy and care of the sick child) to mothers and prospective mothers. During the summer months the field of influence of the Babies' Dispensary and Hospital is considerably widened by the operation of the Babies' Special. This is an automobile clinic which tours the outlying districts and rural communities of the county. The doctor and nurse in attendance give demonstrations and advice upon the care of the babies. The social service workers at the hospitals (Charity, Lakeside and Mount Sinai) and the field agents of the Associated Charities are also important factors in the attempt to make the knowledge of health principles universal. Whenever the Associated Charities' visitors find a health problem in a home they make every effort to cooperate with the nurses of the Visiting Nurse Association or of the Health Centers in promoting good health standards and in following up medical care. These agents also act as distributors of health literature when it is provided by the Division of Health. A private agency which is bringing the message of health to large num- bers of women and girls is the Red Cross. Through the Teaching Center, courses in prophylaxis, home care of the sick and first aid to the injured, ire offered. Courses, consisting of 17 to 20 talks with demonstrations, are *iven by the nurses at the Center and in factories, schools, settlements, department stores and churches. The Anti-Tuberculosis League, in trying to increase the knowledge of tnti-tuberculosis measures, assists by its literature and lectures in spread- ng the gospel of good health. The clubs at the settlement houses (Alta House, Council Educational Alliance and Goodrich House) and at the Y. M. C. A. offer an opportunity or instructing young men and women in social hygiene and tuberculosis prevention. At the Y. M. C. A. it is estimated that 1,000 men are reached n this way each month. At the Central Friendly Inn and the Y. W. C. A. ealth and home hygiene courses are arranged to supplement the domestic cience courses. Hiram House last fall, in its Boys' Department, had a Health Week" and carried on, through lectures, demonstrations and litera- ure, a health campaign. The Boy Scouts, the Girl Scouts and the Camp- re Girls, by a system of awards, put a premium on good health. The public agencies interested in educating the masses along health lines re the Division of Health, the Board of Education and the Public Librarv. 188 Hospital and Health Survey This work is done by the Division of Health through the doctors and nurses at the Health Centers and through the nurses in the homes. Instruction and advice are given on how to keep well babies well, on tuberculosis control and on care and prevention of contagious diseases. At the present time health education is carried on under the Board of Education in the following ways: 1. Through occasional classroom talks on health topics given by- nurses of the Department of School Medical Inspection. 2. Through individual instruction of the children in the schools by physicians and nurses of the Department of School Medical Inspection. 3. Through instruction by the nurses to girls in the seventh and eighth grades, on the subject of care of babies. 4. Through two forty-minute periods a week in physiology and hygiene in the grammar grades. 5. Through physical training in the high schools and elective courses in physiology, botany, cooking, chemistry and social problems. In practice little or no work in hygiene is carried out in the elementary schools. In the Junior High grades an outline has been provided but the teachers are not obliged to follow it. In the high schools the courses in health education are not standardized and it is difficult to tell how much overlap- ping of courses exists. There is need for a standardized syllabus. The Public Library, through its Information Bureau, suggests books to be consulted for light on health matters. From this resume it is evident that health education is carried on quite extensively in Cleveland, but there is need for an organized and intensive health program. The Survey is entirely in sympathy with the views of the International Red Cross, as expressed at the Cannes conference in 1919. "We are convinced of the prime importance of widely disseminating among the people a knowledge of the simple laws of healthful living and a conviction as to the need of apply- ing them. This is the most valuable means whereby we can promote their physical well- being; and, with a 'health conscience' formed, most public health problems become simplified and all public health administration is made more easy. "It may be said that the measure of the public health of any community is in no small degree the measure of self-help in health matters. Official and voluntary health agencies can effect much in the direction of improving the environment of the individual and pre- venting communicable diseases; relatively they can effect little in the direction of securing hygienic observances in the intimate circumstances of living, and in the wider field of non- communicable but preventable disease. Ignorance and carelessness are here responsible for much sickness and premature death. "It is largely because child welfare work is essentially educational that so much suc- cess is obtained in it; and we consider that, profiting from this experience, public educa- tion should be made a prominent part of public health activities in every field of work. Public Health Services 189 "Hygienic precepts and practice, and the training of the older girls in the essentials of infant care and home-making are of fundamental importance as a means of contribut- ing greatly to the health and happiness of a community. For those who have left school an active educational propaganda should be maintained. For popular propaganda pur- poses we would indicate the following as agencies of proved value : 1. The Public Press. 2. Cinema Films. 3. Posters. 4. Exhibits. 5. Popular Lectures. 6. Educational campaigns on special health topics in which all these agen- cies are employed. "We consider that for most effective propaganda assistance is generally necessary from experts in publicity matters." RECOMMEND A TIONS 1. It is recommended that the Board of Education organize consistent education in health through the entire school course of the child. The board should accept the services of the Red Cross Teaching Center to carry on this work until such time as appropriations can be made for the purpose. 2. It is recommended that there be a bureau of public health education in the Divi- sion of Health, with a full-time publicity expert in charge, to carry on the activities out- lined above and to coordinate all efforts of the various private agencies, or that a full-time publicity expert be employed by the proposed Public Health Association or by the Anti- Tuberculosis League. CONTROL OF DRUG ADDICTION Medical service and correctional interests are so involved in the control and care of drug addicts that there must be effective cooperation between the Division of Health and the Police Department in handling the matter. The city police must assist the federal revenue officers in blocking the illegal channels of distribution of the narcotic drugs and in confining the sup- ply and distribution of the drugs to the hands of licensed pharmacists, physi- cians, veterinarians and dentists. The Division of Health must take part in the supervision of the addicts until they are cured or are accommodated in institutions where they can be freed from their affliction and rehabilitated physically. Dispensary and ambulatory care for drug addicts are futile. These pa- tients must be put in institutions where their insane ingenuity cannot avail them in obtaining drugs for the continuance of their habit. To quote from a statement of the Commissioner of Health: 190 Hospital and Health^Survey "City ordinance No. 48247-B places the administration of narcotic drugs in Cleveland as well as the presenting, bartering, selling or giving of such drugs under the control of the Health Division. The enforcement of this ordinance in detail would require the fol- lowing organization: 1 Chief Inspector, 2 Inspectors, 1 Clerk, 1 Physician. "The work of the inspectors would require a continuous inspection of the records and stock of narcotic drugs in the possession of those authorized to deal in the same : namely, wholesale and retail drug houses, hospitals, physicians, dentists and veterinarians. A physician is required to deal with those drug addicts who continually infest the city. Since 1918 the clinic in the City Hall has been maintained in charge of one of the district physi- cians assigned to the sub-division of Communicable Disease. This clinic is financially self-sustaining, as all addicts are required to pay for their treatment while in attendance upon the clinic. However, the necessity of assigning to this work one or more full-time employes of the Health Division has not yet been offset by increasing the number of em- ployes allowed the Division under the existing salary resolution. It should be stated that no request for additional employes to deal with the addict problem has heretofore been made. The city ordinance referred to above was only passed in April, 1919, and until then the handling of this problem by the Health Division had been considered as a tempo- rary matter, only to require the services of employes for a short period. The outlook is now entirely different, and a permanent organization to have charge of the enforcement of ordinance No. 48247-B should be set up." The recommendation of the Commissioner of Health in this matter is heartily endorsed. If all the additions and improvements of service recom- mended in the foregoing consideration of bureaus existing and proposed in the Division of Health were approved and appropriations made, Cleveland would not be spending more per capita per annum than many cities in the country now consider reasonable for public health services. HEALTH CENTERS Centralized control and distributed services permit of sound public health organization, and the principle of health centers upon which the bureaus of child hygiene and communicable diseases depend for their district work is good. The health centers, as at present operated, are little more than dis- trict offices. It is recommended that these centers be increased to sixteen, to permit of one for each 50,000 of the population and that as rapidly as is found practicable other functions be added to those now served at the centers. Until health centers serving as administrative branch offices of public depart- ments include as well all the services or representatives of them which are now contributed by private agencies in the interest of preventive medicine, and are operated in intimate organic, if not physical, connection with hos- pitals and dispensaries, they will not have met their obligations and possi- bilities of public usefulness. Public Health Services 191 PUBLIC SCHOOL MEDICAL SERVICE The Board of Education administers through school education and its medical services to children, public health services of inestimable value. A complete description of this division of public service will be found in Part III. THE CORONER SYSTEM The coroner system is in a way a kind of public health service, as in its conception it is created to protect life by determining accurately the causes and conditions which have brought about sudden, violent or unexplained deaths, especially when the deceased had not been under the recent care of a physician. As long as a coroner is elected or appointed in payment of party political debts, and as long as the coroner selects his medical examiner or assistant more with a view to political availability than as a recognition of his merit, skill and experience in pathology and forensic medicine, our cities, and among them Cleveland, will continue to be ill served in this respect. Opportunity for "graft" is always present, and offering powerful tempta- tions to avoid thorough search into causes of death. The coroner's physician is practically powerless to protect the public against crime. There is every opportunity under the present system to cover up crime and miss important causes of preventable deaths. There is nothing to be said in favor of the coroner, his office, his medical functions or the value of his mediaeval and hollow legal functions. Boston and New York have solved the difficulty in the only reasonable way, by abolishing the office and creating the civil service appointive office of medical examiner. The results have been a striking improvement in the interest of honesty, scientific accuracy and in the field of health protection. Cleveland could not do better than follow their example. It is so recommended. Private Health Agencies THE extent of private endeavor in the field of preventive medicine is hardly appreciated until the whole range of unofficial agencies is pre- sented. We shall not consider here the activities of the national volun- teer health agencies even though they may contribute a definite share to the work in their respective fields in Cleveland, but confine the following brief summary to local organizations: The Anti-Tuberculosis League For a description of the activities of the Cleveland Anti-Tuberculosis League the reader is referred to Part IV., where its accomplishments and recommendations for further extension of its admirable work are presented at some length. The Visiting Nurse Association For a consideration of the work of the Visiting Nurse Association, one of Cleveland's remarkable public health assets, the reader is referred to Part IX., where the extensive project of prenatal and maternity nursing care is proposed as a new undertaking for this association. The Day Nursery and Free Kindergarten Association A description of the functions of the Day Nursery and Free Kindergarten Association will be found in the report on this and other child-caring organ- ization in this part of the report. The Association for the Crippled and Disabled The affiliation of all the agencies dealing with the medical and social problems of the cripple, in the Association for the Crippled and Disabled has brought large benefits to these handicapped people, little and big, and this association is certain to play a part of increasing importance in the future program for preventive and curative orthopedics in Cleveland. This is dealt with in detail in the chapter devoted to the Care of Cripples in this part. The Cleveland Hospital Council The Hospital Council, in which originated the idea of the present Survey, has a record of important contributions to local and national hospital stand- ards, economies and organization. It is described in Part X. The Cleveland Society for the Blind The Cleveland Society for the Blind has been active for many years and carries on its books the records of 545 people not in institutions who are known to be either totally blind or to be suffering from such a loss of sight as to make them dependent on others for care or support. This list includes all ages and both sexes. Of the 545 blind people, the cause of blindness comes within the list of Preventable Diseases, Injuries or Infections in 306 instances as follows: 194 Hospital and Health Survey PREVENTABLE CAUSES Communicable: Syphilis....... 40 Gonorrheal ophthalmia 32 Trachoma 16 Scarlet fever 13 Measles 12 Meningitis 9 Tuberculosis 3 Smallpox. 4 Diphtheria 2 Poliomyelitis 2 Ophthalmia (undetermined infection).... 6 Communicable 139 Injuries 67 Miscellaneous 100 Injuries: Industrial 21 Non-Industrial 46 67 Miscellaneous: Iridocyclitis 1 2 Choroiditis 1 5 Keratitis, interstitial.... 4 Corneal opacity 12 Optic atrophy 51 Vitreous hemorrhage 1 Irregular astigmatism 1 Strabismus 1 Diabetes 2 Nephritis 1 Total 306 100 The blindness of the other 239 instances was due to causes which are considered non-preventable, as follows: Curable: Cataract Ill Congenital cataract 10 121 Miscellaneo us: Detached retina 1 Orbital tumor 1 Sarcoma 2 Ptosis 1 Retinitis Pigmentosa 9 Glaucoma j 28 High Myopia 11 Optic atrophy (brain tumor) 3 56 Not Sufficient Diagnosis: Congenital 55 Sunstroke 2 Insane 1 Eye strain 1 Nervous prostration 2 Chorea 1 62 Curable... 121 Miscellaneous 56 Not sufficient diagnosis 62 Total 239 Diagnosis as to the cause of blindness was not obtained for 16 inmates at Warrens ville Infirmary and 10 inmates of a Home maintained by the Little Sisters of the Poor. According to the very careful survey recently made by the Massachusetts Commission for the Blind, there are probably in any general population in the eastern industrial communities one blind person for each 1,000 people. This would lead one to expect a total of a little less than 800 in Cleveland, including those in institutions. Cleveland shares the experience of Massa- Private Health Agencies 195 chusetts in that a constantly decreasing number of the blind are found in the age group under five years, as a result of intensive campaigns to prevent and cure babies' sore eyes. In a city drawing its population so widely from both native and foreign groups and tempting labor from parts of our Southern states where trachoma is prevalent, and recalling the fact that in Ohio in one county (Ross) at least 1% of all school children were found recently to be affected with trachoma, adequate provision for control of this disease and prevention or correction of the damage done by it among children and adults, must be made by the Board of Education, the Division of Health and by the clinics and hospitals of the city. The field of prevention of diseases of the eye is not entirely filled by the activities or program of the Society for the Blind and it is recommended that they adopt a more aggressive policy so that the broad field of education and action and supervision proposed by the National Committee for the Preven- tion of Blindness may be well cultivated. It is suggested that the society enlist more active interest among the specialists in this field, in private practice and in industry. There has been prepared for the Survey, through the courtesy of the National Committee for the Prevention of Blindness a program covering all aspects of this subject suitable for adoption by the local society. This in- cludes a number of subjects: (a) A list of desirable laws to insure the saving of sight, most of the items of which are covered bylaws in force in Cleveland. MODEL LEGISLATION FOR SAVING SIGHT 1 . Law, or Regulation of the Division of Health, requiring the use of a prophylactic in the eyes of the new born. 2. Law, or Regulation of the Division of Health, making opthalmia neonatorum a reportable disease, giving definition of what may constitute this disease so that no loophole will be left for difference in diagnoses. 3 . Law, or Regulation of the Division of Health, covering the training, examination, licensing, regulation and supervision of midwives. 4. Vital Statistics Law requiring notification of births within 48 hours. 5. Law prohibiting the use of the roller or common towel in public places. 6. Law making trachoma a reportable disease. 7. Law regulating the sale and control of wood and denatured alcohol. 8. Law making wood alcohol poisoning a reportable disease. 9. Law making venereal diseases reportable and providing for the quarantine or compulsory treatment of those capable of spreading infection from these diseases. 196 Hospital and Health Survey 10. Law regulating the projection of moving pictures and the lighting and ventilation of moving picture theatres and prohibiting the use of "rainy" or worn-out films. 11. Law appropriating a minimum of $250 a year for each child requir- ing the benefits of a conservation of vision class. 12. Law providing for the examination by an eye expert of all inmates of penal and charitable institutions. (b) Suggestions for the better training of physicians, dentists and nurses in sight saving. (c) An extensive program for maternal and child care from prenatal to employment age. This does not differ materially from the recommendations given under Child Hygiene in Part III. (d) Proposed use of eye, general and venereal disease clinics for saving the sight of the adult population. This is dealt with in Part X. under the discussion of the dispensary needs of Cleveland. (e) A model plan for saving sight in industry which gives detailed recommendations under the following headings: 1. Lighting conditions, natural and artificial. 2. Protection against industrial poisons affecting the sight. 3 . Adoption of the safe methods for the handling of acids. 4. Routine examination of tools, especially of those likely to become "mushroomed" or "burred." 5. Routine examination of machinery and safety devices. 6. Examination of the eyes of workers before entering industrial occu- pations. 7. Care in the placement of one-eyed workers. 8. Arrangements for adequate first aid for removing foreign substances from the eye, and for treatment of eye injuries, especially of caustic and acid burns. , ■ 9. Education of workers in the use of safety devices and methods and in preventing accidents to themselves and others. The Associated Charities The Associated Charities is properly included among the health agencies, since social reconstruction, the holding together and supporting of family groups by tactful and timely aid and well considered advice, plays as great a part as medical services in relieving anxiety and reestablishing household morale. During the past year the Associated Charities, operating from ten sta- tions, aided 3,676 families (including 239 homeless) numbering 16,803 indi- viduals, toward normal family life. Through 56 trained field workers, Private Health Agencies 197 including Visiting Housekeepers and a Visiting Sewing Teacher, 57,516 visits were made in behalf of those needing assistance; relief in the form of food, fuel, shelter and clothing was provided to 1,168 families in their homes; its initial Nutrition Center for undernourished children was conducted; at the Sewing Center 8,640 old garments were salvaged and 11,842 new ones made for free distribution; at Wayfarers' Lodge 15,211 meals and 4,834 lodgings were furnished to convalescents and homeless (40 per cent women and children); eight classes in social work were conducted, training 114 paid and volunteer workers for community service. Eighty people serve in this organization and the annual expenses were about $250,000 in the past 12 months. The Welfare Federation A good description of the Welfare Federation will be found in the intro- ductory chapter, Part L, giving the history of its development and its present position as a coordinating agency for all the component groups engaged in some form of public welfare. Each of its associated organizations has been, to a greater or less degree, under observation in the present study and to all we owe thanks for their unremitting courtesy and helpfulness. A special study was requested at the beginning of the Survey period, to permit of recommendations in the field of orthopedics and the following chapter gives the result of the inquiries which were made. THE CARE OF CRIPPLES IN CLEVELAND* General Considerations The facts that strike one in a study of the provision for cripples in Cleveland are that less than 25 per cent of the 960 cripples enrolled in the regular classes of the public schools are under any orthopedic supervision or treatment, and that there has been neither recognition nor leadership pro- vided by the Western Reserve University Medical School for this specialty. Boston, with a metropolitan population of 1,500,000, has forty specialists in orthopedic surgery with teaching or hospital affiliations. They are well occupied and supported by the medical profession and the public. In Cleveland and its vicinity there are but seven physicians limiting their practice to orthopedics, and of these but four have permanent hospital affiliations. The experiences and triumphs of orthopedic surgery during the war have opened the eyes of the laity and of the medical profession to the indefinite possibilities for human salvage, for prevention of deformity and dependency, and for the re-establishment of function in those disabled in the spinal col- umn or in the extremities, such possibilities having been in the past hardly conceived of outside of a few groups of leaders in the profession. It will be sufficient here to point out that the specialty of orthopedic surgery differs from most other specialties in that it is a specialty of prin- "Consultant in Orthopedics, Dr. Robert B. Osgood, President of the .American Orthopedic Asso- ciation. 198 Hospital, and Health Survey ciple and not of an anatomical region. This principle may be briefly defined as a principle of the return of function in lesions of the extremities and spinal column. If it can meet its obligations we believe orthopedic surgery should surely include acute as well as chronic lesions, joint infections, acute internal joint derangements, muscular and ligamentous strains, etc., but the majority of cases referred to it will comprise the more or less chronic lesions, in which the return of wage earning capacity in the shortest possible time, is the chief desideratum. The burden of the cripple will continue to be its burden, but the burden should be accepted while the crippling is acute and potential as well as when it is chronic and perhaps permanent. Already the Industrial Accident Insurance Commission of a great state (California) has become aware of the fact that the time of recovery of wage earning capacity, following certain types of bone and joint injuries, varied very greatly when the patients were cared for by different physicians whose general standing in the community was equally good. They have found it a matter of wisdom and economy to turn over these patients to a specially organized group connected with a State Medical Institution, which group have been especially devoting their attention not only to intelligent surgery but to methods of treatment which produced the quickest return of function. Orthopedic surgeons more than surgeons of any other specialty have been obliged to devote their attention more completely to this class of cases.* There are, moreover, in every community large numbers of children and adults whose ordinary efficiency is impaired and whose recovery from any lesion is inhibited by the acquired bad mechanical use of the body, which under proper training is usually capable of correction. This class increases as the facts become known. The great undergraduate universities are recognizing this class and have taken well considered steps to increase the physical well-being of their students by educating them in principles of bodily mechanics. This obligation is not assumed by the Western Reserve University at Cleveland. The size of the class in any community needing this education can be readily gauged by the rejections in the army on this account and the breakdown under rigid training of large numbers of those who had been actually accepted. Let us briefly summarize the functions to be fulfilled in our opinion by any orthopedic organization: 1. The efficient treatment, operative, mechanical and physiotherapeutic of crippling conditions of the extremities and spinal column, looking to the fullest and quickest return to wage earning capacity. 2. The prevention of deformity in potentially crippling conditions in chil- dren and adults. 3. The education of the community in bodily mechanics. To fulfill these functions it would seem to be necessary to arrange for: 1. A Professor of Orthopedic Surgery in the local medical school, of recognized ability in the specialty and with a faculty of unselfish leadership. •Valuable information as to the extent of disabling injuries in the Cleveland district and the large field for the functional rehabilitation of in : ured wage earners by orthopedic surgery and physiotherapy wiil be found in the recent report of the State Industrial Commission. Private Health Agencies 199 2. Orthopedic Departments in all the acute, sub-acute and convalescent teaching hospitals organized under the Division of Surgery, but with their Chiefs of Service holding the same rank as the Chiefs of General Surgery and other specialties. 3. Facilities for the administration of those forms of physiotherapy, which are recognized of proved value, this administration to be directed by a Medical Chief familiar with the mechanical details and capable of carrying out and supervising in a consultatory manner the treatment prescribed by the physicians and surgeons. 4. Facilities for the manufacture of braces and appliances, and at least the simpler forms of prostheses. Departments of orthopedic surgery in general hospitals are desirable in out-patient and house service. Whether or not the acute fractures other than the joint fractures should be considered as orthopedic cases should, in our opinion, depend solely upon whether certain general surgeons of the community or certain orthopedic surgeons have had the larger experience in the treatment of these lesions and whether they retain their interest to continue to supervise the many necessary details of this treatment, looking to the fullest and most rapid return of function. At least we believe there should be constant orthopedic consultation in fracture cases in relation to mechanical treatment, preven- tion of deformity and early return of function. Social Service workers as an integral part of the orthopedic department have proved to be of great value. In the system now in operation at the Massachusetts General Hospital in Boston a head social worker and several assistants are assigned to the Orthopedic Out-Patient Clinic and have an office in the clinic. All cases needing investigation of their home conditions, or help in obtaining apparatus, or more detailed explanation of their pro- posed treatment are referred to this office and the history card stamped "Social Service." All cases referred to the hospital for operation or bed treatment are automatically interviewed by the Social Service worker and the home situation which this emergency creates is ascertained. By means of a card system cases not reporting back to the clinic on the day set for their return are followed up, and when statistics were last taken a 35% loss was reduced to 4%, The cases in the ward are visited by the House and Out- Patient Social Service Worker and arrangements for transfer to their homes and immediate after care are made. The service has a peculiar value to an orthopedic department. A distinct Children's Service in General Hospitals for acute and sub- acute cases is needed unless a separate children's hospital is provided, and a ward or wards should be set apart for children orthopedic patients. There are many adult cases needing operation and bed treatment for chronic lesions of the bones and joints and spinal column, whose stay in a hospital for acute and sub-acute cases need be only two or three weeks, provided they could be recumbent one or two months longer in some con- 200 Hospital and Health Survey valescent or sub-acute hospital which could be administered with less ex- pense than an acute hospital. The problem of convalescents has been shown to be an important one. A few weeks longer in recumbency or under physio- therapeutic treatment, perhaps directly following their surgical treatment, often saves many weeks of idleness and brings about a much more permanent and complete recovery of wage earning capacity. Beds are needed for con- valescent patients in hospitals where their treatment may continue to be directed by the same surgeons under whose care they were, in the acute hospitals. Simple physiotherapeutic plants would prove valuable in every sub- acute and convalescent hospital. By this we mean simple hydrotherapy apparatus, whirlpool bath and douches, electric apparatus for diagnosis, and the simpler forms of treatment by radiant light, baking, galvanism and Faradism (Bristow coil), one or two universal exercising machines of the pendulum type, and facilities for massage. If there were a main physiotherapy plant to serve all hospitals more elaborate and complete hydrotherapeutic, electrotherapeutic, and mechano- therapeutic apparatus could be installed and very properly simple curative workshops established. These workshops might very well be made more than self-supporting. Such a central facility for physiotherapy would benefit many types of patients other than purely orthopedic, and while per- haps the interest of orthopedic surgeons in these methods has been more intense than that of other medical men, few of them in our experience are at present sufficiently well trained to administer these measures. Experi- enced medical supervision of a consultatory character will be required if the results hoped for by physicians and patients are to be expected. Without this dual control there is danger that the treatment may be futile or the service become a fad only. Frequent and accurate records of progress are required in such work, in order that results may be measured. The interest of the patients is greatly stimulated by such records. This orthopedic cen- ter could with much advantage be incorporated in or be associated under the same management with the proposed down-town central dispensary serving especially pay industrial accident patients. The benefits of a group of medical and surgical diagnosticians available for consultation and reference at such a center would be of much importance to an orthopedic or physiotherapy center and vice versa. Brace and appliance shops operated in general hospitals are convenient, but rarely, we believe, successful from either a business point of view or from the point of view of furnishing the highest grade of apparatus at least cost to the patients. If there were a central brace shop where a representative of the shop might measure the patients for apparatus ordered by the sur- geon, the surgeon being present when necessary and practicable, errors would be avoided and changes of apparatus would prove unnecessary which entail extra expense to the shop or patient and delay the delivery. In one hospital shop before this method was adopted it was estimated that one-half the labor of the shop was employed in making unnecessary alterations. The shop should include metal work, leather work, the fitting of corsets and Private Health Agencies 201 corset belts, the making of pylons and perhaps even the provisional jointed prostheses. In general the problem of the care of the crippled in a given community involves consideration of its acute hospital and dispensary facilities; of the availability of the services of men especially trained in that branch of sur- gery known as orthopedic surgery and of the teaching opportunities afforded in this specialty. It also involves consideration of the resources for con- valescent care; of the facilities for the practice of all such branches of physio- therapy as are known to be helpful in functional restoration ; of the resources for the provision of braces and other special apparatus; and of the machinery at hand for both medical and social follow-up work with such additional resources as special schools for crippled children, funds for the provision of artificial limbs, facilities for transportation to and from dispensaries, place- ment agencies for handicapped persons, etc. In studying the problem of the care of the crippled in Cleveland the Hos- pital Survey has endeavored to learn first the scope and character of existing resources; to discover thereupon the unsatisfied needs, and finally to formu- late a program adequately covering the entire field and involving the least change or expense which is compatible with thorough-going work. Teaching of Orthopedics Until this year the teaching of orthopedic surgery in the Western Reserve University Medical School has been carried on as a subdivision of the De- partment of General Surgery. There have been a few lectures with clinical demonstrations and there has been a short course of clinical instruction in the dispensary and in the wards of Lakeside Hospital. By recent vote of the Medical Faculty the Department of Orthopedic Surgery is now separate from that of General Surgery, and the professor of this department will have a service in the university hospital under his own direction. Every effort is now being made to obtain for the head of this department an outstanding leader in the profession. Much for the future of orthopedics in Cleveland depends upon the personality and professional at- tainments of the head of the department in the medical school. The dispensary equipment as proposed for the new Lakeside and Babies' Hospitals will give every facility for teaching not only diagnosis but the modern resources for rehabilitation of orthopedic defects by occupational therapy and by the use of muscle training, and hydro- and mechano-therapeutic appliances, etc. While it may continue to be impracticable to offer the undergraduate medical student more than a brief introduction to the principles and practice of orthopedic surgery, the facilities available and the clinical material which will always be at hand in a city of the size of Cleveland, and particularly the type of patient found in abundance wherever there is such a range of industries and employment of men and women among machines, offer a tempting opportunity to develop special courses for graduates or even to the fourth year student who wishes to specialize at once. The coordination 202 Hospital and Health Survey of the city's clinical resources with the agencies for the social follow-up and convalescent care and schooling of cripples offers an unusual range of experi- ence in study of the preventive and family problems of orthopedics. Hospital Service At Lakeside, Mt. Sinai, St. John's and St. Alexis Hospitals there are specialists in orthopedic surgery in charge of such patients as are generally admitted under this classification. It is not usual in Cleveland to include fractures among orthopedic patients, and at no hospital in Cleveland is there organized what is sometimes spoken of as a fracture team, consisting of a gen- eral surgeon, an orthopedic surgeon and a neurologist. It is not customary and it may be said it is not suitable with the present shortage of hospital beds in Cleveland to set aside a definite number of beds for the exclusive use of orthopedic patients. There are usually to be found at Lakeside Hospital about ten orthopedic patients receiving bed care, from three to fifteen being the range noted during the survey. There are a few orthopedic patients at Mt. Sinai Hospital, rarely more than six to ten, in wards and in semi-private rooms. At St. John's Hospital there are usually two or three and sometimes as many as five orthopedic bed patients. At St. Luke's Hospital, where orthopedic patients are not under the care of orthopedic specialists, there are commonly a few (three to six) cases. The service at St. Alexis Hospital has only recently been organized under a specialist in orthopedics, and the use of beds is irregular, but certain to increase, especially among industrial accident patients. Dispensary Services Dispensary facilities,* more or less complete, are offered at six hospitals. The physiotherapy facilities in Cleveland are extremely limited. Lakeside has three orthopedic clinics a week with an average attendance of 10 to 12. No physiotherapy staff. Mt. Sinai has an orthopedic clinic open every day from 9 to 10:30 and 2:30 to 5:30. During 11 months of 1919, 5,818 physiotherapeutic treatments were given. The clinic is equipped with two Zander machines, quarter circle pulleys, hanging apparatus, dumb bells, and has facilities for general massage, and four well trained masseuses. St. John's has no dispensary, but treatments are given every day to out- patients at all hours by two trained physiotherapists. Emphasis is placed on hydrotherapy. This hospital also has an electric light cabinet, steam cabinet and facilities for general massage. Patients will be accepted from other hospitals or dispensaries for treatment. St. Vincent's has no orthopedic staff. Cases discharged from the wards are followed up. There is an attendant trained in physiotherapy. General massage is given and electrical and steam cabinet treatments are provided. •For special report on all dispensary services in Cleveland, see Part X. Private Health Agencies 203 The Babies' Dispensary and Hospital has an attendant trained in physio- therapy and has equipment for massage and simple electrical treatment. Clinic open three days a week from 9 to 11. Children up to the age of 14 are admitted. The average attendance is 12 children a month. An ortho- pedist visits the clinic once a month for supervision. St. Alexis has three orthopedic clinics a week. There are no facilities for physiotherapy. Convalescent Services Convalescent care* for crippled children to the age of 14 is provided by Rainbow Hospital up to 75 beds. The Fresh Air Camp receives ambulatory crippled children to the same age to a capacity of 50 beds. The Warrens- ville Tubercular Sanitarium and Children's Cottage give convalescent care to crippled children and adults who are suffering with a pulmonary compli- cation. The Warrens ville Infirmary is the last resort for convalescent care for crippled adults and for children who are beyond the age limits set by Rain- bow Hospital and the Fresh Air Camp, but at this city institution no ortho- pedic treatment is provided. Brace-maker Lakeside Hospital gives space in the basement of the hospital to a brace- maker. The bracemaker gives special rates to all hospitals in the city. This service is used by all the hospitals and by the orthopedists. No com- plaint is made as to quality of service rendered, but the facilities are entirely inadequate. Often it is necessary to wait weeks or months for a brace. Social Service The social service facilities for orthopedic patients as provided at several of the hospitals, Lakeside, Mt. Sinai and Rainbow, lack completeness, and even with the central assistance of the Association for Crippled and Dis- abled, fail in their full possibilities both in doing most for the patients and in providing for optimum use of hospital and dispensary services. Lakeside has an insufficient social service staff for adequate follow-up work. The children's worker devotes most of her time to the orthopedic cases. She admits all the children during dispensary hours, but does noth- ing further in the children's clinic. She assists in the orthopedic clinic and arranges for hospital admission. She spends most of her mornings visiting in the homes of orthopedic children. She arranges convalescent care for the orthopedic cases and occasionally for other children's cases from the hospital. Mt. Sinai has an insufficient social service staff but has a fine spirit of cooperation. One graduate nurse does the follow-up work for orthopedic cases, giving about one afternoon a week. Financial investigations are made by the head of the clinic. If the patient fails to attend clinic a follow- up visit is made to the home to discover the reason for non-attendance. •For special consideration of the problem of convalescent care of all kinds, see Chapter on Con- valetcents, Part X. 204 Hospital and Health Survey Rainbow Hospital has endeavored to keep in touch with the children dis- charged from Rainbow as long as anything medically or surgically could be done for them. The Social Service Department of the Association for the Crippled and Disabled has done medical and social follow-up work with all persons referred to its attention. One-fourth of the income from the Benjamin Rose Institute is available to provide funds for the hospital and dispensary care of crippled children. The Association for the Crippled and Disabled The Association for the Crippled and Disabled, a very valuable co- ordinating agency, has a board of trustees elected to be representative of all groups especially interested in the crippled problem. At the present time the board members include representative members of Rainbow Hospital, Holy Cross House, the Hospital Council, Babies' Dispensary and the Public Schools. The Board members also include a large representation of what was formerly the Sunbeam Association for Cripples, which organization and its activities were merged in the Association for the Crippled and Disabled. The Association for the Crippled and Disabled has also recently asked for representation from the Rotary Club, which is now interested in crippled work. An orthopedic council has recently been formed at the request of this association for the purpose of providing for the expression of opinion and forming professional policies for the Association, by joint action of the specialists in orthopedic surgery in Cleveland. The Association functions through the following committees and depart- ments : The Committee on Orthopedic Resources works to organize and co- ordinate the orthopedic resources of the city to the end that all orthopedic needs may be adequately met in the most efficient manner possible. The Social Service Department embraces the following activities: The securing of expert medical diagnosis and making possible any treat- ment indicated. The furnishing of transportation and accompanying patients to hospitals, dispensaries, etc. The furnishing and having repaired braces, special shoes, artificial limbs, etc. Arranging for vocational training and special schooling as well as provid- ing recreation and offering vacation opportunities and arranging for friendly visitors. Providing equipment necessary for employment, supplying home teachers to home-bound crippled children of school age and arranging for a supply of magazines, delicacies, toys, etc., for them. Providing outings and festivities for the children in the School for Crip- pled Children. Private Health Agencies 205 Through its Social Service Department the Association aims to insure to every crippled person in Cleveland, whether child or adult, the best physical condition he is capable of attaining; the best education he is able to assimilate; the best job he is competent to undertake. The Employment Bureau of the Association is now organized in connec- tion with the United States Employment Service and finds suitable employ- ment for crippled and disabled men. The department is experiencing no difficulty with organized labor, because in placing the handicapped there is no effort made to market their labor at a lower price than that offered for similar service of physically sound men. Besides this, the labor unions realize that under certain circumstances men may work for less than the scheduled union wage, as, for example, elderly painters are permitted to work for less than the standard union wages when their physical condition is such as to forbid their working at the same pace as younger men. The Bureau is able to place approximately fifty cases a month. In the nine months from April to December, 1919, there were 1,327 applications and 527 placements. It was not learned what percentage of these place- ments were relatively permanent. The Sunbeam Shop offers employment to crippled and disabled girls and women in various kinds of needle work, and gives a training course in sewing to crippled and disabled girls and women desiring to enter this trade. The shop has an average of 10 workers. The Home Industries Committee provides work for home-bound crip- pled and disabled persons, and furnishes both diversion and income to those whose lives are, of necessity, greatly restricted. It is instrumental in mar- keting the articles produced. During the month of April, 1920, 34 people were carried by the committee. Practically all of the women do sewing. The efforts of the men cover a wider range; i. e., toy-making, book-binding, finishing work for tailors, etc. The Committee on the Welfare of Cripples in Institutions makes a study of the welfare of cripples in public institutions, endeavors to improve these conditions by the furnishing of recreation and employment and by the pro- vision of ordinary comforts where these are lacking. This committee has organized a vocational therapy shop at Warrensville Infirmary, where the men work every day. One full-time instructor and one half-time instructor are at work in the wards. The ward work is an experi- ment on the part of the Association. The Committee on Cooperation with the Public Schools has the follow- ing objectives: The appointment of a Supervisor of Cripple Work in the Medical Depart- ment of the Public Schools, the erection of a new and adequate special school for crippled children, the employment by the school of home teachers for house-bound children of school age, the perfecting of the method of trans- porting crippled children to and from school. 206 Hospital and Health Survey The Association has recently appointed a staff member, skilled in physio- therapy and muscle training. Through this worker an attenpt will be made to give physiotherapeutic care in patients' homes and in settlements, to crip- ples not cared for in other ways and for whom no other provision can be made. Educational Facilities for Cripples in the Cleveland Public Schools Regular Schools: In June, 1919, there were 960 crippled children en- rolled in the Cleveland regular public schools. 65 of the 960 were discharged from the Crippled School. 48% of the 960 were disabled by infantile par- alysis,- 15% by congenital deformities, 10% by tubercular bone disease, 5% by amputations, 6% by fractures and 5% by spastic conditions. Less than 25% of the crippled children in the regular schools of the public school system were under any orthopedic treatment. Special School: The Board of Education at present is conducting a special school for crippled children who cannot take care of themselves in the regular schools, and is providing them with transportation to and from .their homes. In January, 1920, there were 120 pupils in the Cripple School. On the waiting list there were 8 who were out of school, 11 who were in other schools, and 30 who were barred from kindergarten and first grade on account of lack of room. A very small number of crippled children in the regular schools are candidates for the special cripple school. Children are now being sent from the special cripple school into the regular classes, who would benefit by a longer attendance in the special school. Their premature discharge seems the less of two evils. By their transfer, room is made for others usually so handicapped that without a created school vacancy they must remain at home. At the present time there is one worker who investigates candidates for the school. In the Cripple School 68% of the children were disabled by infantile paralysis, and 12% by tubercular bone disease. The remaining 20% were disabled by spastic conditions, amputations, progressive muscular paralysis, congenital deformities, osteo-myelitis, etc. About 95% of the children in the Cripple School are under orthopedic surgical supervision. A lot has been purchased on the Fresh Air Camp site and another special school for cripples will be built there. This school will accommodate about 250. The architect of the Board of Education, after making a special study of schools for cripples in many other cities, has drawn plans incorporating what appear to be the best features of each. There remains simply the question of financing the undertaking. The Board of Education expects to make provision next year for the giving of special exercises in the regular schools to children with slight ortho- pedic defects. The present worker will be used for this purpose and one, or possibly two, assistants will be provided for her. Private Health Agencies 207 Present Needs Briefly, to state the unsatisfied needs in the present situation, the city needs to have orthopedic dispensary facilities developed on the west side of the river. All dispensaries and hospitals accepting for care orthopedic cases should have at their command trained orthopedists, and not trust such cases to the general practitioner, pediatrist, or general surgeon. The present facilities for physiotherapy are inadequate and such as there are, because of location, are wasteful of the time of patients. Rainbow Hospital, which has been and is one of the largest factors in crippled work in Cleveland, has been very much limited in its field of action by fact of the contract affiliating it particularly with Lakeside Hospital. Although Rainbow has offered to receive patients from other hospitals and dispensaries it is not strange that surgeons have been loath to send patients when by so doing they have necessarily lost supervision over them. Hardship is wrought by the fact that there is no place at present for convalescent care of crippled children beyond 14 years of age. When excep- tions have been made by institutions whose age limits have been set at 14 the results have been almost universally unfortunate. It happens, there- fore, that no place is open to the adolescent crippled child, save the wards of the Warrensville Infirmary, and it goes without saying that these wards are not the proper setting for the life of any boy or girl. The adult cripple frequently suffers now along with many medical cases because of the lack of opportunity for convalescent care. A general con- valescent hospital for all adult cases would, of course, greatly relieve the situation. (See chapter on "Convalescent Care," Part X.) The follow-up work with orthopedic cases has been erratic and has suf- fered for lack of organization. Neither Mt. Sinai nor Lakeside has had a social service staff sufficient to insure the proper following up of cases that were receiving medical attention in the dispensaries. There has been con- fusion in the follow-up work done by Rainbow Hospital due to the lack of careful delimitation of work with Lakeside Hospital. The follow-up work of the Association for the Crippled and Disabled has been difficult, because in attempting to supplement the work of the dispensaries there is the con- stant danger of duplication. The Board of Education has not sufficiently recognized the complexity of the problem offered by the crippled school child and has never had a clearly defined program of its functions in this connection. It has not realized the opportunity as a preventive agency in the matter of orthopedic deformities nor has it realized its obligation to the crippled children in the regular schools. There are practising in Cleveland a number of surgeons who are devoting practically their entire time to the practice or teaching of orthopedic sur- gery, or both. General surgeons and some of the practitioners of medicine who have much practice among children take orthopedic patients in their 208 Hospital and Health Survey practice and operate or prescribe or apply corrective measures. Those limiting their practice to orthopedic surgery in Cleveland are in entire agree- ment as regards the deficiencies in the educational facilities of the Western Reserve University Medical School and in the matter of hospital and dispen- sary provision for patients. Program and Recommendations The program which follows is offered to the citizens of Cleveland for their consideration and support, with the conviction that it represents the best thought of the specialists of their city and is in substantial agreement with the accepted ideas of the leaders in orthopedic surgery among the profession elsewhere. St. John's Hospital, because of its location, and because of the small beginnings already made in hydrotherapy and in orthopedic work in the wards, might well develop an orthopedic department in connection with its future dispensary service. Provision should also be made for the inclusion of an orthopedic department in the extension of the work at the City Hos- pital. With such additions the orthopedic needs of the West Side should be fairly met. The Hospital Survey approves of the recently organized Advisory Ortho- pedic Council having as personnel the heads of the orthopedic departments in the various hospitals and such other orthopedists as these men may choose to associate with them. This group could meet upon call of the secretary of the Association for the Crippled and Disabled to advise upon any question of a professional or administrative nature submitted by any one -of the groups responsible for any phase of the crippled problem. There should be a central office which would take ultimate responsibility for all medical and social follow-up work with orthopedic cases. The exist- ence of adequate medical and institutional facilities or, indeed, of adequate resources of any nature does not necessarily signify real accomplishment. If lapses in treatment are allowed, if braces can be neglected, if home condi- tions are destructive of gains previously made, etc., the accomplishment of surgery or medical treatment may be nullified. The Survey would recom- mend that the Association for the Crippled and Disabled, which has already made considerable headway with social service follow-up work with the crippled in Cleveland, should take upon itself the ultimate responsibility for insuring that adequate follow-up work is done in every individual ortho- pedic case. However much or little of the actual case work be done by the Association for the Crippled and Disabled the responsibility for insuring that the work is adequately done by some one and that records are properly kept should reside with the Association for the Crippled and Disabled Social Service Department. There should be established a center of physiotherapy which should have a staff of trained physiotherapists and where equipment for physiotherapy would be available. Such a center should be under the direct supervision of a group of people who would be interested in making it possible to attain a Private Health Agencies 209 high standard of treatment. They would benefit by the advice and sugges- tion of the Orthopedic Council. The services of the center should be avail- able to all surgeons of the Orthopedic Council. A careful plan of cooperation with the surgeons should be worked out so that all work done would be upon the prescription and under the advice and supervision of the surgeon in charge of the case, and such treatment records should be kept as might be acceptable to and standardized by the Orthopedic Council. The Hospital and Health Survey recommends that: 1. The Orthopedic Council, formed at the invitation of the Association for Crippled and Disabled and now organized, include in its membership a representative of the lay management of each hospital which has a dispensary or bed service for orthopedic patients under the direction of an orthopedic surgeon. 2. The Association for the Crippled and Disabled enlarge its activity to include the operation of an orthopedic center where, in addition to fulfilling several of its estab- lished social and welfare functions, the Association should administer a physiothera- peutic service under the direction of an orthopedic surgeon or surgeons nominated by the Orthopedic Council. This service should be, so far as possible, self-supporting and should serve the needs for all manner of muscle training, massage and mechanical treatment of functional and structural disabilities of joints, bones and muscles, and their nerve control, referred by hospitals, dispensaries, private practitioners, shops, industries and schools. 3. The proposed Orthopedic Center include the central Brace Shop now located at Lake- side Hospital, and the Information Center, Social Service Center, Vocational Training Service, Transportation Service, Home Industries Activities, Artificial Limbs Fund Service at present being operated by the Association for Crippled and Disabled, and that this center serve as the point of contact and coordination of all the institutions dealing with cripples, in particular the acute hospitals with orthopedic services, the convales- cent hospitals for orthopedic patients, the services for cripples of school age, and the other social agencies, such as the Holy Cross Home, Employment for Handicapped, etc. 4. (a) Not less than 50 beds be provided for acute orthopedic patients at the new Lake- side Hospital — 30 for children and 20 for adults. (b) Not less than 60 beds be provided in the extension of Mt. Sinai Hospital — 40 for children and 20 for adults. (c) Not less than 50 beds be provided at the new St. Luke's — 30 for adults and 20 for children, and that this service be put in charge of an orthopedic specialist. (d) Twenty beds be provided at St. John's Hospital — 10 for adults and 10 for children, and that an orthopedic dispensary be established at this hospital. 210 Hospital and Health Survey (e) Sixty beds be provided at City Hospital — 30 for adults and 30 for children, this latter to include beds to be made available for isolation for orthopedic patients affected with acute communicable diseases and with venereal diseases in the com- municable stage. That an orthopedic dispensary be established at this hospital. That ward and dispensary service be put under the direction of an orthopedic specialist. (f) Thirty beds for adults be provided at St. Alexis Hospital when this hospital under- takes its program of reconstruction and reorganization, and that an orthopedic dispensary be established at this hospital. (g) Holy Cross Home increase its capacity to provide for orphan cripples of older age groups (adolescents). That a nurse especially trained in the care of orthopedic patients be employed constantly at this institution. 5. The admitting and assigning authorities of all hospitals with orthopedic services either for bed or dispensary patients authorize and require the assignment as patients for the care of the orthopedic surgeon, those suffering from the conditions and dis- eases listed below: Foot Strain (Flat Foot) Hallux Valgus, Scoliosis, Deformities of Rachitis Congenital Deformities, Contraction of fascia or tendons (resulting in deformities of joints), Affections of Bursae, Tuberculosis of Joints, Mon-articular Disease — Gonorrhea, Syphilis, Infections, Deformities of Chronic Polyarthritis, Chronic Joint Strain, Acute Muscular and Ligamentous Strain Involving Joints, Infantile Paralysis (after acute state), Requiring : Prevention of Deformity, Muscle Training, Apparatus, etc., Spastic Paralysis (requiring correction of deformity and muscle training), Traumatic derangement of Joints (cartilage), Bone Disease of Unknown Origin, such as Chondrodystrophy, Osteogenesis Im- perfecta, Adolescent Rickets. Deformities Following Old Fractures into Joints, Deformities Following Dislocations. 6. A fracture team to consist of a general surgeon, an orthopedic surgeon and a neurolo- gist be organized for the treatment of fractures in any general hospital where an ortho- pedic specialist and neurologist are available on the medical staff. Private Healtjh Agencies 211 7. The Department of Orthopedic Surgery in the Medical School and at the University Hospital group be included under the general group of surgery but be allowed full autonomy in the development of the specialty in the diagnosis and treatment of all patients falling within above list (see 5.) and that special facilities be provided for intimate coordination of ward and dispensary services with the social service depart- ment and for development of special clinics in poliomyelitis, scoliosis, and posture defects. 8. Rainbow Hospital be enlarged to accommodate 300 orthopedic or other patients for convalescent care; that the service at Rainbow Hospital be restricted for the present to the convalescent care of adolescents and children; that Rainbow Hospital accept patients from all the hospitals in the city; that patients in the communicable stages of gonorrhea and syphilis and those with open pulmonary tuberculosis be excluded; and that the medical staff consist of the heads of orthopedic services in hospitals pro- viding such services, and such other orthopedic specialists as may be considered quali- fied by the Orthopedic Council — the resident orthopedic surgeon to be nominated by the Orthopedic Council. ( While Rainbow Hospital is, as now organized and equipped, prepared to serve only the needs of children, it may well be that, in the absence of any new undertaking for convalescent care under other auspices, the Board of Managers of Rainbow Hospital will find themselves under much pressure and almost a moral obligation to extend their activities to provide for adults, convalescent from general medical and surgical conditions. 9. The Fresh Air Camp discontinue its service for cripples as soon as Rainbow is prepared to accept all the cases offered for convalescent care. 10. A nurse trained in the care of orthopedic patients be available at all times for service at Warrensville Tuberculosis Sanatorium. (One of the regular nurses always on duty could be trained to meet this requirement.) 11. A visiting orthopedic surgeon be appointed at Warrensville Infirmary to care for convalescent adults, and that a nurse trained to care for orthopedic patients be pro- vided at this institution. 12. When an orthopedic service is established at City Hospital the chief of this service be responsible for the professional care of the orthopedic cases requiring treatment at Warrensville Tuberculosis Sanitorium and the Warrensville Infirmary. 13. To the responsibilities already assumed by the Board of Education in the care of crippled children should be added the following: The prevention, as far as may be, of orthopedic deformities through attention to posture, seating, etc. The recording of every crippled child in the school system. Provision of supervision by an orthopedic surgeon for every crippled child of school age needing such attention. The orthopedic surgeon may be privately employed or his services secured at a dispensary. Provision that each child report at proper intervals to the orthopedic surgeon in charge of his case. 212 Hospital and Health Survey The furnishing of transportation to dispensaries when such transportation is a necessity. The giving of simple massage and special physical exercises, not requiring elaborate equipment, in school buildings, under the close supervision of the orthopedist in charge of each child. The keeping of such records of these treatments as may be suggested by the Ortho- pedic Council. The creation in the public schools within the Department of Medical Inspection of a Department of Orthopedic Supervision; that the supervision be by a trained physiotherapist whose qualifications are such as to be acceptable to the Orthopedic Council, that such other trained physiotherapists be employed as are necessary to carry out the plan as outlined, for work under the supervisor, who could be employed for work in the different schools as needed. 14. The governors of Rainbow Hospital request all nurses training schools in Cleveland hospitals where there is no organized training care of orthopedic patients to send their nurses for a period of not less than two months each to Rainbow for special training, before or after graduation, in the care of convalescent, brace, plaster, paralytic and chronic tubercular joint cases, etc. 15. The support of the Rotary Club be enlisted to add either an acute or convalescent orthopedic service to existing institutions rather than attempt to create a new ortho- pedic hospital. It is apparent that the need for acute hospital beds for orthopedic cases would be much relieved if there were adequate facilities for convalescent care, and we think that the money and interest of the Rotary Club would be more effective if brought to the support of Rainbow Hospital than if a new undertaking, with all the necessary overhead expense to be met by the community, were established by the Rotary Club independently. 16. Efforts be made by the Faculty of the Medical School, by the Academy of Medicine and by the Orthopedic Council to attract to Cleveland well trained young orthopedists and to provide for their development through dispensary and hospital services in this specialty. Additional Private Health Agencies Proposed There are, in spite of the generous array of private agencies above listed, several activities which are still needed to give a completely rounded service to the community in the field of preventive medicine applied through social organization. Cleveland has no organization in the following fields of preventive and social medicine: The Prevention and Relief of Heart Disease. The Prevention and Cure of Cancer. The Prevention and Treatment of Mental Disease. The Prevention and Control of Venereal Diseases. Private Health Agencies 213 Cleveland further lacks a central representative popular Public Health Association, to which reference is made in the introduction to Part I. THE PREVENTION AND RELIEF OF HEART DISEASE Through the courtesy of the Association for the Prevention and Relief of Heart Disease of New York the following text has been prepared. It represents the opinions of a group of physicians and others interested in these objects. The arguments and the projects proposed have been in large measure applied to conditions as they exist in New York City, and are equally applicable to Cleveland. Reference to the list of the chief causes of death in Ohio will disclose the fact that deaths from heart disease are more numerous than those from any other cause, pneumonia and tuberculosis following heart disease (in that order), with small differences. Deaths in Ohio per thousand population in 1917, as reported by the Bureau of Census, were: heart disease, 1.66; pneumonia, 1.48; tuberculosis, 1.42. The figures for these diseases for the city of Cleveland are not sufficiently reliable to be used, for the reason that there is no established policy or standard practice followed by the employe of the Division of Health concerned with the classi- fication of deaths according to the International List which is used by statisticians throughout the country. The report from the Division of Health that there were 855 deaths in the city of Cleveland attributed to heart disease, in 1919, represents considerable margin of error, but indicates the size of the problem with which preventive medicine is faced. At present, there are no facilities especially provided for the diagnosis, treatment, pre- vention or study of the problem of heart disease, with the single exception of the one electrocardiographic station provided for clinical use at the City Hospital. If heart disease can be, to any degree, prevented, and there is good evidence to believe that this is the case, it is time that the facilities and devices which are used elsewhere should be put into operation in Cleveland. But it is not in the actual loss of life that we see the greatest drain upon the community; it is in the mass of children and elders who lead handi- capped, stunted, painful lives because of their chronic disease of the heart. Until recently, there has been but scant attention paid to prevention of heart disease, but now, thanks to active organization among physicians to accomplish sane measures of control and abatement of heart disease, the outlines of the problem, the objects aimed at through the prevention and relief, the agencies which can be availed of, the methods in use and found reliable in attacking this great drain upon the public's health, can be given with some precision. Through the cooperation of the Association for the Prevention and Relief of Heart Disease, the following program has been prepared and is proposed for Cleveland, following the experience and accom- plishments along these lines in New York City since 1916. The Amount of Heart Disease in Cleveland One of every 15 deaths in Cleveland last year was reported as due to leart disease. 214 Hospital and Health Survey Two per cent of the persons examined by insurance companies are re- jected because of serious heart defects. Two -per cent of industrial workers are found on careful examination to be the subjects of definite heart disease. Two per cent of the men coming before the draft boards, and to the camps, were rejected by army medical examiners on account of heart defects. One and one-half to two per cent of the children examined in the schools show serious heart defects. From the above facts we may conservatively estimate that two per cent of the population, or in the United States over 2,000,000 persons, and in Cleveland 16,000 persons, suffer from serious Heart Disease. The objects to be attained in prevention and relief of heart disease are: 1. Removal of the causes of heart disease. 2. Early detection of potential cases of heart disease. 3. Early detection of those having organic disease of the heart. 4. Suitable care of the above, including convalescent care, education, and selection of suitable occupations for those handicapped by heart disease. 5. Institutional care for those hopelessly incapacitated by heart disease for self-support. 6. Economic saving to the community. 7. Humanitarian prevention of suffering and incapacity. Agencies Needed To attain these objectives it would be of advantage to enlist the interest of those who should see and appreciate the need, preferably by organizing a voluntary committee. Such a committee devoted to the problem and willing to take the initiative in this field might well have representatives of the Academy of Medicine, the Division of Health, the Board of Education, the Hospital Council, the Visiting Nurse Association, the social service workers, employers in various trades and interested citizens, both men and women. The function of such a community committee would be to develop in- terest in the preventive side of heart disease, to coordinate existing facilities for prevention and relief, to develop new ones where necessary, and to act as an educational force. Sub-committees on prevention, on relief and on educa- tional publicity, would be found necessary. The agencies needed to provide adequate means for prevention, diagnosis, treatment, etc., are — Clinical Laboratories, Serological, Chemical, X-Ray, such as are found in a number of the hospitals of Cleveland. Electrocardiographic stations, such as are found only at the City Hospital at present in Cleveland. Private Health Agencies 215 Consultations in specialties at the central dispensary as suggested in the chapter on dispensaries. Follow-up system through visiting nurse and social worker services. Special Cardiac Clinics. (New York has 37 such in operation in 17 hospitals, situ- ated so as to be of easy access to different portions of the community, with sessions which do not conflict with school hours, and in the evening for workers.) The professional and associated institutional facilities which are to be provided through these special clinics are: (a) Medical supervision and instruction of patients, instruction of parents, and instruction of school teachers. (b) Special cardiac social service (social service workers are employed in 31 classes in New York City), which will provide assistance in class, education of patients and parents, study of home conditions, study of school conditions, study of employment conditions. It is desirable to arrange for close affiliation with the nose, throat and dental departments of the clinic, and to arrange for admission and investigation of patients by hospitals and for convalescent or chronic care where necessary. Convalescent homes for cardiac patients (similar in service to the pre- ventoria and sanatoria for tuberculosis) are needed for potential cardiacs and for those with organic heart disease in whom improvement is to be expected, with facilities for fifty or sixty beds (350 beds available in New York), where medical supervision, educational, (mental and vocational) exercise and recreational facilities will be provided. This is a function which Rainbow Hospital could well perform. Homes for the incurable cases of heart disease, such as the Warrensville Infirmary will be when it is adequately developed and staffed, are a necessity to avoid the present neglect of the permanent cardiac invalid for whom there is now in Cleveland no accommodation. An occupational bureau which might be established in connection with the employment bureau at the City Hall, or as an addition to the employ- ment function of the Association for the Crippled and Disabled, would provide supervision of and aid in vocational education in selected cases (each of the cardiac clinics in New York has such a service), would provide for selection of suitable occupations for cardiacs referred by hospitals, special clinics, convalescent homes and private physicians, and would provide means for maintaining close cooperation with employers. Prevention In its broadest aspect the prevention of heart disease presents distinctly medical, social and economic problems. From a medical standpoint we have to consider: first, the prevention of disease in healthy hearts, and second, the prevention of disease in hearts which have already been damaged. 216 Hospital and Health Survey The causes of primary injury to the heart muscle may be grouped under those arising from infectious diseases, those resulting from intoxications, and those following improper modes of life. The infectious diseases most fre- quently affecting the heart are rheumatism and syphilis. The destructive effects of syphilis are found most frequently in people in early adult or later life, and this group involves the consideration of the whole problem of social hygiene, as described in the chapter devoted to that subject. (See PartV.) The prevention of heart disease in young people is of the greatest impor- tance, because of their age and the cost of their care to the community. The chief cause of heart disease in early life is acute rheumatism. Although we do not know definitely the causes of acute rhuematism, enough work has been done to make us quite certain that we are dealing with a germ disease, an infection which probably enters through diseased tonsils, adenoids or decayed teeth. Therefore, we consider it a most important duty of parents to have the mouths and throats of their children examined once yearly by a physician. The removal of diseased tonsils and adenoids, and the proper care of the teeth, are the most effective preventive measures against rheumatism at present known to us. Neglect to provide the diet which will permit of unin- terrupted and steady development in weight and height in proportion to age, may also be considered a major cause of cardiac disease in childhood, owing to the lowered bodily resistance to infection and diminished capacity for recuperation from infection. Statistics of 3,134 cases of acute and sub-acute rheumatism, gathered from the records of four New York City Hospitals, show that the greatest number of cases occur during February, March, April and May. That people become "run down" or "below par" physically during the late winter and early spring months, is a fact based upon common experi- ence. We do not know that this physical condition makes people more susceptible to rheumatic infection, but because of the greater frequency of rheumatism at this time of the year, it would seem wise to promote in every- way possible the maintenance of good health during the winter months. The value of out-of-door exercise and sufficient sleep in well-ventilated rooms, as means to this end, cannot be overestimated. People who have had one attack of rheumatism are especially liable to other attacks, and therefore it is of the utmost importance that they observe the preventive measures, outlined above, in reference to the tonsils, the care of teeth and keeping in good physical condition. A person suffering from an acute attack of rheumatism should be placed under medical care at once, and should be kept in bed for some days after the temperature is normal, even though no signs of heart disease can be found. The necessity for a prolonged rest in bed is based upon the knowledge that an acute inflammatory process, which we are unable to detect, may exist in the heart and subsequently develop into severe heart disease. Private Health Agencies 217 Adults leading sedentary lives, whose activities are chiefly mental, who get but little out-of-door exercise, who eat too much and sleep too little, frequently suffer from circulatory changes. The exact effect on the heart of poisons derived from this mode of life, as well as from the habitual use of alcohol, tobacco, tea and coffee in intemperate amounts cannot be defi- nitely and precisely stated, but it is certainly the part of wisdom to change one's mode of life, if it is of the type described, and equally advisable to restrict the use of these poisons. The social problems of the prevention of heart disease require the fullest cooperation of the family, school authorities, and employers in caring for those whose heart's efficiency has been impaired by disease. The economic problem involved in the prevention of heart disease is of increasing importance because in childhood this disease may cripple pros- pective wage-earners, while in adult life, the earning capacity of the patient may be permanently limited or even destroyed, and he and his dependents become a charge on the community. Statistics show that the number of people incapacitated by heart disease is already large and rapidly increasing, but the preventive measures outlined, if widely known and applied, would reduce the number to be cared for by the state and therefore, diminish the drain on the public treasury. Prevention may be summarized to include — Control of infectious diseases, particularly rheumatism and syphilis. Care of teeth, tonsils and adenoids. Lengthening of the period of hospital stay and convalescent care after acute infections, particularly after rheumatism and tonsillitis. Hospitals in Cleveland are not doing their part and cannot until the shortage of beds is relieved. Supervision of home after-care, preferably from a special cardiac class in a dispensary. More regard for "growing pains" in children, commonly found to be of infectious or inflammatory origin, and their importance often overlooked. Supervision of nutritional defects. Avoidance of mid-age over-exertion, habits, intoxications, etc. Prevention of decompensation may well come under this heading. It is really the prevention of serious heart breakdown and is important. Pre- vention of heart overstrain in those with a recognized heart defect is an im- portant service of special cardiac clinic classes for adults. Detection of patients with early or unrecognized cardiac disease is the first step of proper preventive management. Physical examination of all children admitted to schools, public and private, is advised. Re-examina- tions should be made once a year where practicable, and always after an acute illness. 218 Hospital and Health Survey Educational publicity is required to — Encourage the use of physical examinations once a year by all employes in industry, in civil service, and for all children particularly. (Physical exam- ination should be made with clothing removed, and should include a search for foci of infection, such as defective teeth, diseased tonsils, etc.) Encourage life insurance companies to refer applicants rejected for cardiac abnormalities to their family physicians or to cardiac clinics for further observation and advice. Force upon public attention the essentially preventable aspects of heart disease. Disposition of patients discovered. Every child having rheumatism, defective teeth, tonsils, growing pains, and signs or symptoms which suggest or definitely indicate heart disease, should be referred to the family physician, or if not available, to a special cardiac clinic. This applies as well to the great majority of adult wage- earners. The schools might well cooperate through regulations promulgated by the Board of Education directing teachers — - 1 . To refer to physicians for examination pupils showing symptoms suggestive of cardiac disease. 2. To issue passes to permit pupils with heart disease to use special entrances and exits. 3. To permit these children to enter or leave school directly before or after the regular time schedule for normal children. 4. To excuse cardiacs from physical training, fire drills, etc., where the physician in charge thinks this necessary. 5. To lengthen the lunch hour for these children in order to avoid hurry and haste in eating. 6. To revise the ordinary school regime upon the receipt of a report from the home physician that there must be an exception made for the sake of the child's health. Social Service workers will need to give unusually painstaking follow- up to — 1. Cardiac patients discharged from hospitals. 2. Cardiac patients attending Cardiac Clinics, thus providing instruction and advice for parents, teachers, patients and employers, as well as investigation of conditions of homes, school and work. When cardiac classes or special clinics are developed, it will be advisable to assign districts to clinics as is found practicable in the tuberculosis, pre- natal and child-welfare services. Private Health Agencies 219 Records will be needed in hospitals and clinics, and they should include follow-up notes from home visits and notes on convalescent care, whether in institutions or at home. If there is a central record office, such as is proposed for orthopedic patients, a brief duplicate record should be filed there. Transfer cards should be provided for use of patients between hos- pitals, clinics and convalescent homes. Uniform classification of patients with heart defects for clinics, at least, is very desirable, viz. : Class I. Patients with organic heart disease who have never had symptoms of cardiac insufficiency under ordinary conditions of activity. Class II. Patients with organic heart disease who have had such symptoms previously, but who do not have them at present under ordinary conditions of activity. Class III. Patients with organic heart disease who at the time of observation have symptoms of cardiac insufficiency following ordinary exertion. Class IV. Patients with possible heart disease. Patients who have abnormal physical signs in the heart, but in whom the general picture and the character of the physical signs lead us to believe that they do not originate from cardiac disease. Class V. Patients with potential heart disease. Patients who do not have any suggestion of cardiac disease, but who are suffering from an infectious condition which may be accompanied by such disease; or who have suffered from such diseases as rheumatic fever, ton- silitis, chorea, syphilis, etc. Cooperation and frequent communications between school teachers, pri- vate physicians, social workers, cardiac clinics, and employers who have joint supervision over a particular cardiac. This should be provided for through the medium of the special committee already suggested. RECOMMENDA TIONS It is recommended that — (a) The teaching of medicine and pediatrics at the Western Reserve Univer- sity Medical School include the principles of prevention of heart disease. (b) Special classes for the diagnosis and management of heart disease be organized at least at City Hospital Dispensary, Lakeside Dispensary, Mount Sinai Dispensary, and at the Central Downtown Dispensary, as proposed. (c) Rainbow Hospital provide for convalescent cardiac patients from the children's services of the Cleveland hospitals. (d) Warrensville Infirmary provide the necessary medical, nursing, occupa- tional and recreational services for the proper care of permanently incapacitated cardiac adults. 220 Hospital and Health Survey (e) The general hospitals of Cleveland do not discharge patients suffering from cardiac defect without arranging either for adequate convalescent care or for dispensary and home supervision. (f) Physicians having children in their care examine each year the condition of the tonsils, adenoids and teeth of such patients, with a view of de- tecting foci of infection, by the removal of which cardiac disease may in some measure be reduced. (g) The Board of Education provide for special medical supervision and administrative concessions for cardiac children. (h) A committee be formed for the purpose of studying the resources for prevention and relief of heart disease and for developing knowledge of and interest in the use of all means, including education, which may be relied upon to prevent the development of heart disease or postpone its disabling results. Publicity ^■Suitable material for distribution to teachers, nurses, and friends or families of patients will be found among the publications of the Association for the Prevention and Relief of Heart Disease, in New York (327 East 57th Street). Bibliography For those especially interested in this, the most recent field of organized preventive medicine, the following references will be found to contain the best information: Reports of the Massachusetts General Hospital Social Service Department, Boston. 1911, 1918. Reports of the Children's Heart Hospital of Boston, Mass. Annual since 1912. The Trade School for Cardiac Convalescents Reports. 1913-1914, 1914-1916. Reports of the Bellevue Hospital Social Service Department, New York, N. Y. 1914. Reports of the Peter Bent Brigham Hospital, Boston, Mass. 1915, 1919. Reports of the Burke Foundation, White Plains, New York. 1915, 1916, 1917-1918. "Heart Disease and Its Industrial Relations." Warren Coleman, M. D., American Journal of Public Health, 1915, VI, No. 5, 452. "The Prevention and Relief of Heart Disease." Weekly Bulletin of the Department of Health of the City of New York, 1916, V, No. 37. "Heart Disease in Infancy and Childhood." A. L. Goodman, M. D., Archives of Pediatrics, 1916, XXXIII, No. 12. Private Health Agencies 221 "Suggestions for Municipal Control of Carditis." Thomas B. Hegeman, M. D., Monthly Bulletin of the Department of Health of the City of New York, 1917, VII, No. 2. "Recent Statistics of Heart Disease with Special Reference to its Increased Incidence." Frederick L. Hoffman, Journal American Medical Asso- ciation, 1920, LXXIV, No. 20, 1364. "The Organized Care of Cardiac Children." William P. St. Lawrence, M. D. Hospital Social Service Quarterly, 1920, 11, 151. "Heart Disease as a Public Health Problem." Lewis A. Conner, M. D. Journal American Medical Association, 1920, Vol. 74, No. 23, page 1567. "Effect of Tonsillectomy upon the Recurrence of Acute Rheumatic Fever and Chorea." William P. St. Lawrence, M. D. (Read before the American Medical Association at New Orleans, April 30, 1920 — to be published). THE PREVENTION AND CURE OF CANCER If it is true, as it seems to be, that one in ten of the deaths of persons beyond the age of forty is due to cancer, and if the apparently verified in- crease in the death rate from cancer amounts to as much as 2.5% per annum, there is good reason for both public and private health agencies to start upon their studies and their education of others, so that at least the resources for early accurate diagnosis and cure may be put at the disposal of all who need it. The American Society for the Control of Cancer which has led the coun- try in this subject has been instrumental in organizing state and local socie- ties with the same purpose. No such society independently or as a branch of the national society has been formed in Cleveland, although during the spring of 1920 a number of Cleveland's public spirited surgeons devoted them- selves for the better part of a week to lecturing before lay audiences on the subject of early diagnosis, cure and prevention of cancer. The National Society has contributed to the Survey by preparing a pro- gram suitable for adoption by Cleveland. Such an undertaking will need the support of the Division of Health, and especially of any publicity or edu- cational service the city can supply, and of private agencies, particularly of any special society which this statement of the case may tempt into existence. Some of the activities proposed have been adopted by many health departments. In no place have all the possibilities of an organized attack upon public and private indifference been employed. Suggested activities of a local Cancer Prevention Society are as follows: Program of Activities As the purpose of the National Society as well as the State and Local Committee is to bring essential cancer control facts to as nearly as possible 100% of the adult popula- tion, this subject of activities should logically be considered in connection with the appoint- ment of certain sub-committees. 222 Hospital and Health Survey (If the committee as a whole prefers to carry on the various phases of the program instead of appointing sub-committees, it would doubtless tend to greater efficiency in most cases if the main activities were apportioned among the committee members. In this way individual members should be made responsible for the prosecution of definite parts of the program.) /. Activities of a sub-committee for work with professional or quasi-professional groups. (a) Division of Health. First ascertain through the central office what, if anything, the Division has done. Assist in securing the Division's cooperation in printing and distribut- ing pamphlets suggested by the society. Encourage the Division to provide free examination of specimens of suspected cancerous tissue for diagnostic purposes. If a regular health bulletin is issued persuade the editor to devote cer- tain numbers or parts of numbers to cancer control. The Division should be encouraged and assisted in the preparation of popular articles on cancer for newspapers. If the Division has a health exhibit it should devote a portion of it to material for education regarding cancer. Where health centers are established they should be provided with exhibits, placards and literature for general public distribution. The Division should be urged to prepare circulars on danger signals of cancer for distribution to all midwives. (b) Medical Associations, Academies and Societies. As above, find out first of all by writing to the National Society Office what has been done by these organizations. Assist the Central Office in securing the appointment of a permanent Cancer Committee in the Academy of Medicine. Encourage all such organizations to cooperate with the society and other organized groups in educating both the medical profession and the public. Endeavor to have each medical organization devote at least one meeting each year for its own members to a discussion of cancer, and hold at least one public meeting on the same subject each year (perhaps in cooperation with other groups or with the Division of Health.) Present to all organized medical groups their responsibility for the education of the medical profession and attempt to have them publish, either alone or in cooperation with the Health Division, the society's hand- book for this purpose. Private Health Agencies Encourage the publication of good articles on cancer in state and local medical journals. (c) Hospitals and Dispensaries. Prepare posters and placards on cancer for bulletin board display. Encourage the distribution of appropriate literature on the subject to patients. (d) Nursing Organizations and Schools. Every training school for nurses should be urged, through the appropriate surgeon of the hospital, to include cancer control in the lecture course. All such schools should be supplied with the special literature prepared for nurses by the society. Efforts should be made to provide speakers for meetings of state nurses' associations and before local nurses' organizations and clubs. All public health nurses should be provided with the society's special nurses' literature. A special effort should be made to acquaint all industrial nurses with the facts necessary for their use in advising employes on the subject of cancer. (e) Medical Schools and Colleges. A special effort should be made through the dean or head of the Depart- ment of Pathology to give due attention to instruction of students in the recognition of pre-cancerous conditions. This will require considerable tact in all cases and an excellent beginning would be made by securing their consent to procure and distribute Dr. Greenough's handbook to the students of each senior class. Those conducting courses in Public Health should have the literature of the society brought to their attention for use with their students. (f ) Public Health Association when formed. These excellent non-official public health agencies are already doing some most effective work. Where such associations exist they should always be asked to cooperate in any campaign started in their states or coun- ties. Made up as they are of representatives of all health and civic organiza- tions, together with prominent members of Chambers of Commerce, Rotary Clubs, manufacturers' associations, labor groups and representatives of the press, the cancer campaign could be conducted by them (with guidance) ■in its entirety. (g) Association of Industrial Physicians and Surgeons when formed. Such associations, together with all other organized groups, are circular- ized from time to time from the office of the National Committee. Much local assistance can be rendered by following up these letters and applying the suggestions in individual plants. 224 Hospital and Health Survey 2. Activities of sub-committee for work with lay or non-professional groups. (a) Social Workers. Contacts should be formed with the heads of all charitable organiza- tions doing home visiting or nursing with the idea of instructing these social workers in regard to early cancer, in order that they may be in a position to advise properly those with whom they come in contact. Associated Charities, and similar groups, may be willing to cooperate in arranging for public meetings. (b) Women's Clubs. The organized women's clubs should be specially urged to provide for a discussion of cancer at their annual meetings. The local clubs should prove of the greatest assistance in arranging public meetings of women to be addressed by qualified physicians. Many clubs maintain a Public Health Committee and through this much valuable cooperation can be secured by public meetings, holding ex- hibits, distributing literature, participating in special "health days," etc. (c) Chambers of Commerce. The Public Health Committee of the Chamber of Commerce should be stimulated to give the cancer control program attention in their public dis- cussions and press bulletins. Literature on the subject should be provided for distribution to their members and to be picked up by visitors to their rooms. The same applies to the Men's City Club and to the Rotary Club. (d) Trades Councils and Unions. These industrial groups should be encouraged, through their officers, to allow the subject to be discussed at some of their meetings and be provided with literature for distribution. (e) Ministerial and other clerical groups. These influential organizations should arrange for a full presentation of the subject before their whole membership. Opportunity should be sought to have the cancer control progress out- lined to church clubs, men's and women's. Churches will often cooperate in the conduct of public meetings. (f ) All other organized groups should be made acquainted with the purposes of the society and the information which it is prepared to disseminate. Some of the other organiza- tions which readily come to mind are: Fraternal Orders — Young Men's and Young Women's Christian Asso- ciations and Young Men's and Young Women's Hebrew Associations. Private Health Agencies 225 3. Activities of Sub-Committee on Publicity. This is one of the most important functions of a local committee and much of the success of the campaign will depend entirely upon the efficiency of this sub-committee. While all possible avenues of publicity cannot be covered, some of the obvious methods to follow are: (a) First of all cultivate a personal acquaintance with editors of the principal newspapers. (b) Offer assistance to any of the above groups planning to hold meet- ings of any kind on cancer by : helping to prepare material for announcement cards, "throw-aways," window posters, newspaper advertising, etc.; preparing and sending out notices to be read in churches, lodges, clubs and similar places, and by assistance in every way in calling the attention of the public to the coming meeting. (c) Follow up every meeting held by sending a digest of it, carefully prepared, to the newspapers. The editor, if already a friend of the move- ment, will usually send a competent reporter to cover an important meeting. No chance should be lost to get into the good graces of the best reporters, for they will often prepare the copy themselves if they feel it is appreciated. (d) Material should be prepared either from the monthly bulletin of the society or other sources, or be written by a qualified practitioner connected with the society, for special news articles or editorial comment in papers. (e) Where "Health Columns" are run by papers, encourage the editor to devote the space (or part of it) to the cancer control movement from time to time. If it is run in the nature of "Questions and Answers" it can be used to great advantage by asking the editor leading questions on the subject, which will often elicit a rather thorough, popular discussion. In addition to this description of what may be called the mechanics of educational publicity there is an opportunity for research in the local inci- dence, the occupational distribution and whatever special etiological factors may be discovered in the trades and industries of Cleveland. That much can be done to reduce the high incidence of inoperable cancer, no one doubts. We know enough about the subject to have no excuse for our silence. Ignorance of the resources of preventive surgery and early diagnosis is a direct challenge to our energy, and this ignorance is wide- spread among all classes of the population. THE PREVENTION AND RELIEF OF MENTAL DISEASE The need for a local society to promote the interests of the mental hygiene movement is well described in Part VI., together with suggestions for suit- able activities. The Women's Protective League is the only private agency dealing with any phase of this problem, and its activities are confined closely to relations with court cases and delinquency. THE PREVENTION AND CONTROL OF VENEREAL DISEASE The work to be done by a local society along lines so successfully followed by the American and various state Social Hygiene Associations is described in Part V. A nucleus for such an organization was formed in Cleveland and did active work during and just after the war. It should be revived and resume its work. •226 Hospital and Health Survey SUMMARY OF RECOMMENDATIONS Public Health Services: Any repetition of the numerous suggestions or specific recommendations concerning the personnel, organization, authority, functions or performance of the public services which have been analyzed in the previous pages would be superfluous for those whose interest has been aroused by the text. A few main features will be mentioned to call attention to the relative importance of the recommendations as they appear to the members of the Survey staff. General Administration Under general administration it is considered to be of chief importance that a Com- missioner of Health be appointed whose entire time may be devoted to his duties in the Division of Health, and that the salary be adequate to demand the undivided interest of a trained sanitarian (not less than $7,500). Civil service appointments for the entire division are thought to be essential to the best service, in the case of nurses, the Central Nursing Committee to be the agent of the Civil Service Commission in determining fitness of applicants. Medical examination and a probation period of three months for all employes before definite acceptance are advised. Sanitary areas as defined for Cleveland by the Bureau of the Census should be used as the basis of all administrative districts for health work. The commissioner should hold regular conferences on policies, programs and results, with his chiefs of bureaus. The power to make sanitary rules and regulations should be vested in an advisory board of which the Commissioner of Health is a member, the regulations to have the force of city ordinances. An assistant or deputy commissioner should have in charge all legal actions taken at the instance of any of the bureaus of the division. Bureau of Communicable Disease The control of the communicable diseases of animals (other than those used for slaugh- ter) should be vested in this bureau. A skilled intubator in the employ of the Division of Health is considered a necessity for emergency work in diphtheria. The service of the district physicians would be greatly improved if the ten recom- mendations presented are met. Bureau of Child Hygiene The thorough consideration of the Bureau of Child Hygiene in Part III. makes un- necessary any statement of recommendations here. Bureau of Sanitation The needs of the Bureau of Sanitation are: a full-time trained chief of the bureau, sufficient sergeants to maintain field supervision of the work, and the assigning of all Summary of Recommendations 227 sanitary patrolmen from other bureaus to work under the direction of this bureau, in small districts where they may cover all types of field inspection, functions now served by them for any bureau. The work that should be vigorously prosecuted by this bureau includes enforcement of housing regulations, the making of a sanitary survey of the city especially to locate all privies, private water supplies and stables. Bureau of Food and Dairy Inspection The Bureau of Food and Dairy Inspection should modify its methods for milk control to make use of the bacterial counts of milk as a basis of exclusion of supplies. There should be required the sterilization of containers, discontinuance of holding milk after pasteuriza- tion before bottling, and a standard bottle cap to indicate the place and date of production or pasteurization of the milk and the grade. No milk showing counts of over 500,000 bacteria per cubic centimeter in the pasteurized product should be allowed on sale or for distribution. Bureau of Laboratories The Bureau of Laboratories requires the undivided attention of a full-time chief. This bureau should be relieved of its inspectorial functions. Determination of meningo- coccus in spinal fluids for type, and of pneumococcus in sputum for type should be offered by the laboratory. Specific antisera and vaccines of proved value should be available through this laboratory. Additional activities suitable for this bureau to initiate are proposed in the special chapter on "Patent Medicines." Bureau of Vital Statistics The Bureau of Vital Statistics needs a full-time trained statistician as chief to inaugu- rate and direct to completion the plan of work presented in the special chapter on this subject. New Activities New activities are considered essential through: the appointment of a Commissioner of Publicity and Research within the Department of Public Welfare to inaugurate and coordinate facilities for health education in Cleveland; the organization of a bureau of institutional inspection or a subdivision of an existing bureau in the Division of Health, to insure adequate sanitation of environment and medical care of inmates of institutions; the organization of a bureau of industrial hygiene to protect employes against the hazards of their occupations; the provision of a corps of physicians to make initial medical exami- nations of all city employes on admission to the city service and periodic re-examinations annually thereafter; the organization of an inspection and treatment service for the con- trol of narcotic drug habitues as required by city ordinance ; assumption by the Division of Health of the responsibilities assigned to it by city ordinance in the supervision over day nurseries; provision for sufficient physicians and nurses to permit of inspection of children in the parochial schools in a manner comparable with the service of medical pro- tection given to the children of the public schools. The Health Centers should be increased in number to sixteen, with appropriate in- crease in personnel and the functions served in these district offices increased to cover all 228 Hospital, and Health Survey field services of the Division of Health and to provide for opportunities for including the private agencies dealing with health protection and for affiliation with hospitals and dis- pensaries. The coroner system should be abolished and the system of medical examiners as in existence in Boston and New York adopted. Private Health Agencies It is believed to be of great importance that a Cleveland or Cuyahoga County Public Health Association be formed to give direction and more effectiveness to the efforts of all the public and private agencies in this field. A secretary for health to act as advisor in health problems to the Director of the Welfare Federation is advised. For detailed recommendations dealing with the activities of the Anti-Tuberculosis League, the Visiting Nurse Association, the Association for Crippled and Disabled, the Hospitals and Dispensaries the reader is referred to the special parts and chapters devoted to these subjects. New private committees or agencies are urged, so that public interest and action may be developed in the subjects of Prevention and Relief of Heart Disease, Prevention and Control of Cancer, Prevention and Treatment of Mental Disease and for the Prevention and Control of Venereal Diseases, for all of which projects detailed plans are presented in the appropriate chapters. Appendix Appendix o c n •< ^~> O) en -t- eo to Health Districts — — OJ to t-> t-l Total Births *> 00 to o H- Co ^J Co oo oo *> Co -p> o Co Ov iO Co en to to Males a » 3 H o OtOtOI-'l-'tOCO© Undetermined ©*-©©©©►-©© Triplets !-*)-• CO K3 CO tOt->l-> viCOOvtOOOCnCOOOl wii^f (/>►-©!— -&.tO©-^vO wtllIC n a H cs > i 03 a" ■M «< " *0 >— >- ,-,.. OvO\0000O*o>voen*- Other P-* Ji. Co Co Oi vo OOOvvO^cnCovOCo Midwife -f**O*OCn00^J©eniO^l NO (-■ l-> lO I— (-■ H- I— >-> to CTi VO 00 Q\ 00 Physicians © — co (-• i— t— 00 Ov O h- Co >-> to ^ Cn en to -j CO 4^ to VO 00 VO Native H- © H ^ Ol »J H* © oo oo oo "to Foreign --j 'HO sqxqdXs 3 sssnBQ jaq^o ax O >-H CO o VO 'H i-H CO »h © CN T(- cn © © © © © CM O iH ^ .-H © CN <3" CN CN ©. © CN i-l <-H +3 i*j O .fa C ■C 4J 5 sa 3 e V O p w ^ f Appendix TABLE III. Communicable Disease Morbidity Reports Disease 1919 1918 1917 1916 Actinomycosis Anthrax Cerebro-spinal Meningitis 73 Chancroids Chickenpox 864 Diphtheria 2,017 Erysipelas 113 Favus Gonorrhea 242 Impetigo 95 Infantile Paralysis 10 Influenza 4 , 558 Malaria Fever Measles 2 , 135 Mumps 251 Ophthalmia Neonatorum 1 , 140 Pellagra Pneumonia 1 ,274 Puerperal Fever Rabies 2 Scabies 30 Scarlet Fever 580 Smallpox 232 Syphilis 512 Tetanus 9 Tinea 4 Tonsilitis 72 Trachoma 30 Trichinosis Tuberculosis 1 ,464 Typhoid Fever 80 Typhus Fever Whooping Cough 634 Total 16,421 39,444 15,751 14,623 1 1 158 46 45 2 577 1 ,218 989 1,265 1,371 1 ,856 1,909 2,030 172 308 285 266 1 89 53 105 26 113 110 106 173 23 35 38 143 26,998 10 97 118 2 4 6 15 1,234 2 ,656 4,027 4,294 316 809 600 452 1,004 1 ,294 692 601 1 1 1 2,440 1 ,453 1,375 1,606 1 2 4 7 3 19 24 17 35 408 618 866 927 1,120 661 204 45 305 232 257 56 11 9 3 5 8 3 4 6 51 71 74 102 50 58 47 57 1 1 1,606 1 ,761 1,964 1,619 143 206 209 313 1 1,379 2 ,140 697 1,201 234 Hospital and Health Survey u © ■*■ © ,_, Tj- CO © CN CO rtNiN m © © 00 © CN t~ CO ■* Ol rH m © © J3 Q 1—1 CN 0\ ^N VO CO LO 1/1 *-H CN CN C o > o co CO CO t^ © © © - -J- © t-^ OO © ^H © >, i 0. u CO oo m *J- t^ rH t^ © -t © CN •>!- CO CO CN CN O i-i CN C^ 4-1 CO CO *-. <* ^- 00 i-i « ■w ei 3 © oo © © lO f~ t>. -5f o © *!■ © o ~* LO CO —1 MKN © © I-H f^ © © CN Ol £ < * CO CN rt t-» CN »H oa u CO ©" o © j* 3 rH CO © 1- in CN CN IONN CN ir> o © © Oi «NHN © © Tj- W >■ < © © »-j CN CN O CN CN i-H CN Ol " c CJ C^ CN CN m M t>- ^ J3 o c *•> 3 CM CN OlN^ CN CN CO -H © * * P)H Cn O rH CN CJ> G o 1-1 c-n co CO ** m CN C?l CN © rH ^J" Ih 3 a o >> CO co CN © © IT) rH CO © O - -h co Mrt N m © co -IHTj- » CO CN rH © CO © Ol •H © rH © CN O CN CN rH rH © •X CO I-H IT) » «d — CO u co *C 00 UO © VO tN. © CO 13 - > a in CN rH ,j- in c^ m tj- •h i-i «a- tslONH rH m O t» u 9) a < < f^ © CO ^n t^ CN O CN rH rH CN © < Ih a CO "ee u CO oo CO rH m *■» CN * t~ r~ t}- rH «> "*• * © © © © CN rH m CN rH CJl CN CO I-H t^ ^H t^ CO m rH rH » CO 0* S U CO CN © © CO **■ OB CN CM tJ- io CO -N ■* lO lOlflTf m o> co co CN Ol CO CN V fe rt CO co CN 00 -H O Tf t-^ rH rH in — c co 00 ■* CN oo 00 Tj- 1-1 cji oa © Ol CN CN © CN C^ CO *0 ■cf CN t^ Ol » - OS »-J i-H CN CN ^ oo Tf rj- 00 rH CO Ih U ■-H CO r. > CO 1 >^ •o c a -C -3 J3 J3 rC rfl rC "3 > c 1> S cj S C CJ 9 a o " o 8 2 u 2 sj O o « 2 o £ is £ ? s S E S £ £ £ E u Sjjd In In ri' U In _ NUN In U CJ CJ rC C rp In U CJ CJ £ a c a a-g aa^ -c 40 aa c CJ H "O T3 cj 2 o-c a a •a o ■a T3 2 TJTJ O •ca o •o o TJ -O •5 e ss CJ CJ P 4) U C ■4J «-> «n u cj p CJ CJ > p CJ p CJ CJ 4J JJ ~ 3 +J >" 4-» N-» 0. Q. epor epor per v. epor epor per d epor epor per .3 epor epor per per CJ "* U U a a CJ CJ >-« U CO U U CO . w U U CO to U In CO In In CO CO a N c In CO U 1- u £ to 5 co CQ 4) co en ■§ jj t> +i CO CO co NN CO CO "P. eo co co •5 5. CO CO "S u u rt CO CO CO In 05 c« "S *s "J *> « « co co CO co e cases e death umps C0 CO CJ CJ CO CO CO *> "S CO CO H -2i CO CO V o CO CO « N. co co cj aj CJ CO CO < S-o g CD 4) • (3 CJ 1) 1) < O cj "O cj cj u -c •S- O cj "O "O CJ CJ CJ CJ 3 <* CJ o CJ CJ c ,>> ex eX ^ CO CO i* zl -J zl 01 Cl OL ■4 cioici CX CJ3 ex ex c 0/1 0D Hh CO CO < ex o* r- CO CO CO tfl CO CO CO CO CO CO Q CO CO CO CO -. CO CO U In In In U U In In In In U In U In U In U In In cj cj V II u V V V CJ CJ CJ CJ CJ CJ CJ CJ CJ CJ CJ > > > > > > > > > > > > > > > > > > > < < < < < < < < < < < < < < < < < < < Appendix 235 -H O Tj- w4 0> Irt CO to i-c 00 CO *o 1-1 t"» t^ cs © aoicsi -h eo ih vo VO o VO iO o IO Ol hN -1 O -H <*" es t-~ vO —: CO m cs oo . 10 o 00 VO r^ cs CO CO to CO ID ■* CS O t~» to H C-» oo oo 00 o ~4 oo 1" >*■ — oo co es <3\ 00 — o M 6. C v g g § o o 2 & ft p oo,; K CO CB SO to tO u u > > £ ft c Jl bfl ,3 to K, v > < ■jl J* *, 1) c 1) o * £ u u 5 8. ft ft to « Si 611 CO « > £ a ft »c m c o * £ to to •a *o 1) V oil b£ cs to u u > > << § s c a u - flj -G Tj O Bfe h ftS. E a £ - o fe « ft a o 1/5 rt CO CO TJ- © CS © es ^h I £ u > oofe a ft a oo « 00 CO -< oo CD i» eg tO »-S ^ to O 6J5 b£ tO C3 U Ih > > to « o T3 v > << »5 B3 "H ' D u -M 05 (0 tO to to JJ u ufl 4J HJ 11 o/j b£ M to to to u u u v aj u > > > to ^; •* r I £ tO CO on ui to to u u > > 236 Hospital and Health Survey y„/C T , anTin MOOONOBHHOn JB3A X JSpUn U)MOlO'l-H(Off)H^ sqieap jjy ot^r-»©OiCTi©*'-<^ g fa 3 S3TSB3W *0O*00tJ-NH(ON00 I *g XOdllBUIS (NO^HOOOOtNOO I >rt BUBIBI^ ^HOfNOi-lOOOCSO I *D OHNM^WWNOOOl £ ^H ^H »-( rH i— I tH t-l iH T-t 1H f* CUCTiOlOlOlOlOlOlOlO* Appendix 237 TABLE VI. Report of District Physicians — 1919 Districts 12 3 4 5 Total Patients 673 1,007 1,855 597 1,697 Old ._. 135 14 201 34 114 New 538 993 1,654 563 1,583 Total Calls (On the above) 2,559 1,979 2,948 1,173 1,737 Home 2,035 1,628 2,403 1,157 1,307 Office 524 351 545 16 430 Number of calls per case 3.8 1.96 1.58 1.96 1.02 Miscellaneous, not included in the above Wrong address 26 7 91 41 26 Not found 25 12 77 40 15 Not ill 59 11 20 Death Certificates 55 51 66 118 62 Contagious Investigation 245 83 169 370 155 Board of Education, etc 169 181 76 Vaccinations 4,523 474 949 1,554 5,129 Disposal of Cases Continued 37 11 103 39 79 Discharged : 247 846 1,564 392 1,059 Died 13 10 32 5 5 To nurse 79 358 16 191 To hospitals 146 122 152 83 188 To dispensaries 129 31 127 42 60 To dentists 38 12 1 17 To private physicians 21 13 To correctional agencies 8 4 5 To relief agencies 7 6 6 37 Percent of total cases referred to hospitals dispensaries, private physicians 40.8 15.2 15.04 24.5 15.4 Note Calls out of district (Included in home calls above.) 238 Hospital and Health Survey •*mM ^- oo in © oo c^ o o n^ h Hi £*jia i-c O 00 CS © CO UB3p A^JIE^ in 00 N O £> ^- o oo UB3 ID o ■* o> cs o oo h ^ « m oo o •d -d J3d OOO'OS -'SAO }uriOD jBuaioeq Ag S^ c^ Sa tH ©^ a « ffl < Q J4 — ■ n > £ 8* pq a < H a> ft a CO ^O -oO vJ3 vJS vJD v p C\ 0~- cN CN a"- O- 4S3} spijos JB10} Ag CO CO O N + O to ih e* f-« e» ^fr <*■ ■* Tf co "*■ cs o^o^o\ ©^ Cj^ cN }S3} 5BJ Ag ^ N « H ON Tf <*■ m m m m &5 feS fc? £S £S &s isa} ja^auioioBi Ag m m in o oo in t N f) N fl N }sa} spijos jb^oj Ag ^ H . * * ° ^ CS CS i-H r-< CS CS 1S3J ibj Ag m in ^t m m m co co co co co co ^c£^^^c£ }S3} J313UI01DBI Ag «>; oo in ^" 00 00 © © O © © ^H CO CO CO CO CO CO in r-~ in co r-~ oo cs o sajduiBs jo •Ofj jbiox m co cs .-^ o o co oo CS ih rt tj- m o t> oo cti C^ C7i Oi Oi CJ\ C7t Appendix %I!i t£ S? i£ *£ &S e£ O « O 00 N H O O O © © <-H X^JIQ ueap A^jib j i£ e£ &S fc* S* c£ 10 m «) h in m h s » id o\ + ^- m 01 n o "i >> UB3I3 >t 00 CO O 00 Ol H 03 zz W< OH w 04 •d o jad OOO'OS J3AO }unoo jBuarpBq Ag (U isa} spiTOsjTBtio:! Ag }sa}~}Bj Ag t-» IM 0\ © mono c^ ro cn m is to oo o o a CM 00 f~ VO ift © U) 1ft t !fl !0 * N O t Ol H O Oi n io C oo in }S3} J3^3UIO^OBl Ag co LO 00 O* iH C-» CM i-H i-l 00 1 00 CM C-. 0> i-H i-H i-H CM i-H i-H }S3} }BJ Ag co CO CO CO CO CO CO CO CO CO CO CO }S3} J313UIO;0BI Ag 0\ CTl O CM CJ •n rn « o <1) o X) c C3 OJ en cu "1 uo T3 ^ - s i-h .: ca o £ «- .S3 O C o cd ©_ l-H i-H I-H I-H i-H * i/j © © © © © © .a o U =0 co" 03 ■u -y 03 o fa H J2 c "3 03 M iJ W o o 2 " c bfl '" a t3 ^H « V, 3 8 £ TJ - *» "2 « c 5 •£ OJ 03 £ £ w 03 dj " CO pq 240 Hospital and Health Survey TABLE IX. Synopsis of Classified Report of Bacteriological Examination of Cleveland Market Milk "The age of the milk after pasteurization is indicated as nearly as possible by "Fresh" if less than 24 hours after pasteurization, and by "24 hours" if bottled for that period or longer. Group I. — 12 samples: Class A — 3 samples Class B — 8 samples Class C — 1 sample Group II. — 54 samples: Class A — 6 samples Class B — 28 samples Class C — 20 samples Group III. — 34 samples: Class A — 1 sample Class B — 18 samples Class C — 15 samples Patron Milk Bacteria Patron Milk Bacteria Class Age Group I. Class A Count Class Age Group II. Class A Count Y. Fresh 20,500 Y. Fresh 35,000 X.Y. 24 hrs. 20,000 X. Fresh 32,000 X. Fresh 10,000 X. Fresh 16,000 Y. Fresh 2 spreaders Class B Y. Y.Z. Fresh Fresh 20,000 19,000 X.Y.Z. Fresh 114,000 X. Fresh 116,000 Class B X. Fresh 97,000 X.Y.Z. Fresh 109,000 Z. Fresh 224,000 X.Y.Z. Store 223,000 Y. Fresh 65,000 Y.Z. Fresh 70,000 Y. Fresh 72,000 X.Y.Z. Fresh 58,000 X. Fresh 115,000 X. Fresh 214,000 Z. Fresh 320,000 Y. Fresh 65,000 Class C Z. Z. Fresh Fresh 120,000 130,000 Y. 24 hrs. Over 500,000 Y. Fresh 225,000 Appendix 241 Group II. — (Continued) 24 hrs. 490,000 Fresh 256,000 Fresh 107,000 24 hrs. 15,000 24 hrs. 117,000 Fresh 35,000 Fresh 95,000 Fresh 234,000 Fresh 56 , 000 Fresh 261,000 Fresh 108,000 Fresh 55 , 000 24 hrs. 95,000 Fresh 74 , 000 24 hrs. 420,000 24 hrs. 400,000 Fresh • 60,000 Fresh 104,000 Fresh 115,000 Class C z. Fresh Over 500,000 z. Fresh Over 500,000 Y. Fresh Over 500,000 Y. Fresh Over 500,000 Y. Fresh Over 500,000 X. Fresh Over 500,000 Y. Fresh Over 500,000 Y. Fresh Over 500,000 Y. Fresh Over 500,000 Y. Fresh Over 500,000 Y. 24 hrs. Over 500,000 Y. 24 hrs. Over 500 , 000 Y. 24 hrs. Over 500 , 000 Z.Y. 24 hrs. Over 500 , 000 Y. 24 hrs. Over 500,000 Y. 24 hrs. Over 500,000 Y. Fresh Over 500,000 Y. Fresh Over 500 , 000 Z.Y. Fresh Over 500,000 X. 24 hrs. Over 500,000 Y. Z. Z. z. Y. Y. Y. Z. Y.Z. Z. Z. Z. Y. Y. Y. Y. Z. X. X. Z. Z. Z. Z. Z. Z. Y. Z. Z. Z. Z. Y.Z. Y. Y. Group III Class A Fresh 26,000 Class B Fresh 150,000 Fresh 300,000 Fresh 91,000 Fresh 1,000 Fresh 210,000 24 hrs. 97,000 Fresh 143 , 000 Fresh 7,000 Fresh 71,000 Fresh 55,000 Fresh 140,000 24 hrs. 135,000 Fresh 434,000 24 hrs. 156,000 Fresh 95,000 Fresh 180,000 Fresh 109,000 Fresh 136,000 Class C Fresh Over 500,000 Fresh Over 500 , 000 Fresh Over 500,000 Fresh Over 500 , 000 Fresh Over 500,000 Fresh Over 500,000 Fresh Over 500,000 Fresh Over 500,000 24 hrs ; Over 1 , 000 , 000 Fresh Over 500 , 000 Fresh Over 500 , 000 Fresh Over 500,000 Fresh Over 500,000 24 hrs. Over 500,000 24 hrs. Over 500,000 242 Hospital and Health Survey Reference Tables on the Movements of the Population of Cleveland * TABLE X. Rank and growth of the population of Cleveland, in comparison with twenty other cities, 1900 to 1920 1920 1910 1900 City Population Rank Population Rank Population Rank Cleveland. _ New York Chicago. Philadelphia Etc This table is intended for census years primarily but may be used for intercensal years on the basis of Census Bureau estimates. TABLE XI. Principal color, nativity and parentage classes of the population. Percentage of total, -and rate of growth of each class, 1900 to 1920 1920 1910 Class of Population Popula- tion Per Cent of Total Per Cent Increase Since 1900 Popula- tion Per Cent of Total Per Cent Increase Since 1900 Total White- Native-born — Of native parentage.... Of for. or mxd. ptge. Foreign-born Negro Other Colored — Chinese Japanese Others of this class This table is intended for census years primarily but may be used occasionally for intercensal years for the calculation of differential birth rates and death rates for each class of the population. * In such of the following tables as subdivisions of the city are used for the tabulation of population, morbidity, mortality, etc., it is recommended that the sanitary areas (131), as established by the Bureau of the Census for Cleveland, be used in preference to wards or other political or administrative districts of the city's area. This will affect Tables XV., XVII., XX., XXI., XXII., XXVII., XXXIII., XXXV.. XXXVI. Appendix 243 TABLE XII. Number and percentage of population in each age period, by sex, 1910 and 1920 1920 1910 Age Males Females Males Females No. Per Cent No. Per Cent No. Per Cent No. Per Cent Total Under 5 Under 1 1 2 : 3 4 5 to 9 Etc., to 95 and over... For census years primarily, but should be used also intercensally to show the basis for age, death rates and also for fecundity rates; f. «., births per 1,000 women at the child- bearing ages, 15 to 45 years. TABLE XIII. Number and percentage of population in specified marital condition classes, by sex and age, 1920 Total Single Married Widowed Divorced Age Period and Sex No. Per Cent No. Per Cent No. Per Cent No. Per Cent No. Per Cent 15 years and over — 100.0 100.0 Female 15 to 24 years Male. .._ Female 25 to 44 years Male... Female 45 to 64 years Male. _ 100.0 100-.0 100.0 100.0 100.0 100.0 100.0 100.0 Female... 65 years and over Male Female This is for the census years only and the figures may be made the basis of the calcula- tion of death rates by sex and marital condition at each age period. 244 Hospital and Health Survey TABLE XIV. Country of origin of the foreign white stock in the population of Cleveland Foreign Born White Native White of Foreign or Mixed Parentage Country of Origin Total Foreign White Stock Total Both Parents One Parent Number Per Cent Born in Specified Country Native, Other Born in Speci- fied Country* 100 (List countries here) Foreign or mixed Parentage* *For native whites whose parents were born in different foreign countries included in last line. This table is intended for census years only and may be made the basis of computa- tion of death rates in 1920 of the various foreign born stocks in the city. TABLE XV. Ward or "sanitary district" population of the city of Cleveland, 1920 Item Total City Ward or Sanitary District 1 2 3 4 Etc. Total population — Male Female White- Native-born Of native parentage Of for. or mxd. ptge. Foreign-born . s Negro.... Chinese and Japanese Foreign-born white Born in (List countries here) Land area (acres) Persons per acre .- Dwellings (number) i, Families (number) Persons per family This table is for census years only and may be used as a basis for educational and Americanization work, especially in those wards where the foreign-born live. Transit and park facilities may also be gauged therefrom. Appendix 245 TABLE XVI. Number of persons 10 years of age and over gainfully employed in specified occupations. By sex and age. Total Males Females Occupation Total 10 to 16 16 to 19 Etc. Total 10 to 16 16 to 19 Etc. All occupations (Abbreviated list of occupations and industries — about 50 titles) This table is for census years only. It is planned also to tabulate the occupations of the deceased of 1920 in a similar manner to permit the computation of death rates for the more important occupations of the city. TABLE XVII. Estimated population of the city of Cleveland and of its subdivisions, 1920 to 192 — Ward or Sanitary Area 1925 1924 1923 1922 1921 1920 1910 Total _ Ward 1 Ward 2 Ward 3 Etc This table is required each year and is based on arithmetic increase of population during the last decade. If this can be proved reliable, it becomes the denominator of all important measures of the movement of population in each ward of the city, including marriage rates, birth rates, death rates, sickness rates, etc. TABLE XVIII. Number of livebirths and birth rates (a) per 1,000 of total population, and (b) per 1,000 women of childbearing age (1) Year (2) Births (3) Birth Rate per 1,000 (4) Birth Rate per 1,000 Women 15-44 (5) Number of Stillbirths (6) Per Cent Stillbirths of Total Live and Stillbirths 1925....; 1924 1923 1922 1921 1920 This is a permanent table and may be used to advantage to detect the trend of the birth rate and to control the waste of stillbirths which may be looked upon as an impor- tant element in infant mortality. 246 Hospital and Health Survey TABLE XIX. Number of livebirths, by sex of cbild, color and nativity of parents, each month in 192— Month (1) Total (2) Parent Nativity and Color Sex of Child White Col- ored (8) Color For- eign (5) Both Parents Native (6) One Parent Native, Other Foreign (7) Unknown Male (3) Female (4) (9) Total year._. January.... February.. March .. April May Etc This table is permanent and should be the basis of infant welfare work by depart- mental agencies, such as clinics, visiting nurses, etc. TABLE XX. Number of livebirths by nativity of white mothers in specified wards, 192 — Country of Birth of Mother of Child Total City Ward 1 Ward 2 Ward 3 Etc. United States Great Britain Etc This table supplements the following one and is especially useful to determine the educational work required to obtain the cooperation of mothers for better obstetrical service, clinic attendance, etc. Appendix 247 eo o cr M ? (i it »' £ 8 £ CO ft> (H O 05 „. co to ►*» $ *o £± S* 2 ^23 *ri r fD £* S 3 q § 2 ps* a. 3g" M 8-5 S- o » S 3 S* Sf 3 n £ TO g* « n fj£ 5" o S c o^ _ co 2. 2. n> J? ~ 3> 2. » c 5- S 05 n ° s> 05 rf M •"* 2 05 CO £5 O n rt o S "8 & < 2 O 05 O ^ &"0 _ co tr o ** ? ? o S* rt O* SS o S! " *i •o < 8 P* ° "2. d a- n> 2. n O (D &• ^ X 3 Si g tf 3, < B* w O rt> O a m, 13 O 05 n "I "1 2. to' 3 O rt o ■ O 3 ^ O . 5° J? 3 to V <5 3. o 8 S ft 3 3 Iff 2 o g!w2 3£P 5*ro n s a a ft) W 248 Hospital and Health Survey TABLE XXII. Number of livebirths in specified districts by calendar months Ward or Sanitary Area Total Year Jan. Feb. | Mar. i Apr. Etc. Total Ward 1 Ward 2 Ward 3 Etc P This table will prove a useful check on the attendance of mothers at maternity and infant welfare stations in the various sections of the city during the course of the year. TABLE XXIII. Illegitimate births by color and nativity of parents, 192 — Total WHITE Colored Color Ward or Sanitary Area Foreign Born Native Unknown Both Parents Native One Parent Native, Other Foreign Total Ward 1 Ward 2 Ward 3 Etc. This table may be tried out for one or two years for the city as a whole. If returns are fairly complete, the fuller tabulation by wards may be given. This may prove to be a very useful instrument for the social service agencies of the city in indicating where illegitimacy prevails and the peoples who contribute most to this problem. The figures will serve also to compute the infant mortality rate of illegitimate children. TABLE XXIV. Deaths of infants under one year of age. Principal causes of infant mortality, by wards, 192 — Cause of Death Total Ward 1 Ward 2 Ward 3 All causes Abridged list of causes This table is permanent and is the keystone of the whole plan of infant welfare work of the department. It determines where the chief infant mortality occurs and the causes of such mortality, whether from diarrheal, respiratory, or other infections, a preventable disease, or particularly from congenital causes indicating poor obstetrical or prenatal service. Appendix 249 » g" fl> 3^ 3 c •o M ■d •< 3 (» o 3 35 2 ft a 7 X k X < "< CO Q) O 3 X X Si < ta 'U 3 a 3 1B- . rt 3 a r* n s» ?r re 3 m Si •< 3* rt o 3 rt rr 3* 3* (t rt 3 a rt rt ft T-l P. m rt- ■a 3 J? 3t 2 ft ** 3 I ft .1 3 ft ft n> 3^ < a o 3* »ij > — ■ ft o 3 g £L 8 <" ™ 00 0> c B3 SL « U. fD OJ 3. ? e- << 3 M a X 4. a 0) tn *L s* o <^ O M 250 Hospital and Health Survey TABLE XXVI. Deaths of infants under one year of age, by calendar months and by causes of infant mortality, 192 — Cause of Death Total Year Jan. Feb. Mar. Apr. Etc. All causes (Ten abridged list of causes) This table supplements table XXIV. and locates the departmental service to be ren- dered in time of year. TABLE XXVII. Deaths of infants under one year of age, per 1,000 livebirths (infant mortality rates). For principal causes of death. By specified districts. Cause of Death Total City District 1 District 2 District 3 Etc. All causes (Then abridged list) This table is a composite of tables XX. and XXIV. above. The rates are more definite than the absolute numbers of table XXIV. in indicating where conditions are most serious — although the figures of the previous tables must be used as well to show the size of the problem in each area. TABLE XXVIII. Deaths and death rates per 100,000 from principal diseases in Cleveland Cause of Death No. of Deaths Death 100,000 19— Rate per Population 1915-1919 All causes of death (Then give detailed list of causes of death) This is a permanent table and fundamental to the work of the health department. It indicates what diseases and conditions are especially serious in the mortality experience of the city. The comparison between the year in question and the previous five-year period, 1915 to 1919, indicates the trend of the death rate for the several causes. Appendix 251 TABLE XXIX. Number of deaths from principal causes of death, by age period Cause of Death All Ages Under 1 1 2 3 4 Total Under 5 5 to 9 Etc. All causes — total (Detailed list of causes of death) This table supplements table XXVIII. and indicates the age periods wherein most of the deaths occur from each of the causes. These two tables will serve to formulate the gen- eral policy of the department in its attack on the more important diseases and conditions. They both cover the city as a whole. • TABLE XXX. Number of deaths from principal diseases in wards during 192- Cause of Death Total City Ward 1 Ward 2 Etc. All causes of death (Then abridged list of causes of death) This table shows the wards in which the problems outlined in the previous two tables may be more profitably attacked. TABLE XXXI. Number of deaths from principal diseases, by calendar months Cause of Death Total Year Jan. Feb. Mar. Apr. May Etc. All causes — total (Then abridged list of causes of death) This table will direct the attention of the health officer to the months of the year in which more of the preventable diseases cause death. Campaigns of control may thus be prepared and instituted prior to the period of highest incidence. 252 Hospital and Health Survey TABLE XXXII. Deaths and death rates per 100,000, by sex and by age, 1920 MALES FEMALES AGE Population Deaths D. R. Per 100,000 Population Deaths D. R. Per 100,000 All ages.. Under 1 1 to 4 5 to 9 10 to 14 : 15 to 19 20 to 24 25 to 34 ! 35 to 44 45 to 54 ... 55 to 64 65 to 74 75 and over. This table is intended for use only in census years and points out the conditions of mortality in each sex in the various age periods of life. Its greatest use will consist in giving the basis for the construction of decennial life tables. TABLE XXXIII. -A, B, C, Etc. Deaths and death rates per 100,000, from certain diseases,* by wards or sanitary districts, for years 1915 to 1919 192— 1915-1919 Ward Deaths Death Rate Deaths Death Rate Total city Ward 1 « Ward 2 Etc | •Typhoid, tuberculosis, measles, scarlet fever, whooping cough or other diseases. Table XXXIII. is one of a series, each one relating to a cause of death, such as typhoid fever, tuberculosis, whooping cough, measles, scarlet fever, diarrhea and enteritis, automobile accidents and, in fact, any other condition which is subject to the control of the health authorities. The figures indicate the number of deaths annually and the death rate in each one of the several wards of the city. Comparison with the five-year period, 1915 to 1919, makes it possible to determine the effectiveness of the control against the diseases in each of the several wards. Appendix 253 TABLE XXXIV. Number of deaths of persons in specified color, nativity and parentage classes, by sex and age Color, Nativity, Parentage All Ages Under 1 Under 5 Total — Male... Female White— total Male Female Native-born — Male Female of native parentage — Male Female of foreign and mixed par- entage — Male Female Foreign-born — Male Female Colored — total Male Female Negroes — Male Female Other Colored — Male Female This table will be most useful for census years, although it should be available for intercensal years as well as a reference table. Coupled with the data available in the census publications, it will make possible the construction of life tables for each one of the chief classes of population. 254 Hospital and Health Survey TABLE XXXV. Cases and deaths from notifiable diseases, by wards or sanitary areas, 192 — Total City Ward 1 Ward 2 Disease Cases Deaths Cases Deaths Cases Deaths Etc. Typhoid fever Etc. This table should be available not only annually but for shorter periods, perhaps monthly, and certainly quarterly. It indicates where the notifiable diseases are prevalent and shows also from the relation of cases to deaths how serious the cases. An additional column may be added to show the lethal rate for each one of the diseases. TABLE XXXVI.-A, B, C,* Etc. Cases of notifiable disease in each ward or sanitary area, by calendar month, 192 — * Year Total Year Jan. Feb. Mar. Apr. May Etc. Total... _ Ward 1 Ward 2 Etc. *One table for each disease Table XXXVI. supplements table XXXV. and indicates the seasonal distribution of the several notifiable diseases in each ward. This is an annual table. TABLE XXXVII. Number of marriages and divorces and rate per 1,000 of population by month Marriages Divorces Month Number Rate per 1,000 of Population Number Rate per 1,000 of Population Year January February March April May June July _ August September October November December Appendix 255 TABLE XXXVIII. Number of marriages by age of groom and bride Age of Bride Age of Groom All ages Under 20 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to. 59 60 to 64 65 to 69 70 to 74 75 to 79 80 to over All ages Under 20.... 20 to 24 25 to 29 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 and over TABLE XXXIX. Results of Medical Examinations of Children in Institutions Capacity Cleveland P. O. Asylum 68 St. Joseph's Orphan Asylum 236 Cleveland Christian Orphanage ^ 46 House of the Holy Family 37 Detention Home 104 Jewish Infant Orphan Asylum 72 Jewish Orphan Asylum 473 Mount St. Mary's 152 St. Ann's Infant Asylum-. 100 St. John's Orphanage 20 Jones Home 75 St. Vincent's Orphan Asylum 236 House of the Good Shepherd 185 Salvation Army Rescue Home 17 Children's Aid Society 103 Holy Ghost Orphanage 14 Girl's Farm 42 Training School for Friendless Girls 30 Catherine Horstmann Home 22 Children Examined Found Normal to have one or more defects 22 1 21 41 1 40 9 1 8 10 10 16 16 12 12 74 3 71 25 1 24 15 1 14 6 3 3 12 1 11 38 38 34 34 4 4 24 2 22 4 4 10 10 9 9 6 6 Total Institutions — 19. 2,032 371 14 357 JO -on 1E40X snoaueipostj^ O IH rH VO o oo © CO CTl ID CTi VO O rH O CO o ct. o O O rH CM O VO CM n to in CO rH tH snoAja^ oipadoqiJQ O l-H o o o o O CO o o o o O CM o o o O -I o O H O o o o o mCTi'tf-rH©' , 3-fom ,H ri-HeMCMCo©co o o o o o o * n h CO O i-H i-t r-f © H- CO O CO o o l-H l-H l-H O O CM rH CTl © VO CM ^t" rH l-H CTi CTl H H i-H VO o H/ O N 1^ o o CTl O CM CM VO O l-H O CO rH i-H l-H O O o o o rH O O l-H TH H N 9 O O © O l-H O CM O lO O in o vo o oo o m rH VO rH <*■ o t> CM O O © o vo o CM O VO CM o o o O O rH O rH © o o o O CM rH rH rH CM rH CM rH rH CM rH y-< rH O O O rH CM O O CO o o o o o O O o •* rH © rH CM CM m vo m CO rH rH CM > I §1 o •*h ji aw O t> CO c ca (X a 3 6 > *-) > rj aj . u o s J3 « O .S3 K .S H .5 J3 U CO H O Appendix 257 No. of Institutions Overcrowding '. — 6 Building not screened 3 Sexes not separated 2 No play ground 1 TABLE XLI. Sanitary Summary Inadequate fire protection 12 No fire drills 9 Improper fire escapes -- 8 No regular fire drills.. .— - 8 Fire extinguishers unfit... 4 Obstructed fire escapes.... — 2 No fire extinguishers — - 1 Children, two in a bed 7 Improperly placed beds.. — 4 Improper bed springs..... 3 Wooden beds. — 2 Unclean bed linen 1 Clothing used in common — 2 Donated clothing used without first washing it — - 1 Soap used in common 18 Common roller towel.. 9 Individual towels and wash cloths not provided - 8 Individual combs and hair brushes not provided. - — 8 Inadequate lavatory and toilet facili- ties... - — - 7 Unsanitary toilets — 4 Inadequate bathing facilities... 4 Several children bathed simultaneously in same tub 3 Common toilets for both sexes — 2 Dirty wash basins - 2 No drinking fountains '. 9 Common drinking cups 8 Leaky plumbing 5 Enclosed plumbing - 2 Inadequate light in classrooms 8 Inadequate light in toilets — 3 Inadequate light in playrooms 2 Poor ventilation in toilets 11 Poor ventilation in other rooms 8 Unventilated closets.. — 2 Poor ventilation in schoolroom 1 Poor ventilation in playroom 1 Improper refrigeration of food 7 Worn oilcloth on dining room tables. 4 Kitchen tables not zinc covered 4 Unguarded laundry and other machin- ery. Dry sweeping - 6 Defective plastering - - 4 Defective flooring.. 4 Backless benches used in classroom 5 Unsanitary school desks 2 258 Hospital and Health Survey TABLE XLII. SUMMARY OF PHYSICAL EXAMINATION OF BOARDED-OUT CHILDREN Total number examined — 57. Normal — 4. Defective — 53. o £ , "5 j« '2 "5 "5 E j=> .2 « S ™ u O 3 to 3 t. u >KH!SfflH 2 U 0, O £ 7 28 29 24 26 3 3 20 Miscellaneous Defects Cervical Glands..... _ 23 Conjunctivitis 1 Ringworm 1 Enlarged Thyroid 2 Adenoids.... 1 Epitrochlear Glands 1 29 The sanitary conditions in these boarding homes were not included in this study. 29 THE CLEVELAND HOSPITAL AND HEALTH SURVEY REPORT List of Parts and Titles I. Introduction. General Environment. Sanitation. II. Public Health Services. Private Health Agencies. III. A Program for Child Health. IV. Tuberculosis. V. Venereal Disease. VI. Mental Diseases and Mental Deficiency. VII. Industrial Medical Service. Women and Industry. Children and Industry. VIH. Education and Practice in Medicine, Dentistry, Pharmacy. IX. Nursing. X. Hospitals and Dispensaries. XI. Method of Survey. Bibliography of Surveys. Index. The complete set may be obtained at a cost of $5.50 plus the postage and single parts at 50 cents each plus the postage, from THE CLEVELAND HOSPITAL COUNCIL, 308 Anisfield Building, Cleveland, Ohio Printed by The Pbemibr Presb Cleveland, O. A Program for Child Health Part Three Cleveland Hospital and Healtn Survey Copyright, 1920 by The Cleveland Hospital Council Cleveland, Ohio Published by The Cleveland Hospital Council 308 Anisfield Bldg. Cleveland - Ohio Preface The Hospital and Health Survey of Cleveland was made at the request of the Cleveland Hospital Council. The T Survey Committee appointed to be directly responsible for the work' and through whose hands this report has been received for publica- tion consisted of the following: Malcolm L. McBride, Chairman; Mrs. Alfred A. Brewster, Thomas Coughlin, Richard F. Grant, Samuel H. Halle, Otto Miller, Dr. H. L. Rockwood, Howell Wright, Secretary The staff responsible for the work were: Haven Emerson, M. D., Director and the following collaborators: Gertrude E. Sturges, M. D., Assistant Director; Michael M. Davis, Ph. D., Director of the Hospital and Dispensary Survey; Josephine Goldmark, A. M., Director of the Nursing Survey; Wade Wright, M. D., Director of the Industrial Hygiene Survey; S. Josephine Baker., M. D., D. P. H., Director of the Infant and Maternity Survey; T. W. Salmon, M. D., Director of the Mental Hygiene Survey; W. F. Snow, M. D., Director of the Venereal Disease Survey; Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey. The expenses of the Survey and of the publication of the report have been met by appropriations received from the Community Chest, through the Welfare Federation, of which the Hospital Council is a member. The report as a whole, or by sections, can be obtained from the Cleveland Hospital Council. A list of the parts will be found in the back of this volume, together with prices. TABLE OF CONTENTS Page I. Present Organization 267 II. The Problem 269 III. Proposed Organization ..... 270 IV. Functional Activities Prenatal Care.. 273 Maternity Care 275 Infant Care 280 Pre-School Age Care 284 Child-caring Institutions _____ 287 Children's Dispensaries 288 Schools Health Supervision . 288 Sanitary Supervision _ 297 Recommendations ___ 301 Issuance of Work Certificates 318 V. Conclusions _ 319 A Program for Child Health Work in Cleveland By Josephine Bakes, M. D., D. P. H. "The aim of hygiene in general is to render growth more perfect, decay less rapid, death more remote and life more vigorous and suc- cessful." IN presenting a program for future child health work in Cleveland, it has been considered essential, first, to analyze the work as it is carried on at the present time; second, to discuss certain basic needs, and third, to suggest measures that should be instituted to obtain more effective results. Present Organization The survey has emphasized the lack of strong central control and effec- tive coordination of the activities for child welfare as a whole. Public and private agencies are, in many instances, carrying on service of excellent quality and distinct merit, but these activities are limited in extent and, with one possible exception (the hospital maternity service) they are inade- quate to meet the self-evident needs of the child population of Cleveland. The lack of coordination by each agency with other agencies or as part of the child health program of the community, and the absence of a definite program for continuous, adequate and progressive action, are detrimental to the full effectiveness of each group. Some of the children of Cleveland are receiving at certain periods of their growth a type of care that is excel- lent and should be commended, but the unrelated functions of the various child hygiene activities have left children as a whole without that con- tinuous oversight which alone can guarantee the type of good health that will serve throughout life. With the exception of the prenatal work and certain parts of the work carried on in the prophylactic baby-health stations, the Survey would seem to show that there is lack of preventive health functions. Emphasis has been placed on corrective work and there is too great a tendency to view the immediate results as justifying or proving the effectiveness of the *For the collection of the information from which this report was prepared the author is indebted to many of her colleagues, and their assistants, in the other subjects of the Survey. The author wishes to express her appreciation particularly for the studies contributed by Gertrude Sturges, M. D., Michael Davis, Ph. D., Anna Richardson, M. D., Miss Josephine Goldmark, Miss Elizabeth Fox, Miss Janet Geister and Miss Florence V. Ball. L 268 Hospital and Health Survey methods employed. Intensive effects often unconsciously interfere with proper perspective. Extreme specialization has, in some instances, resulted in too great concentration upon the activity and not enough upon the child as a whole. Treating disease is essential. Removing diseased tonsils and filling decayed teeth are important activities, but the full fruition of normal and sound health cannot be achieved by these methods alone, however well they may be performed. The admirable work that is being carried out should receive its full measure of praise. On the other hand, we cannot ignore the fact that the present facilities are inadequate in extent, that in some instances they are not functioning effectively, and that the lack of unity of purpose and central control has resulted in markedly lessening the results that might reasonably be expected from the amount of effort that has been put into the work as it is carried on at the present time. There are two fundamental bases for effective child-hygiene work in any community: First — Object: Prevention of disease is the first consideration, with such corrective health measures as may be necessary to assure a normal physique during childhood and sound health throughout adult life. Second — Method: Continuous coordination and effective health super- vision from the prenatal period through adolescence, by means of public and private community provision of all essential educational and health aids, including health instruction, supervision and care of the indi- vidual mother and child. Cleveland's problem does not differ from that of other communities in this regard. Mention should be made of the efforts which are directed toward meeting the situation. Praise should be given to the four great features of Cleveland's child-caring program: (1) The prenatal and maternity services for expectant mothers, originating in the work of the Maternity Hospital, and now shared in by other hospital and nursing agencies; (2) The Babies' Dispensary, which serves the whole city in the diagnosis and treat- ment of the ills of infancy; (3) The prophylactic baby health stations of the Division of Health, which serve by teaching mothers how to keep well babies well; (4) The system of school medical inspection, under the Board of Edu- cation. A creditable infant mortality rate and a widespread public interest in the necessity for correction of physical defects and the resources for main- taining children's health are the logical results of these activities. It is evident, however, that there are many gaps in the continuity of an effec- tive health program for children. There is not only lack of coordination in the work of the agencies in the field but, in many instances, there are insufficient equipment and personnel to meet existing needs in a manner at all adequate. A Program for Child Health 269 The Problem Concretely, the problem in Cleveland may be outlined as follows: 1. There are approximately 240,000 children in Cleveland under sixteen years of age. 2. There were 19,123 registered births in Cleveland during 1919. Con- servatively estimated, fifty per cent or ten thousand of these mothers require medical and nursing supervision and care, at the expense of the community, during their prenatal period and at time of confinement, and an equal number of babies need care during the period of infancy. It is estimated that the remaining fifty per cent are able to obtain the essential care through individual effort, although a relatively small pro- portion of the latter group actually receive what is recognized as ade- quate prenatal care. 3. On the basis of an estimation of approximately twenty thousand children in each year age-group under five years, it is probable that there are about sixty thousand children between two and five years of age in Cleve- land. From experience with this age-group in other cities, it is esti- mated that at least thirty thousand of these children need the type of health supervision they can obtain only through concerted action of community forces. 4. To the number of children attending the public schools (103,273, not including students in Senior High Schools) should b*e added the full number in attendance at the other free schools in the city (35,000, in the parochial schools), whether under denominational or other control. In its expen- diture for and interest in the welfare of its children, Cleveland should not discriminate in its bounty. All children of school age should receive equal advantages and have equal opportunity for the best type of health care. 5. Children of whatever age who, through no volition on their part, are deprived of home care, should be placed in other homes as wards of the city, or should be given proper care in modern, well-equipped and ade- quately maintained day nurseries or resident institutions. These children are entitled to the same kind of health supervision that is considered essential for all children. 6. The adolescent child is entitled to adequate protection from exploitation in industry. The period of adolescence is one of extreme importance 270 Hospital and Health Survey from the health standpoint. This is particularly true of girls, and for individual sound health and future welfare of the race, there should be stringent regulations from the health point of view for the protection of all children during this hazardous period of life. Proposed Organization The outstanding need for effective child-hygiene work in Cleveland at the present time is proper organization of existing facilities of public and private agencies and the public departments. In order that this may be made effective, there must be (1) central control; (2) proper coordination. At the present time the community as a whole expresses itself in health matters through the Division of Health and through the health control of children of school age provided by the Board of Education. Even within the public departments there is divided control, but among the private and semi-public agencies this division is more sharply marked. It is neither necessary nor wise for private agencies to sacrifice their individuality in any way or to become part of the public work except as it may be thought wise from time to time for the public to assume certain types of child-hygiene effort that now are being carried on by private associations. It is essential, however, that there should be some coordinating force and some form of central organization among the private agencies so that they may function completely with the public departments in the most effective manner. /. CENTRAL CHILD HYGIENE COUNCIL As part of the general health organization of private and public agencies, there should be a Central Child Hygiene Council. This Council should have a membership consisting of a representative from each private or public agency dealing with any phase of child health supervision. To facilitate administrative procedure, such a council should be divided into functional groups, each having in its membership one person representing each agency in its class. Each group or subdivision should elect a chairman, such chairmen to form the execu- tive committee of the Central Child Hygiene Council. In turn, the executive committee should elect their own chairman and should have at their disposal a paid, full-time executive secretary as the executive officer of the Section on Child Hygiene of the proposed Cleveland Public Health Association. The Central Child Hygiene Council should — /. Coordinate the work of all public and private agencies, promot- ing effective cooperation while preserving the integrity of each unit. 2. Provide for an equitable distribution of functional activity to (a) meet existing needs. (&) prevent duplication of effort. A Program for Child Health 271 C^ H g-. 3 g»< 5 3 "3.5 O p — 5- o cr* en O s- ft s 3 ^ B h A < w 5 2 B. I 5' ° 3 i g: *- S 3" 3 ■o 3 — 3 O s n n 3 o 3 a- sr 3 ^< n ■5 3 12 O o O fl> 3 on ernil pital 3 a w ^ a B O 2 n o 3 3 3 3" 3 D. B n b 3 n < rr •a a 3 tra 3 n "0 n3 n 3 8 3 2 g "t p 3 2. S. n n 5' s O o 3 p IK 0_ 3 3 rt 3 3- 3 n 3 O rt B O B a ■a n I 3 ■< 3- < B a ■a n of o 3 * 3 sr c a n B 3 q ■a 3 1 O 3 3" v." < § B < m to t» o s n o B o 3" O C 3 P n a TJ 3 a" sr 2. i 3" B n T3 *< jq < 10 o s n W 3" 3 rt 3 sr D rt 3 c 1X3 O B n n i in 3 ft n =T SI 3 ■< W a. . o 2 n 13 2. 3 3 3 "* 3 rt 3 3" D >< » 5 3 n 3- < "S % ft a 3 3 g> 3 2 o o 3 P« ft .? 3 3 3 1 ■< (A ST re n C/5 o rt 5' o g 3. o 3 3. ft ro ft (t 3 3 3 B m o c r* Ch cecuti n < 2. fD O CD 3 3 ft) p r+ y O 3 Ht 60 -, o c 3. S 2, o' o °S 3 „ 3 fD fD ^ fD 13 o CD o •-t era p CO i— i . 13 n era CD n o c o 272 Hospital and Health Survei (c) attain uniform methods of procedure. (d) extend the functions to cover all parts of the city and provide the needed health supervision for each part. 3. Provide for each type of child hygiene work in each of the health zones* or districts as established by the Division of Health. 4. Maintain a central clearing house to (a) receive and tabulate all essential statistics on child welfare work; (6) act as intermediary and communicating link between the functional groups, unless (a) is provided for as suggested in the chapter on "Vital Statistics within the Division of Health." (Part II.) 5. Stimulate public opinion to obtain adequate appropriations for child health work under the Division of Health and the Board of Education. 6. Act in an advisory capacity and as a closely cooperative group to the city government to promote effective public health work for children. 2. PUBLIC DEPARTMENTS The Division of Health and the Board of Education should provide for closer cooperation with each other and with the private child hygiene agencies. This may be done by — /. The appointment by the respective public departments of a representative, preferably the Director of the Department of School Medical Inspection of the Board of Education and the Director of the Bureau of Child Hygiene of the Division of Health, to serve as a cooperative and coordinating committee to act on all matters pertaining to child health which concern the work of both departments, such as — (a) Supervision and control of communicable diseases in children. (6) Sanitation and hygiene of school buildings and the homes of school children. (c) Supervision of the health of children of pre-school age. 2. The appointment by these departments of appropriate represen- tatives to serve on the committees of the Central Child Hygiene Council. The above type of organization will provide for strong central represen- tation from the Division of Health and the Board of Education, and a strong * Throughout this report the term "zone" will be used to designate that division, census area or health district that may be decided upon as the unit for health work. These zones or districts should have definite boundaries, which may comprise one or more sanitary areas, and it is recommended that such zones be the unit for all health work. A Program for Child Health 273 central body representing all private agencies, with the machinery so arranged that these public departments and private agencies shall function harmoniously and without waste of effort. Such a type of organization will not only provide for covering the territory as far as present facilities admit, but also will call attention to existing needs, provide a way for extension of types of work already organized, and the institution of new kinds of work that are essential for continued, well-rounded child care. Functional Activities Prenatal Care Present Status and Needs: The object of prenatal care in Cleveland should be to provide adequate instruction, supervision and health care during the prenatal period for approximately fifty per cent of all pregnant women, estimated at ten thousand. About thirty-five per cent of all deaths under one year of age occur during the first month of life. Statistics obtainable from many cities show that this death rate under one month may be reduced one-half or even two-thirds by proper prenatal supervision. Provision for such prenatal care in Cleveland would mean that from three hundred to four hundred baby lives would be saved each year. Present Provision for Prenatal Care in Cleveland: During 1919, 2,848 prospective mothers received prenatal care under the auspices of four institutions through nine organized centers. This work is of good quality. In addition, the Visiting Nurse Association and a number of nurses from the Division of Health gave prenatal advice to all pregnant women with whom they came into contact. The latter service undoubtedly gives good results, but it would seem that all pregnant women should have the advantage also of the type of service rendered by the prenatal clinics. In addition to the care provided for 2,848 mothers in 1919, it is evident that Cleveland should make provision for prenatal care for at least seven thousand more prospective mothers annually. A study of the records of 442 mothers receiving prenatal care in the University district, where the baby death rate was found to be much higher than the rate for the city as a whole showed that, even under such circum- stances, it was possible to reduce the mortality rate among babies under one month of age to 24.8 per thousand births, as compared with the city rate of 31.4 per thousand births, as a result of prenatal care. If results like these can be obtained in a district where the racial, social and economic condi- tions are such as to result ordinarily in an unusually high baby death rate, it is quite evident that far better results might be expected if provision for prenatal care could be extended to all pregnant women of the city who otherwise would be without such supervision. By extending this service, 274 Hospital and Health Survey Cleveland could not only actually save from three hundred to four hundred baby lives a year but the death rate among mothers from accidents and diseases at time of confinement could be reduced materially. What can be accomplished in this regard may be seen from the figures given out by the Maternity Center Association of New York City, which show that among 502 women supervised during their pregnant periods and receiving proper care at time of confinement, there was only one death. Maternal mortality Tanks second highest in the list of causes of death among women between fifteen and forty-five years of age in the United States, being exceeded only by tuberculosis. Reduction in the death rate of mothers and babies as a result of prenatal care can be effected with mathematical certainty. It is simply a question of providing the type of care that has already been recog- nized and standardized. Reduction of the still-birth rate in the University District from 28 per thousand births for the city as a whole to 20.4 per thousand births among the prenatal cases, and reduction in the death rate from puerperal sepsis from four per thousand births for the city as a whole to 1.4 per thousand births for the cases having prenatal care also warrants favorable comment. It must be remembered, however, that this reduction applies only to a limited group of pregnant women, i. e., 2,848 of a total of 19,123 registered births in 1919. It shows what may be done and makes it clearly evident that Cleveland needs three times the facilities for prenatal care that she has^at present. RECOMMEND A TIONS 1. It seems evident that the Division of Health cannot at present secure the neces- sary funds to carry on a city-wide service in prenatal care. Ultimately, this work should be one of the functions of the Bureau of Child Hygiene, paid for by ap- propriation of city funds. Until this can be accomplished, however, the respon- sibility must rest upon private initiative and should be carried on by private agencies. 2. It is suggested that a Committee on Prenatal Care of the Central Child Hygiene Council be composed as follows: (a) An obstetrician or other representative from each hospital or other institution having an obstetrical service under the direc- tion of a specialist in obstetrics, either in the hospital or at the patient's home. (b) A member of the Academy, Committee on Public Health.' (c) A representative of the nursing staffs of the University District and the Visiting Nurse Association. (f the Division of Health to see how many had been registered. The following results were obtained: Total for 1918 1919 1920 1918-19-20 128 429 57 614 82 267 34 383 Total for 1919 1920 1918-19-20 451 77 669 362 46 522 Total number of birth records investigated.. Total number found registered.... Percentage of birth records investigated found registered 64% 62% 59.5% 62% These results, with 55 additional, were checked over carefully, looking under every possible date and spelling. As a result of this re-investigation, the following results were obtained: 1918 Total number of birth records investigated... 141 Total number found registered 104 Percentage of birth records investigated found registered 74% ' 80.2% 59% 78% In addition, a list of baptisms from various churches of the city were looked up, with the following results: Pilgrim Trinity St. Paul's 2d Presb. Total Total number of birth records in- vestigated 25 28 11 3 67 Total number found registered... 22 24 8 3 57 Percentage of birth records investi- gated found registered 88% 86% 73% 100% 85% These investigations would seem to show that not over eighty per cent of the births occurring in Cleveland are reported to and registered by the Bureau of Vital Statistics of the Division of Health. Xo action is being taken by the Division of Health against persons who fail to report births, nor is there any evidence that proper measures are being taken to check up birth registration. A beginning has been made toward requiring a birth certificate as evidence of age for school enrollment. Failure to report births seems to be common both to physicians and midwives. Analysis was made of one hundred deaths under two years of age, which showed that physi- A Program for Child Health 277 cians had failed to report 39.2% of the births which had occurred under their supervision, and midwives had failed to report 47% of the births attended by them. 3. Midwives: It is estimated that there are one hundred and sixty licensed and one hundred and ten unlicensed midwives in Cleveland. It is evident that the regulations of the State Medical Board of Ohio are such that midwives are practically barred from obtaining licenses in Cleveland at the present time. During 1919-1920 only two midwives received licenses to practise. The type of supervision given to midwives who are practising is inadequate, amounting to an average of less than one call a year upon each midwife during 1919. It is evident, also, that midwives are allowed to practise without being licensed. 4-. Relative Number of Births Reported by Midwives and by Physicians: During the past five years, of the total number of registered births, from 55.5% in 1913-14 to 65% in 1918-19, were reported by physicians, and from 44.5% in 1913-14 to 33.9% in 1918-19 were reported by mid- wives. From this it is apparent that, while the practice of midwives is decreasing, it still is of sufficient extent to warrant attention, serving as it did in 1919, 5,903 pregnant women. It is evident that, notwithstanding the extensive hospital and out-patient maternity services, there is a large proportion of women in Cleveland who prefer the services of midwives at the time of confinement. This experience is common in all cities having a large alien population. The great majority of these women accept the midwife in the traditional manner. Neither they nor their families have ever known any other type of attendant at birth. In addition, among certain foreign groups, the husbands of the women are prejudiced against having men in attendance at the time of confinement. There can be no doubt that, from the point of view of the patient, the midwife fills a social need. There is no evidence to show that midwives can be eliminated by outlining regulations of so stringent a character, as a requisite for a license to practise midwifery, that no midwife can possibly comply with them. There is, furthermore, a serious inconsistency in any type of administration which allows unlicensed and untrained midwives to practise, but refuses to recog- nize the graduates of such schools as that maintained by the City of New York, or graduates of the high types of schools that are maintained in Eng- land. In fact, the regulations now in force in the City of Cleveland would bar not only graduates of the best schools in this country but those of the great majority of the European schools. The regular course in midwifery schools in England covers a period of six months, in New York City eight months, while on the Continent the average course is from twelve to eighteen months. To require a two years' course in midwifery, therefore, is pro- hibitive. It is appalling to think of the results of a system of midwifery L 278 Hospital and Health Survey control which, by its inherent qualities, systematically ignores the dangerous results that may come from allowing ignorant, untrained women to prac- tise midwifery without supervision or instruction. 5. Prevention of Blindness: Excellent results have been obtained from the follow-up of cases of ophthalmia neonatorum. It is stated that only one case of blindness due to gonococcal infection has occurred among children born in Cleveland during the past five years. RECOMMEND A TIONS 1. Committee Formation: In order to provide for the right distribution of the present hospital facili- ties for maternity care throughout the city, there should be an Obstetrical Coun- cil or a Committee on Maternity Care of the Central Child Hygiene Council, such committee to consist of (a) An obstetrician or other representative from each of the mater- nity hospitals. (6) A representative of the Bureau of Child Hygiene of the Division of Health. (c) A representative of the Visiting Nurse Association. The functions of this committee might well be served by the committee on prenatal care as outlined above, page 274. 2. Birth Registration: (a) Adequate birth registration is absolutely essential as a basis for effective child hygiene work. It is essential to know how many babies are born, their race, sex and residence. The Division of Health should take whatever steps may be necessary to give Cleveland as nearly one hundred per cent birth registration as is humanly possible. This may be done by 1 . Investigating deaths of babies under six months of age to deter- mine whether the births were registered. 2. Receiving reports of names, addresses, dates and places of birth of all babies registered at the health centers and investigating same with reference to birth registration. 3. Returning a copy of the birth certificate to the mother of each baby whose birth is recorded. 4. Prosecuting all physicians, midwives and others who fail to report births as required by law. (6) In order to make the statistics of births available as a basis of work, facilities should be afforded for analysis of these records, by zones, so that any information regarding distribution or other questions connected with the birth rate may be available immediately to persons interested in child welfare work. For further details see chapter on Vital Statistics, Part II. A Program for Child Health 279 3. Hospital Facilities: The present provision for beds for maternity cases seems adequate, and when the out-patient maternity services also are considered, it is deemed inadvisable to recommend any extension of free maternity bed service at the present time. There are, however, methods which might be employed to make this service a more integral part of the child health program. These are that (a) Each hospital providing maternity service should assume respon- sibility for certain zones and for the care of all women needing and desiring free obstetrical care who reside in such zones. It should be agreed that patients residing in other zones will not be taken by any hospital other than that responsible for the zone in question, unless by special arrangement in each case with the hospital or institution in charge of the zone in which the patient resides. (b) All patients who register in advance should be referred to the prenatal clinics for proper supervision. (c) Standard forms of record-keeping and compilation of statistics as outlined by the Committee on Maternity Care should be used. (d) All mothers after confinement should be referred to the health centers. This can be done by using a duplicate card, one sec- tion to be given to the mother, referring her to the health center or prophylactic baby health station in the zone in which she lives, the other to be sent to the executive secretary of the Cen- tral Child Hygiene Council, who will refer it to the indicated health center. If the mother does not appear at the center within twenty-four hours, a nurse should visit her at her home to induce her to register. Whenever a mother is referred to a health center, the essential points in the history of the case and the feeding and care of the baby should be forwarded by the hospital or other institution to the health center. (e) Extension of the out-patient service in zones where the hos- pital facilities are inadequate. (f) Extension of the work of the Visiting Nurse Association to give proper obstetrical nursing for the out-patient service in all zones. 4. Suggested Program for the Control of Midwifery: (a) Regulations for the control of midwifery should be amended so that the graduates of reputable midwifery schools of recog- 'iSO Hospital and Health Survet nized standard, which maintain courses of not less than six months' duration, may be admitted to practise, after passing the necessary state examinations. All midwives who are unable to qualify under such a system of regulation should be denied the right to practise, and should be prosecuted if they attempt to. (6) The present midwifery law should be amended so that it will not be retroactive from the date of its first enforcement. Mid- wives who were already practising when the law became effective should be granted licenses to continue, by virtue of their having practised before. Reasonable and adequate but not unattain- able standards should be drawn up for midwives who, in future, may apply for permits to practi s e. The rules and regulations governing the practice of midwifery should be enforced rigor- ously, and any midwife who is found not to have complied with such rules and regulations should be prosecuted. If found guilty, her license should be revoked. By this method a gradual elimination of unfit midwives can be accomplished in a manner that will protect the interests of the community and of the mothers, and at the same time solve the problem of the present incongruous situation in Cleveland, whereby unlicensed mid- wives are permitted to practise but are not kept under proper supervision. (c) A system of supervision should be inaugurated at once, under the Division of Health, Bureau of Child Hygiene, whereby as part of the work of the health centers midwives will be kept under constant and continuous supervision. They should be encouraged to improve the methods of their practice, should be taught how to attain a safe, decent technic and, as far as possible, the actual type of work performed by them should be known by having nurses attend cases with them and keep them, under constant supervision. Midwives should be required to keep records of all cases attended by them and should be held strictly accountable for adherence to the rules. The rules and regulations governing the practice of midwifery in New York City and in New York State will serve as useful examples of practical measures which can be and are being enforced. Infant Care Present Status and Needs: Infant care in Cleveland is carried on under the control of the Bureau of Child Hygiene of the Division of Health, through fourteen health centers. In eight of these centers work for the control of tuberculosis, supervision A Program for Child Health 281 of contagious diseases, including eye conditions and nursing inspection of children of the parochial schools, also are provided for. In two of the centers venereal disease work also is carried on. 1. It is estimated that there are in Cleveland at least twenty thousand children under two years of age who should have the type of health super- vision which their parents are unable to obtain for them without community help. 2. The health centers are well distributed throughout the city but, owing to the widely scattered population in certain areas and consequent dis- tances to be traveled by the mothers, they do not cover the field of needed infant care. 3. The medical work in these health centers is of the five types enu- merated above. It is controlled by the heads of three bureaus of the Division of Health — the Bureau of Tuberculosis, the Bureau of Communicable Dis- eases, and the Bureau of Child Hygiene. *The nurses in the health centers carry on what is known as "generalized" nursing; that is, they divide their time among all the functions that are served by the centers. From the point of view of the efficiency of the infant welfare service, this type of nursing would seem to be unfortunate. The proportion of time given to infant care at the centers is wholly inadequate. 4. Administrative work and office duties by the nurses occupy too great a proportion of their time. On a basis of one hundred hours of service for the nurses at the health centers, 41.9% of this time was found to be devoted to office duties. This disproportion of service works to the detriment of the regular nursing functions, and may account in great measure for the neglect of the proper follow-up work among babies. 5. Not enough nurses are assigned to duty at each center to care ade- quately for the functions placed under their supervision. Each nurse has too many patients under her care. Reference to the chapter on Nursing Service, Part IX, will show that each nurse has approximately three hundred cases to care for, including two hundred babies. This is greatly in excess of the maximum that can be supervised effectively. A study of the records at the Health Centers shows that an average of .4 visits is paid each baby each month; that is, each baby is visited about once in every two to two and a half months. One in every nine babies comes to the clinic once during the month. It is evident from a study of individual record cards and of the various reports on nursing service in this Survey that home visits to babies are neglected, that there is little attempt to check up regularity of attendance, to give proper and necessary home supervision, or to see that delinquent cases are brought back to the centers. It is evident that too great reliance is placed upon distribution of milk as a bait to draw mothers to the centers. While this may account in great measure for the fairly ade- quate attendance, it in no way compensates for the loss that is apparent in the lack of proper teaching of hygiene in the home and supervision of the baby's environment. * The information concerning the scope, character, excellencies and defects of the nursing service- in the Division of Health and the schools, used in this report, was obtained from the reports of the investi- gators who collaborated under Miss Josephine Goldmark's direction in the preparation of the chapter on Nursing Service in Cleveland, Part IX. Hospital and Health Survey 6. There is no organized method of referring cases to the health centers. Outgoing mothers and babies from maternity hospitals are not referred to the centers, and there is no apparent recognition of the value of enlisting the cooperation of midwives in referring babies born under their care, a type of case which is particularly in need of such supervision. 7. Infant feeding by artificial means has been developed to a high standard of efficiency, but statistical evidence would seem to show that too great emphasis is placed on methods of artificial or substitute feeding, with consequent apparent neglect of the importance of breast feeding. Three separate studies which were made of babies under the care of the health centers, show that the number of babies breast fed varied from 29 to 60 per cent. There is indisputable evidence available to the effect that ninety- five per cent of all women can nurse their babies. As a measure for the reduction of infant mortality, encouragement of breast feeding is probably of greater importance than most highly developed methods of substitute feeding. 8. While specific criticism of the many and varied types of work required of the nurses may not be advisable, in view of the determined policy to carry on generalized nursing service, there is evidence that infant hygiene work, both at the health centers and in the homes, is neglected. The nursing reports show that home visits are too infrequent and irregular, and from the records it appears that nursing care (to infants) is rarely given, and then very inadequately. Owing to the many duties which the nurse is called upon to assume and the large number of patients under her control, follow- up visits to babies in their homes, and the supervision necessary to see that the babies are brought to the clinics regularly, have been so far neglected that in a considerable proportion of instances it was found that the babies had not been seen for periods of from two to three months, and that there was no record as to what had become of them during that time. Such neglect leads to the inference that preventive health work for infants has been relegated to a place of minor importance. Such a result may reason- ably be expected when the nurses are required to attend to so many kinds of work which, by their very nature, are of more emergent type. It is quite natural that in any combined medical or nursing work the corrective or emergent cases will be given precedence. Without underrating the impor- tance of contagious disease and tuberculosis supervision, venereal disease control or school inspection, attention may well be called to the inequality of the prophylactic work for babies which, by its nature, is non-emergent in character, but which is of the utmost importance in any effective public health program which has for its object a reduction of infant sickness and death. While medical advice can be given in an adequate manner at the health centers, the value of the nurses' work is more clearly shown in their home visits. Only in that way can they be sure that the proper routine is being- carried out, that the directions of the doctor are being obeyed and that the mother not only understands but actually puts into effect the essential methods of babv care. The baby's immediate environment is its mother, A Program for Child Health 283 but its home surroundings are only slightly less remote in degree, con- sequently the many factors of hygiene and sanitation which have so direct an effect upon the lives of infants can be adjusted and controlled only if the nurses make systematic and regular home visits. If the administrative experiment in so-called "generalized" public health nursing is to be con- tinued, as for some reasons appears desirable, radical change in the organiza- tion, distribution and supervision of the nurses' work must be undertaken promptly. 9. There is no agency in Cleveland for supplying wet nurses. The use of wet nurses is recognized as an important factor in saving the lives of young babies. Breast feeding plays such an important part in the pre- vention of infant sickness and death that provision for some opportunity for obtaining the services of wet nurses is a recognized part of the community program for the reduction of infant morbidity and mortality. RECOMMENDA TIONS 1. A Committee on Infant Care should be formed as part of the Central Child Hygiene Council. This committee should consist of (a) A representative from the Bureau of Child Hygiene of the Divi- sion of Health. (6) A representative of the Visiting Nurse Association. (c) A representative of the Babies' Dispensary. (d) A representative of the hospitals providing special maternity services. (e) A representative of the Committee on Prenatal Care. 2. The Division of Health should extend its health centers, particularly those devoted wholly to preventive health work for infants. If it is not possible at the present time to establish more of these health centers, the minimum require- ment should be at least one center in each zone, with sufficient nurses attached so that home visits may be made to the families of all infants who need such attention and who live at too great distances from the centers to attend regu- larly. 3. Each center should be furnished each day with a list of names and ad- dresses of all babies whose births were reported from the indicated zone on the previous day. Each such case should be visited and the mother urged to attend the center. If she is unable to do this, she should be kept under observation by the visiting nurse. 4. The personnel of the staff at each health center should be increased. With the present distribution and types of work, each nurse should have under her supervision not more than one hundred cases. If it is impossible to increase 284 Hospital and Health Survey the staff at the present time, attention should be directed immediately toward relieving the nurses of the greater part of their office duties. Clerks should be employed for this purpose, and the nurses should devote their entire time to nursing work. 5. It is essential for effective work that the number of home visits to babies should be increased and that these home visits should be carried out with reg- ularity. 6. More emphasis should be placed upon the general education of the mother in methods of proper baby care, in addition to the question of feeding. 7. Increased attention should be paid to the necessity for breast feeding. Methods of restoring lactation and encouraging mothers to continue to nurse their infants should be insisted upon more vigorously than they are at the present time. Every effort should be made to increase the relative proportion of breast feeding among infants in attendance at the health centers. 8. Efforts should be made through the committees of the Central Child Hygiene Council to obtain effective cooperation from other agencies. Coopera- tion should be maintained with the prenatal clinics and maternity hospitals in obtaining histories of all cases cared for by them who afterward are referred to the baby clinics of the health centers. 9. Babies should not be discharged from control of the health centers when they reach the age of two years. 10. Health centers should extend their functions to include care of the child of preschool age. For discussion of this question, reference is made to the discussion of "Preschool age Care," which follows. 11. There should be established at each health center a wet nurse registry. This should be maintained in cooperation with the Committee on Maternity care of the Central Child Hygiene Council. Effort should be made also to obtain the cooperation of midwives in this regard. Mothers whose babies have died should be asked to register as wet nurses. Each woman so registered should receive a thorough physical examination, including a Wassermann test. The facilities of this wet nurse registry should be open to all physicians of the city. Pre-School Age Care Present Status and Needs: 1. Statistics of the United States Census Bureau show that eighty per cent of all deaths from contagious diseases occur under five years of age. Less reliable morbidity statistics would seem to indicate that from eighty- five to ninety per cent of all cases of contagious diseases occur in children A Program for Child Health 285 under five years of age. Examination of children of this age group has re- vealed the presence of physical defects in greater proportion than in the ten to fifteen-year-age group. Studies of the relative occurrence of physical defects show that practically all of them can be prevented or at least cor- rected in their early stages during the pre-school age period. 2. Facilities for the health supervision of children of pre-school age in Cleveland are almost wholly lacking. There are seven day nurseries in Cleveland, five of which — the Mather, Louise, Lend-a-hand, Perkins and Wade — are branches of the Cleveland Day Nursery and Free Kindergarten Association. One — Merrick House — is conducted in connection with that settlement house, and the other — Joseph & Feiss — by that industrial plant for the children of its employes. The aggregate service provided by these day nurseries in 1919 was 47,085 child days, and the daily average attend- ance was 184.75 children. It may thus be seen that the day nurseries of Cleveland are caring for less than two hundred children daily out of an estimated child population of sixty thousand between two and five years of age. 3. It is estimated that fifty per cent of the children between two and five years of age, a total of thirty thousand, are probably without any health supervision. 4. This neglect of supervision of the child of pre-school age is the greatest gap in the continuity of Cleveland's child-health program. The importance of caring for this age-group cannot be overestimated. RECOMMEND A TIONS Immediate steps should be taken to provide the necessary facilities for health supervision of children of pre-school age. It is recommended that this be done through the health centers as a continuation of the work of infant care. It is realized that the pre-school age bears a very intimate relation not only to the period of infancy but also to the period of school life. It may well be considered, therefore, whether the school should be responsible for the care of the pre-school age child, or whether this should be considered simply an extension of the period of infancy. Logically, the school should consider that the pre-school age bears the same relation to the school age as the prenatal period bears to infancy, and, theoretically, it should be the duty of the school authorities to see that children of pre-school age are so cared for and their health so supervised that they will be in sound physical condition when they enter school. From a practical view- point, however, such a course seems inexpedient at the present time. It is probable that money appropriated for school purposes could not be used for the benefit of children who have not yet reached the legal school age. While it is possible, of course, that private funds to establish clinics for children of pre-school age in connection with the service of school medical inspection in the public and parochial schools may be obtained, it seems at the present time that the need would be most completely served by considering the supervision of children of pre-school age one of the functions of the health centers, under the Division of Health. "286 Hospital and Health Survey Such service should be carried on as follows: 1. Children who, as infants, have been under the care of the health centers, up to two years of age, should not be discharged from observation at the end of that time but should be continued on register as preschool age cases. 2. The personnel of the health centers should be increased to pro- vide sufficient doctors and nurses to give the necessary supervision to children of pre-school age. 3. Close cooperation should be maintained with hospitals, day nur- series, the Board of Education, social service agencies and other sources so that children between two and five years of age may be referred to the health centers for health supervision. 4. Each child of pre-school age should receive a physical examination at least once every six months and after any acute illness. If pos- sible, the service should be extended so that examinations may be made every three months. Every case, whether considered nor- mal or abnormal, should be placed under the supervision of the nurse and visits should be made to the child's home at frequent intervals so that environment may be adjusted, the hygiene of its daily life regulated and all possible prophylactic and early corrective measures taken to insure prevention of disease and future sound health for the child. 5. In connection with the dental clinics, a system of oral hygiene should be maintained, and all children of pre-school age should receive the advantage of this service. It has been proved definitely that proper methods of oral hygiene, begun in early childhood, have a more definite and lasting effect in preserving the teeth than any future corrective work can possibly accomplish. Moreover, the cost of proper oral hygiene is only a fraction of the cost of corrective dental work. To be effective, oral hygiene should be commenced before the child's second teeth have begun to appear, and certainly well in advance of the appearance of the first permanent teeth — the sixth year molars. 6. In the pre-school age clinics facilities should be provided for performing Schick tests on all children and for giving toxin- antitoxin injections for immunization of proved susceptibles against diphtheria. The period before five years of age is the time when natural immunity to diphtheria is at its lowest and when the death rate from this disease is at its highest point. There is little doubt that A Program for Child Health 287 this disease could be largely, if not entirely, eliminated if Schick tests and toxin -antitoxin immunizations of non-immune children could be carried out throughout the entire child population under five years of age. Child-Caring Institutions Present Status and Needs: There are in Cleveland nineteen children's institutions with a capacity of 2,032 children. In addition, about 800 more children, under the super- vision of the Humane Society, are provided for in boarding homes and in free homes where they have the status of adopted members of the family. A medical survey of these institutions gave the following results: 1. Only three out of a total of nineteen institutions investigated have an entrance physical examination. 2. Only three have an admission quarantine to prevent new entrants from bringing contagion into the institution. 3. Eleven have ample isolation facilities; eight have not. 4. Thirteen have adequate hospital facilities, while six have inadequate facilities, or none at all. 5. Not a single institution of the nineteen investigated conducts a periodic physical re-examination. 6. Thirteen of the homes have hospital and dispensary affiliations, while six maintain no relationships of this nature. 7. Children are allowed as visitors in seventeen of the institutions investigated. In only two is this practice prohibited. A sanitary survey of these institutions showed a great variety of inade- quacies of equipment and insanitary conditions prevailing (For details see chapter in "Child-Caring Institutions," Part II.). RECOMMENDA TIONS 1. The licensing of all child-caring institutions and their regular and ade- quate inspection and supervision by the municipal government should be pro- vided for through the Division of Health. 2. Extension is advised of the boarding-out system in private homes, under compe- tent supervision. Homes offering to receive children to board should not be allowed to do so before having received permits fcr the purpose, such permits to be issued by the Division of Health. Permit holders should be kept under close supervision and the per- mits revoked if any negligence is found at any time. As rapidly as possible provision should be made so that every mentally normal child who cannot otherwise receive home care may be placed in a properly licensed private home, under adequate supervision, and such child should receive, either through the pre-school age facilities of the health cen- 288 Hospital and Health Survey ters or through the school medical inspection of the public and parochial schools, the same type of effective health supervision that is given to children whose parents are alive and able to provide for them. Children's Dispensaries A detailed statement of existing facilities, the needs to be met and the remedies proposed, will be found in the chapter oh "Dispensaries," Part X. School Health Supervision Present Status and Needs: School health supervision in Cleveland must be considered from two angles: school medical inspection in parochial schools, and school medical inspection in public schools. School Medical Inspection in Parochial Schools: There are about 35,000 children attending the parochial schools in Cleveland. The authorities of these schools provide no medical or nursing care or health education, either in the school or in the home. In March, 1917, nurses of the Division of Health were assigned to duty in seventeen parochial schools. In 1919-1920 this work was carried on in twenty-one parochial schools. Records seem to show that 9,323 pupils in these schools received a physical examination. Notices were sent to the parents and some effort was made to follow up the children found to have defects. No records are available to show what percentage of defects the nurses had corrected. During the school year 1919-1920 the total number of parochial schools, sixty-eight in number, with a registration of ap- proximately 35,000 pupils, were placed under the supervision of these nurses. As the staff of field nurses averages only about fifty and as they have their work at the health centers in addition to this work in the parochial schools, it was impossible for them to carry out any system' of school health supervision in the parochial schools that could be considered at all adequate. One observation was made in each classroom to discover evidences of contagious diseases. Visits were made once a week to each school and a certain amount of absentee visiting is recorded. No provision for the assignment of doctors to this work has been made. It is evident that the work is not well organized or at all extensive and in no sense can it be considered an adequate system of health supervision of the children in the schools in question. School Medical Inspection in Public Schools: Services dealing with health in the public schools in Cleveland are carried out through four distinct groups: (1) a Department of Medical Inspection under the control of a Direc- tor who is on part-time; (2) physical education, under control of a Director; (3) health education, without any organized or central direction, and (4) sanitary supervision, under the Director of Buildings. The Directors of the Departments of Medical Inspection and Physical Education report to an Assistant Superintendent of Schools, while the Director of Buildings is under the control of the Director of Schools or chief of the service department for the Board of A Program for Child Health 289 Education. It may thus be seen that there is divided responsibility for the health of the school children, and that at present there is no coordinated program of such type that the work may be considered effective. More specific consideration may be given to these matters as follows: /. Medical Inspection: This department is organized with a director, who is responsible, through an assistant superintendent, to the Superintendent of Schools. The following groups of employes and functions come under the supervision of the director of this department: (a) Medical inspectors, staff nurses, field nurses and junior health workers. (b) Clinics: Dental clinics and eye clinics. (c) Special Classes: Classes for the blind, school for the deaf, school for crip- pled children, classes for mental defectives, open air classes, classes for tuberculous children. (d) Issuance of work permits. (e) Advisory capacity at preventorium (Children's Fresh Air Camp) and the Boys' Farm at Hudson. Medical Inspectors: There were at the time of this investigation twenty-one school inspectors with a total registration, in the elementary schools and junior highs, of 103,272 for 1919-1920. This allows one medical inspector to each five thousand pupils. These inspectors give part time, or from 9 a. m. to noon five days a week. The qualifications for this position have not been standardized, other than that a degree in medicine is required. The director inter- views the candidates personally and uses his judgment as to the applicants' suitability for the work. The chief incentive of many of the force is interest in the work rather than the salary paid, which is low. Each inspector is responsible directly to the director, as there is no assistant director. Each follows a schedule which has been prepared at the central office and provides for a visit by a doctor or nurse to each school practically every day. The inspector may not visit each school assigned him oftener than one to three times a week, as each doctor has from six to nine schools under his supervision. At these school visits the doctor's routine is as follows: 1. Inspection of all children who have been selected and referred by the teachers as possible cases of illness. 2. Routine physical examination of pupils. The physical examination is in reality an inspection. It seems to be fairly competent as far as examina- tion of teeth, tonsils and eyes is concerned, but the rest of the examination is casual and hurried, and heart, lungs, joints, musculature and hearing are examined only in special instances. Children are not undressed, nor are height and weight recorded. Apparently no investigation is made as to the health habits of the children, nor is any advice in general health habits given at the time of the medical inspection. It is evident that the so-called "physical examination" of the children is of a superficial type and that it cannot be considered either thorough or satisfactory. In fact, it does not warrant the name "physical examination," for in many "290 Hospital and Health Survey instances it seems to amount to little more than a casual inspection, cer- tainly not thorough enough to discover physical defects except those of the most obvious types. Plans are under way to adopt the recommendation of the Survey to improve radically this department. School Nurses: There are about thirty school nurses and each has under her supervision approxi- mately three thousand school children. School nurses have the following duties: 1. To assist the medical inspectors in the physical examination of children. 2. To inspect all pupils, by rooms. This is done usually after the summer, Christmas and Easter vacations, when the children are inspected, a roomful at a time, by the doctor and nurse for signs of communicable diseases. Once a month the nurses make similar inspections, devoting from seven to ten minutes to an entire roomful of children. 3. To secure correction of physical defects found in the physical examina- tions by means of (a) Notices and messages to parents. (b) Consultations with parents at the schools. (c) Visits to homes. 4. To maintain a dispensary hour in each school for treatments, dressings, emergencies and inspection of children returning to school after exclusion. 5. To give health talks to individual pupils and to classes in classrooms. 1. Assisting the Doctors in Physical Examinations: • In assisting the doctors in physical examination of school children, the work of the nurses is distinctly clerical in character. A large proportion of her time is thus taken from strictly nursing duties and the results obtained do not justify the use of nurses for the purpose. 2. Inspection of Pupils in Classrooms: The nurses spend an entire hour or more each school day making classroom inspection s of the children for the purpose of detecting communicable diseases. On account of the preoccupation of the nurses with other duties, even this necessarily superficial inspection can be repeated only at intervals of about four weeks. In the intervals the teachers must be relied upon to notice symptoms and refer children to the nurses for proper care. 3. Correction of Physical Defects: In Cleveland at present much time is given to finding defects and recommending treatment; little time is given to seeing that those defects are remedied and the child's mode of living and home surroundings are improved. Reliance is placed largely on the sending of notification to the parents and having parents' consultations at school. The correction of physical defects and the elimination of those home, school and personal environmental conditions which may cause physical defects are among the most impor- tant activities of the school nurses, yet at the present time the unsatisfactory results of the methods used are apparent from the report of the Department of Medical Inspection for the school year 1917-1918, where it is shown that although 32,918 children were found to have physical defects, only 38.1% of these are reported as having been corrected. It is, moreover, striking to note that, according to the table of defects found and corrected, A Program for Child Health 291 corrections were almost all of the most obvious defects — those of teeth, tonsils and eyes — while those defects listed as anemia, scoliosis, poor nutrition, defects of the extremities, chorea, chest defects, discharging nose, cardiac disease, goitre and discharging ears — a total of 1,213 cases — showed only five corrected. For the 32,918 children found defec- tive, the nurses had only 6,397 consultations with parents, with possible duplications included in this number, and made only 9,010 visits to the homes, thus visiting fewer than one out of every three defective children found. This small number should be in part ascribed to the fact that the nurses assisted in a very large number of vaccinations dur- ing the year, over 45,000 as against approximately 16,000 in the next year. The figures contained in the report of the Department of Medical Inspection for 1918-1919 show an improvement in the correction of defects; 32,747 defects were found and 14,295 or 43.6% were corrected. It is clearly evident that the essential follow-up work to obtain proper care and treatment for these children is almost wholly lacking. It is of no practical value to discover physical defects in children simply for the gathering of statistical data. The true test of efficiency in the matter of preventing and correcting physical defects in children is not the number found but the number which receive proper medical and health care. It is evident that neglect of this important work is due to the use of the nurses in so many other duties and to the fact that, with the limited staff, there is little time left for making home visits. An important innovation in the field of preventive medicine and remedy of physical defects has been made in the schools of Cleveland following the demonstration of success in the schools of Akron, Ohio; namely, the detection and abatement of enlarged thyroid glands among the girls of 10 years and over. The detection is simple, by direct inspection supplemented by palpation to verify the presence of the residual stalk and the central body as well as the lateral lobes. Enlargement is found in about 80% of the girls of 10 years and over, unless they have had specific treatment under their family physician. The reduction of the glandular enlargement to normal size is easily accomplished by the use of small doses of iodide of soda in aqueous solution for a week or ten days in the fal 1 and in the spring of the year until the age of 16. The advice is given on a printed slip as follows: Division of Medical Inspection and Physical Education BOARD OF EDUCATION, CLEVELAND, OHIO To the Parents of Bearer: Cleveland is located in a goiterous district. About one-third of our girls in the public schools above the age of ten years have some degree of enlargement of their thyroid glands or simple goiter. The expenditure of a trifling sum yearly will prevent this affection. Three grains of Iodide of Soda taken in a glass of water once a day for ten days in the fall and again in the spring will prevent goiter. This treatment should be carried out yearly between the ages of 11 and 16 years. Director, Medical Inspection Department. TAKE THIS HOME 292 Hospital and Health Survey That surgical treatment, nutritional, circulatory, nervous and cosmetic defects are thus avoided for these children in the future by such corrective medicinal treatment can hardly be doubted. The inconvenience of residence in the goiterous region on the great glacial plateau is easily remedied by an intelligent application of the facts established by physiological research. The school children of Cleveland owe much to the studies made in this field by Dr. Marine in particular and by others whose contributions to science in the field of physiological chemistry, clinical medicine and physiology have built up the facts upon which education and specific treatment are now based. 4. Maintenance of Dispensary Hour at Each School: Nearly half the nurse's time is spent in dispensary work. This consists in assisting the doctor in his physical examinations, inspecting children and doing emergency dress- ings and treatments. This seems to be a high percentage of time for this work, and a great part of it is not properly part of the nurse's duties or of the school health service. The use of nurses for this clerical work absorbs a large proportion of their time and takes them away from their essential school duties. The treatment of minor illnesses and injuries takes a great deal of time and should properly be carried out at dispensaries located out- side the school buildings. The use of nurses for this work for practically half the day reduces the efficiency of the school health work to a marked degree. 5. Health Talks to Individual Pupils and to Classes in Classrooms: While the nurses are supposed to give individual health talks to the pupils, it is evi- dent that the dispensary work is so hurried as to render this impossible. As a general rule, the talks given are of a very hasty and superficial character, and it is doubtful whether they make any very lasting impression upon the children. In addition, the fact that the talk is given to the child in school and not made the subject of a follow-up visit to the home, where also the parent or guardian may be talked to, would seem to render these talks of but little value. As to the health talks to classes in classrooms, there is always a difference of opinion as to whether they should be given by people who know how to teach but who are not necessarily experts in the subject matter, or by persons who are experts in the subject matter but who do not know how to teach. It would seem as though nurses generally come under the latter classification. In the talks on health subjects given by the nurses in the classrooms, a wide variation of ability is shown. Some of the nurses are quite competent to teach the subject, while others, although knowing their subject well, do not know how to teach. The present unstandardized, ungraded and unsystematic methods tend to diminish the value of these talks. Field Nurses: Supervising nurses in Cleveland are called "field nurses." The spirit, intentions and desires are excellent and their ideas seem to be good. There are, however, too few of them to enable them to visit the staff or school nurses at sufficiently frequent intervals. Because of the unusual outside demands made on these nurses during the past year, the present average of visits was only two in a year. Last year several of the school nurses were not visited at all by the field nurses. It is evident that the question of proper supervision is not clearly understood and this is one of the most serious weak- nesses in the system. The results are evident in the nurses' work, which has tended to become routine in character, often lacking in originality, in vision, in social spirit and in A Program for Child Health 293 grasp of opportunity. These nurses are performing their duties conscientiously, but without imagination. It is felt that their work could be improved if more time could be devoted to their supervision. Junior Health Workers: These employes, of a type which seems unique to the city of Cleveland, are giving excellent results. They are well educated women of an unusually high type, and have relieved the nurses of much routine work, in attending the doctor during physical examina- tions, in making efforts to obtain correction for dental defects, and taking children to dispensaries. These junior health workers are paid one hundred dollars per month. They are not under civil service regulations but are, in general, women of excellent training, college graduates, and their opportunities could be increased and their sphere of usefulness greatly extended with resultant advantage to the system. Clinical Facilities: There are certain clinical facilities available in the schools: 1. Emergency treatment in the dispensaries. 2. Dental clinics. These are held in six schools for half of each school day. The work is mainly on first and second grade children. Older children are sent to their own dentists or to the dental college clinic. 3. Eye clinics. There are two eye clinics, one on the east side at Brownell School and the other on the west side. In addition, there is a trachoma clinic in the Murray Hill School. Nose, throat, ear, skin and orthopedic cases are sent to private phy- sicians, hospitals or clinics. Facilities for dentistry and the treatment of abnormal eye conditions are inadequate. In this respect, however, Cleveland is as well equipped as most cities in the country. The value of dental clinics, particularly for prophylactic work and oral hygiene, has not been widely recognized in the past. Plans have been made by the Department of Medical Inspection to increase greatly this branch of the work during the coming year by the appointment of capable assistants to the school dentists and by training them as dental hygienists. Also, there can be no criticism of the maintenance of special clinics for the treatment of trachoma. The Department lacks the services of an oculist to guide policies and supervise trachoma work. That is a contagious disease and its elimination is dis- tinctly a function of the city authorities. Special Classes: 1. Open Air Classes. There are nineteen fresh air rooms in various schools, caring for about two hundred and seventy pupils. In some districts the fresh air classes can take care of practically all applicants, but, in general, there are always more pupils than can be accommodated. These classes care for anemic and sickly children and those exposed to tuberculosis. Even limiting the attendance to cases of these types, it is clearly evident that the present fresh air classes are wholly inadequate to care for the chil- dren who are in urgent need of this type of care. Admission to these classes is decided upon by the doctors and nurses who go through the classes and, with the cooperation of the teachers, pick out 294 Hospital and Health Survey children who are considered to need this kind of treatment. The children selected include those who are lagging and are not doing well and those who come from home with insufficient food. Each child receives a com- plete physical examination before admission to the class. Underweight and malnutrition are considered to be sufficiently evident, without weigh- ing, as scales are not provided by the Board of Education. The health routine in the fresh air classes is under the control of the Direc- tor of the Department of School Medical Inspection. This official does not appoint the teachers, however, but acts in an advisory capacity to them. The nurse takes the temperature of the children in these rooms twice a month. If the temperature is over ninety-nine degrees in any case, she takes it every day until it returns to normal. She tries to have the chil- dren weighed once a month. A loss of two and a half pounds is reported to the doctor. All possible efforts are made to have physical defects cor- rected. As far as possible, these children have a rest period of at least twenty minutes during the noon hour and additional rest periods are provided for individual pupils when, in the judgment of the school doctor, such rest is deemed necessary. Cots are provided by the Board of Education for these rest periods. Physical exercise for these children includes only light gymnastics and games, with much emphasis on deep breathing. Children in the open air classes receive a lunch twice a day, consisting of milk, cocoa, graham crackers, furnished by the Federated Women's Clubs and the Board of Education jointly. 2. School for the Deaf. One school for the deaf is maintained. In this school seventeen teachers care for about two hundred and fifty pupils. Children are referred to the school by the school doctors when they find cases of markedly defective hearing. Children with slight defects of this kind or whose defects are under treatment usually are kept in their regular classes. The present facilities would seem to be adequate, both in quality and in their provision for the number of children needing this kind of care. 3 . Classes for the Blind. There are classes for the blind in twelve different schools. The Department of School Medical Inspection selects the chil- dren for these classes. In addition, a number of sight-saving classes are maintained. A child is sent to a sight-saving class when it is felt that the ordinary routine of school work would damage its eyesight. These chil- dren receive a complete physical examination. Routine inspection is also made in these classes. It would seem that the provisions for caring for this class of cases are adequate. 4. School for Crippled Children. While a special school for crippled children is maintained, there is always a waiting list for entrance and the authori- ties have recognized the need for increasing the facilities. Children are referred to this school by the medical inspectors. Canvass is made also of all schools in the city for children who should receive this type of treat- ment. Busses are provided by the Board of Education for transporting A Program for Child Health 295 these children to and from their homes and to and from the dispensaries. It is evident that the facilities are inadequate and that this work should be extended. It is planned to build a new school especially adapted to the needs of these children. 5. Classes for Correction of Speech Defects. Eighty-one classes for correction of speech defects, with an enrollment of 1,182 pupils, are maintained. Pro- vision for the correction of these defects by class instruction seems to be adequate. 6. Nutrition Classes. Special nutrition classes have been established in two schools. However, the work applies only to a small number of pupils and is intensive in character. As is well known, the causes of undernourish- ment are many and complex, and intensive work, taking each child indi- vidually and giving it unusual care, undoubtedly gives the best results. At the same time, it must be remembered that undernourishment is one of the most extensive and serious diseases met with during child life. The statistics for many cities and for the country at large show that twenty to twenty-five per cent of the children of school age suffer from some degree of malnutrition. It is stated that plans are under way for extension of the special nutrition work throughout the schools. 7. Provision for Mental Hygiene. Thirty schools have classes for mentally defective children. This subject is dealt with in the special report on Mental Hygiene, Part VI. 8. Cardiac Classes. There is no provision for children with cardiac disease. The need of special provision for the cardiac child in and out of school is described in the chapter dealing with this problem, Part II. School Dispensaries: Each school is provided with a so-called "dispensary" where emergency treatments are given for minor injuries or ailments. In these school dispensaries, emphasis is laid upon corrective rather than upon preventive health work or health education. Conferences: Doctors meet every two weeks with the Director of the Department. At these meet- ings papers on the Schick test, goitre, contagious diseases and so forth, are read and discussed. The nurses meet each week. The whole group meets from time to time for special lectures. To help the nurses special courses are given, tuition free, at the Summer Session of the Normal School. Health Records: The health records of the children are deficient. Neither the nurses nor the doctors keep these records filled in properly and many of the cards do not show the essential points which would be of value in determining the type of health care the child needs. At the present time the cards do not seem to serve any useful purpose. Such records, however, should be one of the most important features of a well-organized system of school health supervision. A cumulative record card, having on it the social history, physical examina- tion and follow-up, is being prepared by a committee of the Department of School Medical Inspection. The child's individual record is kept in the classroom. It is very brief and 296 Hospital and Health Survey tells little of what has been done for the child. The doctor's orders are entered on this card, but the work done by the nurse is usually, although not always, entered on the cor- rection slip in her file. Home visits are recorded on still another card, so that any effort to check the nurse's accomplishment against the doctor's recommendations is almost hopeless. The individual health records of the children are kept on the teacher's desk. They are suppesed to keep the teacher informed of the children's physical condition. These records follow the children from class to class, together with the school records. The teachers seem uninterested, however, because nothing appears on these records that would give them a clear idea of the children's physical condition. The nurses have a habit of using the ordinary correction slips for making notes of home visits. This method is extremely bad, as it does not make for permanency and there is absolutely no way in which such records can be made the basis of analysis of work done and results obtained. The absence of monthly reports of the work of the nurses is also a factor in making it difficult to show what she has actually accomplished. It is doubtful whether any of the nurses have any idea of the amount of work they do every month and the amount that is left undone because of the number of children handled. Neglect of Statistics in Regard to Physical Defects. In common with most systems of school medical inspection, particular emphasis is laid upon the number of defects found and the number corrected. In this regard, how- ever, the records of Cleveland are not complete. It is evident that results obtained in cases of physical defects are not recorded on many of the cards. It is impossible, there- fore, to state the actual percentage of corrections obtained. Of two hundred cards studied it was found that 15.2 % of the defects found were recorded as corrected. The report of the Department of School Medical Inspection, however, states that 38.1% of the defects found were corrected. This discrepancy is obviously due to incompleteness in the records as available to the investigator. Supervision of Control of Communicable Diseases! Although minor complaints have been recorded about the failure of nurses to take cultures in cases of sore throat, there is no evidence to show that the doctors and nurses of the Department of Medical Inspection are not carrying on the work with reference to the control of communicable diseases in a satisfactory manner. There seems to be good cooperation between the Department of School Medical Inspection of the. Board of Edu- cation and the Division of Health in this particular and the present regulations, if enforced, are adequate to protect the children and the public. 2. Physical Training: The Department of Physical Training has charge of the physical training of children, their exercise and athletics. In addition*, it makes a certain number of physical examina- tions of children in the junior high schools and in the high schools. There is no definite cooperation or coordination of this work with the Department of School Medical Inspec- tion. Plans are under way for the coordination of these two departments. School medical inspection, as it is commonly understood, does not exist in the high schools. It is stated that all pupils, before they are admitted to the physical training classes in the high schools and junior high schools are examined by the teachers of physical training. This examination covers heart, lungs, eyes, back, weight, etc. It is stated, however, A Program for Child Health 297 that not nearly all the girls have been examined. The elementary school health records do not follow the children into the junior high schools or the high schools; therefore they are not used by the Department of Physical Training. 3. Health Education: At the present time this work is carried on in the following ways: (a) Through occasional classroom talks on health topics given by nurses of the Department of School Medical Inspection. (b) Through individual instruction of the children in the schools by physi- cians and nurses of the Department of School Medical Inspection. (c) Through instruction by the nurses, in the seventh and eighth grades, on the subject of care of babies. (d) The curriculum in the grammar grades provides for two forty-minute periods a week in physiology and hygiene. No material is provided the teachers for giving this course. (e) There is instruction in the high schools in physiology, botany, cooking, chemistry, social problems and physical training. These courses, except physical training, are elective. In actual practice, according to conferences held with various teachers and principals little or no work in hygiene is carried out in the elementary schools. The whole matter depends upon the initiative of the individual teachers. In the seventh and eighth grades an outline has been provided, but the teachers are not obliged to follow it, and in the cases of the teachers with whom the matter was discussed, very little of it had been used. Many of the principals and teachers stated that they are eager to have definite material furnished them from which a course in child hygiene could be given. In the high schools, the work of health education, while claimed to be thorough, does not seem to be standardized. It is stated that points on personal hygiene and sanitation are covered more by chance than premeditation, that correlation between the teaching departments is weak, and that it is difficult to tell how much overlapping of courses exists. The general feeling among the teachers seemed to be that there is great need for a standardized hygiene outline — some- thing systematic, clear and concise. Examination of Teachers: Each teacher's contract contains a requirement that she shall receive a physical ex- amination. The Director of the Department of School Medical Inspection stated that the teachers and custodians had a thorough physical examination two years ago, given partly by the school physicians and partly by outside physicians of the city. He stated also that no examination has been made of is contemplated of other employees of the Board of Education, but that, in his opinion, such a procedure would be desirable and that there should be a physical examination of teachers at least every year. 4. Sanitary Supervision: Sanitary supervision in the schools is primarily under the Department of Buildings. This department is directly responsible to the Director of Schools or the Chief of the Serv- vice Department of the Board of Education. The actual work is carried out by a group of employes known as "custodians," who are responsible to the supervising custodians, who, in turn, report directly to the Director of Buildings. Various sanitary standards for 298 Hospital and Health Survey sweeping, dusting, care of water closets and drinking fountains, provision of soap and towels, control of temperature and ventilation of classrooms, have been outlined by the Board of Education. The Director of Buildings states that the supervising custodians try to make sanitary inspections of the schools twice a month, and that some buildings which give a good deal of trouble are visited more frequently. (a) Ventilation: While the operation of the ventilating systems is placed under the control of the custodians, the law of the state determines the type of ventilation that must be used. It is stated that there are old-fashioned gravity heat and open window ventilation in sixty to seventy schools. There is shut window, forced draft ventilation, which is the policy of the department in all new plants, in fifteen to twenty schools. Not more than eight or ten schools have provision for humidification. One school has air washers. When the mechanically operated systems are working the windows in the schools cannot be opened without interfering with the ventilating systems. Open Window vs. Mechanical Methods of Ventilation. Proof is available that children in open air classrooms or children in classrooms ventilated by open windows will increase in weight and strength, that conditions of undernourishment may be overcome and sound health re-established and that respiratory diseases may be prevented if children receive the advantages of such care. In view of these established facts, it is difficult to under- stand why fresh air in abundance, by means of open window ventilation, is not made available in all classrooms. From the economic point of view, the establishment of open window ventilation is not only possible but desirable. Official statements have been made that the cost of any school building in Cleveland will average $30,000.00 per class- room. It has been stated by sanitary engineers that the cost of installing heating and ventilating plants in school buildings amounts to fifteen per cent of the cost of construc- tion. The main objection that has been raised against the open window system of ventila- tion is the increased amount of heat required and the consequent expense for additional fuel. It may be estimated that the approximate cost of the ventilating plant is seven and a half per cent of the total cost of construction of the building. If the cost of each class room is $30,000.00, it may be seen that, in addition to the ordinary appropriations for fuel, there would be a sum amounting to $2,250.00, available for extra fuel before the total cost of the classroom ventilated by open window ventilation would reach the estimated cost of the room ventilated by artificial means. From the point of view of health, open window classrooms are essential. The cost is not excessive and in all probability it is not greater than the present cost of school maintenance. (6) General Construction. The regulations governing general construction of classrooms require that sixteen square feet of floor space be allowed for each child. The color of the walls and ceilings is a standard soft gray. Maple flooring is required to be used in new classrooms, and tiles in corridors. In new buildings these regulations have been complied with, but they are not common in old buildings. (c) Temperature. Each classroom is supposed to be equipped with a thermometer, but no provision has been made for systematic testing of the thermometers, and the reporting of variations of temperatures is very generally left to the principals. A temperature of sixty-five to sixty- A Program for Child Health 299 eight degrees is recommended. In many instances investigated, however, the temperature was found to be distinctly above this standard. Upon inspection in various schools the temperature was found to be as follows: Total Number of Temperature Classrooms Per Cent Under 70 degrees F. 14 20.9 70 degrees F. 19 28.3 71 degrees F. 2 2.9 72 degrees F. 11 16.4 73 degrees F. 7 10.4 74 degrees F. 11 16.4 75 degrees F. 1 1.5 76 degrees F. 2 2.9 Total- 67 Outside temperature was forty -five degrees F. when forty-three of these temperatures were recorded, forty-nine degrees F. when three were read, forty-three degrees F. when nine were read, twenty-nine degrees F. when seven were read and thirty-eight degrees F. when five were read. Principals, nurses, physicians and custodians interviewed seemed more or less inter- ested in the temperature, reporting that "they looked at the thermometer when in the room," but no regular inspection of the thermometers in the rooms was found to be provided for. Responsibility for the temperature of the room seems to lie between the teacher and the custodian, and is a more or less constant source of friction. (d) Lighting: The state law requires that the relation of window space to floor area in classrooms shall be as 5 to 21. In the construction of new buildings, rooms are lighted from the left or from the left and rear. Window shades are of a new standard type, matching the indoor paint. Plans are in preparation for improving the lighting of rooms now in- adequately lighted. In rooms where the lighting is artificial, the system is semi-indirect, allowing six hundred watts per room with two candle power on desks. (e) Seating: While seating adjustments in classrooms are taken care of by the custodians at the request of the principals, inspections and requests for special adjustments are supposed to be made both by teachers and by the Department of School Medical Inspection. About fifty per cent of the schools are equipped with adjustable seats. Forty per cent of these schools have what are known as "shifting" classes, so that the seats are not continuously occupied by the same pupils. 300 Hospital and Health Survey (f) Cubic Air Capacity: The state law covers the distribution of cubic air capacity and floor space. The number of children allowed in a room about 24 x 28 is now forty-two (eighteen square feet per capita). The ordinary system of ventilation allows for changing the air in these class- rooms six times per hour. This change of air is recorded by a meter which is checked up by the Department of Buildings. Inspection of the proper functioning of the ventilating system, to check up the required number of changes of air per hour, is made by the super- vising custodians. (g) Blackboards: In new schools blackboards are generally adjusted in height according to the age of the child. These adjustments have not been completed, however, and at the present time a number of schools still need to have their blackboards replaced at the proper heights. (A) Cleaning: Definite rules are given to the custodians with regard to sweeping, dusting, window- washing, scrubbing, etc. Thorough inspections as to cleaning are made in September, at Christmas and in the spring. The custodians are supposed to visit classrooms at least once a month, and more often if conditions warrant. Five or six schools are equipped with vacuum cleaning systems. (i) Drinking Facilities: All schools are equipped with drinking fountains, but not every school has as many fountains as the number of children requires. Practically all these fountains are located in basements. They are of standard type, with pressure jet. In the type of fountain used, the flow of water through the outlets can be regulated to the water pressure, but in many cases the fountains investigated did not have sufficient force to obviate the danger of com- municating disease. In some of the fountains seen the force was scarcely sufficient to carry the water over the side of the nozzle. The greatest force in any fountain seen was only sufficient to raise a stream about two and one-half inches. All fountains seen were vertical in type. Some had a continuous stream, while in others it was necessary to turn on the water. It was impossible to place any responsibility for the control of the condi- tion of these fountains, although the matter of adjustment of the proper functioning of the fountains as to pressure and cleanliness is supposed to be left to the custodian of the building. Summary of Drinking Fountains Inspected Per Cent 12.7 8.4 22.6 16.9 7.0 11.3 7.0 14.0 71 99.9 Number Inspected Height of Water 9 Practically no force 6 Min. 16 Kin. 12 Min. 5 1 in. 8 iy 2 m. 5 2 in. 10 2 Min. A Program for Child Health 301 It will be seen that only twenty-one per cent, or about one-fifth, of all the fountains had a force of two inches or over, which the Department of Buildings gave as the standard to be achieved, and certainly desirable in the interest of health protection. (j) Toilets: One toilet is allowed for each fifteen girls and one for each twenty-five boys. The number now provided is below the standard required by the state law. Inspection of the toilets is made by the Department of School Medical Inspection once a month, and some physicians also stated that they made periodic investigations. Other physicians stated that they had no responsibility in the matter. No report of conditions found is registered unless complaint is made. Unsatisfactory conditions are reported either to the custodian, the principal or to the Department of School Medical Inspection. RECOMMEND A TIONS School Medical Inspection in Parochial and Private Schools: Parochial Schools: Provision should be made, either in the budget of the Division of Health or through private contribution, for immediate extension of the school medical inspection service to all parochial school children in the city of Cleveland. There are now about thirty-five thousand children in attend- ance at these schools. If the city cannot appropriate sufficient funds at the present time, it would be very desirable if the parochial school authorities could undertake the work themselves, but, ultimately, it should be carried on by the Division of Health. It is evident that the type of health supervision which has been shown to be so essential for children in the public schools must be equally essential and desirable for children in the other free schools of the city. Their needs in this respect should no longer be neglected, nor should there be any discrimination practised in the matter of health supervision against any group of children who are receiving instruction in any schools. Private Schools: In discussing the question of health of school children, a point has arisen which may not be considered within the scope of this particular inquiry, nevertheless, as the health of all children of the city of Cleveland must be considered in any adequate program for child hygiene, it is recommended that rules and regulations be drawn up by the Division of Health for the sanitation and hygiene of the private schools of the city, and that standard methods of health supervision be devised, also, in cooperation with the private sohool authorities, and that they be put into effect in the private schools under the auspices and at the expense of the schools in question. School Medical Inspection in Public Schools: Much of the work carried on for the health of the children in the public schools of Cleveland is of an extremely high type and warrants commendation. The present form of organization, however, is a great drawback to the efficiency of the work and, in addi- tion, there are numerous points in connection with the various types of work where changes 302 Hospital and Health Survey are indicated. Lack of coordination of the different types of health work is a serious detriment. There are many points of overlapping of function. For instance, the cus- todians are responsible for the sanitary and hygienic maintenance of the school buildings, yet it is apparent that control of proper ventilation, adjustment of seats, attention to drinking fountains and toilets, and general sanitary surveys, with adjustment of com- plaints, are left to the sporadic attention of teachers, doctors and nurses. This neglect to fix definite responsibility and to have well-directed, central control is manifest through- out the system. In order that the health of children of school age in Cleveland may receive adequate protection, the following program of reorganization, readjustment and the addition of new activities is suggested: Organization: There should be coordination of all services dealing with health; that is, the Department of School Medical Inspection and the Department of Physical Training, the Department of Sanitary Supervision and the teaching of health education should be under the control of a single individual, an assistant super- intendent of schools. This employe should be a full-time employe, preferably a physician, at a suitable salary. The department might be called the "Depart- ment of Health Supervision of School Children." The director of this depart- ment should be in full charge, and there should be two Assistant Directors, one in charge of the work of school medical inspection and one in charge of physical training. The Director of School Custodians should be under the jurisdiction of the Director of Health Supervision of School Children, and the control of subject matter for health education should be placed with the Bureau of School Medical Inspection. Specific recommendations are offered as follows: School Medical Inspection: 1. Personnel: The number of school medical inspectors should be increased so that there is one doctor for every three thousand children. There should be included on the staff an oculist who would act as consultant in regard to trachoma cases. The number of nurses should be increased so that there is one nurse for every two thousand children. The number of junior health workers should be increased so that there is one for each nurse. 2. Duties: (a) Duties of School Doctors: /.• Sanitary Surveys: At the beginning of each term the school doctor should make a complete sanitary survey of each school under his jurisdiction. This survey should be fol- A Program for Child Health 303 lowed up by a report outlining conditions of sanitation and hygiene found in each school and classroom, calling attention to any changes or readjustments to be made or new equipment or replacements necessary in order to maintain the classrooms in a wholly hygienic and sanitary condition. Comment should be made also upon the nature of the routine supervision of the hygienic and sani- tary condition of the school building and classrooms. These reports should be made out on a standard form and, when completed, should go to the Director of the Department and by him be transmitted to the supervising custodian for adjustment. The latter should thereupon see that the matters complained of are adjusted, then report back to the Director of the Department of Health Super- vision of School Children. 2. Physical Examination: Physical examination should be made by the school doctors of all pupils in the schools in the following order: (a) Children entering school for the first time. (6) Children specially referred by teachers or nurses. (c) Children in the third grade. ( v_ / \ > \ • \ 30 \ \ , ^' \ *• •» ^ 20 f / / / / \ S S \ s / 10 * • ***' >* \ \ s > * * **"" / ^^ * * *" "«> -**■ 1873 — First Board of Health of Cleveland. 1882 — Koch's discovery of the tubercle bacillus. 1901 — City Bacteriological Laboratory opened. Disinfection after death from tuber- culosis begun. 1904 — Tuberculosis dispensary opened by the Anti-Tuberculosis League. 1905— International Classification of Causes of Death first used in Cleveland. Smallpox Hospital on City Hospital grounds renovated and opened as a sanatorium for tuberculosis. 1906 — Tuberculosis dispensary started in City Hall. Open evenings. Discontinued after a few months. Tuberculosis made reportable. 1907 — Tent colony opened by the Anti-Tuberculosis League. In 1915 this was moved to Warrensville and the expense of maintenance borne by the City. 1910 — City took over tuberculosis dispensary which had been maintained by the Anti- Tuberculosis League and opened two other tuberculosis dispensaries. 1911, 13, 14, 15 — Additional dispensaries were opened. 1913 — New sanatorium at Warrensville opened. 1914 — Day camp in operation during the summer. Operated one or two years and then discontinued. 1915 — Compulsory pasteurization of all (except Grade A) milk used in the city. 342 Hospital and Health Survey Tuberculosis Deaths by Age. The distribution of tuberculosis deaths by certain age groups for the period 1913 to 1918, inclusive, is presented in Table I. (Appendix). As usual, it is seen that the non-pulmonary deaths are high under five years of age. The total deaths under five constitute 7.3 per cent of all the tuberculosis deaths for the period. It will also be noted that the deaths for the age periods 20-39 total just 50 per cent of all the deaths from tuberculosis. This reflects the high mortality in the industrial age period, and also reflects the large male industrial population. From this table it may also be seen that the non-pulmonary deaths constitute 13.6 per cent of the total deaths. The tuberculosis death rates by estimated population for age groups are shown in Table II. (Appendix). Tuberculosis Deaths by Sex. The distribution of tuberculosis deaths by sex is indicated in Table III. (Appendix). From this table it will be seen that the deaths among males constitute 64 per cent of the total. This high male tuberculosis mortality is to be considered in connection with the high percentage mortality for the industrial age groups (50 per cent) as pointed out in the discussion of Table I. Occupation. Through the cooperation of the Division of Health the distribution of tuberculosis deaths by occupations was obtained for the period 1914 to 1918. It is perhaps not worth while to present all of these figures, but in Table IV. there is given the total number of deaths by occupation for these five years, according to the 18 leading occupations of those dying of tuberculosis. The prominence of "housework" is a typical finding and seems to indicate not so much the hazardous nature of housework as the fact that the majority of tuberculosis patients among women are not found in industry, but, by the time they become active, do gravi- tate to the home, and are consequently recorded as being "at home" or "housewives," or as doing housework. Important evidence has been recently collected and published by Dr. George M. Kober in United States Public Health Reports (March 26, 1920, Vol. 35, No. 13), showing increasing damage properly attributable to occupations as a contributing factor in pul- monary tuberculosis, as well as the substantial results which have been obtained in reducing tuberculosis where dusts and other air pollutions have been controlled or reduced in a variety of trades. Such studies as are here reported by Dr. Kober must be undertaken in Cleveland if the true nature and extent of industrial hazards, as accessory causes of tuberculous diseases among the operatives in metal and textile trades and in mercantile establishments, are to be appreciated and removed. The relationship of the pollution of the air of the city by coal dust, ash and trade wastes, permitted to escape from chimneys without any pretense at effective restriction, is well worth studying, district by district. Form. The percentage of non-pulmonary deaths (Table V., Appendix) is a fairly satisfactory showing, though with a concentration upon the detection of early disease and upon the Tuberculosis - 343 stimulation of tuberculosis reporting, and upon the encouragement of greater reliability in death certification, it is probable that this percentage would be increased. Residence. As previously stated, the figures for tuberculosis deaths and mortality rates for Cleve- land do not include deaths among Cleveland residents at Warrensville Tuberculosis Sana- torium. On the other hand, they do include deaths among non-residents in Cleveland. It would, of course, be more logical to exclude non-residents and to include Warrensville deaths, but the practice has not been carried out in the past. As a matter of fact, however, an analysis of the reports of deaths in 1918 and 1919 indicates that these two factors approximately balance. For 1918 the non-residents dying in Cleveland (residence less than one year) were 42. For 1919 this number was 38. On the other hand, for 1918 it was estimated by the Divi- sion of Health that the residents dying out of town number 46. The actual difference would make only a slight modification in the tuberculosis rate. TUBERCULOSIS MORBIDITY Reporting. During the study in Cleveland, physicians and others frequently expressed the opinion that the reporting of tuberculosis, as well as of births, was incomplete. This is, of course, more or less reflected in the ratio of reported cases to deaths, which will be touched upon shortly. As will be described in more detail later, the ratio of active cases to annual deaths in Cleveland is running about 4.7 to one. In Framingham, Mass., this ratio for active cases during the most intensive year (November, 1917, to November, 1918) of the work, was in- creased to approximately nine to one — 115 cases to 13 deaths. It is stated by the Division of Health that 20 to 30 per cent of the tuberculosis deaths are not reported as cases before death. 1918 1919 1920 (4 mos.) 1020 841 260 285 190 61 27.9% 22.5% 23.5% Deaths from pulmonary tuberculosis Not reported as pulmonary tuberculosis before death Per cent of unreported cases In Framingham, Mass., this percentage runs about 6. On the other hand, this is comparing the Cleveland conditions with experimental and more or less ideal conditions. The ratio of 4.7 to 1 for cases and deaths is a better ratio than will be found in many, if not most, other American cities. Case Classification. While the method of case classification at the health centers and at the Division of Health has been worked out on a good practical routine basis, it is, as would be the case in most communities, not wholly satisfactory. A modified method of case bookkeeping, based on a somewhat altered system of case classification, has been suggested in some detail to the department officials. Such a system as has been proposed, if carried out in 344 . Hospital and Health Survey each health district, supplemented by monthly summaries to the central office, would have a great many advantages. It would help to visualize the situation as it runs in the health districts from month to month. It would facilitate a summarization of cases according to classification groups at any time. It would encourage the more persistent follow-up of arrested cases and suspicious cases. Health Center Attendance. The details as to actual attendance at the health centers for a period of years are indicated in Table VI. (Appendix). The totals for these years indicate a decided falling off in attendance, the total drop- ping from 14,753 in 1915 to 10,765 in 1918. This has been a common experience else- where. New Cases at the Health Centers. The total number of new cases at the health centers is indicated in Table VII. (Ap- pendix). Here again will be found a falling off in new cases, the total for 1915 being 3,416, and that for 1918 being 2,482. This falling off of new cases in dispensaries and health centers is not unique in Cleveland, but is characteristic of other cities. In New York, for in- stance, there were 4,010 fewer cases on the records in 1918 than in 1917. This has been ascribed to a number of reasons, including the following: 1 . The fact that during part of the period a very large percentage of the male population in the most susceptible age group had been drafted into the army. 2. The hold which the war industries have had upon the working population, and the unwillingness on the part of anyone to forego the high wages unless absolutely compelled to do so by prostrating illness. 3. The falling off of immigration. 4. The general let-down in anti-tuberculosis educational work. 5. The fact that the influenza epidemic may have killed off a large percentage of the individuals who might subsequently have been reported as tubercu- lous cases. Active Cases. The grand total of cases for all of the health districts was 5,565, while the actual active cases on record at each of the health districts were as follows : District No. of Cases 1 697 2 and 8 1157 3 464 4 430 5 1092 6 859 7 886 Tuberculosis 345 Ratio of Active Cases to Deaths. The ratio of active cases to deaths for all the districts combined is 4.7 to 1. The total number of deaths for 1918 is 1,190. This includes 1,073 cases distributed by health districts, and 117 deaths of residents out of town, or of non-residents in town. New Tuberculosis Cases Reported in 1919. The total number of pulmonary tuberculosis cases reported in 1919 was 1,442. For the entire city the ratio of newly reported cases to deaths is 1.2 to 1. The Stage of the Disease as Reported. The stage of the disease as reported is not only a measure of the accuracy of reporting, but also indicates the relative efficiency of the medical profession in the early detection of the disease. Through the help of the Division of Health it was possible to make two separate tests in reference to the stage of reporting. Five hundred cases were classified according to stage as reported at health centers 2 and 5. Here it was found that of the total number of cases reported 43.6 per cent were classified as early cases. Again, at the Division of Health a group of 500 were classified according to the stage in which they were reported by the physicians. These were cases which came in indepen- dent of the health centers. In this group 51 per cent were reported in the first stage. In contrast to these two percentages for the health centers and for the Division of Health of 43.6 and 51, respectively, it may be stated that in Framingham, Massachusetts, where a special effort has been made to encourage reporting, the percentage for the last three years has averaged 74. It is evident that something could be done in Cleveland to improve upon this factor. The discovery of the disease in its early stages, in order that treatment may be applied when most effective, is of vital importance in the control of the disease. 346 Hospital and Health Survey IV. General Provisions for Attack and Defense Against Tuberculosis THE machinery which a community constructs for its defense against disease is of two main types : first, certain general measures, such as educa- tion, legislation, general sanitation, nutrition, etc.; and, second, certain specific devices, such as institutions or clinics for the special care of the particular disease under consideration. The present chapter will be devoted to a brief review of the Cleveland equipment for meeting the tuberculosis problem, from the more general point of view. EDUCATION There cannot be said at present to be any organized attempt in schools or for the public to carry on systematic education in the nature, cause and prevention of tuberculosis. LEGISLATION For the Direct Control of Tuberculosis. Cleveland is well equipped with measures for tuberculosis control. The more im- portant legislation may be summarized as follows: 1. Provision for the disinfection of premises (1901). 2. The prohibition of spitting (1905). 3. Tuberculosis a reportable disease (1907). 4. Provision made for compulsory removal and detention of dangerous tuberculosis cases — practical segregation (1910). 5. Prohibition of the employment of any person suffering from tuberculosis in a school (1914), and the prohibition of the employment of any tubercu- lous individual in a food handling establishment (1914). 6. Legislation against common drinking cups (1919). With Reference to Milk. City ordinance, No. 34648-A makes adequate provision for the control of the milk supply of the city of Cleveland. This ordinance includes measures prohibiting the sale of dipped milk; requiring that all certified milk be obtained from tuberculin tested and negatively reacting cattle, from regularly inspected plants, handled by medically inspected employes; that all milk be sold according to specified grades; that all uncertified milk be pasteurized; that all pasteurization be according to the holding process for definite temperatures, etc. Housing. In Cleveland, houses while under construction are under the supervision of the Divi- sion of Buildings of the Department of Public Service. When occupied, so far as general control is concerned, they are under the Bureau of Sanitation of the Division of Health. Tuberculosis 347 Legislation has been provided, along the lines of the regulation housing code, known as ordinance No. 32186-A, which apparently makes adequate provision for hygienic equip- ment and control. Certain sections of this code cover specific matters of direct importance to personal hygiene and home living methods, including water supply, water closets, general cleanliness, etc. It was not possible to make an exhaustive comparative analysis of housing legislation in Cleveland, but a cursory study of the provisions would seem to indicate that the legislation is reasonably adequate." The question as to its actual enforce- ment will be discussed later. GENERAL SANITATION It has been pointed out that the community is well equipped as regards sanitary legislation. How adequately is that legislation enforced? This question cannot be answered from the point of view of minute details of general sanitary provisions. It has been considered only in its more important aspects. The Milk Problem. Through the cooperation of the Division of Health and the Cleveland Consumers' League, fairly definite answers were secured to specific questions with reference to the milk^situation in Cleveland. The Consumers' League investigators reported: l.jThat the estimated total milk consumption in Cleveland was 60,000 gal- lons per day. (80,000 including milk used for ice cream.) 2. That one concern, the Telling-Belle- Vernon Company, handles about 40 per cent of this entire supply. 3. That practically all of the milk, except the certified, is pasteurized, the amount pasteurized approximating 98 per cent of the total supply. 4. That about 300 gallons per day is certified, or approximately .37 per cent of the total. The bacterial content of this certified milk is kept below 10,000. 5. This would leave about 2 per cent of the supply in the unpasteurized class. The bacterial content of this milk is limited by legislation at 50,000, but was said to be running at 15,000 in the winter months. All of this raw milk comes from tuberculin tested cattle, the tests being made once a year. 6. Pasteurization is by the holding process, at 145° F. for 30 minutes. 7. At the present time about 10 per cent of the total milk supply is said to be sold at retail as dipped milk. From control observations made by bacterial counts of milk samples taken in the open market, as delivered to the consumer in March and June, it is apparent that although the inspection service appears to be thorough and conscientious, not more than half the milk sold complies with the legal sanitary standards of bactei ial purity. 348 Hospital and Health Survey Milk Consumption — Its Dietary and Nutritional Aspects. Tuberculosis usually results from the inter-play of a number of factors. These may be environmental, such as bad housing, unsanitary surroundings, low wages, etc.; indi- vidual or race habit, such as the prevalence or absence of maternal nursing, adequate or inadequate food habits, etc.; and finally, race stock. There is no doubt that nutrition," related as it is to race habits, economic status and general education is of basic importance in the incidence of disease and perhaps particu- larly of tuberculosis. Just how important nutrition is in tuberculosis we do not yet know. Possibly certain studies now being planned will throw light on this problem. So far as the Cleveland situation is concerned, it has seemed worth while to make a modest, though intensive, effort to study some factors of the most important single food consumption problem; namely, the question of milk. This problem is of importance not only to children, but to adults as well. A somewhat similar study carried out recently in Framingham, Mass., indicated that 69 representative families, with 173 adults and 261 children, were taking 92 quarts of milk a day. Now if each child under 2 requires a quart of milk, and if each family should use in addition at least a pint per capita for the fundamental cooking necessities for proper diet for adults, it is evident that this group should have been consuming between two and three times as much milk per day as they did. In Cleveland, with the help of the Division of Health Nursing Bureau, the Visiting Nurse Association and the Associated Charities, an effort has been made to make a some- what similar analysis of the situation in a thousand families. The results from this study may be presented in the following way: /. Agencies for Families Covered. Division of Health 536 families Associated Charities 310 " Visiting Nurse Association 154 " 1000 families Distribution of Families by Health Districts. District 1 15.6 per cent District 2 6.9 " " District 3. '. 18.9 " " District 4. 10.9 " District 5 12. " District 6 21. District 7... 9.3 " District 8 2.2 " Outside or not stated 3.2 " " 100 per cent Tuberculosis 349 It is evident from this table that these families were fairly generally distributed over all parts of Cleveland. 3. A Census of the Group Covered. Of the 1000 families, 117, or 11.7 per cent, were taking lodgers. A distribution of the population by age groups in these families was as follows: Adults (adults and relatives over 14) 2221 Children (6 to 14) , .". 1541 Children (under 6) 1534 Lodgers 217 5513 From the foregoing it will be observed that the census of the families, excluding lodgers, totaled 5296. The total number of children under 14 was 3075. The number of children per family was 3.1. The number of individuals per family (without lodgers) was 5.3. The number of individuals per household (including lodgers) was 5.5. 4. Relief and Non-Relief Families. Families receiving relief. 42.7 per cent Families not receiving relief. 57.3 " " 100 " " 5. Kinds of Relief. The kinds of relief being received by the 42.7 per cent of the entire group of families may be stated as follows: money, 9.6 per cent; food, 21.2 per cent; clothing, 13.6 per cent; medical care, 24.9 per cent; not stated, 2.6 per cent. These percentages do not of course total 100 in view of the fact that the percentages were calculated on the basis of the entire group. Further, many of the families were receiving two or more kinds of relief. 6. Sickness Prevalence. While it was realized that the group being covered was in no sense typical of the population as a whole, it was thought worth while to take, in an informal way, a sickness census of the families reached by the study. The illnesses recorded were classified accord- ing to the headings indicated in Table VIII. (See Appendix). This is of course an atypical group, and is not to be compared with other standard sickness censuses. It will be remembered that the Metropolitan sickness surveys have shown a prevalence of illness ranging from 1.5 to 2.5 per cent. These percentages apply to incapacitating illnesses. The sickness census in Framingham, including minor illnesses as well as major affections, showed a percentage sick of 6.2 per cent. This special study in Cleveland of a group being covered by nurses and relief workers, for a number of causes, including medical as well as nursing needs, showed the percentage ill, for adults and chil- dren combined, 12.7 per cent. For adults the percentage was 16.16 and for children 10.14. 350 Hospital and Health Survey A special tabulation has also been made of the prevalence in the group not only of active tuberculosis, but of suspected tuberculosis, and of individuals exposed to tubercu- losis. The results are presented in Table IX. (Appendix). From Table IX. it will be observed that, for adults and children combined, the num- ber being recorded as actively tuberculous constitute 2.11 per cent of the entire group. This again reflects the fact that the group is not a typical group. A typical cross section of such a community as Cleveland if actually medically examined would show the presence of approximately one per cent actively tuberculous, according to Framingham experience and standards. It will be observed that for the group as a whole, including adults and children, 3.5 per cent were classified as being either actively tuberculous or showing sus- picious signs or as having been exposed to the disease. 7 . The Number of Families Taking Milk. The number of families in the group actually taking milk and the way in which milk was received is shown in Table X. (Appendix). Owing to a duplication in this table it is impossible of course to have percentages or numbers total. It will be observed, however, that 77.9 per cent of the families were re- ceiving milk in bottles. The percentage of families in which milk was bought in whole or in part by bulk was 3 per cent. It will be remembered that previously it was stated that approximately 10 per cent of the milk in Cleveland was being sold as dipped milk. From these two observations it appears probable that some of this dipped milk is not being distributed through ordinary family channels. 8. Home Refrigeration. In answer to the question as to whether or not the milk was kept cold, the question- naires answered this inquiry in the affirmative in 76.5 per cent of the cases, in the nega- tive in 6.5 per cent, and failed to answer in 17 per cent. It will be remembered that this survey took place during the winter season. 9. Was the Milk Kept Covered at Home? The families were classified as follows under these headings: yes, 80 per cent; no, 4.6 per cent; not stated, 15.4 per cent. It would appear from these inquiries that, so far as this season of the year is con- cerned at least, the home methods as regards milk handling are above average in Cleve- land. 10. The Daily Amount of Milk Consumed. This of course is a point of vital importance. How much milk were these families consuming, and how does their total milk consumption and average milk consumption compare with the theoretically desirable use of milk for such a group of the Cleveland population? Apparently the sanitary aspects of the milk situation are passable. How about the nutritional and dietary sides of the problem? The approximate amount of milk consumed as recorded, in the group, will be shown in Table XI. (Appendix). Milk purchased in canned form is relatively only a small frac- tion of the total, and has been eliminated from this tabulation. Consequently, the sum of the families does not equal 1000. Tuberculosis 351 From this table it will be observed that the 920 families were taking 1480 quarts of milk a day, or 1.61 quarts per family. How does this compare with the normal needs of this group? The 920 families contained 2852 children. On the basis of one quart per child per day this would mean, for the children alone, 2852 quarts. If there is added to this one pint for the general family needs, or 460 quarts, the total requirements of the group are 3312 quarts daily. Consequently, the families were securing only 44 per cent of the amount of milk necessary or at least desirable to meet their nutritional needs. To put the matter in another way, as there were 3.1 children per family the quarts per day necessary for the average family would be 3.6 quarts. This need is to be contrasted with the actual consumption of 1.61 quarts per day. //. Milk Consumption by Relief and Non- Relief Families. With reference to milk consumption in bottle or bulk only, the amount purchased by relief families is shown in Table XII. (Appendix). From this table it will be observed that each family was securing 1.67 quarts per day' The 390 relief families theoretically totaled 1209 children (on the basis of 3.1 children per family), and if to this is added one-half quart for each family, the total need of the relief families would be represented by 1404 quarts daily. The amount of milk consumed, or 654 quarts, represents 46 per cent of this theoretical need. The situation as discovered in non-relief families is indicated in Table XIII. (Ap- pendix). The non-relief families were receiving on an average of 1.58 quarts per family, or a little less than the relief families (1.67). The 530 non-relief families would total 1643 children, and would require, with a half quart for additional family needs, a total of 1908 quarts per day. The actual amount consumed, or 839.25 quarts, represents 43 per cent of this theoretical need. Evidently the families not receiving relief are receiving less milk than the relief fami" lies, which probably reflects the effect of relief measures and possibly of the educational work being done in the families in contact with relief workers. In justification of the amount of time in the investigation and the amount of space in the report, devoted to an analysis of the consumption of milk in Cleveland, it is well to recall the extent to which milk is recognized as the foundation of nutrition, especially in children, as is indicated in the follow- ing quotations from Public Health Reports (Vol. 35, No. 17, April 23, '20, pp. 994-6). "Our present knowledge of nutrition justifies more fully than ever before the statement that the dietary should be built around bread and milk, bread or other grain products being the foods which furnish the most nutriment for their cost (whether in money or in land and labor), and milk being by far the most efficient nutritional supplement to bread or other grain products. Therefore, somewhat more of our grain crops than is the case at present should come directly into human consumption to augment the bread supply; and of the grain fed to cattle more should be used for the production of milk and less for the production of meat. 352 Hospital and Health Survey "In general, ten pounds of grain may be expected to produce not over one pound of meat or about three quarts of milk. If the three quarts of milk cost the consumer more (because of greater labor cost in production), they are also certainly worth more to him. In so far as things as different in their nutritional properties as meat and milk can be compared, it is fair to say that one quart of milk is at least as great an asset in the family dietary as one pound of meat. The per capita consumption of meat in the United States is so high that it might be reduced by onerthird, or even one-half, with little or no nutritional loss, while a corresponding increase in milk consumption would certainly constitute a great improvement in the average American dietary. We are confident that a moderate shifting of emphasis from meat to milk will help in the normal evolution of American agriculture and im- prove the food economy and public health of the American people. "Considering the whole length of life of the animal, Prof. Wood, the leading English agricultural expert, estimates that the cow returns in milk, veal and beef one-twelfth as much food as she has consumed, while the beef steer returns only one sixty -fourth. In other words, the cow is five times as efficient as the beef steer as a food producer when the whole life cycle of the animal is considered. Similarly it has been estimated by Cooper and Spillman (Farmers' Bulletin, No. 877, 1917, U. S. Dept. of Agriculture) that the crops grown on a given area may be expected to yield from four to five times as much protein and energy for human consumption when fed to dairy cows as when used for beef production. "Quite recently Dr. Armsby has pointed out (Yale Review, January, 1920) that 'the dairy cow shows the highest efficiency of any domestic ani- mal, both as regards conversion of food and availability of the product for men.'" From studies recently made by the Children's Bureau of the United States Department of Labor in three representative American cities it appears that the insufficiency of the milk supply and of the use of milk by children is wide- spread and that Cleveland shows no important difference in this respect from Baltimore, Washington and New Orleans. The Consumers' League of Ohio has been so convinced of the necessity of educational propaganda to increase the use of milk in the homes of Cleveland that it proposes to undertake the following program in the field of public education during the summer of 1920: 1. Milk stations will be installed at five settlement houses, Woman's City- Club Food Shop and public parks (if possible). These organizations appear ready to cooperate. 2. Milk will be sold to cover its own cost. 3. Educational material, posters and printed matter will be furnished by the Consumers' League. Dispensers and helpers will be furnished by the Settlements. Containers and some other equipment will be furnished by milk companies. Ice, paper cups and straws are to be paid for (it is hoped) by the Federation through funds to be advanced to each station. Tuberculosis 353 The Housing Problem. As stated under the discussion on Legislation, the housing regulations are representa- tive and reasonably complete. Further, no effort was made in this tuberculosis survey to conduct a field study of living conditions. On the other hand, it so happens that a very recent study, made by the Committee on Housing and Sanitation of the Cleveland Cham- ber of Commerce, published in October, 1918, covered many of the important considera- tions in the relationship which housing bears to disease. This is a report which has been studied with some care and is recent enough to be considered representative of current conditions. Consequently, certain of the facts presented in the Chamber of Commerce study will be reproduced here. This study was comprehensive in character, covering about 80,000 people or approxi- mately one-tenth of the population. It included the collection of data by factory ques- tionnaires, a lodging house survey, and primarily a house-to-house canvass covering 6,292 houses, 14,688 families, and 69,894 individuals. The reader whose interest lies in this direction should consult the original report. We are in entire agreement with the conclusions arrived at and quote from the report as follows: "First: The type of industrial housing in Cleveland is not as high as the standard set by the Government for industrial war workers and not as high as we had heretofore believed the Cleveland standard to be. The standard of property maintenance, both as to repair and cleanliness, is not good, and sanitary equipment is inadequate and much of it is of antiquated type. There is unnecessary lot overcrowding, the median percentage of lot occupied being seventy-seven per cent, and the result is high fire hazard. "Second: There is a rapidly increasing tendency on the part of our industrial workers to live in tenements, 27.1 per cent or more than one-fourth of them living in tenements or under tenement conditions. There is also distinct room overcrowding, 50 per cent of the families having less than one room per person. Tenement conditions and overcrowding are two housing evils that a city which has every possibility of expansion, both in territory and in transportation facilities, might and should avoid. "Third: Rents are not high in terms of percentage of earnings spent in rent, but high in terms of value received as so many of the houses and suites within the range of price that workmen can afford are old and in a poor state of repair and sanitation." With reference to the housing situation, a conference was held with Mr. Robert Whitten, Director of the City Plan Commission. Mr. Whitten stated that the Building Department records for the last five years (1915 to 1919, inclusive) showed the following percentages for new construction: Tenement houses.. '. 25 per cent Two-family houses 5 1 per cent One-family houses 24 per cent The evidence in this and in other cities, here and abroad, tends to prove the Value in prevention of tuberculosis of the single or two-family house as 354 Hospital and Health Survey compared with tenement blocks or especially with remodeled houses made to serve the needs of a number of families and their lodgers. It is from the latter type of adapted residences that Cleveland suffers, particularly in its congested Negro and Italian sections. General Cleanliness. As stated previously, no special studies of general sanitation were at- tempted. So far as the tuberculosis is concerned, Cleveland has adequate legislative machinery. This applies to milk control, specific tuberculosis prevention' housing, etc. From the point of view of milk, the practice is fair. From the point of view of housing, it is woefully inadequate. It is important to see how effective may be the administration of sanitary legisla- tion along other lines. As regards an item of vital importance in anti-tuberculosis work, namely, the enforcement of the anti-spitting ordinance, a little information is avail- able. In 1917 there were 41 convictions for violation of the anti-spitting ordinance. In 1918 there were seven convictions, and in 1919 there were no convictions, and there have been none in the first six months of 1920. This would seem to indicate indifference to the enforcement of this measure. It is hoped that this may not be justified as an index of cleanliness and sanitation along other lines, such as food handling, dust control, fly sup- pression, the elimination of common utensils, etc. For further information on the general compliance with sanitary requirements the reader is referred to the description of the Division of Health in Part II. Tuberculosis 355 V. Special Provisions for Figuring Tuberculosis The particular resources employed in Cleveland may be discussed under the following headings: THE DIVISION OF HEALTH This Division is a section of the Department of Public Welfare, and is composed of a number of Bureaus, many of which touch the tuberculosis problem. These Bureaus may be briefly described and discussed as follows: THE BUREAU OF TUBERCULOSIS This bureau is at present without a head, though a considerable proportion of the time and interest of the Health Commissioner is devoted to its interests. Related to this bureau, though not functionally a part of it, are the seven health centers under the direc- tion of the Division of Health. So far as tuberculosis work is concerned, the activities of the bureau quite largely clear through these outposts. The health centers are distributed fairly uniformly throughout the city, and each center is in charge of a supervising nurse. A part-time physician is engaged in connection with each center, being present at clinic hours. In three of these centers also there are dental clinics, and attached to each center are a number of nurses who work from the stations as a center. On the whole, the work of these centers seems to be worthy of high commendation. While developed somewhat rapidly and perhaps a little haphazardly, without much reference to other social and relief activities in Cleveland, they do meet many of the health needs of the community. Each station holds five tuberculosis clinic sessions weekly, one session being at night. With increased personnel, both as to clinic attendants and field nurses, the need for a more frequent use of the clinic facilities would probably develop. It is apparently diffi- cult under the present arrangement to secure enthusiastic and specially trained physicians for tuberculosis work in the clinics. The men are for the most part young physicians who have had no special training for their work. The work is part-time and receives only part of their interest and enthusiasm. The inadequate facilities with the resulting insufficient uses of dispensaries for diag- nostic and therapeutic services in tuberculosis in Cleveland is indicated by comparing the hours of special tuberculosis clinic service given per thousand of the population in Cleveland with service of a similar nature offered in seven other of the large cities of the country. 356 Hospital and Health Survey In 1920, basing the service per 100,000 upon the population figures recently issued officially by the Census Bureau as of January, 1920, there were provided for the citizens of: Tuberculosis Clinic Hours of Service per Week per 100,000 of population Boston. _ _20 hours Philadelphia. 13 " New York 10 " Cincinnati 10 " 3 St. Louis 9 " Cleveland 8 " Buffalo 6 " Detroit 5 " Under the Bureau of Tuberculosis there is an institutional case clerk who places, by whatever means necessary, cases recommended for institutional care. All cases admitted to Warrensville are admitted through the Bureau of Tuberculosis, and unless a permit is issued by the Bureau cases are refused admission. Before a case is sent to City Hospital arrangements are made with the hospital and a permit issued. THE BUREAU OF NURSING At the present time there are approximately 80 nurses (including supervisors) in the Division of Health, distributed among the health centers. They are doing generalized public health nursing, and are looking after tuberculosis work, prenatal work to a slight extent, well-baby work, pre-school work to a slight degree, parochial school work, com- municable diseases, boarding homes inspection, trachoma, ophthalmia, etc. A visit to the health centers, and particularly to the teaching center, convinced the writer that generalized nursing has many advantages. From the point of view of the effectiveness of the nursing work as it touches the tuberculosis problem, a special appraisal was made by the other members of the survey staff, particularly concerned with a study of nursing service. These survey investigators were requested to comment upon the effectiveness of tuberculosis nursing from the following points of view: 1 . The efficiency of bedside care. 2. The interest and efficiency of the nurses in finding new tuberculosis cases, in urging the families to come to the clinics for examination, etc. 3. The efficiency of educational work along the lines of home hygiene and personal hygiene. 4. The adequacy of relief measures. For the general comments on the nursing situation the reader is referred to the report on the nursing work, Part IX. With special reference to tuberculosis, the investigators stated that active cases were not visited with sufficient frequency (once a month or less often) ; that arrested cases, suspects, and contacts were seen only once in two to six months; that the individual nurses have too many cases and too large a territory to cover; that the pressure is too great to permit of much activity on the part of the nurse in the direc- tion of finding new cases. The home work is said to be excellent from the point of view of securing cooperation from physicians and others, though not so good in giving specific Tuberculosis . 357 instructions to patients. A set of rules to cover this aspect of the work is recommended by the nursing investigators, together with more expert supervision of the field work. While some public health representatives in Cleveland seem to feel that tuberculosis work has suffered of late, with the development of the generalized nursing system, on the other hand the general consensus of opinion seems to be that the method provides many advantages to offset its few defects, even from the tuberculosis point of view. It is true that the clinic attendance has fallen off and the number of new cases annu- ally discovered has decreased concomitant with the development of the generalized system. However, this falling off in clinic attendance in the past two years has been experienced widely throughout the country and presumably does not reflect the results of the nursing method alone. THE BUREAU OF STATISTICS The Bureau of Statistics provides a very indifferent service. It has no full-time chief, and the methods of developing statistical data seem to be informal and haphazard. No effort is made in tuberculosis mortality to eliminate non-resident deaths and to include resident deaths dying out of town. This is a practice which ought to be instituted. THE BUREAU OF FOOD AND DAIRY INSPECTION This Bureau has the responsibility of inspecting food establishments, food handlers, milk control, etc. No special opportunity was afforded for the determination of the effectiveness of this work. THE BUREAU OF SANITATION The Bureau of Sanitation has on its staff a number of sanitary officers who are respon- sible for the suppression of nuisances, for housing inspection, etc. The work of this bureau might with advantage be further developed and the standards of sanitary supervision raised THE BUREAU OF LABORATORIES The Bureau of Laboratories has charge of the inspection of food handlers for com- municable diseases, sputum examinations, etc. INSTITUTIONAL PROVISION The special provisions made for the institutional care of tuberculosis patients in Cleveland are as follows: FOR PULMONARY TUBERCULOSIS The Warrensville Sanatorium. This is a city institution about twelve miles from the heart of Cleveland, very attrac- tively located on the highest point of land in the county. The equipment makes a very pleasing first impression, which is well sustained by further contact. The general man- agement of the institution, including the records, etc., seems first class. The equipment includes an excellent laboratory, an X-Ray plant, facilities for pneu- mothorax operations, a nose, throat, ear and eye room, dental equipment with full-time resident dentist, etc. There are four or five physicians on the staff, the physician in charge being a graduate of Western Reserve University, and of the special course at Tru- 358 Hospital and Health Survey 1. Only available playground space in an overcrowded district. 2. Flashlight photograph of dark passageway between two te: earms of flies. 3. Typical of many homes in the Haymarkct district. Sanitation unheard of here. 2. Flashlight photograph of dark passageway between two tenements. Rotting garbage and filth here attract swarms of flies. Tuberculosis 359 $8% >■ ■■■•■ ■ Warrensville Tuberculosis Sanatorium where the "tuberculosis patients 360 Hospital and Health Survey deau. This institution has a capacity of 254 beds for pulmonary tuberculosis, a number of beds being vacant at the time of visit. Most of the cases are moderately advanced, and a few far advanced. This admission of advanced cases in an institution that is sup- posed to care for early cases is unfortunate from many points of view. It tends to increase the mortality of the institution and to make comparisons between it and other sanatoria unfavorable from the point of view of Cleveland. It tends to give the institution a local reputation for having a high mortality, and to increase the unwillingness on the part of patients to be hospitalized. The Commissioner of Health stated that a large percentage of the patients left against advice, though only a few because of genuine dissatisfaction. He stated that the average length of stay had been increased from three months in 1913 to six and a half months in 1918. Those in charge, under the direction of the Health Commissioner, have developed an excellent method of grading patients at Warrensville on the basis of their ability to take exercise, the work merging into occupational therapy. Patients are graded all the way from active bed patients to those in an arrested stage, and followed up by occupational service. The plan seemed to be unique and very desirable, and its operation effective. Somewhat comparable to this occupational therapy system is the current classification chart in use at the sanatorium for patients of all types. This was devised by Dr. Frye, the resident physician in charge, and should be given wide publicity, for it is a device which would be useful for many institutions. This chart, by a series of colors, shows at a glance for each ward the beds occupied, the vacancies, the age, stage on admission, pres- ent condition, sputum findings, etc., for each case. The institution deserves much com- mendation for the maintenance of this system. From the point of view of the future working adjustment of the patient, it would be well to develop at this institution a system of special vocational training. This might well be looked upon as an economic obligation which the institution owes to the individuals under its charge. The Ohio State Sanatorium. This institution provides approximately 23 beds for Cleveland cases, of the early pulmonary type. The City Hospital. This institution provides 100 beds for advanced pulmonary tuberculosis, 84 of which are for men and 16 for women. The tuberculosis ward is situated on the edge of a deep valley, overlooking a number of industrial plants, and is exposed to a great deal of dust and smoke. At the time of the visit there were only 70 patients in the hospital, the empty beds being all on the male side. It was stated that the average length of stay is approxi- mately one year, though some patients have been there six or seven years. Two patients were being held under compulsory segregation. This institution comes in for a great deal of criticism with reference to food, nursing, medical care, general attention, etc. How much of it is justified is difficult to say. Cer- tainly in physical equipment and general appearance, the building used by the tuberculosis patients has nothing to recommend it and should be replaced. State Insane Hospital. This institution provides approximately 6 beds for advanced pulmonary disease from Cleveland. Tuberculosis 361 Other General Hospitals. A sickness census of the other hospitals of Cleveland at the time of the survey indi- cated that there were perhaps ten or a dozen cases of advanced pulmonary disease in the general hospitals of the city. FOR NON-PULMONARY TUBERCULOSIS, ARRESTED DISEASE, PRE- VENTORIUM CARE, CLOSED CASES AMONG CHILDREN, ETC. The Warrensville Children's Camp. This camp is adjacent to the sanatorium at Warrensville, and has provision for 30 children. The provision is inadequate and the equipment could readily be expanded to provide for at least 50 cases. The Rainbow Hospital. This institution cares for an average of 40 non-pulmonary or arrested cases among children, chiefly orthopedic convalescents. The Home for Crippled Children. This institution has provision for about 25 cases of non-pulmonary tuberculosis. The Fresh Air Camp. This institution offers preventorium advantages for approximately 30 children through- out the year and occasionally takes discharged children from the Warrensville institution. There are, in addition to this camp, a number of others for preventorium care in Cleveland. All told there are 12 or more summer camps for children and mothers with a capacity of over a thousand beds. These activities were for the first time correlated during the summer of 1919, by the Cleveland Welfare Federation. To summarize the bed facilities, the situation may be indicated as follows: For Pulmonary Disease Warrensville Sanatorium 254 beds State Sanatorium _ _ 23 " City Hospital _ 100 " Insane Hospital ._ 6 " General Hospitals _ 10 " Total #- 393 beds For Non-Pulmonary Disease. Warrensville Camp 30 beds Rainbow Hospital ._ 40 " Home for Crippled Children 25 " Fresh Air Camp __ _ 30 " Total _ _ 125 beds Grand Total 518 " 362 Hospital and Health Survey While at the present time many of the beds in Cleveland are unoccupied, it was only a year or two ago that patients had to wait five months or more for admission. This lack of insistent demand for bed facilities at the present time is quite characteristic of national conditions, and is presumably tem- porary. As a matter of fact it seems to be an unanimous opinion in Cleveland that there are many urgent needs for increased bed capacity. The most conspicuous of these may be briefly listed. They will be mentioned again in somewhat more detail subsequently. (See Part X.) 1. Beds for early pulmonary adult cases. 2. Beds for advanced pulmonary adult cases. 3. Beds for open pulmonary childhood cases. ' 4. Beds for surgically convalescent adult cases. 5. Beds for complicated adult cases, such as in pregnancy. 6. Beds for exposed early non-pulmonary cases among children from birth to five years of age. 7. Beds for closed childhood cases. 8. Possibly beds for relatively well-to-do, able-to-pay patients. OTHER ORGANIZATION COMMUNITY MEASURES The Department of Education. (See Part III. for details.) This department has one full-time physician on its staff, and employs 25 physicians on'part-time. The department has a supervisory nurse and 30 field nurses. It also has six dentists and six dental hygienists. Several eye clinics are in operation and a system of physical education is carried out. Twenty open air schools for under-par children, with morning and afternoon feeding, are conducted. There are at the present time also two nutrition classes in the Cleveland schools. Further, it was stated that one of the physicians on the part-time service had had special tuberculosis training and acted in a measure as a consultant for the other physicians. The Anti-Tuberculosis League. In the past the Anti-Tuberculosis League of Cleveland has seized the opportunity to make Cleveland a city with recognized leadership in tuberculosis work. Most of the tuber- culosis activities that are now carried on in Cleveland by official or private agencies were a result of the initiative and constructive energy of the League. At the present time the League is somewhat at a stand-still in its active program. It is subsidizing other agencies quite generously. With the funds at its disposal it is giving financial aid to the teaching district. It is financing the health crusade movement in Cleveland, under the agency of the State Tuberculosis League. It is responsible for the excellent system of occupational therapy and follow-up in connection with the Warrens- ville Sanatorium. Tuberculosis 363 The chief field for the League should lie along educational lines. However, during the past few years very little has been done in this field by any agencies in Cleve- land. An educational campaign should be mapped out, a campaign which would fall primarily to the League for execution. It is understood that the League has adequate financial resources, through the Welfare Federation and as a result of the sale of Red Cross Seals, which would make possible a genuine up-to-date educational program. Charities,' The Associated Charities of Cleveland is said to be one of the best organizations of this kind in the country. It employs 45 field workers, who operate in close cooperation with the health centers and the nurses doing tuberculosis work. There is also operated what appears to be an efficient case clearing house. The Associated Charities is supple- mented by Jewish and Catholic charities as well. The districts employed by the charitable organizations in Cleveland in no way coincide with the health center districts. Industrial Medical Work, (See special report on Industrial Medical Service, Part VII.) The medical work in the industries of Cleveland is at the present time very inade- quately developed. While there are several part-time physicians and a large body of nurses engaged in this work, there is no special tuberculosis work, very little routine medi- cal examining, and an inadequate program for health and anti-tuberculosis education. A thorough system of educational work in industry should be developed. This would be a legitimate activity for the Anti-Tuberculosis League. A plan should be mapped out somewhat similar to the recently proposed program of the New York City Tuberculosis Association. This calls for a campaign to secure the cooperation of the Chamber of Com- merce, and the manufacturers' associations, noon-day special talks to the men in the fac- tories, the distribution of literature to industrial workers in their shops, the organization of shop sanitation committees, the development of sentiment and demand for medical examination in industry, the establishment of model examining rooms for tuberculosis work, the development of exhibits for use in industrial establishments, etc. The Red Cross, the Consumers* League and other private agencies. Through these organizations, particularly the Red Cross, a number of demonstration and lecture courses in home nursing, home economics, infant care and feeding, and home sanitation and personal hygiene are offered. Interpreters are used for foreign groups, diplomas and pins are given for satisfactory attendance. 364 Hospital and Health Survey VI. A Summary of Activities ana Equipment ON the basis of the foregoing material an attempt will be made to present a brief summary of the methods used and equipment developed to fight tuberculosis in Cleveland. The situation may be summarized under certain conspicuous headings, the first of which is: THE PREVENTION OF TUBERCULOSIS Tuberculosis is, first, an almost universal infection; second, an extensive disease; and third, a prominent cause of mortality. It is possible to take measures to prevent the infection, to prevent or arrest the active disease, and to prevent or postpone mortality. It is necessary, in fact, to consider the problem of prevention from these three points of view: The Prevention of Infection. Infection is acquired through contact with sick individuals, through sputum, through infected milk, or through intermediate contact by means of common utensils, etc. To prevent unnecessary exposure by direct contact between sick and well individuals is largely a matter of education in personal hygiene. This is a field that has been only slightly developed in Cleveland, and should be considered a major activity for the immediate future. The segregation of dangerous cases of open tuberculosis is another matter of extreme importance. Cleveland has legislation for the control of incorrigible consumptives, but uses it only rarely. It is probable that its use could be materially increased. The control of sputum transmission is a matter of sanitary law enforce- ment and education. Both the enforcement of sputum ordinances and the education of the public about the dangers of sputum are at present much neglected. In the matter of milk control Cleveland seems to be meeting the situation with only fair success. In the matter of the suppression of common utensils, no direct data are at hand. This, of course, is largely a matter of education in personal hygiene, through schools, factories, and among the general public, and it must be admitted that much remains to be done along that line in Cleveland. There is also involved here the essential equipment for proper living, such as ade- quate and hygienic equipment in housing. We have seen that the situation in Cleveland in this regard is in many respects deplorable. The Prevention of Disease. If infection cannot be prevented, what measures can be taken to prevent disease? How adequately are these measures developed in Cleveland? The incidence of active disease, upon the basis of almost universal infec- tion, is a matter of individual break-down under some form or combination Tuberculosis 365 of stress or strain, physical or mental. This strain, of course, is most preva- lent in the younger age groups, particularly in the industrial period. It is there that we find the greatest economic handicap from tuberculosis disease. To combat this factor in industry, there is needed an aggressive campaign of industrial hygiene, and this is yet to be developed in Cleveland. It means education in industrial sanitation, of employers and employes. It means the establishment of adequate medical, nursing and clinical facilities and personnel in industry. It means the routine regular examination of industrial employes to detect the beginning of signs of disease. It means the consistent and thorough occupational and educational follow-up of arrested cases of disease as they return to industrial pursuits. The prevention of disease is also a matter of increasing individual resistance, as well as reducing the factors of strain. This means general education along the line of constructive hygiene. It means the promotion of home hygiene. It involves the development of various preventorium activities, such as summer camps, etc. It implies a campaign to improve food habits and particularly to increase milk consumption. In the matter of summer camps and preventorium facilities, particularly for children, Cleveland seems reasonably well equipped. Something is being done by the Red Cross and other agencies in the matter of home hygiene. Very little is being done for the general population in the matter of hygienic education. Finally, the situation with reference to food hygiene, and particularly milk consumption, is serious. This latter problem, of course, is not only one of increasing milk de- mand but also of increasing milk supply. It is a matter which deserves the serious consideration of all interested in the welfare of Cleveland, and is an economic as well as nutritional problem. It is possible that eventually the solution of this problem in municipalities will be found in the field of the socialization of city milk supplies. The Prevention of Unnecessary Mortality. This is in large measure a matter of improved therapeutic practice. It means the popularization of adequate treatment measures, the enhancement of institutional methods, or increased institutionalization of active tubercu- losis disease. For Cleveland it means an aggressive educational campaign to popularize and stabilize the use of existing sanatorium and hospital equip- ment, and it will mean eventually an increase in that equipment. An exten- sive, popular educational campaign might do much to increase the willingness of patients to come to the institutions, and to hold them there once they are hospitalized. Probably consistently high grade professional service for the sick will be the most effective solicitor for the use of Warrensville for early cases of tuberculosis. THE DETECTION OF TUBERCULOSIS As pointed out previously, the amount of known tuberculosis in Cleveland in ratio to deaths is at least up to, and perhaps above, the average for other American municipali- ties. The nursing and health center organization is certainly of an advanced type, and Cleveland is to be congratulated upon the progress that has been made in that field, and upon the example which the city sets for other municipalities. 366 Hospital and Health Survey On the other hand, when measured by theoretical standards of probable tuberculosis incidence, the actual ratio of reported cases to deaths (4.7 to 1) is low. Nine or ten cases to every ann ual death should be under observation or treatment. The percentage of early cases (approximately 50 per cent) of the total cases reported is low, as compared with what may be accomplished with special machinery for the detec- tion of tuberculosis (Framingham — 74 per cent). The percentage of cases reported before death (75 per cent or less) is also low. (Fram- ingham — 94 per cent). As supplementary equipment to the nursing and health center work, to the medical work in schools, and to a certain extent in the infant clinics, Cleveland needs much addi- tional routine medical and disease detecting machinery, particularly in the field of indus- try. Further, the discovery of tuberculosis could be greatly enhanced by the establish- ment of some form of advanced diagnostic training for the physicians in the clinics and in general practice, and particularly by the establishment of an expert consultation service working for the detection of disease, through the health centers, and with the general practising physicians in the city. THE TREATMENT OF TUBERCULOSIS As might be pointed out Cleveland is at the bottom of the list of a number of com- parable American cities in the ratio of tuberculosis beds to population. The investiga- tion, and the numerous conferences with leaders in tuberculosis work in Cleveland have emphasized that there is at present pressing need for institutional provision for the many types of tuberculosis patients. On the basis of experience elsewhere, it has been accepted that each community should provide at least one bed for every annual death from tuberculosis. Cleveland averages from 1,000 to 1,200 annual deaths and now has available 518 beds for pulmonary and non-pulmonary disease. This means that to meet the minimum requirements, the existing facilities should be approximately doubled. The nursing work, while of importance in disease detection, is of primary signifi- cance in treatment. The generalized system seems to work with fair advantage in meet- ing the tuberculosis problem. On the other hand, the present supply of nurses is inadequate. There are 80 nurses provided by the Division of Health, approximately 32 nurses doing district nursing for the Visiting Nurse Association, 31 school nurses of the Board of Education, and a variable number of student public health nurses in the University District estimated as equalling 10 nurses in- amount of service rendered. This gives a total of 153 nurses available for public health nursing in Cleveland. Over one hundred more are needed. It is estimated that it requires at least one nurse for every 3,000 of the population (some authorities estimate one to 2,000 of population) to cover all the needs of the popula- tion in the generalized system. By the generalized system is meant a system by which the city is divided into small districts, one nurse to each district and the one nurse doing all kinds of nursing and instruc- tion in health in that district. In no large city has a completely generalized system been Tuberculosis instituted; in Cleveland generalization has reached the point of concentrating all public health nurses in three agencies. These agencies again have generalized their activities by having one nurse in each district carry on all services which the agency offers. In the University District generalization is carried farther, the school nurses being the only separate group. It is also probable that treatment could be improved by supplying more adequate specialized supervision. This is essential where generalized nursing is employed. Material relief is of vital importance in the treatment of many tuberculosis patients and seems to be on the whole adequate. This is the opinion of the Division of Health workers, as well as of the Associated Charities. On the other hand, certain of the nurses seem to feel that it is difficult to get from the Relief Organizations an adequate budget for food for tuberculosis families. It is quite evident from the milk study that while the relief families are a little better off on milk supply than the non-relief families, they are receiving, nevertheless, a milk supply which falls short by nearly 50 per cent of being adequate to meet the family needs. This is a situation which should be recognized and met. The conditions at the Warrensville Sanatorium do, of course, bear an important rela- tion to treatment. Much has been done in a practical way during the last year or two^to improve the situation there. Heating arrangements have been perfected and improve- ments made in the food supply. Those in charge have also been successful in increasing the average stay of patients, the figure now being six and one-half months. This compares favorably with other institutions of similar character. For instance, at the Maryland Tuberculosis Sanatorium in 1917 the average stay was five and one-sixth months. The war industrial developments since then must have tended to reduce that figure rather than to have increased it. FOLLOW-UP METHODS An effort is being made in Cleveland by the Anti-Tuberculosis League to follow up cases being discharged from or leaving the sanatorium. The secretary in charge of this work, endeavors to find employment for arrested cases, through the Chamber of Com- merce Employment Managers Group, the City Employment Office, the Division of Labor, the Negro Welfare League, the Y. M. C. A., etc. He endeavors to follow up all Warrensville cases, but is of course by no means always successful. He was successful in 1918 in placing 24 cases in satisfactory occupations. This, however, was only a small percentage of the total cases leaving the institution. For instance, for the period of one year 135 males alone left the institution. Of all the cases that do leave and are classified as arrested, it is essential that they be followed up for at least a year to determine the degree of satisfactoriness with which they are making an industrial and social re-adjustment. It is customary in Cleveland to drop arrested cases after an observation period of six months. From the point of view of follow-up, this time could with advantage be extended. The percentage actually leaving the Warrensville institution is in a sense a measure of the need for follow-up, and is also a measure of the effectiveness of treatment. On the male side alone during a recent annual period 135 left the institution, 59 of whom were unimproved. This is 44 per cent of the total and seems like a high percentage. In reality it does not compare very unfavorably with other institutions for which similar figures are .368 Hospital and Health Survey available. At the Raybrook Sanatorium in New York State, for instance, in 1917, of the patients admitted as incipient, 5.5 per cent left unimproved; of those admitted as moder- ately advanced 33.8 per cent left unimproved; of those admitted as advanced 61.9 per cent left unimproved. It is probable that this figure of 33.8 for Raybrook's moderately advanced cases is in a genuine sense comparable with the Warrensville percentage of 44. It is probable that most of the cases admitted at Warrensville are in a moderately ad- vanced state when institutionalized, even though the institution was designed as a place for the treatment of incipient disease. Such it should be, but it is not at present. Cer- tainly an energetic effort should be made, not only to institutionalize more early cases, but also to reduce the percentage leaving in an unimproved condition. Finally, with reference to Warrensville, it may be said that the "case bookkeeping" at the institution is admirable. The quality of the professional records as to examinations, and appended notes, is all that could be desired. EDUCATION AGAINST TUBERCULOSIS Much has been said already about education under the headings Prevention, Detec- tion, Treatment, etc. Educational measures against tuberculosis in Cleveland are for the most part lacking at present. Much, in fact, should be done by the League and by other agencies to fill this lamentable gap in the Cleveland bulwarks against disease. Very little special educational work is being carried out against infection, against disease, or against premature death. Very little educational work is being done in industry. Special efforts at education are needed to increase the effectiveness of the existing diagnostic and treat- ment facilities. TUBERCULOSIS RESEARCH AND TEACHING At the present time there is in Cleveland very little opportunity for special research in tuberculosis work. This applies to laboratory as well as social research. There is need of a special experimental demonstration along the lines of disease detection and control and there is an excellent opportunity for such work in the established health dis- tricts. While Cleveland possesses an excellent medical school, very little advantage is taken of the equipment and personnel to enhance the knowledge of tuberculosis among the medical profession in general. No post-graduate work is offered in tuberculosis at this institution. No special training is provided for the physicians engaged in the health centers. No special opportunities for training and for consultation are offered to the general practitioners. All of these might legitimately be expected from a medical institu- tion of the standing of Western Reserve University. ANTI-TUBERCULOSIS ORGANIZATION The establishment of the Bureau of Tuberculosis in the Division of Health was a great step in advance. However, to realize the full advantages of this measure this Bureau should be given a full-time chief. The Bureau should be brought into closer relation with the medical school, for teaching purposes at least. Tuberculosis 369 Other obvious needs in organization, if the tuberculosis situation is adequately to be met, include improved statistical work in the Division of Health, modifications in the system of case bookkeeping, the extension of the program and personnel of the Anti- Tuberculosis League, a closer inter-relation between the League, the Bureau of Tubercu- losis and the medical school, etc. 370 Hospital and Health Survey VII. Recommendations THE foregoing analysis of tuberculosis work in Cleveland has indicated that in many respects Cleveland is to be congratulated upon the admir- able way ii which the public and private agencies have pushed forward the organization and program for combating this disease. The report has also indicated that the chief deficiencies in the tubercu- losis machinery at the present time are in the fields of tuberculosis detection, treatment, education, organization and general sanitation. In summarizing the conclusions and recommendations made in various sections of the foregoing report, the particular suggestions which seem worthy of special consideration are as follows : ADDITIONAL MACHINERY FOR THE DETECTION OF TUBERCULOSIS To supplement the existing machinery for disease detection we would, on a basis of the report, recommend the following supplementary measures: A Post -Graduate Training Course in Tuberculosis. This course should presumably be organized at the Medical School, though its actual operation might be carried out in cooperation with the Bureau of Tuberculosis or the Anti-Tuberculosis League, or both agencies. In its curriculum it should emphasize the medical problem of diagnosis, classification and treatment. If a general diagnostic medical center is established, it might be operated in close cooperation with such an agency. The courses should be open to the general practitioners in Cleveland and elsewhere, and should be made compulsory for the physicians serving in the health centers. Should the Medical School wish to establish such a service, active cooperation could be secured from the Medical Department of the National Tuberculosis Association. An Expert Consultation Service. Such a service, on tuberculosis, should be established either by the Bureau of Tuberculosis or by the Anti-Tuberculosis League, working in close coopera- tion with the Medical School. This might be at the start either a general service covering all sections of the city, or perhaps preferably a special demonstration service, concentrat- ing in one health district, and working with the physicians of that district, through the center. This service should be, in the first place, for the clinic physicians, but should gradually be extended through the clinics to the physicians in the neighborhood. Tuberculosis 371 Such a consultation service may be counted upon to do the following things for tuberculosis detection in Cleveland: It will increase the number of cases under care. In Framingham, Massachusetts, it helped materially to increase the number from 27 to 200. It will increase the percentage of early cases under care. In Framingham, Massachusetts, it assisted materi- ally in increasing this percentage from 46 to 74. The percentage of early cases in Cleveland at present is approximately 50. It will increase the num- ber of cases cared for in institutions. In Framingham, Massachusetts, this percentage was increased from 20 to 33 per cent. It will help to increase reporting. In Framingham, Massachusetts, the consultation service and other activities quadrupled reporting over previous experience. It will serve as an excellent basis for medical education, being in itself a constantly operating post-graduate instruction course. The consultation service acts as a triple link in the community, connect- ing up the patient and the doctor for early diagnosis, the patient and treatment facilities, and the doctor and scientific knowledge. Routine Work Among Infants, in Schools, in Factories. While the consultation service is the most valuable single measure for the detection of tuberculosis, to be effective it should be supplemented by routine medical work in schools, factories and elsewhere. The consultant may act in his special capacity with as great advantage for the ordinary physician in school and factory work as for the private practitioner. As has been pointed out in the report, there is a glaring need for adequate full-time medical examination and nursing work in the industries of Cleve- land. While the school work is relatively adequate, there is an undeveloped field in prenatal care and among children of pre-school age. ADDITIONAL TREATMENT FACILITIES This report has indicated that there are at present 393 beds for pulmonary tubercu- losis, and 125 beds for non-pulmonary tuberculosis, making a total of 518 available beds in Cleveland. It has also been stated that there should be in Cleveland approximately one bed for every annual death, which at a minimum would mean one thousand beds. The report has also discussed those elements in the population and those forms of the disease which most need increased bed facilities. These needs might be summarized as follows : Increased capacity for early cases. It is estimated that at least 200 beds for early cases should be added to the Warrensville equipment. A concentration upon the discovery of tuberculosis will soon more than fill such an institution. It is understood that there has been in the past several hundred thousand dollars available for tuberculosis institutions. If this is still available or can be re-appropriated, it should be immediately employed for the extension of sanatorium accommodations at Warrensville. As the work in Cleveland progresses, and indeed before very long, there will also develop a pressing need for hospital care for advanced cases. It is suggested that at least 200 beds be made available for this type of case, prefer- ably in connection with the City Hospital. 372 Hospital and Health Survey There is at the present time a pressing need for treatment facilities for open active cases among children. A ward of at least 30 beds should be added to the Warrensville equipment for this purpose. The facilities for the treatment of the closed cases among children at Warrensville are inadequate and could with advantage be expanded to include 20 additional beds. Some provision should also be made for surgical cases complicated by tuberculosis, at City Hospital for acute and at Warrensville Infirmary for chronic surgical disabilities. Provision should also be made for complicated tuberculosis cases, par- ticularly among women, where the disease is associated with pregnancy, syphilis, or other conditions. There is at the present time an urgent demand for preventorium insti- tutional facilities for children under five years of age who have incipient disease, or who have been exposed to the disease and are in an under-par condition. There is probably also a need for institutional provision for the type of case that can afford to pay a self-supporting fee for hospital treatment. This would add approximately 450 beds to the existing equipment, making a total of 968 beds. At Warrensville at the present time there are 254 beds for adults and 30 beds for children, or a total of 284 beds. If to this should be added 200 beds for early cases, 30 beds for open cases among children, and 20 beds for closed cases among children, or a total of 250 beds, the grand total of bed facilities at Warrensville would amount to 534 beds. If, further, 200 additional beds were provided at Warrensville for advanced cases, as has been planned for by the tuberculosis leaders in Cleveland, it would bring the capacity of the Warrensville institution to 734 beds. This would make a decidedly unwieldy institution as to size, and from that point of view it would be more advantageous to con- sider attaching the 200 beds for active advanced pulmonary adult cases, and for cases held pending distribution to sanatoria outside of the city, to a city institution, such as the City Hospital. Provision for 200 beds for pulmonary tuberculosis is planned in the proposed additions to the City Hospital. TUBERCULOSIS EDUCATIONAL PROGRAM An educational program against tuberculosis may develop three main points of attack : against infection, against active disease and against mortality. Among every 100 people in the average community there are 80 or 90 infected with tuberculosis. An educational program should attempt to reduce this percentage. In these same 100 people at any one time from one to two will be suffering from tuberculous disease. An educational program which fails to prevent infection should at least endeavor to prevent tuberculous disease. Approximately 10 of the average group of 100 people are going eventually to die of tuber- culosis. An educational program to be complete must, therefore, aim not only against infection and against disease, but against mortality. A complete educational program against tuberculosis may find its development in two fields: public hygiene and personal hygiene. Public hygiene will in large part deal Tuberculosis 373 with the equipment for hygienic living. Personal hygiene will deal with the modes of existence. Personal hygiene aimed against infection will be of the suppressive type, and personal hygiene aimed against disease will be creative in character. Finally, the chief considerations of creative personal hygiene are three in number: home hygiene, food hygiene and the more distinctively personal hygiene. There follows a very brief skeleton outline of some of the main considerations in the development of a complete educational program. For the utilization of this program, not only will the details have to be filled in, but the suggestive theoretical considerations will have to be translated and developed into practical illustrative propaganda. The custom of the State of Missouri might with great benefit be followed by the State of Ohio, through state legislation or by the Board of Education of Cleveland through resolution or enactment of city ordinance. The statutes of Missouri, R. S. 1909, Section 10,806, provide that "special instruction as to tuberculosis, its nature, cause and preven- tion, shall constitute a part of the course of instruction and be taught in all public schools supported wholly or in part by public money or under state control." EDUCATION AGAINST INFECTION Public Hygiene. Milk pasteurization. Elimination of common utensils. The enforcement of spitting ordinances. The encouragement of institutional treatment, with enforced segregation when necessary, particularly for the protection of exposed children. The development of routine medical detection machinery for all types of active tuberculous disease, including examination work in schools, fac- tories and elsewhere. Personal Hygiene (Suppressive). The avoidance of unnecessary contact with the sick. The avoidance of common utensils or other points of intermediate contact. The avoidance of dangerous coughers, sneezers, etc., and the encourage- ment of respiratory hygiene. EDUCATION AGAINST DISEASE Public Hygiene (Equipment for Living). The encouragement of proper housing equipment, with education against congestion and the lack of facilities for cleanliness. Occupational hygiene, with the relation of overwork, excessive fatigue, unnecessary dust, and other industrial hazards, etc. The development of special medical machinery for the detection of incipient disease, such as the consultation service. 374 Hospital and Health Survey Propaganda to emphasize the basic importance of the elimination of extreme poverty and destitution. The promotion of special hygienic equipment measures and practices, such as open-air schools, recreation facilities, posture clinics, nutrition classes, etc. Personal Hygiene (Methods of Living — Creative). Home Hygiene : Ventilation. Cleanliness, hand washing, etc. Illumination, etc. Food Hygiene: Economy and selection. Home care and preservation. Dietetic control. Personal Hygiene: Exercise. Rest. Recreation. Recognition of early symptoms as danger signals. A moderate life — avoidance of excess, elimination of strain, etc. Regular medical examinations. The creation of a "will to be healthy." EDUCATION AGAINST MORTALITY Public Hygiene. Popularization of hospital and sanatorium treatment, creation of public demand for adequate clinical and nursing service, etc. Institutional treatment or follow-up — economic and social adjustment. Personal Hygiene. Advice to seek the best medical opinion early and follow it. Information regarding the danger of contagion and the spread of the disease. Education against drugs and patent medicines. Emphasis on tuberculosis therapy: rest, fresh air, food, etc. Attractiveness and value of institutional treatment, with minor importance of climatic conditions. Education regarding the proper adjustment of the arrested case to life and work. Tuberculosis 375 ORGANIZATION The Division of Health. The Bureau of Tuberculosis. It can be recommended that in the Division of Health a full-time chief be found for the Bureau of Tuberculosis. This chief should administer the activities of the Bureau, should also presumably be a man of sufficient clinical training to act in the capacity of expert tuberculosis consultant, and might also serve in a third capacity as head of the tuberculosis post-graduate instruction work at the Medical School. In this way these three important services — administration, consultation and instruction — might be effectively linked together. Such a service, under present conditions in Cleveland, if established under the Division of Health, would probably have to be subsi- dized from the financial resources of the Anti-Tuberculosis League. The Statistical Bureau. It is of particular importance to tuberculosis study, and presumably of great importance to all other health problems, that the Bureau of Statistics be further developed than has been the case at present. At the present time it appears that not enough money is appropriated for this work, and that the records are inadequately provided for. From a statistical point of view, it is also important that an effort be made, in figuring tuberculosis death rates in the future, that non-residents be excluded and residents dying out of town included. The records for the past decade at least should be gone over with a similar object in view, in order to furnish a statistical basis for future comparisons. (See special section on Statistics in Part II.) The Nursing Staff. The nursing staff could with advantage be materially increased. The 80 nurses for the Division of Health, plus approximately 32 nurses of the Visiting Nurse Association, 31 school nurses and 10 student nurses in the University District, totaling 153 doing generalized public health nursing work, would have to be supplemented by 113 nurses to bring the total to what is con- sidered a minimum requirement, making available one public health nurse for every 3,000 of the population, or 266 nurses for Cleveland. While the generalized system seems to be working admirably, there are some indications of the need of greater specialized supervision than it has been possible to provide to date. While this is of general importance, it is of particular significance in tuberculosis work, if a special interest such as tuberculosis is not to suffer. Case Classification. There has been recommended a somewhat modified system of current case bookkeeping, a system based on the functional tuberculosis classification chart developed by the Frarningham Community Health and Tuberculosis 376 Hospital and Health Survey Demonstration. This chart has been described in available literature, and need not be discussed in detail here. The system of classification of cases is somewhat modified, on the basis of the National Tuberculosis Association classification. The cases are then tallied on a current functional chart, this chart makes clear the channels through which new cases are being unearthed, shows the variety of early cases that are bound to be discovered in any com- munity, emphasizes different types of advanced cases and distinguishes between different types of arrested cases, reflects the closeness of case follow- up, demonstrates the progression or retrogression of each case under considera- tion, makes simple a monthly summing up of case records by a health center, encourages the persistent follow-up of arrested cases, and has other advan- tages too detailed to be discussed here. Such a system, if incorporated under the health center routine, would greatly facilitate the intimacy of contact between the central bureau of tuberculosis and the outlying clinics, an object to be accomplished by routine summaries from the current classification chart, submitted regularly to the central office. The Anti-Tuberculosis League, It is to be hoped that the League personnel and program can be expanded to meet the current tuberculosis situation in Cleveland. The League requires a full-time secre- tary, and should have at least one main division of work, an educational division, with an assistant in charge of that division, organized for educational purposes. This division should continue the follow-up work from the sanatorium, the occupational therapy, etc. and should be primarily concerned with the development of the comprehensive program of anti-tuberculosis and health education previously outlined. If for reasons of local expediency it turns out to be impracticable to develop the con- sultation service and other newly proposed medical services in the Bureau of Tuberculosis of the Division of Health, it may become necessary for such a bureau to be developed in the League itself. This would constitute a second division of the League; namely, a medical division, headed by a medical secretary, to help in the development of the post-graduate training course at the Medical School, to foster the development of institutional facilities, to cooperate with the Division of Health dispensaries in the development of a consultation service, and possibly to operate a traveling clinic in the county outside Cleveland. Such a bureau, even if developed under the auspices of the League, would form a unit in organization and operation, and might eventu- ally as a unit be transferred to the official health body. This, however, is suggested simply as a possible alternative, recognizing that all of this work logically belongs in the Division of Health, and should, if possible, be developed there from the beginning. To carry out such a program the League would require a secretary, an educational director and a medical director. To develop an educational and medical program without a suggested traveling clinic equipment and operation, would require an annual budget of approximately $20,000.00. With such a traveling clinic the estimated annual budget would more nearly approximate $35,000.00, including clinic equipment. It is understood that the League could probably raise this amount of money with the help of the Welfare Federation, supplemented by the Red Cross Seal Sale. If, however, the medical work can be developed under the Division of Health, the budget required would be approxi- mately fifteen thousand dollars. Tuberculosis 377 The Spirit of Cleveland CLEVELAND has always been a pioneer community, a community with courage, resourcefulness and vision. A forward-looking city, guided by the spirit of cooperation and good will, it is seeking a true appraisal of its genuine needs. In the past the city has admirably accepted the challenge to make Cleve- land the national leader in health and tuberculosis work. Its obligations have been met in the Cleveland way. Having accomplished much, it was legitimate to ask: "What is the next step in the control of tuberculosis in Cleveland?" The willingness of Cleveland to face its problems with patience and courage, its social motive, its spirit of digested idealism, all give assurance of exceptional accomplishment in the future. It remains for a leading American municipality to demonstrate that tuberculosis can, under intense urban conditions, be controlled. Cleveland possesses the knowledge, the resources and the spacious-minded leadership essential to this task. 378 Hospital and Health Survey TABLE I. Tuberculosis Deaths by Age, Pulmonary and Non-Pulmonary, 1913-1918, Inclusive Forms Under 1 yr. 1-4 5-9 10-19 20-29 30-39 40-49 50-59 60-69 70 Total Pulmonary 45' 65 45 395 1465 1299 891 515 249 85 5054 Non-pulmonary.... 116 196 78 106 40 121 61 41 23 12 794 Totals 161 261 123 501 1505 1420 952 556 272 97 5848 Per cent of total.... 2.8 4.5 2.1 8.6 25.7 24.3 16.3 9.6 4.6 1.5 100. TABLE II. Tuberculosis Death Rates per 100,009 for the Years 1913-16, Based on the Estimated Population by Age Forms Under 1 yr. 1-4 5-9 10-19 20-29 30-39 40-49 50-59 60-69 70 Total Pulmonary 45.6 12.7 10.3 54.5 148 172 178 188 189.4 144 116 Other Tuberculosis 113 50 20.2 14.4 13.7 15.2 10.3 16.7 19.4 26.4 20.3 TABLE III. Tuberculosis Deaths by Sex (All Forms) 1914-1918, Inclusive Sex 1914 1915 1916 1917 1918 Total Male _ 542 546 635 776 768 3267 Female.._ _ 301 315 387 432 422 1857 Totals 843 861 1022 1208 1190 5124 TABLE IV. Pulmonary Tuberculosis Deaths by Occupation, 1914-1918 Occupation Total Deaths Housework 1107 Laborer 985 Clerk (office) 185 Student 181 Machinist 165 Teamster and Truckman 99 Carpenter and Woodworker... _ 94 Seamstress and Tailor 91 Moulder , 62 Clerk (store) 56 Metal Worker 54 Painter 49 Salesmen (traveling) r 46 Saloon Keeper 38 Seaman 36 Printer and Lithographer 35 Cook 33 Stenographer 33 Tuberculosis 379 TABLE V. Forms of Tuberculosis Percentage of Total Pulmonary Non-Pulmonary Non-Pulmonary Period Tuberculosis Deaths Tuberculosis Deaths Tuberculosis Deaths 1917 1024 184 17.9 1918 _ 1020 169 16.6 1913-1918 5848 794 13.6 TABLE VI. Attendance at Health Centers for 1914-1918, Inclusive Centers 1914 1915 1916 1917 1918 Total l._ 1,812 . 1,438 1,539 2,232 1,624 8,645 2 2,630 3,008 3,074 2,232 1,788 12,732 3 2,296 4,402 2,101 1,066 861 10,726 4 1,645 2,087 1,755 1,201 1,201 7,889 5 1,768 2,098 1,706 1,433 1,506 8,511 6.__ 211 1,572 2,175 1,536 1,539 7,033 7._ 148 1,906 1,646 2,246 5,946 Totals 10,362 14,753 14,256 11,346 10,765 61,482 TABLE VII. Number of New Cases at Health Centers for 1914-1918, Inclusive New Cases 1914 1915 1916 1917 1918 Total 1 626 398 453 409 390 2,276 2 546 663 554 468 443 2,674 3 573 859 v 423 227 195 2,277 4.__ 1 383 482 405 277 321 1,868 5 464 533 428 393 363 2,181 6 59 456 444 348 377 1,684 7 25 352 332 393 1,102 Totals 2,651 3,416 3,059 2,454 2,482 14,062 380 Hospital and Health Survey TABLE VIII. Illness in Special Milk Consumption Study Families Among Adults and Children Adults Children Causes No. Per Cent No. Per Cent General — Tuberculosis 88 3.95 24 .78 Typhoid 1 .045 .0 • Whooping Cough..._ .0 9 • .292 Cancer _ 6 .27 .0 Rheumatism. 12 .54 1 .032 Contagious - 20 .90 73 2.37 Other .0 1 .032 Nervous and Special Senses — Spinal Cord 12 .54 1 .032 Cerebral Hemorrhage 5 .225 .0 Mental Alienation..... 5 .225 .0 Epilepsy - .0 1 .032 Other Nervous 4 .18 1 .032 Eyes and Ears.. .0 14 .455 Circulatory — Heart. 7 .315 4 .13 Other._ 4 .18 .0 Respiratory — Nasal Fossa .0 1 .032 Bronchitis 6 .27 8 .26 Pneumonia 4 .18 11 .358 Asthma. 3 .135 .0 Other. _ 7 .315 17 .552 Digestive — Pharynx..._ 5 .225 7 .228 Stomach (ulcer, etc.) 7 .315 7 .228 Hernia .0 2 .065 Malnutrition .0 22 .715 Other... _ .0 9 .292 Genito-urinary (non-venereal) — Nephritis... 3 .135 .0 Other 7 .315 .0 Puerperal Normal Child-birth 66 2.96 .0 Skin .- 6 .27 6 .195 Bones 1 045 1 .032 External 13 .584 6 .195 111 Denned— Miscellaneous.... 68 3.05 86 2.79 Total - 360 16.16 312 10.14 Grand Total >- 672—12.7% Tuberculosis 381 TABLE IX. Tuberculosis — Active, Suspicious, and Exposed, in Milk Consumption Study Families Adults Children Total Forms No. Per Cent No. Per Cent No. Per Cent Active 88 3.95 24 .78 112 2.11 Suspicious 22 .99 20 .64 42 .79 Exposed _ 7 .31 26 .84 33 .62 Total 117 5.25 70 2.26 187 3.52 TABLE X. Methods of Milk Purchasing How Delivered Number of Families 4 Bottled 779 Bulk-_ 6 Canned 67 Bottle and Bulk _ 14 Bottle and canned _ 212 Bottle, canned and otherwise 1 Bottle and otherwise 2 Bulk and canned _ 6 Bottle, bulk and otherwise 4 Percentage of Families .4 77.9 .6 6.7 1.4 21.2 .11 .2 .6 .4 TABLE XI. Amount of Milk Consumed Daily Amount per Amount in Bottle Family or Bulk No. of Families Qts. Qts. 6 _ 4- H 1 65._ y 2 32 y 2 358 _ 1 358 86 : 1 y z 129 274._ 2 548 22 : iy 2 55 71 3 213 5 - zy* im 19 4 , 76 10 5 50 920 1480 382 Hospital and Health Survey TABLE XII. Milk Consumption by Relief Families (Bottle or Bulk, Only) Totals No. of Families Quarts per Day 2 4 M 23 K ' 136 l 35 iy 2 131 2 9 2^ 35 3 1 3K 10 4 4 5 i 390 Total Quarts 1 11.5 136 52.5 262 22.5 105 3.5 40 20 654 TABLE XIII Milk Consumed by Non-Relief Families (Bottle or Bulk, Only) Totals No. of Families Quarts per Day Total Quarts 1 3 H .75 42 y 2 21 217 i 217 51 iy 2 76.5 143 2 286 13 2H 32.5 36 3 108 9 sy 2 31.5 9 • 4 36 6 5 30 > 530 839.25 THE CLEVELAND HOSPITAL AND HEALTH SURVEY REPORT List of Parts and Titles I. Introduction. General Environment. Sanitation. II. Public Health Services. Private Health Agencies. III. A Program for Child Health. IV. Tuberculosis. V. Venereal Disease. VI. Mental Diseases and Mental Deficiency. VII. Industrial Medical Service. Women and Industry. Children and Industry. VIII. Education and Practice in Medicine, Dentistry, Pharmacy. IX. Nursing. X. Hospitals and Dispensaries. XI. Method of Survey. Bibliography of Surveys. Index. The complete set may be obtained at a cost of $5.50 plus the postage and single parts at 50 cents each plusthe postage, from THE CLEVELAND HOSPITAL COUNCIL, 308 Anisfield Building, Cleveland, Ohio Printed by The Premier Press Cleveland, O Venereal Di enereai disease Part Five Cleveland Hospital and Health Survey Copyright, 1920 by The Cleveland Hospital Council Cleveland, Ohio Publisbed by The Cleveland Hospital Council 308 Anisfield Bldg. Cleveland - Ohio Preface The Hospital and Health Survey off Cleveland was made at the request of the Cleveland Hospital Council. The Survey Committee appointed to be directly responsible for the work and through whose hands this report has been received for publica- tion consisted of the following: Malcolm L. McBride, Chairman; Mrs. Alfred A. Brewster, Thomas Coughlin, Richard F. Grant, Samuel H. Halle, Otto Miller, Dr. H. L. Rockwood, Howell Wright, Secretary The staff responsible for the work were: Haven Emerson, M. D., Director, and the following collaborators: Gertrude E. Sturges, M. D., Assistant Director; Michael M. Davis, Jr., Ph. D., Director -of the Hospital and Dispensary Survey; Josephine Goldmark, B. A., Director of the Nursing Survey; Wade Wright, M. D., Director of the Industrial Hygiene Survey; Donald B. Armstrong, M. D., Director of Tuberculosis Survey; S. Josephine Baker, M. D., D. P. H., Director of the Infant and Maternity Survey; T. W. Salmon, M. D., Director of the Mental Hygiene Survey; W. F. Snow, M. D., Director of the Venereal Disease Survey; Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey. The expenses of the Survey and of the publication of the report have been met by appropriations received from the Community Chest, through the^Welfare Federation, of which the Hospital Council is a member. The report as a whole, or by sections, can be obtained from the Cleveland Hospital Council. A list of the parts will be found in the back of this volume, together with prices. TABLE OF CONTENTS Page I. General Statement Present Facilities .-■. 395 Past Accomplishments - 395 Present Needs..... 395 Recommendations - 396 II. Medical Phases Introduction — Prevalence — Size of Problem.... 398 Diagnosis -, 400 Treatment 401 Dispensaries and City Hospital 404 Division of Health - 410 III. Legal Aspects Introduction — Relation of Law Enforcement to the Medical Problem 419 Existing Laws 421 Amendments Suggested 421 Administration : Women's Police Bureau 424 Citizens' Committee 426 Women's Court 427 Finger-Print System 427 Vice Conditions - - 427 IV. Protective Social Measures Recreation ----- 429 Preventive W'ork for Women and Girls Women Police 429 Probation 429 Institutional Care of Sex Delinquents 430 V. Sex Education Sex Education for Children. - 431 Sex Instruction for Young Men and Women 432 Social Hygiene Information for Parents and Leaders of Public Opinion 432 Ways and Means of Promoting Educational Measures - 432 Venereal Disease* By Alec N. Thomson, M.D. Mr. Bascomb Johnson Mrs. Martha P. Falconer Mr. F. 0. Nichols I. General Statement PRESENT facilities in Cleveland for the control of the venereal diseases are, generally speaking, as satisfactory as those in the more advanced cities throughout the United States. There are three dispensaries treating cases of gonorrhea and syphilis, and one clinic serving as a diagnostic and advisory center. Facilities for treating cases that require hospital care exist only at the City Hospital. The present laws for the prevention of infection through sexual promiscuity are in the main adequate. The official machinery for the enforcement of these laws exists, but in certain instances is practically inoperative. The institutions that are a necessary corollary to the proper functioning of this machinery are in part lacking, and, where existent, need rearrangement or reorganization to fulfill their greatest usefulness. Other facilities that are distinctly of value as preventive measures (such as recreation, amusements, playgrounds and the like) have not been thor- oughly appreciated as factors tending to reduce or control the venereal diseases, nor have they been correlated with the latter. Facilities for the social hygiene education of the general public, of special groups (such as teachers, parents, nurses, doctors, etc.) and of community leaders may be said to be non-existent. Past accomplishments of the City of Cleveland in the combating and control of the venereal diseases may be summed up by saying that, aside from such treatment facilities as have been available through the dispen- saries, the City Hospital and the general medical profession, no appreciable amount of continuous, constructive work has been done. In this respect Cleveland does not differ from many other cities of the same size; but, with its remarkable community spirit, one is surprised to find that it has not forged ahead in this field during the past few years. The Division of Health has made some sporadic attempts under great handicaps to educate the public, and the clinics have grown steadily, but no concerted effort can be said to have developed. The present needs of Cleveland are the present needs of the country at large — a greater appreciation by, the leaders of the community of the serious- ness and prevalence of the venereal diseases, as well as a greater under- standing on the part of the general public of the practical and comprehensive program of social and medical measures that must be carried out. Perhaps •The services of the investigators were contributed by the American Social Hygiene Association 396 Hospital axd Health Survey the compelling need of the moment is a complete community understanding of the importance of promptly availing itself of competent, adequate treat- ment for the infected, and, as a corollary to this, of the necessity of provid- ing adequate treatment facilities. It is, of course, self-evident that the utilization of all measures which may be brought to bear against the further spread of gonorrhea and syphilis must be promoted simultaneously if any great reduction in the number of cases is to be secured. Equally urgent, then, is the present need for planning a general educational campaign through every available channel to reach the many groups that make up the com- munity. » RECOMMEND A TIONS The methods of demonstrated value in combating and controlling the venereal f diseases which should be considered in determining a plan for a city such^as Cleveland may be divided into: /. Protecting Individuals from Exposure. (a) An educational program for the purpose of character building, through the home, schools, churches, associations and business and fraternal organizations. (b) Instruction of the public regarding public health and hygiene and the need for adaptation of the natural but controllable instinct of sex to the environmental conditions resulting from our present manner of com- munal living. (c) Enlightenment of the general public upon the prevalence, method of spread, economic and social loss, serious consequences to the individual and damaging effects upon posterity, of the venereal diseases. This should be accomplished through the appropriate use of all the civic agencies for education and promotion of social relations; and is the peculiar obligation of the medical profession, through the medium of its membership, supporting the efforts of the Division of Health and the Academy of Medicine. (d) Improvement and regulation of amusement, entertainment and recrea- tion facilities through playgrounds, clubs, theaters and literary, musical and athletic organizations, by appealing to and developing individual tastes and activities, in addition to stimulating group activities. (e) Safeguarding and bettering home surroundings and influences by meas- ures tending to increase home comforts and attractions and better hous- ing and living conditions. Particular stress should be placed upon the encouragement of early marriage and upon such social measures as may be developed to protect and aid children and parents in securing the normal satisfactions of family life. The proper care of the feeble-minded and the discouraging of unwise mating of individuals bear upon the lessening of the number of exposures to infection. (f) Warnings to individuals regarding specific sources of infection; and per- sonal instruction to applicants for information concerning the use of Yenereal Disease 397 mechanical and antiseptic methods of preventing infection either extra- genital or genital. Measures properly included under this heading are discussed in Section II below, devoted to medical phases. 2. Elimination of Environmental Conditions Favoring Dissemination of Venereal Diseases. (a) Elimination of the commercialized aspects of prostitution. 1. Its advertisement — The best advertisement of prostitution is the red light district or tolerated house open to the public. 2. Its protection — Such districts or tolerated houses operate in violation of law and cannot exist without official protection, which means corrupt officials. 3. Its exploitation — The exploiter is the go-between or middleman whose interest it is to stimulate both the supply of and demand for prostitution. Under this head come the illicit activities of procurers, panderers, chauf- feurs, bell boys, keepers of hotels, rooming houses and apartments, man- agers of dance halls, cabarets and other forms of commercialized amuse- ments, who cater to prostitution. (b) Repression of the individual activities of men to purchase sexual grati- fication and of women to sell themselves for this purpose. 1. Prevention of solicitation for prostitution or sexual gratification by either sex in public places. 2. Repression of clandestine prostitution in hotels, rooming houses and apartments by passage and enforcement of prohibitory laws effective equally against both sexes. 3. Provision and Maintenance of Facilities for Diagnosis, Treatment and Control of Infected Persons. (a) The discovery of infected individuals through laboratory aids to diag- nosis, through the maintenance of an advisory clinic, through the stimu- lation of better diagnostic service by dispensaries and hospitals, as well as through examinations made by the general medical profession in private, public and industrial practice. (b) Provision of treatment through the maintenance of dispensaries with adequate equipment and personnel to supplement the service afforded by the medical profession and the enactment of legislation against treat- ment by unqualified persons. (c) Control of infected persons through thorough instruction regarding the venereal diseases by the physician responsible for the treatment of such patients, through the provision of hospital facilities, the quarantine of cases under certain circumstances, the establishment of standards for discharge from treatment and the enforcement of penalties for exposing others to infection. 398 Hospital and Health Survey II. Medical Phases INTRODUCTION— PREVALENCE— SIZE OF PROBLEM THE frequency with which venereal disease occurs in civil life was realized by but few persons until the United States entered the World War. The country was shocked by the prevalence of gonorrhea and syphilis, as shown by the first draft. Although this prevalence is recognized, the unorganized defense (until recently) against gonorrhea and syphilis as compared with other communi- cable diseases makes it impossible to obtain material upon which a positive statistical statement may be based. A conservative estimate, however, can be made to approximate conditions existing at the present moment. Upon these estimates certain positive and constructive plans can be formulated. Cleveland did some pioneer work in venereal disease control, and has in many respects made much progress. It is reasonable to assume that, in general, Cleveland is no worse nor better equipped to handle the problem than any other American city of its size; nor is the total amount of venereal disease that requires attention greater in Cleveland than elsewhere. How much venereal disease exists in Cleveland? From army figures we get merely an idea of the amount of venereal disease work to be undertaken, for it must be realized that army and draft board figures do not include boys below twenty-one, men over thirty, nor the women and children. It must be further understood that gonorrhea and syphilis are germ diseases whose mode of transmission is known; that they are found in all walks of life, at every age from birth to old age; and, finally, that they are respon- sible for many symptoms and conditions classified as diseases other than those generally recognized as or admitted to be venereal diseases. In the second million men called to the colors in the late war 275 cases of venereal disease were recorded for the 6,189 Cleveland men examined at the camps, or 4.44%. If this rate of 4.44% of the pick of Cleveland's men were found infected, it is reasonable to expect to find at lea&t the same rate among all men of the age group of twenty-one to thirty years in Cleveland now, or a total of 7,637. Venereal diseases have been reportable but a very short time. False modesty still lingers, and any estimate of the prevalence of gonorrhea and syphilis throughout the United States is necessarily incomplete. In a very few states venereal disease has been reportable for more than a year; in only one, over three years. The figures for the last six months of 1919 are, therefore, a conservative index only of the incidence, and justify us in con- sidering them as a marked underestimation of prevalence. The number of cases of gonorrhea and syphilis credited to Ohio during the last six months of 1919 in the U. S. Public Health Service reports was 7,380. The total num- ber of cases reported to the Ohio State Department of Health for the period of July-December, 1919, was: gonorrhea 4,438, syphilis 3,869, making a total Venereal Disease 399 of 8,307. Of this number there were reported from Cleveland during the same period: gonorrhea 246, and syphilis 497, making a total of 743 cases. During this same period the City Health Division informed the Survey that 911 cases of venereal disease had been reported, which is a smaller number than were cared for by the clinics or were reported to the Cleveland Hospital and Health Survey by the physicians of Cleveland. In the following table five states and Continental United States as a whole are compared. An equally active anti-venereal campaign, similar to the Ohio State Health Department program, was conducted by each state, except that Ohio had not "pushed" reporting to quite the same degree. VENEREAL DISEASE REPORTED LAST SIX MONTHS OF 1919 S. 8b G. Rate Rate Total Population Gonorrhea per Syphilis per Rate per (Est.) (Reported) 100,000 (Reported) 100,000 100,000 Continental U. S 106,871,294 92,218 86. 68,963 64.5 150.5 Illinois 6,400,473 9,109 142. 5,652 88.2 230.2 Massachusetts 3,889,607 4,996 128. 2,348 60.2 188.2 Michigan 3,173,089 5,496 173. 3,253 102.4 275.4 Minnesota.. 2,378,128 2,586 109. 1,797 75.6 184.6 Ohio. 5,335,543 4,003 75.1 3,377 63.3 138.4 The dispensaries of Cleveland treated more than 1,453 patients for venereal disease during 1919. From correspondence with physicians in Cleveland, and from personal inquiries of physicians and nurses in hospitals and dispensaries and of those engaged in health work outside of hospitals in Cleveland, it appears probable that between 8,000 and 10,000 patients in Cleveland are treated annually for venereal infections. There is good reason to believe that there are in any metropolitan community at least as many venereal disease patients that are not under professional medical care as there are diagnosed and under treatment, and there is some good evidence that there are generally twice as many such patients untreated and prob- ably unrecognized as there are under medical supervision. Recalling the careful estimates of such competent students as Dr. Prince A. Morrow (namely, 3% of the population infected), and using the present day infor- mation as a further basis of estimating, we may properly offer as a reason- able guess that approximately 30,000 individuals (3.8% of the population) are today suffering from gonorrhea or syphilis in Cleveland. This repre- sents the traffic to be handled in office, clinic and hospital. Cleveland must, therefore, prepare to combat the wastage due to gonorrhea and syphilis, diseases that are preventable by known and proven methods — medical, legal, educational and environmental. 400 Hospital and Health Survey DIAGNOSIS The facility for the diagnosis of gonorrhea and syphilis provided through the Health Division laboratory, while probably not sufficient for the full volume of business that can be developed, is meeting the present needs. This is adequate at the moment from the standpoint of technical procedure: the provision of materials, such as slides, Wassermann tubes, etc. The Division of Health, however, seems to be rendering unsatisfactory service from the standpoint of returning reports, as there is considerable complaint about the long period of time elapsing between the sending of the specimen to the Division and the receipt of the result by the physician. The pres- ent scheme of utilizing the temporary service of a college student as serolo- gist on a part-time basis is not sound from the standpoint of organization, nor is it productive of a feeling of confidence on the part of the general medi- cal profession. During the first ten months of 1919 the laboratory of the City Health Division made 525 microscopic examinations for the detection of gonorrhea. During the same period the Wassermann test for the detection of syphilis was performed upon 5,807 specimens of blood. The increase in demand for laboratory aid in the diagnosis of gonorrhea and syphilis has been gradual, but has shown a steady growth, indicating increasing appreciation of the value of the laboratory as a factor in diagnostic procedure. Private laboratory facilities in the City of Cleveland are adequate. A number- of physicians maintain their own laboratories. Many physicians connected with hospitals use the laboratory facility of the institution with which they are connected. Thus, in addition to the work done by the laboratory of the Division of Health, a very considerable number of blood and microscopic tests are done by the hospital and private laboratories. The Health Division laboratory figures can be taken as an index of the volume of private and hospital work that is done in the field of laboratory diagnosis. There is no supervision nor regulation of private, hospital or commercial laboratories by the Health Division. Laboratories used for the detection and control of communicable diseases must be adequately equipped and staffed with thoroughly competent personnel in order to be of real value to the city. The so-called "Government Diagnostic Clinic," 64 Public Square, Cleve- land, Ohio, is probably responsible for a considerable percentage of the increase in the work done by the laboratory of the Health Division. From September 10 to November 22, 1919, this clinic made a total of 265 exami- nations of individuals suspected of being infected with either gonorrhea or syphilis. About 216 cases were received from the courts, 39 cases were referred by doctors, and 10 cases came of their own volition because they had heard of the facility. The quarters are adequate for the purposes of a diagnostic clinic and are well maintained; but they are in an old, unat- tractive building and are inconvenient of access from the street. The loca- Venereal Disease 401 tion on the Public Square is convenient and, with proper publicity, most excellent service can be rendered by such a clinic organized purely as an ad- visory and diagnostic station. RECOMMENDATIONS It is recommended that the Cleveland Academy of Medicine emphasize to physicians the importance and relative value of laboratory aid in diagnosis, in the control of treat- ment and as a check before the discharge of patients as cured; That the Division of Health establish rules and regulations for standards of pro- cedure, equipment and inspection of laboratories offering facilities that have any rela- tion to the diagnosis of communicable diseases. (See page 416.) That the Division of Health serological laboratory be placed on a sound basis of organization with full time personnel; That the diagnostic clinic be continued, preferably as a part of the central downtown dispensary. (See chapter on Dispensaries, Part X.) TREATMENT In considering the treatment of venereal diseases we recognize the need for facilities for the very poor, the self-supporting group that, cannot finance the additional cost of long continued medical care, as well as the group that can pay the entire cost of treatment. Cleveland, like all progressive com- munities, has developed dispensaries to cover the need of those unable to pay, and was the third city to establish pay clinics for treating venereal diseases in the group that is normally self-supporting but unable to meet the financial stress of specialized treatment over a considerable period of time. The third evening-pay-clinic established in the United States is at Mt. Sinai Hospital, which is doing an admirable piece of work. One of the largest and best syphilis clinics in the country, conducted under the most unfavorable conditions as far as quarters are concerned, is at Lakeside Hospital. Charity Hospital established a clinic for venereal diseases in September, 1919. In general, the dispensary facilities for treating gonorrhea and syphilis are inadequate, although the personnel is generally competent, interested and anxious to improve. The patients get good treatment, under condi- tions (except at Mt. Sinai) that not only make the work of the doctors difficult but also must have a very depressing effect upon the patient. It is not possible to gauge the clinics accurately, because of the inadequacy of the record systems. No definite attempt has been made by the clinics to measure their own efficiency, to determine costs, or to plan for future^ad- vancement. Hospital beds are required in but few cases of venereal diseases. When required, the need for beds for such patients is urgent, frequently as a matter of public health protection. 402 Hospital and Health Survey Hospital facilities for treatment of the venereal diseases may be said to be practically non-existent, as Cleveland still maintains the age-old attitude that gonorrhea and syphilis must not be admitted to a hospital. This seri- ously handicaps the work of the private physician as well as the work and development of the out-patient department of the institution. The only available hospital facilities are at the City Hospital, with the exception of almost negligible provision of beds for women at Lakeside in connection with the gonorrhea clinic. The number of beds provided at City Hospital is not sufficient for more than the care of those cases that require control by quarantine because of the patients' lack of ability or actual unwillingness to cooperate in the protection of the public health. There are available for this purpose 75 beds for syphilis and 50 beds for gonorrhea. It is practically impossible for a venereally infected person, who is will- ing and able to pay, to be admitted to any hospital in Cleveland for gonor- rhea or syphilis in the communicable stages. It is the general consensus of medical opinion throughout the country that patients infected with syphilis or gonorrhea present no problem in hospital administration and medical and nursing services of greater menace to the other patients or attendants in the hospital than do those suffering from such diseases as typhoid, pneu- monia, infected wounds, and the like. The latter group of communicable diseases are regularly admitted to the general hospitals without question. The hospital door closed against gonorrhea and syphilis is a relic of the doc- trine that venereal disease is the just punishment for a moral transgression, and is not based upon any inherent technical difficulty of hospital man- agement. It is probable that many cases of venereal disease are admitted to the hospitals of Cleveland under a ""camouflage" diagnosis. Cases have been brought to the notice of the Cleveland Hospital and Health Survey in which the individual, because of his environment, such as living in a hotel or board- ing house, was unable to follow the advice of his physician, and in some instances was actually put out of his place of abode. It is impossible to care properly for these cases under existing conditions. They are not en- titled to admission to the City Hospital because they are capable of paying for their care; and, in spite of this fact, there is no place where they can be provided with the care for which they can pay. Treatment for gonorrhea and syphilis by private physicians in the city of Cleveland is available through a group of specialists, and of course is car- ried on by a large number of physicians who are not specializing in venereal diseases. As a result of the questionnaire sent to the physicians of the city, we find the number of venereal disease cases treated by private physi- cians to be difficult of estimation. 2,060 cases were reported by the 241 physicians that replied to the Survey's questionnaire. A very considerable percentage of patients was reported as having discontinued treatment before having been cured. The reasons given were the usual reasons that are Venereal Disease 403 heard everywhere: "continued treatment at free clinics," "lack of funds," "unwillingness to pay fee," "carelessness," "dislike of treatment," "removal from city," and similar excuses. Without doubt the medical profession of Cleveland as a whole ranks as high as in any city with an equal number of physicians. The treatment of the disease is oftentimes scientifically outlined, but the patient's individual problem is frequently neglected — his or her economic status, environment, personal feelings, and the like, are given scant, if any, consideration. It must be realized that the average doctor has neglected the social phase of medical work, both as general practitioner and as specialist, in that he has made no attempt to follow up the patient who discontinues treatment. RECOMMEND A TIONS It is recommended that all general hospitals change the rules of admission so that there may be no discrimination against venereal diseases, and that pay beds may be made available for gonorrhea and syphilis in any stage of the diseases. That each hospital that maintains a dispensary for the treatment of venereal diseases organize a special department for the purpose of correlating the dispensary and hospital work in the care of these diseases, and that a definite bed allotment for free, part-pay and pay patients be assigned to the reorganized venereal disease service. The service can be classified in the hospital organization singly, in one unit, as the Department of Venereal Disease; or into three divisions: Urology, Dermatology and Gynecology. In this latter plan syphilis would be assigned to Dermatology, gonorrhea in the male to Urology, and gonorrhea in the female to Gynecology. That closer cooperative arrangements be developed between the clinics and the City Hospital for the care of indigent and irresponsible cases at the hospital, with more effective methods for the return of these patients to the clinic for after-care following their release from the hospital. That the City Hospital administration be so improved and supported that hospital or city politics will not be able to ruin what can and should be the biggest and best venereal disease service in the city. That the Academy of Medicine bring to the attention of all physicians of Cleveland the sociological aspects of venereal diseases, and place squarely before the doctor his peculiarly strategic relation to the problem. This might well be done by letters, pam- phlets, clinics, meetings and the use of such clinical motion pictures as are produced by the governmental and other agencies engaged in the national campaign for the control of gonorrhea and syphilis. That private physicians be urged to cooperate in the educational and social protec- tive work which tends to reduce the number of exposures. That physicians prepare themselves to advise exposed individuals as to means for prevention of infection ; and equip their offices and dispensaries with facilities for prophy- lactic treatment, supervise such treatment when it will be of value, and maintain contact with the exposed person so advised and treated during the period of presumed incubation. 404 Hospital and Health Survey That the Bureau of Venereal Diseases in the Division of Health cooperate actively with the Academy of Medicine in the diagnosis, treatment and control of venereal dis- eases; and to this end receive the benefit of the opinion and advice of a special committee of the Academy, appointed from among its members, in matters of educational policy and administrative control of patients. DISPENSARIES AND CITY HOSPITAL Cleveland has three dispensaries that maintain clinics for the treatment of gonorrhea in the adult male and syphilis in both sexes and all ages. Gonor- rhea in the female and in children is cared for, if cared for at all, in the de- partments of Gynecology and Pediatrics. No clinic is located in quarters that tend to promote the best effort of the doctors or the most cooperation on the part of the patient. One clinic (Mt. Sinai) has quarters in a remodeled residence that meet the requirements of cleanliness, relative privacy, separate waiting rooms for the sexes, and confidential conference between physician or social worker and patient. The patients are drawn to each of the venereal disease dispensaries from all parts of the city, and there is a great deal of cross traffic. The location of the clinics is brought to the attention of the general public by means of a large placard posted by the Division of Health in a few public places, such as toilets, shops, and the like. In general it can be said that good professional care is available at all the clinics, although, under the difficulties inherent in poor and crowded quar- ters, by no means the best that the physicians are capable of rendering. RECOMMEND A TIONS It is recommended that the city be districted and the public toilets located in each district be thoroughly placarded by the Division of Health to call attention to the venereal disease clinics in the district; and that additional publicity be given all the clinics in places such as railroad stations, industrial plants, public toilets, and the like, which, because they are primarily used by people from all parts of the city, will not fall readily into a dis- trict plan. That a new, smaller and more attractive placard be prepared by the Division of Health for this purpose. The number of placards required will exceed 10,000 if complete coopera- tion of the industrial plants is secured. That new clinics be established on the west side and southwest side of the city. That the present so-called "Government Clinic" be developed into a diagnostic and advisory clinic, maintained or closely supervised by the City Division of Health, properly advertised throughout the entire city; that it refer to private physicians all applicants that can pay, and refer to the clinics serving the district in which the patient resides all applicants that cannot pay the private practitioner's fee ; that it serve as a center to which the physician may send his patients for diagnostic assistance; and that it be incorporated as part of the proposed central downtown dispensary. (See chapter on Dispensaries, Part X.) Vex ere a l Disease 40.5 Chart of Cleveland showing distribution of patients treated at Lakeside, Charity and Mount Sinai Hospital Dispensaries for venereal diseases, according to residence by Health Division Districts. The percentages of patients recorded at each dispensary as living in a given district are shown in parallel bars. The total cases for each hospital, upon which the chart was based, are as follows: Lakeside 1,062 cases of syphilis Charity.. 140 cases of venereal disease Mount Sinai... 250 cases (Syphilis, 65%; Gonorrhea, 35%) The narrow eastern end of District 6, extending along the lake shore is not included in this map. 406 , Hospital and Health Survey That supervision of the clinics and the establishment of reasonable standard mini- mum requirements for their equipment and services be undertaken by the Division of Health after conference with the proposed Dispensary Committee of the Cleveland Hos- pital Council; and that no dispensary (public, private or commercial) be permitted to treat gonorrhea or syphilis unless the requirements are met as certified by the Division of Health. (See page 417.) That more educational work be done in all the clinics by means of personal interviews, pamphletSj wall placards and similar methods. That printed material, such as cards, pamphlets, wall charts, and the like, be pro- vided for the clinics by the Division of Health. Lakeside Syphilis Clinic — Day — Men, Women and Children A patient who applies for treatment at this clinic must apply at the admission desk in the main dispensary, receive the medical record, walk across Lakeside Avenue to the clinic building, wait in a small crowded room for the opportunity to see the doctors, then visit the social worker, then return to the main building to turn in the medical record and have any prescription filled or receive salvarsan, before being free to go home. This useless consumption of time, and exposure to inclement weather, coupled with the unsightly old wooden tenement that has never been remodeled to meet clinic purposes, is an affront to the self-respect of the patient and a dis- couragement to the personnel. During the winter months this building is improperly heated and inadequately supplied with water. At times there is no water. Educational work with the patients for the protection of the individual, the family, and the general public, is well done. The personal relationship between the staff and the patient is excellent, but is maintained in spite of the handicapping conditions mentioned above. The patients are educated to the great need for treatment continued over a long period of time; and, if they fail to keep their appointments, are requested, by postal card, to return. This failing, effort is made, by home visits, to bring the patient back to treatment. Effort is also made, with considerable success, to bring to the clinic the other members of the patient's family. Largely due to the personality of the physicians and the social worker, the handicap of poor quarters is overcome and the clinic "atmosphere" is quite human. That the patients are aroused to an interest in their own welfare, as well as in the protection of the public health, is evidenced by the enrollment of 800 cases of syphilis — largely by the "family groups" — under observation and treatment. Venereal Disease 407 Syphilis Clinic — Evening — Pay The general personnel is the same, and similar measures are followed. As this clinic is housed in the main dispensary building, it presents a dis- tinctly better appearance and can be managed more efficiently. About 400 syphilis cases are registered as under observation or treat- ment. Compliance by the dispensary management with the simple recom- mendations of the personnel would greatly increase the efficiency of the clinic and would promote the comfort and convenience of the patients. RECOMMENDA TIONS It is recommended that, because of the existing handicaps inherent in the present quarters, the growth of this clinic be checked; unless the volume of work be taken care of by the increasing usefulness of the other clinics and the opening of new clinics, and the overcrowding be overcome by the separating of the syphilis cases from the dermatological cases. Gonorrhea — Male The clinic, aside from the actual professional treatment of the "case," in no way meets the requirements of a modern clinic for treating communi- cable diseases. The quarters are cramped. There is no privacy. No attempt is made to follow up the patients that fail to continue under treat- ment until no longer a menace to the community. Little or no effort is made to educate the patient regarding his condition for either his own good or the protection of the public health. Gonorrhea — Female The Gynecological Department treats gonorrhea in women and vaginitis in children, but has only 32 women and about 20 children registered. Re- cently a social worker was detailed to the clinic. Hospital beds are avail- able, and the method for treatment calls for three or four days' hospitaliza- tion. This is the only clinic in Cleveland for women suffering from gonor- rhea that provides any bed facilities for its patients. If really active work were done in conjunction with the men's clinic, the women's clinic should be very much increased in its facilities, proportionate to the accommoda- tions of the men's clinic. An excellent public health protection should be available to Cleveland through the Lakeside Dispensary Gonorrheal Clinics. RECOMMENDATIONS It is recommended that a complete reorganization of the gonorrheal service of the Lakeside Dispensary be undertaken, in order that both male and female patients may receive^adequate, humane treatment under conditions that will tend to increase rather thandestroy the*self-respect of the patients. 408 Hospital and Health Survey That a follow-up systerr. be established. That adequate quarters be provided. That the evening and day-time clinics be under the same medical supervision. That a responsible person be placed in charge of the men's service, and that this physician be the urologist to the hospital and to the dispensary. That the placards advertising the "pay clinics" be removed from the dispensary, on the ground that they are justly criticised by the medical profession as being too com- mercial, particularly when considered in conjunction with the general method of organ- ization of the evening pay clinics. These clinics are practically distinct from the dispen- sary day clinic, and are not under the supervision of the hospital staff. Mt. Sinai Gonorrhea — Men. Syphilis — Men. Women and Children Evening — Pat/ This clinic, located in a remodeled dwelling (semi-detached), is well arranged on two floors, and has separate waiting rooms for men and women. It is well equipped, clean, efficiently and humanely managed. Every effort is made to impress the patient with the seriousness of his condition and the importance of continuous treatment and observation until he is pronounced cured by the physician. Follow-up of patients that do not return for treat- ment is done by mail, but house visiting is done only in exceptional cases. The clinic is rapidly outgrowing its present quarters, although it is still possible to maintain a considerable degree of privacy. This tendency to crowding can be met by an increase in personnel and the opening of the clinic every night instead of only three times a week. RECOMMENDA TIONS It is recommended that the service be improved by the addition of a clinic clerk and the use of a social worker, so that follow-up by mail may be re-established and consistently carried out, by using a less cumbersome system of form cards for this purpose and allow- ing a shorter time interval to pass before follow-up work is begun. That the clinic be open every night except Sunday in order that it may meet the demand bound to result from the national, state and local campaign for combating venereal diseases. That a gonorrhea clinic for women be established. St. Vincent's Charity Hospital Gonorrhea — Evening — Male This clinic was established in September, 1919, and has grown" very rapidly — so rapidly, in fact, that organization has not kept pace with growth. Administration is not smooth and there is no separation of patients in the waiting room by age, sex. or color. Venereal Disease 409 Educational work with patients is not carried out to any great degree, and a full understanding of- the function of a modern clinic that deals with a communicable disease, such as syphilis or gonorrhea, is apparently lacking. There seems to be no responsible direction of the clinic by the physician in charge. The staff is irregular in arriving and departing. The great need of a clinic in this area is demonstrated by the growth of this clinic despite the irregular service rendered. Facilities exist for the development of a modern clinic that would render positive service to the patients in a location of great strategic value for the protection of the community. With more time for organization, with careful study of the problem of clinic management, with better social treatment of the patient by the personnel, and with a definite follow-up system to bring back the patients that discontinue treatment, this clinic can fill an important need of the city of Cleveland — a responsibility not now being met. Gynecology — Female Gonorrhea in women and children is treated in the Department of Gyne- cology. Syphilis Syphilis in men. women and children is receiving attention in a special clinic, which has possibilities of development as outlined above. The laboratory facilities are probably adequate, although not used as freely as one would like to see. This is due, in a large measure, to the lack of organization and correlation. The method of collecting blood specimens for the Wasserniann test by means of a capillary tube appears to be decidedly obsolete, and the requests for additional specimens seem to bear out this observation. The follow-up methods are not bad if well conducted. Letters or notices are sent the patients that fail to return. Obviously, three letters a month apart, and then reference to the Health Division for action, cannot be expected to function for the benefit of the patient or the protection of the community. There has been a falling off in the volume of work done since January, 19*20, which we believe can be attributed to the staff personality and method of handling patients, as well as to the irregularity of time of arrival and de- parture of the doctors. The ""floating" population, the clinic hours, the poor arrangement of rooms, lack of system and long periods of waiting are all contributory factors. RECOMMEND A TIONS It is recommended that better management be instituted. That gonorrhea in women be given proper consideration; and, That, because of the present need and the indicated future growth, the clinic be open six nights a week. 410 Hospital and Health Survey City Hospital The venereal disease service of the City Hospital has never been entirely satisfactory. Gonorrhea in both male and female has been neglected, and the importance of the urologic and gynecologic services has not been recog- nized or developed to a degree at all commensurate with the city's responsi- bility in caring for the individual. It is estimated that about 150 beds will be required in making adequate provision for the venereal disease patients; and this must receive considera- tion in the plans for the reorganization of services and rebuilding of the City Hospital. In general it may be said that, while the syphilis service as main- tained prior to its discontinuance during the recurrence of influenza in Febru- ary and March, 1920, was excellent, and the quarters in which the depart- ment of dermatology was housed (in a remodeled and repaired building) are the best, in the present City Hospital marked improvement is required to make the most of the possibilities. In other words, nothing short of a new building will make it possible to provide the type of venereal disease service that the City Hospital of Cleveland should maintain. Gonorrheal service for women can be rated as only fair, because it varies with the different services; while the gonorrheal service for men is not satisfactory and is, as a matter of fact, neglected, if not ignored. It is recommended that for the sake of the future development of venereal disease service, a definite plan of procedure free from any consideration of professional jealousy or controversy on the part of the staff and manage- ment, be put into effect. Two possible plans may be considered: one a venereal disease service, caring for all cases of gonorrhea and syphilis in both sexes of all ages, under one member of the staff acting as chief of a major hospital service, with a corps of associates especially trained in the various ubdivisions of venereal disease treatment, plus a cooperative arrangement for consultation service with the other departments of the hospital organization; the other a three-headed service, with syphilis assigned to dermatology, gonorrhea in the male to urology, and gonorrhea in the female to gynecology. In this second scheme of organization the department of dermatology as now organized should continue to function in its present efficient manner. The urologist and gynecologist must have a full service under the surgical division of the hospital organization. These services should be continuous through- out the year. The appointees should be definitely charged with the respon- sibility of caring for all cases of gonococcal infections, both acute and chronic, in their respective fields, and at the same time charged with the care of the surgical work properly falling within the domain of the special divisions of urology and gynecology. DIVISION OF HEALTH Six years ago the Division of Health outlined a campaign for the control of the venereal diseases. One of the things proposed under this campaign was the establishment of a special bureau to devote its energies to educa- Venereal Disease 411 tional and medical work and particularly to the reporting of cases. This bureau was never established; reporting has not been stimulated or enforced; and it is found that little work along educational lines has been attempted. The only Division of Health activity is the laboratory facility mentioned as a special topic under Diagnosis. During the war certain renewed activity was stimulated by the United States Government and the State Board of Health. Advantage should be taken of the public sentiment then developed, and the continued national campaign should be used as the foundation upon which to base the future activities of a special bureau of the division. This can be done in such a manner that the confidence of the medical profession will be regained and retained. The general public not only needs but will welcome educational information. The only educational material used in the city at present is provided by the State Health Department. Theoretically, one of the important functions of the Division of Health in controlling exposure to syphilis or gonococcus infection is to warn indi- viduals regarding specific sources of infection; but few of the practical procedures worked out for other infections are applicable to the venereal diseases, and such special measures as are being tested out for the latter are thus far limited largely to what may be accomplished by the private physician and through tactful social service follow-up among the families and intimate associates of infected individuals. Again, personal instruction of individuals likely to be exposed is of great importance. The pupil nurse, for example, who is about to assist in an Operation or care for an active case of syphilis should be instructed in mechanical and antiseptic methods of preventing infection of herself or others. It is not difficult to train her to wear rubber gloves, to wash her hands thoroughly with soap and water, to avoid touch- ing her eyes or lips with her hands, and to use such antiseptics as may be designated. In theory it is just as possible to instruct individuals to employ similar methods for avoidance of genital infection. In practice, however, the health officer as well as the physician finds himself confronting the facts that genital exposure to venereal infection is not consciously risked within marriage, and that exposure outside of marriage is not sanctioned under any conditions by American public opinion or by law. Consequently, to undertake popular education for individual prophylactic measures presents the dilemma of over emphasizing the importance of what is a relatively small number of cases of exposure in wedlock, or of admitting a very large number of violations of law and public standards of morality by illicit inter- course. Scientific knowledge exists upon which have been based useful military measures for promptly cleansing exposed surfaces and membranes of the body and applying effective antiseptics.* As- a part of a general adminis- trative program in the army, where all the men can be required under mili- *The essential factors in the procedure generally known as "medical prophylaxis" are: the appli- cation within a short period of time after exposure (preferably within an hour) of mechanical cleansing of exposed parts with soap and water; the administration of an antiseptic solution to the urethral and vaginal mucous membranes for protection against gonorrhea; and the application of a germicidal oint- ment for protection against syphilis. 41 ^ Hospital axq Health Survey tary regulation to carry out instructions given them, and where every man must be taught the purpose and relative importance of each measure in the entire program, so-called "medical prophylaxis" has its place. In civil life to achieve the same results even among those who could be reached, it would be necessary for physicians and clinic chiefs to advise with individuals, who apply to them immediately after exposure, to provide adequate supervision of the prophylactic treatment recommended and to keep in touch with each individual until all danger of infection is passed. The difficulties of securing such administrative efficiency, and the dangers of stimulating undue dependence upon prophylactic measures officially recom- mended, have prevented the development of practical prophylactic measures of general public health importance. Furthermore, the promulgation of such measures has been constantly met by opposition from those who earnestly believe that popular education concerning the methods and the places where such preventive treatment may be administered, would be interpreted as public sanction for greater sexual promiscuity, at the same time diverting popular attention from the larger and more effective preventive measures of the program. It is believed that prophylactic measures of this character are of relatively slight practical importance in civil life. It should be stated in this connection, however, that this applies only to prophylactic measures for genital exposures, because popular opinion holds that it is reasonable to demand that individuals protect themselves through the more effective and morally far more desirable measure of avoidance of any exposure through sexual contact. In contrast, public opinion fully supports and laws demand prophylactic measures for prevention of the development of gonococcus in- fection of the eyes of new-born children exposed by passage through the infected birth canal of the mother. RECOMMEND A TIONS It is recommended that the Division of Health establish a special bureau in charge of a full-time medical officer, with the needful number of assistants (such as nurses, clerks, etc.), to conduct properly a comprehensive campaign for the eradication of gonorrhea and syphilis. The duties of such a bureau should be the organization, the supervision and the stimulation of treatment facilities; the returning to treatment of those patients who fail to continue under medical care until cured; the education of the public upon the methods of contraction, spread, control, prevention and treatment of veneral diseases- The duties of the chief of this bureau in completing a comprehensive program would pre- clude any clinical work, either private or public. In order to gain the absolute confidence of the medical profession, he should have had clinical experience in the treatment of the venereal diseases, and he should not be required or permitted to do clinical work. The following plan of organization for the venereal disease bureau of the Division of Health is suggested : Venereal Disease 413 Proposed Organization for Venereal Disease Bureau of the Division of Health 1 Chief (full-time physician). 2 Nurses (female). 1 Agent (male). 1 Stenographer. 1 Clerk. The function of the special bureau of the Division of Health devoted to the combating and control of the venereal diseases should be primarily educational — education of the public upon the general subject of prevalence, mode of transmission, serious consequences of gonorrhea and syphilis, and the necessity for prompt and continuous treatment. This educational work must reach all classes and ages in the community, directly or indirectly, through lectures, the use of motion pictures, stereopticon slides and pam- phlets and other means of printed publicity. Special educational work is required to reach the physicians, not only for the purpose of arousing their interest as members of the community in the campaign for the combating of venereal diseases, but also to develop the professional appreciation of the necessity for better diagnosis and more con- scientious, continued treatment. An active campaign along strictly pro- fessional lines should be conducted by the Division of Health in cooperation with the Academy of Medicine, using as the vehicle, existing motion picture films upon the modern diagnosis and treatment of gonorrhea and syphilis, supplemented by such printed material as is available or may be produced. An efficient campaign of this character will stimulate the reporting of gonorrhea and syphilis, which has been neglected in the past. The adminis- trative function of the Division of Health, Bureau of Venereal Diseases, should include the education and stimulation of the hospitals of Cleveland to an appreciation of the necessity for bed treatment for selected cases, the inspection and supervision of dispensaries treating gonorrhea and syphilis, and the stimulation of the clinics to improve continually the existing facili- ties. Material assistance can be rendered to dispensaries in various ways, and the City Division of Health should act not only as the stimulating agency but should also assume the function of intermediary between the local clinic and the state and federal health authorities. The state subsidy, both in the form of financial aid and of free arsphenamine, should be received by the department and distributed to the approved clinics. The reports from the various clinics can be consolidated for forwarding to the proper authori- ties. Provision for examination, diagnosis and treatment of cases requiring control should be made by the City Division of Health. Quarantine of those individuals unwilling or unable to protect the community must be assumed by the Division of Health, and its facilities should be so adjusted that they may be available for the private practitioner, clinic, hospital and the court. 414 Hospital and Health Survey Various social measures come within the function of the Venereal Disease Bureau of the Division of Health through its close cooperation with courts, clinics, physicians and the organizations represented in the Welfare Federa- tion. A standard method of follow-up should be developed, and it is recom- mended that some series of forms similar to that suggested in the following recommendation be used for both publicly and privately treated individuals. Full use should be made of, and thorough cooperation given by the Division of Health to the social service machinery of the city, whether this be through a central organization serving all the hospitals, clinics and physicians of Cleveland, or through the social service departments of the individual insti- tutions. The duties of the chief should be to direct the general activities of the bureau, to inspect the diagnostic and treatment facilities throughout the city, to stimulate greater activity and improve the efficiency of all the agen- ices engaged in the combating and control of the venereal diseases, to main- tain close cooperative arrangements with state and federal agencies, both public and voluntary, and, finally, to institute such new procedure as may be required from time to time. The duties of the nurses should be to aid and inspect follow-up work, to assist in the transferring of patients from hospital to clinic or vice versa, to cooperate with the probation officers, and to assist in the various activi- ties connected with the work of the courts. The duties of the agent should be to placard the city, check drug store prescribing, investigate the advertising and non-advertising medical charla- tan, and carry on such other activities as call for the services of a non-medical male employe. The duties of the stenographer and clerk should be the ordinary activity of routine office work. The Division of Health should prepare and provide the printed material for educational and follow-up work required by dispensaries that treat venereal diseases. Details of a follow-up plan are outlined below: Follow-up To control the spread and prevent the future development of disastrous sequelae of gonorrhea and syphilis, continued effort must be made by the Division of Health, physicians, clinics and drug stores, to the end that the patients understand the necessity for uninterrupted treatment and observa- tion until pronounced cured by the physician. This can be accomplished by the judicious use of educational material, such as public lectures, pam- phlets, posters, and the like, coupled with the institution of the most modern therapeutic procedures in clean, orderly and generally well-maintained treat- ment quarters — all coordinated with broad human understanding by a trained physician, who, realizing his responsibility, carefully explains to each patient, at the first visit, the serious nature of the complaint and empha- sizes the necessity of conscientious, continued treatment. V-E NEREAL DISEASE 415 Some infected individuals need to be brought to a forceful realization of their personal or public responsibilities with regard to communicable dis- eases. For their benefit the Division of Health must be prepared to meet its own responsibility and, in cooperation with the physician in either his private practice or clinic service, should arrange methods of varying degree for the purpose of again placing the delinquent patient under treatment. A simple "request" card has been found efficient in a number of clinics, and has also been used by physicians in their private practice. These cards are sent out in sealed envelopes as first class mail. Mr _ _ : _ No. You are requested to return on or before _ You were not cured at your last visit. You need further treatment or observation. For youi own good and the protection of others this card is sent to you. Kindly answer this note. M. D. Upon receiving no response to these calls for more active measures, the use of the following form is suggested: Mr : No... You were requested to return on or before Will you return on You were not cured at your last visit. You failed to keep this appointment or to notify us in any way. If you are under competent medical care, we are satisfied. Failure to notify us of your present arrangements for medical care will force us to report you to the Division of Health. For your own good and the protection of others this card is sent to you. Kindly answer this note. M. D. 416 Hospital and Health Survey The third form should be a final notice that, unless the individual return for treatment, his or her name and address will be reported on a certain date to the Division of Health, in compl ance with the law. Two extra blanks will be required for reports to the Division of Health : one for the physician to report his patient under treatment elsewhere, and one to report failure of his patient to return for treatment. Any efficient plan for holding individuals to prolonged periods of treat- ment and observation requires that patients be educated to the end that they understand the need for continued treatment; the advisability of notify- ing the doctor when unable to keep an appointment; the real power possessed by the Division of Health; and, finally, the likelihood of action by the clinic or physician should circumstances demand force. Equally necessary to make any "follow-up" notification efficient is the proper timing of the notices. The first notice ought never to be delayed more than a week after the first neglected appointment; the second notice must go out, if it is to carry weight, on the day of the unkept new appoint- ment; and the third highly official notice should be timed for not more than a week later. The Division of Health, upon receipt of notice of discontinu- ance of treatment, should begin official action by sending its inspector promptly to visit the patient for the purpose of persuading the individual to return to treatment. If the patient does not respond to persuasive methods, quarantine or isolation should be enforced. The Division of Health should establish rules and regulations prescribing minimum requirements for the conduct of dispensaries that treat gonorrhea and syphilis. (See page 417.) The Division of Health should be guided in its activities by an advisory council or committee on venereal diseases, appointed by the Commissioner. Rules and Regulations Governing the Conduct and Maintenance of Laboratories Rules and regulations governing the conduct and maintenance of labora- tories that offer facilities for the diagnosis of gonorrhea and syphilis should be formulated by the Division of Health. These rules should apply in general to the entire field of infectious diseases. The lack of supervision by the Division of Health over private, hospital and commercial laboratories is undoubtedly a weak link in the general problem of venereal disease control. The Sanitary Code should have a section stating that all laboratories in Cleveland that offer facilities for the diagnosis of communicable diseases shall not be conducted or maintained without a permit issued by the Divi- sion of Health, or otherwise than in accordance with the regulations. The regulations should provide for: 1. Applications for permits to conduct and maintain laboratories. 2. Duly qualified persons to be in charge. Venereal Disease 417 3. Proper handling of specimens received at the laboratory by a method of numbering and designation that will definitely establish the identity of each particular specimen in order that errors may be avoided. 4. Proper records covering the following points: (a) Laboratory number and date of receipt of specimen. (b) Name and address of the person from whom the specimen was taken, or some symbol possible for identification. (c) Name and address of the person to whom the report of the result was made. (d) Finally, the result of the test The records should be available for inspection by the duly authorized Division of Health representative. 5. Establishment of reasonable minimum requirements in order to safeguard the provision of adequate facilities for the proper performance of the test undertaken by the laboratory. In line with this should be some definite recognition of a reasonable method of procedure. Rules and Regulations Governing Dispensaries Rules and regulations should be formulated' under the Sanitary Code to govern dispensaries wherein communicable diseases are treated or diagnosed; so that they shall not be conducted and maintained without control and supervision of the Division of Health. Rules governing the conduct of dis- pensaries for the treatment of persons afflicted with syphilis or gonorrhea may be divided into two divisions: Syphilis Regulations for the treatment of syphilis should provide for : 1. A special department that shall be responsible for the care of all indi- viduals that come to the dispensary infected with syphilis, with the pro- yiso that when the nature of the part affected requires treatment in some other department of the dispensary, treatment may be given jointly by the two departments. 2. Microscopic examinations of suspected lesions by the syphilis depart- ment. 3. Laboratory facilities for making Wassermann tests in the dispensary, or the use of the Division of Health laboratory or other approved labora- tories. 4. Prompt, intensive treatment, by the use of salvarsan, mercury, or other accepted means of treatment in sufficient quantities in all cases of syphilis. In order to fulfill the public health function, the clinic must be made to appreciate its obligation to render an infected person non-communicable at the earliest possible moment. 418 Hospital and Health Survey 5. Regulation of the number of patients to be treated, in order to overcome crowding and the reduction of efficient service to the patient and, there- fore, to the community. From experience throughout the country, it is generally conceded that the maximum number of patients to be treated by a clinic should be limited and not exceed ten an hour per physician. 6. Complete and adequate records. These are of primary importance to the successful conduct of a dispensary, and should be, in so far as possible, standardized and made available for the approved clinics. 7. Maintenance of a follow-up system according to a plan approved by the Division of Health, in order to insure regular attendance. 8. A standard procedure providing for the discharge of patients, to include test and subsequent observation. 9. Having dispensaries open at least three days a week, preferably during evening hours on at least two days. Gonorrhea Regulations for the treatment of gonorrhea should provide for: 1 . Systematic microscopic examination of all discharges in every department of the dispensary wherein any person is treated. 2. Provision for and employment of proper facilities for asepsis and antisepsis. 3. Facilities for urethroscopic and cystoscopic examination to be regularly employed by the physicians in attendance. 4. The use of complement-fixation test for gonorrhea. It is deemed advis- able to recommend this, although this test is not as yet thoroughly estab- lished in medical practice. 5. 6, 7, 8 and 9 are the same as for syphilis. Venereal Disease 419 III. Legal Aspects THIS Survey is concerned not only with what Cleveland is doing and should do to detect, diagnose and treat venereal disease, it is even more vitally concerned with what Cleveland is doing and should do to prevent, detect, diagnose and treat sex delinquency, as the cause of venereal disease. The analogy is a fair one, because prostitution and other forms of sex delinquency are certainly diseases of society and require the application of the best social science for their amelioration. Laws relating to sex delinquency follow the outlines of the average medi- cal text book. They define and name each disease or offense, provide sani- tary measures in the shape of decent environments, describe the symptoms of each disease in terms of human conduct, provide for the early detection of those symptoms by the police, the diagnosis in the verdict of the jury, and the treatment in the sentence of the court. Much other machinery necessary in one or the other of these processes, such as prosecutors, probation officers, psychiatrists, jails, detention houses, reformatories and feeble-minded colonies, require the sanction and support of laws to operate. It is fairly obvious, therefore, that a consideration of the laws on this subject is of first importance. The Legal Section of this Survey will attempt to cover Cleveland's laws or sex delinquency and some of the machinery for their enforcement. The relation of sex delinquency laws and their enforcement to venereal disease is the relation of cause and effect in the inverse ratio. This is true, because the aim of such laws is to prevent sexual relations outside marriage, and such relations are known to be the immediate or ultimate source of most venereal disease. If we could devise 100% perfect laws prohibiting extra marital relations, and have them enforced with 100% efficiency, venereal disease would after a while disappear. No community has been found, however, and probably none will ever be found in this country, willing to undergo the paternalistic supervision and to make the sacrifice of personal liberty, necessary to accomplish this result solely by repressive measures. Religion and education will and should be relied upon to penetrate and influence the more intimate and private lives and standards of the people. The sexual conduct of the individual becomes a matter of public concern and therefore of legal regulation, only when it seriously affects the sanction of monogamous marriage, or the integrity of the family, or the public health. J-'-iO Hospital axd Health Survey From all three points of view, the niost serious menace to the public wel- fare in sexual conduct, is promiscuity. From the public health point of view promiscuity may fairly be said to cause the vast majority of all venereal disease. That female is the most dangerous of sex delinquent women who is most promiscuous, because she is most likely to be diseased and to transmit dis- ease, and this regardless of whether she demands money or its equivalent or not. Similarly, the male who most frequently consorts with promiscuous females is the most dangerous of sex delinquent males. In fact, this type of male is probably a greater menace to public health than the promiscuous female, because he is the immediate source of many infections of innocent wives and children, in addition to infecting the other women with whom he consorts. It was because prostitutes have always been the most promiscuous per- sons of either sex that laws aimed at their activities and the activities of the third parties who promoted or exploited prostitution have been passed nearly everywhere in this country and have found a large measure of public support. AYhile the enforcement of such laws has eliminated red light districts and open houses of prostitution, and has greatly reduced the total number of contacts of prostitutes and, consequently, the amount- of disease that they spread, these laws have yet failed to accomplish the results which we have a right to expect from the expenditure of so much time and money on their enforcement. The reason is not far to seek. Until 1919, when a standard form of law on this subject was prepared and presented to the legislatures of the several states by the Federal Government, prostitution was, with few exceptions, an offense for which a female only could be held guilty. Generally speaking, also, the acceptance of money by the prostitute was a necessary ingredient of her offense. It is axiomatic that, as long as men can with impunity buy such services from women, there will always be found women, foolish, ignorant or lazy enough to adopt this apparently easy way out of life's difficulties. Furthermore, as the life of the professional prostitute becomes more and more hazardous, many of them are forced to go to work, and the amateurs are retaining their jobs for the same reason. Under the disguise of honest working girls many such women are supplementing their incomes, or secur- ing the luxuries which they think are necessary to them, by building up what they fondly believe to be a select clientele. They are careful when taking a new customer not to ask for or take money. They very often accept gifts of jewelry or wearing apparel, theatre parties or expensive meals, either as a test or as a real quid pro quo. Venereal Disease _ 421 How far the activities of such amateur prostitutes make up for the reduc- tion in the activities of the professionals no one knows. The doctors testify, however, that a large number of their men patients claim to have been infected by such amateurs. It became obvious, therefore, if further progress was to be made, that the definition of prostitution would have to be enlarged to include all males whose payments make prostitution possible, and all males and females sexually indiscriminate, even though the element of hire, which usually exists in some form, could not be proven. Following the recommendation of the Federal Government in this regard the legislatures of eleven states, in 1919, remodeled their prostitution laws. Ohio was one of these eleven states, and has therefore had since June 21, 1919, the best law on prostitution (except for paragraph C under subsection 17) that sound social experience has yet been able to devise. This law amends Section 13031 of the General Code by adding seven new subsections, 13 to 19, inclusive. This law not only attempts to reach all promiscuous sex delinquents but sharpens and renders more serviceable the legal weapons against the third parties to prostitution, particularly the taxicab chauffeur, that most modern and elusive of go-betweens. It is suggested, however, that paragraph C of subsection 17 of this law be 'amended to read as follows: The name and place of detention of any person charged with a violation of Section 13031-13 of the General Code shall immediately be reported in writing to the district or city board of health by the department making the arrest. No person so charged shall be discharged from custody on bail or other- wise until 12 hours after the receipt by such district or city health board of the name and place of detention of such person so charged. It shall thereupon be the duty of such district or city health board to determine forthwith whether there are reasonable grounds for believing that such person is infected with a venereal disease, or has been exposed thereto. If such district or city health board shall determine that such reasonable grounds exist, it shall be the duty of such board to cause such person to be examined immediately for such venereal disease, by a physician competent to determine the existence of such disease. In order to make the findings above outlined, the district or city board of health shall have the power to detain any such person so charged for a period not exceeding 48 hours, after expiration of the 12 hours following the receipt by such board of the notice from the department making the arrest. Any such person found to have a venereal disease in an infectious form shall be treated under quarantine, at a clinic, or otherwise, as such district or city health board may determine shall best protect the, public health. 422 Hospital and Health Survey Such infected person shall pay for such treatment, if able to do so, but if not, such medical treatment shall be at the expense of the municipality or county. The purpose of this amendment is to separate the detection, diagnosis and treatment of venereal disease, from the detection, diagnosis and treat- ment of delinquency. Experience has shown again and again that police and courts are confused and diverted from the solution of the problem of delinquency with which they are charged, by imposing medical or quasi- medicalj duties upon them. Furthermore, this mixing of venereal disease and delinquency is not in the best interest of public health. Under this act, as it now exists, the judge can have in many cases no basis for issuing or withholding the order for medical examination. This basis is, as suggested in the proposed amendment, a reasonable ground for believing that the defendant is infected or has been exposed to infection. The mere fact that the defendant is charged with a violation of Section 13031-13 would be wholly inconclusive in many cases from a legal point of view. Suppose the defendant was charged with soliciting, procuring or trans- porting for prostitution — all offenses which do not involve proof of sexual contact to constitute the offense. In the exercise of his discretion, the aver- age judge might well conclude that no justification exists for compulsory examniation in such cases, whereas the physician would see on the faces of many such defendants the clinical evidence or stigmata of their disease. Furthermore, evidence of exposure to disease, which has no bearing what- ever on the defendant's guilt or innocence of the crime charged, could be heard by the health authorities, but not by the courts. It is believed, therefore, that some such procedure as that suggested in the proposed amendment would much better serve the interests of both courts and health departments. There is one type of disease, however, that is known to have a direct and vital bearing upon delinquency, and that is mental disease. So many careful and authoritative studies have been made of this rela- tion between delinquency and mental defectiveness that it may be taken as settled that from 20% to 50% of sex delinquents are mentally defective, and will not be benefited by the ordinary dispositions of such cases made by the courts. The law for the diagnosis and treatment of mental defectives should be amended so as to make available to every Cleveland court, juvenile and adult, which handles sex delinquent cases, competent and adequate psychiatric service for the routine mental examination of all such delinquents, prior to sentence by the court. Unless this be done, Cleveland may expect to see a procession of non- reformable sex delinquents returning again and again to its reformatories, and see its probation officers struggling vainly to control the conduct of Venereal Disease 423 feeble-minded prostitutes who are spreading disease broadcast, and who would never have been put on probation had their true mental condition been known. The older penal statutes of Ohio go still further and prohibit couples from indulging in habitual fornication or adultery. To the extent that such couples remain true to each other and avoid promiscuity, they may be said not to constitute a serious public health problem. Ohio also has the injunction and abatement law, which enables the prose- cuting attorney or any citizen of the county to enjoin perpetually the use of any property for purposes of lewdness, assignation or prostitution, and abate the same as a public nuisance. (Approved March 30, 1917.) This law exists in 39 other states and has been found extremely valuable in preventing unlawful use as houses of prostitution, of hotels, rooming houses or apartments, against whose owners, managers, or lessees it was difficult or impossible to prove violations of the criminal laws. Such owners, managers or lessees of property have often been so politi- cally intrenched that officials have not dared to move against them. For this reason the provision in such laws that individual citizens could bring such injunction and abatement suits has been found particularly valuable. It is in this last provision that the Ohio Injunction and Abatement Law is defective. The Ohio legislators, in an apparent desire to protect property owners from frivolous suits, have so hedged about the right of a citizen to bring such suits with burdensome and unnecessary restrictions and penal- ties, as to operate as a practical prohibition of this sort of activity by a private citizen in the public interest. Experience in all other states, whose laws do not contain these restric- tions, proves conclusively that they are unnecessary and that the fears of the Ohio legislators were groundless. It is suggested, therefore, that section 3 of this law, approved March 30, 1917, be amended by omitting the last half of the section, so as to read as follows : Whenever a nuisance exists the attorney general of the state, the prose- cuting attorney of the county, any person who is a citizen of the county, or any organization of citizens of the county may bring an action in equity in the name of the state of Ohio, upon the relation of such attorney general, prosecuting attorney, person or organization to abate such nuisance, and to perpetually enjoin the person or persons maintaining the same from further maintenance thereof. The laws against so-called White Slavery, Keeping Disorderly Houses and Rape appear to be adequate. The "age of consent" law should be amended to protect young boys as well as girls under 16, and more protec- tion should be given to mental defectives generally. It is believed, however, 424 Hospital and Health Survey that the best protection to such mental defectives is afforded by laws which provide for early registration, and supervision inside or outside institutions, of this class of individuals. Cleveland's ordinances providing licensing and supervision of commer- cialized amusements, such as dance halls and pool parlors, are well in the van of such legislation, particularly the one relating to pool parlors. The state law for the licensing and supervision of hotels (defined to include most transient rooming houses) and restaurants is adequate. It would help if this law could be extended to apartment houses. There should be, however, a law or ordinance providing for the revocation of licenses of chauffeurs who agree to act as go-betweens for prostitution. This study of the laws indicates that Cleveland, in the main, is legally well equipped for the prevention, detection and diagnosis of delinquency, except in cases of mental defectives. Let us turn to a consideration of the administrative machinery for carrying out these laws. ADMINISTRATION The real functions of police and courts are, in the modern view, the pre- vention and cure of crime and delinquency. The old emphasis on detection after the crime was committed, and punishment as a satisfaction to society is giving way to a more intelligent and humanitarian doctrine. Cleveland has in its ordinances for licensing and supervising commercialized amuse- ments, and in its state law treating hotels, transient rooming and boarding houses and restaurants in the same manner, legislation of this preventive character. The inspection of these different sorts of places is scattered among several departments, such as the Mayor's inspector of dance halls, the Direc- tor of Finance's billiard hall inspector and the hotel inspectors of the State Fire Marshal. These laws and ordinances all provide for .the revocation of licenses or closing such places for disorderly or immoral conduct on the premises. If the previous recommendations regarding licensing and inspection of apartment houses and chauffeurs are adopted, there will exist two more types of inspection to be made with inspectors probably from one or more departments. It is believed that much of this routine inspection could be covered by a special women's bureau of the police department, with econ- omy to the city and state and with advantage to the public welfare in the prevention of crime. The officers of this bureau could be deputized by the departments now charged with this duty, if by reason of the other structural and technical points to be covered by such inspections, it is not deemed wise to turn over the entire inspection to this women's bureau. Such a bureau, having access to police information and becoming ac- quainted with criminals and delinquents, would be in a much better position to prevent such places from becoming the resorts of disorderly characters than could the inspectors of departments not so acquainted with the underworld of a large city. Venereal Disease 425 Such women police could also protect girls who are employed at such places by insisting on the establishment and maintenance of proper rules and regulations. In addition to these inspection duties, experience in many cities where women police are employed has proven their value as street and park patrols, and in the investigation and adjustment of all sorts of home and employment conditions of girls who are either delinquent or in great danger of becoming so. Finally, there exists in many cities, including Cleveland, a hiatus in official case work with girls, between purely protective work and probation work. The Cleveland Municipal Court Act (Sec. 1579-50) provides, for instance, that probation officers "shall devote their time to the interests of persons placed on probation." The girl who has been arrested for a sex offense in this court has no one officially interested in her, until she has been tried, convicted and sentenced. When she has at last arrived at this stage in her travels through the legal machinery, she is apt to be hardened or bitter, and experience shows that she is infinitely more difficult to influence and handle then than immediately after her arrest. A sympathetic and intelligent woman police officer, with social experience, can learn the truth from such a girl, investigate her environment, shield her from unnecessary repetitions of her story and bad associations pending trial, see to it that she is mentally and physically examined, and be of infinite value to the prosecutor and judge in the trial and disposition of the case. She may even, as is done in one large city, prevent a charge being filed against her if, after informal consultation with the prosecutor and the judge, such a course seems best for the girl and society. It goes without saying that on the personnel of such a bureau everything depends. To secure the right type of women it would be necessary to pay the chief inspector at least $2,00*0, and the others from $1,200 to $1,800. It is our opinion that most harmony and efficiency will result if this bureau is made a part of the police department, responsible to its chief. The contact with the delinquents would be much closer thereby, and no jealousy between the men and women police officers need result, if it is made clear from the beginning that all credit for arrests belongs to the men and that the women derive their credit from the amount of real help they can give. Further details concerning such bureaus can be learned from the head of one of the most progressive and effective of them, in Washington, D. C. If it be argued that much of this work is now being done in Cleveland by the private unofficial Woman's Protective Association, and that, there- fore, such a woman's police bureau is not needed, our answer would be: First — That in proportion as such private organization has shown its necessity to the police and courts, in that same proportion has it proved such service to be a legitimate responsibility of government. 426 Hospital and Health Survey Second — That, having demonstrated the need, and blazed the trail, such private organization should insist on the city paying its own way, and should assist the city in getting such a bureau well organized, and see to it that it functions in accordance with the best and most approved methods. Using this modern conception of the function of police departments, that they aim at prevention as well as detection of crime, it is suggested that the test of their efficiency lies not in the number of arrests and convictions (the usual form of report made), but in the relation which such number of arrests and convictions bears to the whole number of offenses committed. This test is easily applied to crimes which become public, such as mur- der, burglary, etc., or even to all minor offenses concerning which complaints are filed. Even as to such offenses, however, the reports of the police departments rarely bring out the deadly parallel. A real difficulty confronts us when we try to apply the test to sex offenses. These offenses differ from offenses against the person or property in the fact that the danger to the public, while more serious, is less apparent, so that the public rarely and the individuals most directly concerned never file complaints. The police could not, therefore, if they wished, apply this test to their efficiency in preventing and detecting sex offenses. The fact, therefore, that the Cleveland police department has not issued a report for six years is of less importance to this survey, than would at first seem probable. There are two remedies for this situation, both of which have proved successful. 1. Educate the public to make complaints. 2. Form a committee of citizens, whose duties shall include vice investiga- tion. The citizens of one large camp city, during the war, were so educated to the necessity of protecting the troops, that the Vice Squad spent its entire time investigating complaints filed by patriotic citizens. New York, Chicago, Minneapolis, San Francisco, Los Angeles and many other smaller cities have adopted the second alternative and maintained a committee with investi- gators to check up the work of its departments and to take the place of the reluctant public in filing complaints. The second alternative is believed to be the best, because while working gradually to bring about the first (a slow and laborious process in peace times), it can secure immediate results from the police and greatly strengthen and coordinate all the various municipal de- partments which handle this problem. It can strengthen these departments by interpreting them to the public and the public to them. It can also help them to get needed legislation, appropriations and the right kind of personnel. It can coordinate them by helping to bring about team work in govern- ment. In our government system of checks and balances, there often de- velops a tendency to "pass the buck" from one department to another. Venereal Disease 427 If things go wrong and crime increases, the police and the courts blame each other and the prosecuting attorney, while the latter shifts the burden to the other two. An intensive comparative study of records and methods, by an impartial organization, will reveal the weak links in the chain. Tactful and constructive criticism given privately to the departments at fault will often serve to remedy conditions. Conferences arranged between department heads with the secretary or a member of the citizens committee, acting as liason officer, may remove the friction. As a last resort the public can be informed and the pressure of public opinion applied. We desire to make two recommendations in connection with court ad- ministration. These are the establishment of a Woman's Court and a finger- print system for all convicted sex delinquents. The essentials of a woman's court are the trial of all women sex offenders in a separate court, or at least at a separate period of the day, by one judge, and the exclusion of everyone from the trials who cannot show a legitimate interest therein. The advan- tages of such procedure are the development of expert knowledge by the judge, a consistent judicial policy and an immense improvement in the dignity and efficiency of court procedure. The finger-print system for convicted sex offenders is of the utmost value to the judge in his disposition of cases. Repeaters constantly give false names and often escape identification without such a system. As above indicated, the test of court treatment is the proportion of offenders who repeat. This test cannot be applied without an infallible system of identi- fication. The finger-print system is the only one that is infallible. Con- structively it enables the judge to determine, within five minutes after con- viction of an offender, the probable value of probation, reformatory treat- ment and the need for mental examination. Its cost would for Cleveland probably not exceed $2,500 for the first year, and less thereafter. Any intelligent policeman can be taught to oper- ate it. VICE CONDITIONS In an attempt to apply the test of efficiency above described to the Cleve- land police department, an under-cover investigation was made to determine the extent to which the laws against sex offenses were being violated without fear of the police. This investigation did not disclose the existence of a red light district or any open or public houses of prostitution. Little soliciting was observed on the streets, and the dance halls were not apparently being used for this purpose. The situation at many of the hotels was, however, found to be inexcusably bad. Prostitutes in many of these were permitted to operate without fear, and in some of them employes of the hotels assisted the prostitutes by bring- ing customers to them or sending them to the rooms of customers. 428 Hospital and Health Survey Many chauffeurs and taxicab stands readily agreed to take investigators to prostitutes and a few restaurants were observed to permit this type of women to frequent their dining rooms. In general it may be said that prostitutes do not flaunt themselves in the public eye. but there appears to be a large amount of clandestine prostitu- tion, which easily escapes detection or restraint by the police. Much of this fearlessness by Cleveland's prostitutes has probably been due in the past to the Golden Rule method of treatment which turns these women back on the streets on confession of their offenses. None of the city departments was apparently aware of the existence of the new state law against prostitution above described, as late as November, 1919, some five months after its passage. This law eliminates fines and provides for long sentences. It is our understanding that sex offenders will be charged under this law exclusively hereafter, and the golden rule system abandoned. Improvement should result. The police have ample legal weapons for breaking up automobile traffic in vice under the new prostitution law. This law, together with the Injunc- tion and Abatement Law and the law giving the State Fire Marshal power to close hotels and restaurants which permit immoral or disorderly conduct, provide legal tools which leave the city authorities no excuse for the condi- tions above described. Venereal Disease 429 IV. Protective Social Measures Recreation AS a large part of venereal disease is due to the wrong use of leisure time, wholesome recreation for its right use is a measure of prime im- portance in any venereal disease reduction campaign. The public responsibility in this regard is established. Millions of dollars are being spent by official and unofficial organizations throughout the country to fill this need. Playgrounds, parks, public school athletic leagues, gymnasia, swim- ming pools, recreation piers, as well as such national organizations as the Boy Scouts, Girl Scouts, Campfire Girls, and others, attest the general recognition of this responsibility. In spite of these developments in which Cleveland shares with other cities of its size and importance, much yet remains to be done to discharge this community responsibility. The exhaustive recreation survey recently com- pleted by the Cleveland Foundation renders unnecessary here a detailed analysis of the needs of Cleveland, and the recent employment of a director of recreation is an excellent guarantee that the city accepts the responsibility. It is sufficient for our purpose to state the relation of recreation to the venereal disease problem and its importance as a measure for prevention of disease. Prevention Work for Women and Girls Pending the development of an adequate recreation program, and indeed supplementary thereto, is the responsibility for the protection of those indi- viduals who do not or cannot avail themselves of these opportunities for the right use of leisure time. Protection also is needed for individuals who have failed to adjust themselves to their environment and are guilty of some infrac- tion of the law through ignorance or heedlessness, in order to prevent them from becoming habitual delinquents. A further type of protection involves the supervision of commercialized amusements, such as theaters, dance halls, restaurants, cabarets, public parks, beaches, road houses, etc. The most recent development in administrative machinery affording such protection is the Woman's Police Bureau. In Cleveland, as in other cities, this respon- sibility has been assumed largely by the unofficial Women's Protective Asso- ciation. In Washington and other cities this work has been accomplished by the Women's Police Bureau attached to the Police Department. Rightly organized and with adequate personnel it is believed that the Police Bureau offers the best machinery for providing this protection. The guidance and supervision of sex delinquents who are not yet hardened offenders, through probation, has demonstrated its value in the prevention of much social wreckage, with its resulting venereal disease. Wise, kindly, and humane probation officers can and do adjust economic and domestic difficulties and are agents of recognized value in preventive medicine. 430 Hospital and Health Survey Institutional Care of Sex Delinquents Where the mentality of a sex delinquent is weak or the environment has been such that the delinquent will not be benefited by probation, the com- munity as well as the individual must be protected by institutional care. Colonies for the feeble-minded, reformatories, etc., for those for whom rehabilitation is possible, have been approved by the most advanced thought of students in this field. Venereal Disease 431 V. Sex Education ANY program for the eradication of hunian-contact diseases, such as tuberculosis, syphilis and gonococcus infections, which are so diffi- cult of prompt recognition, so insidious in their onset and methods of transmission, and so successful in their development of carriers, must in- clude education as one of its outstanding features. Such education naturally divides itself into, first, the training of those not yet infected in the applica- tion of measures for their protection, and, second, the instruction of those who are already infected in the value of persistent and curative treatment and in measures for the avoidance of infection of others. The latter in- struction must necessarily be carried out by doctors, nurses, public health officials and others who are dealing with infected persons. For practical purposes, therefore, educational measures must be directed toward the great mass of the population who are not infected, and may be grouped under four headings : Sex education for children. Sex instruction for young men and women. Social hygiene information for parents and leaders of public opinion. Permanent sex education measures. Sex Education for Children It is just as reasonable and practicable for the health officer to plan twenty years into the future a campaign of protection of the public from a given disease, as it is to plan ten thousand miles in distance. In the latter case the federal public health authorities expect and receive the support of the public in placing health officers in India, China and other distant lands, in order to prevent bubonic plague from reaching the seaports of the United States and becoming an imminent danger. In the former case it is reason- able for the health officer to expect full cooperation and support of the public in placing proper officers, so to speak, twenty years in the future to establish barriers for the prevention of exposure of citizens of the United States to syphilis and gonococcus infections. This is only another way of stating, of course, that the barriers which will prove most effective in pro- tecting against these diseases are proper sex education, right methods of thought, religious and ethical training, and adequate environmental protec- tion against exposure. For such educational and environmental measures to have their largest influence, work must be begun in early childhood and be continued until the individuals concerned are fully established in their homes as adult citizens. The task of promoting this phase of preventive measures must eventually necessarily fall to the trained educators, although all public health officials can be of very great assistance. While the purposes of this report do not permit of full discussion of sex education, it is, perhaps, permissible to point out that the consensus of opinion of educational and public health authorities favors a sex education program based on the fundamental proposition, that social hygiene education 43-2 Hospital and Health Survey in schools and colleges should not be given prominence as a so-called course or courses of sex instruction by a special individual or teacher, but rather, that all teaching concerning sex and its manifold relations to human life should be merged unobtrusively into regular subjects of training and instruc- tion, notably the biological sciences, general hygiene, nursing, physical edu- cation, social ethics, literature, home making, practical training for an occupation or profession. Sex Instruction of Young Men and Women. Annually a very large number of young men and women emerge from the state of protected childhood to the responsibilities of maturity and adult life. The age at which this transition occurs for different groups varies according to the home conditions, industrial demands and environmental and educational influences for each group. The transition having occurred prior to successful sex education work and training, there remains the oppor- tunity to give these young people sound instruction in matters of wholesome sex relations and the methods of transmission and prevention of the venereal diseases. For the most part, since young people at this age are no longer in school, the dissemination of such knowledge must be through continuation school courses, instruction of the membership of religious, fraternal and other social organizations, and the voluntary efforts of social hygiene agencies, working in cooperation with the health education authorities. Socl\l Hygiene Information for Parents and Leaders of Public Opinion. In promoting this, as in all other public health programs, it is essential to have the support of public opinion. And since syphilis and gonococcus infections are spread by human carriers through methods which may best be combated by simple measures of control which lie within the power of the individual not yet infected, even though he does not know the identity of the infected persons, the active cooperation of parents in beginning the edu- cation and training of their children toward the ultimate application of these methods is of paramount importance. For these reasons it is necessary to promote in every practicable way the extension of social hygiene information to parents and leaders of public opinion. Among the successful plans which have been tried in this connection are parent teacher meetings, popular addresses to industrial groups, luncheon discussions under the auspices of commercial business and social organizations, clubs of men and women, appropriate distribution of selected pamphlets, motion picture and exhibit presentation of the venereal disease problem and its solution. Permanent Sex Education Measures. By way of illustration, various temporary expedients in promoting educa- tion have been indicated under "a," "b" and "c," but it should be borne in mind that ultimately as time, adequate methods and personnel become available, the essentials of needed sex education should find their way through the normal channels of popular education and religious and social training. As a rule permanent advances in any field of social betterment result from Venereal Disease 433 activities which pass through three stages: first, the assembling and testing of data and proposal of practical measures; second, active propaganda for the adoption of the proposed measures in the course of which the subject comes to popular attention with an apparently exaggerated view of its im- portance in relation to the whole of life and social progress; third, the quiet, general application of the permanent measures public opinion endorses, and education of each succeeding generation as to the need for continuing such measures. The latter task always falls to the constituted educational authorities with the cooperation of parents and the powerful influence of convention and custom. Success may be hoped for in the elimination of venereal disease only in so far as such broad principles of education are applied. THE CLEVELAND HOSPITAL AND HEALTH SURVEY REPORT List of Parts and Titles I. Introduction. General Environment. Sanitation. II. Public Health Services. Private Health Agencies. III. A Program for Child Health. IV. Tuberculosis. V. Venereal Disease. VI. Mental Diseases and Mental Deficiency. VII. Industrial Medical Service. Women and Industry. Children and Industry. VIII. Education and Practice in Medicine, Dentistry, Pharmacy. IX. Nursing. X. Hospitals and Dispensaries. XI. Method of Survey. Bibliography of Surveys. Index. The complete set may be obtained at a cost of $5.50 plus the postage and single parts at 50 cents each plus the postage, from THE CLEVELAND HOSPITAL COUNCIL, 308 Anisfield Building, Cleveland, Ohio Mental Diseases and Mental Deficiency Part Six Cleveland Hospital and Health Survey Copyright, 1920 by The Cleveland Hospital Council Cleveland, Ohio Published by The Cleveland Hospital Council 308 Anisfield Bldg. Cleveland - Ohio Preface The Hospital and Health Survey of Cleveland was made at the request of the Cleveland Hospital Council. The Survey Committee appointed to be directly responsible for the work and through whose hands this report has been received for publica- tion consisted of the following: Malcolm L. McBride, Chairman; Mrs. Alfred A. Brewster, Thomas Coughlin, Richard F. Grant, Samuel H. Halle, Otto Miller, Dr. H. L. Rockwood, Howell Wright, Secretary The staff responsible for the work were: Haven Emerson, M. D., Director, and the following collaborators : Gertrude E. Sturges, M. D., Assistant Director; Michael M. Davis, Jr., Ph. D., Director of the Hospital and Dispensary Survey; Josephine Goldmark, B. A., Director of the Nursing Survey; Wade Wright, M. D., Director of the Industrial Hygiene Survey; Donald B. Armstrong, M. D., Director of Tuberculosis Survey; S. Josephine Baker, M. D., D. P. H., Director of the Infant and Maternity Survey; T. W. Salmon, M. D., Director of the Mental Hygiene Survey; W. F. Snow, M. D., Director of the Venereal Disease Survey; Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey. The expenses of the Survey and of the publication of the report have been met by appropriations received from the Community Chest, through the*,Welfare Federation, of which the Hospital Council is a member. The report as a whole, or by sections, can be obtained from the Cleveland Hospital Council. A list oT the parts will be found in the back of this volume, together with prices. TABLE OF CONTENTS I. Introduction Page Mental Factors in Medical and Social Problems 443 Complaints of the Community 444 II. City Facilities for Diagnosis and Treatment Cleveland City Hospital 446 Provisions for Mental Patients in Other General Hospitals Lakeside Hospital _ 460 Fairview Park Hospital 461 Mt. Sinai Hospital. 461 Lakewood Hospital 461 Other General Hospitals .. 461 Dispensaries __ '. 462 Private Sanitaria for Mental Patients... 462 Places Other Than Hospitals for Detention or Care County Jail 464 City Infirmary 465 III. State Facilities for Diagnosis and Treatment State Board of Administration 467 Laws Relating to Insane, Mentally Defective and Epileptic 468 State Hospitals for Mental Diseases 469 State Institution for Feeble-minded 471 State Hospital for Epileptics : 473 Bureau of Juvenile Research . 473 IV. Courts and Correctional Agencies Courts Probate Court _ 476 Municipal Court 478 Parole Board I 479 Juvenile Court and Detention Home 480 Correctional Agencies House of Correction _ 482 Farm School 484 Girls' Home _ 484 House of Good Shepherd , 485 Boys' School 1 , _ 486 Other Homes _ 487 V. Mentally Atypical Children Special Classes for the Mentally Defective 488 Work Permits for the Mentally Defective 490 Special Types of Atypical Children _ _ 494 After-care and Supervision 1„ 495 VI. Welfare Organizations 497 VII. Prevention — Mental Hygiene 501 VIII. Summary of Recommendations Dealing with State Legislation and Local Ordinances or Charter Changes 503 Dealing with Departments of State and City Government..... 505 Dealing with Private Agencies by Groups 508 Dealing with New Agencies or Private Facilities to be Established, 509 PREFACE THE National Committee for Mental Hygiene was requested by the Director of the Cleveland Hospital and Health Survey to make a study of the provisions for dealing with the medical and social problems aris- ing out of mental disease and mental deficiency, as it was felt that the field to be covered was such a special one that an organization with experience in conducting such studies would be most apt to obtain a clear picture of existing conditions and to make sound recommendations. Those in charge of the general Survey have made me feel at all times that my share in the work constituted an integral part of the larger undertaking, and I wish to express my deep appreciation not only of their cooperation but of the sym- pathetic understanding with which my work in a special field has been re- garded. It is difficult to render proper acknowledgment to individuals for assist- ance and advise when all of those with whom I came in contact during the Survey gave me every possible assistance. Nevertheless, the following per- sons contributed of their time and wise counsel so liberally that special acknowledgment should be made: Hon. Howell Wright, who supplied information, advice, and secured data otherwise difficult to obtain; Hon. Alexander Hadden, Judge of the Probate Court; Hon. George S. Addams, Judge of the Juvenile Court; Hon. Dudley S. Blossom, Director of Public Welfare; Dr. Chas. W. Stone; Dr. Leonard R. Ravitz, who assisted in the neuro-psychiatric examinations; H. Austin Aikins, Ph. D., Professor of Psychology, College for Women, Western Reserve University, who made the psychological tests; Miss Claire Walters, who assisted actively with personal work, information and in secur- ing documents; Miss Cecelia A. Evans, of the Public Health Nursing Course at Western Reserve University, who took much interest and enabled three of the pupils, Miss Nesbit, Miss Graham and Mrs. King, to render valuable direct assistance in the work; Miss Charlotte Steinbach, Supervisor of Spe- cial Classes in the public schools. The various welfare organizations, especially the Associated Charities who cooperated in making a study of their families, and the Welfare Federa- tion and the Humane Society who arranged for and assisted in the examina- tion of inmates of orphanages and other institutions and of children boarded out in families. The methods by which my studies were carried on are of little general interest and so I will not describe them in detail. Every institution in which the problems of mental disease and mental deficiency seemed likely to be encountered was visited, in many cases a number of times. Five hundred and forty-one individuals in various hospitals, homes, clinics and schools were carefully examined by psychiatrists and psychologists with a view to determining their mental condition and the type of treatment or supervision that they actually required. A large number of people whose work dealt even slightly with these problems, were consulted personally or through correspondence, and official reports and other publications were freely used. It is impossible to assign proper credit where extracts have been made from so many different publications, so I take the opportunity here of making a general acknowledgment. Jesse M. W. Scott, Field Consultant, National Committee for Mental Hygiene Mental Diseases and Mental Deficiency by Thomas W. Salmon, M. D. Director of Mental Hygiene Survey and Jesse M. W. Scott, M. D. Field Consultant National Committee for Mental Hygiene Introduction NOT long ago mental diseases and mental deficiency were thought to present only one group of problems, that dealing with the proper institutional care of persons who suffer from these disorders. Slowly, as medical and social work in relief and rehabilitation became more ex- tensive in scope and intensive in method, it became apparent to those en- gaged in such work that mental factors, at one time in one form and again in another, complicate, or, in many cases, entirely condition the individual or social situations which require attention. No American cities attempt now to deal with the great social problems arising out of disorders of con- duct of their* citizens by measures applicable only to groups of persons. We know that behind social mal-adaptation lies the mal-adaptation of some individual or individuals, and that behind the mal-adaptations of individuals lie those mental factors which determine behavior. Sometimes such factors produce conditions which are generally recognized as mental disease or states of defective mental development. Sometimes they produce altera- tions in behavior which do not follow conveniently the conventional boun- daries of mental disease or mental defect. It is very widely recognized, however, that the success of efforts for the economic or social reconstruction of individuals or families who become liabilities to their community instead of remaining assets, depends largely upon the personal resources of the individuals concerned, and that among these resources none compares in its actual influence upon life with their type of mental reactions. With a normally adaptable mind, severe physical and economic handicaps are overcome, but with a mind defective from birth or damaged by disease, ordinary tasks in personal or social adaptation are difficult or impossible. Mental Factors in Medical and Social Problems It is one thing to recognize the importance of mental factors in the social and medical problems of a community and another to devise methods by which the community can best deal with these factors. There is general lack of exchange of ideas on this subject between American cities. Experi- ments that have failed in one place, through intrinsic causes of failure, are embarked upon hopefully in another. In no city is all the work of the community that deals with mental disease and mental deficiency centered in a single administrative department. In general, the task of unofficial wel- fare agencies is to make beginnings before the official authorities are ready or free to act, and to deal informally with individuals who are in difficulties before the graver situations with which the official agencies are especially 444 Hospital and Health Survey prepared to cope have arisen. Often, unfortunately, there is lack of con- tinuity between the activities of official and unofficial agencies. In con- sequence, one sees the most perplexing and wasteful duplication of effort. Water is poured liberally on the smoke while the fire often burns unchecked. It has been the purpose of this Survey not only to trace as closely as possible the tangled relationships which mental disease and mental deficiency bear to other problems and to examine and appraise the value of the dif- erent efforts, large and small, official and unofficial, which the city is putting forth in its effort to deal with them; as so much of real governmental re- sponsibilities are taken over, for the time being at least in this country, by voluntary welfare agencies, the Survey has dealt quite as fully with the work of the latter as with that of the city itself. It is felt that the presentation in full of the very large amount of detailed information collected would serve no useful purpose, and so only an outline of actual findings is given, the space available in this report being devoted chiefly to a consideration of the means by which the city can best deal in a constructive and progressive way with the problems that are indicated. Complaints of the Community In medicine, no intelligent physician undertakes to examine a patient or to recommend treatment until he has heard a spontaneous account by the patient himself of the complaints which led him to seek assistance. It seems proper, therefore, to commence this Survey with a brief statement of the complaints that the community has to make in relation to the provisions existing in Cleveland for the diagnosis, treatment and supervision of persons with mental diseases or mental deficiency. Physicians complain that no adequate provisions are made by the city for the temporary observation of persons with mental diseases during the period in which measures for their future are being considered, nor for their emergency treatment. They say that the rich or well-to-do find the facilities they need in private institutions, but for the poor and those in moderate circumstances, upon whom the stress of disease falls so heavily, the city offers nothing more than a partly custodial and partly correctional type of institution connected with the City Hospital, in which the modern treatment of mental disorders has no place. They complain also that the state of Ohio has made so much less provision for the continued care of mental cases than the population requires, that Cleveland, in addition to performing the emer- gency services mentioned above, must also provide continued care for many persons simply on account of the failure of the state to perform its well- recognized share of the duty. They assert that such conditions make per- sons with mental diseases reluctant to apply for treatment in the earlier stages of their disorders, in which effective measures of treatment are most likely to prove successful. Far from extending aid to those suffering from mental disorders, the absence of proper facilities and the harsh legal methods so generally employed serve, they say, most effectively to cause mental patients to conceal their troubles. They complain that the law plays a much larger part than medicine in the management of mental diseases in Cleveland, Mental Diseases and Deficiency 445 and that legal measures properly applicable to a very small proportion of mental patients are applied to practically all, with the result that much avoid- able suffering and humiliation accompanies illnesses painful enough to the patients and their relatives without such additional inflictions. Welfare agencies which have to deal with that part of the city's problem of caring for the mentally ill that has been mentioned and, in addition, with many trying social situations which grow directly or indirectly out of mental disorders, complain that there are many insane and feeble-minded persons in institutions not intended for them and in families in the community, and that the presence of those who are for purely humanitarian reasons sheltered in institutions designed for another purpose prevents such institutions from successfully carrying out their original purposes, and is of little or no benefit to the mentally defective who are received. These agencies complain that no psychiatric or psychological examinations are made when dependents are received into orphanages and other welfare institutions or sent to homes to be boarded out. They say that, in the absence of facilities for psychiatric diagnosis in well-staffed, well-equipped psychiatric clinics, they have to make shifts for themselves which are not only ineffective but often wasteful of time and money. They feel that some of their most difficult and apparently hopeless problems could be solved if the state bore the share of the burden of institutional care that is borne by most other states. The judges complain that the task assigned to them by the archaic laws of Ohio governing the legal management of mental diseases, is a burden- some one and that not infrequently they are compelled to do grave injustice to sick persons because of the lack of an adequate mechanism for determin- ing the questions at issue. It has been our task to examine the foundations for these grave com- plaints and to suggest remedies that have been effective when applied else- where. 446 Hospital and Health Survey City Facilities for Diagnosis and Treatment WHAT basis is there for the complaint by physicians that Cleveland is without facilities even for the emergency care and observation of mental cases, because, for this type of illness, the public and private hospitals of the city have practically nothing to offer? It is convenient to consider first the great City Hospital — the chief resource of the sick poor — and then the other hospitals which can be looked to to supplement ihe work of this institution. Cleveland City Hospital The general features of Cleveland City Hospital have been very fully described in other sections of this report. This hospital is far from being adequate. As the report in Part X. indi- cates, the buildings are old, equipment is largely out-of-date, and many facilities possessed by a hospital completely equipped to discharge its obli- gations to the sick of the community are lacking. Nevertheless, scientific medicine and surgery find their way into every general ward to the ex cent of the facilities available. When a new patient is admitted every effort is made to discover the nature of the disease from which he suffers and the possibility of bringing about his speedy recovery, amelioration of his con- dition or relief from his distress. Let a medical or surgical discovery in therapeutics be made in any great medical center of the world and it is only a little while before it is applied to the benefit of patients in this hospital. Forming as it does a part of the clinical resources available for teaching in the medical school of Western Reserve University, cases are studied not only with reference to their own needs, but to the means by which their diseases and the causes of these diseases can best be presented to medical students who will be required to treat similar conditions in their own practice later on. All this, however, refers only to the general ivards of the City Hospital. When one leaves these wards, crosses a little strip of grass and enters the doors of the building devoted to mental cases he leaves behind him not only the medical science of the present century, but, in a large part, its humani- tarian attitude towards disease and suffering. The building in which the wards for mental patients are located was erected in 1851 and used as the city poorhouse. In its arrangement you will see no evidence of thoughtful hospital planning to meet a special need nor even bright sunny wards such as those to be seen in other portions of the hospital. A wide, dark corridor runs down the middle of each floor, with little cell-like rooms on either side. At about the middle this central corridor is crossed by another, one arm of which serves as a dining room and the other as a crowded day room. The arm of the transverse corridor used for a day room has a bare table and not enough chairs or stools for the patients to be seated. Along the central portion are cots for the overflow. The place would be depressing enough, with this dark corridor and the cell-like rooms, but the discolored and dilap- idated walls increase its gloomy appearance. The rooms are about eight by nine feet in size. Although they provide the minimum of floor space allotted to one person, many of them are occupied by two patients. Their windows are Mental Diseases and Deficiency 447 barred; they have no provision whatever for artificial illumination and for heat they depend upon radiation from the corridors. The wooden floors are worn nearly through and it is impossible to keep them in a clean and sani- tary condition. A short time ago a woman pulled up a part of the floor in one of the rooms and escaped through the hole which she had made. Rats and bedbugs are numerous. Each floor, which accommodates 60 patients, has but a single bathtub and one toilet in a dilapidated room. There are no arrangements for the use of hydrotherapy nor for prolonged tepid baths. The building is lighted by gas, in spite of the dangers in this kind of illumina- tion to hospitals for mental cases. There are no outside porches, but a small area of the ground is enclosed. Women occupy this part of the day, and men the other, except in bad weather, when, for weeks at a time, no one is out. There is no classification of patients. The anxious and depressed and the excited and noisy occupy the same ward. Childhood and old age mingle. Social distinctions are left outside. The hard-working, self-respecting mother who has reared her children in a clean American home and has in her later years developed certain mental changes listens all day to the curses of a young prostitute in a bed adjoining hers. For the care of those 120 persons suffering from serious and complex diseases, nearly every one of whom presents an individual problem in diag- nosis or treatment, there are but two trained nurses; one for each floor. For the rest, dependence is placed upon untrained women attendants for the female patients, and male attendants for the male patients. Mechanical restraint is used freely. In the absence of any other provision dealing with disturbed conduct, it constitutes a relatively humane method. The one bright spot about these miserable wards is the kindly spirit which is shown by attendants toward those whom misfortune has brought into their care. Although those who govern this great, rich city have failed to recognize the needs of the most unfortunate of all its citizens, the poorly-paid and poorly- trained people who spend their days in these wards try to make up by their own devotion for the city's neglect. The "laboratory" of this department is in keeping with its inadequacy in all other respects. It is a single room where analysis of urine can be made, but with provision for practically nothing else. There is no diag- nostic or therapeutic equipment, whatever, not even an apparatus for test- ing blood pressure. Simply for convenience, a certain number of convales- cent cases and a few organic nervous cases are cared for in this department. This place has been visited by many medical visitors familiar with the provisions for acute mental diseases in other large cities in the United States, and they are agreed that none maintains a poorer, shabbier, more barren place than this. It is a place of custody and safe-keeping to which no term suggesting a hospital is applicable. It represents, however, the exact measure of the sympathy, kindness and helpfulness which the city of Cleveland extends to its insane poor. Nothing could be better calculated to deter those seek- ing treatment during the earliest and most curable stage of the disease. Nothing could give medical students and pupil nurses a more distorted con- ception of the needs of the mentally sick and of the resources which modern &q ss 448 450 i*3 =: 451 Wards for Mental Patients, Cleveland City Hospital — General Bath and Toilet for Men. 452 A Modern Mental Hospital — Baths for Treatment. 453 Wards for Mental Patients, Cleveland City Hospital — One of the Cell-rooms 454 A Modern Mental Hospital — Single Room for Disturbed Patient. 455 Wards for Mental Patients, Cleveland City Hospital — Excitement controlled by isolation in "Strong Rooms." 456 A Modern Mental Hospital — Excitement controlled by prolonged baths and skilled nurse. 457 458 Hospital and Health Survey science and humanity, under happier conditions, is able to bring to bear upon their illness. Nothing could affect more adversely a person suffering from a depressed form of mental disease, in which foreboding and fear have taken the place of the normal mental attitude, than to be brought into these wards, every feature of which suggests neglect and hopelessness. Time and indifference have painted the scenes so vividly shown in the accompanying photographs, but had a skillful "movie" director desired to create a setting symbolic of poverty and despair he could have done no better. Fortunately, this deplorable place will soon be a thing of the past. The approval of the bond issue for a new City Hospital makes it possible to tear down these dilapidated wards and replace them by a building that will reflect the modern attitude toward mental illness. It is proposed to provide from 128 to 200 beds in the new City Hospital for the observation and tem- porary treatment of mental cases. If these provisions are wisely planned so as to provide the facilities for classification and special care which are required for the modern treatment of acute mental disorders, the neglect of the last half century may be atoned for. It is extremely important that the plans for the new psychopathic building should be prepared in consultation with those who are familiar with such departments elsewhere and who know the precise purposes which they must be designed to serve. Not only are new buildings needed, however, but the city must be prepared to provide the personnel of physicians, nurses and attendants needed to carry on treat- ment in accordance with modern standards. An adequate ambulance service is essential in order that mental cases may be brought there from homes under the same conditions as those by which other sick persons com- ing under treatment are received. A full-time, resident psychiatrist, and at least two assistants, with a sufficient number of internes, will be needed. It will also be necessary to have an assistant superintendent of nurses who will not only have charge of the nurses and pupil-nurses attached to the psycho- pathic department but will direct their training in the practice of mental nursing. Occupation instructors will be needed to institute, at the bedside and in the workrooms, occupational treatment especially designed to meet the needs of individual cases. When such provisions exist, the Probate Court will no longer be the only course of admission. Patients will be freely transferred from the other wards of the hospital and back again, and many will come voluntarily to avail themselves of the special facilities provided and to seek the services of physicians and nurses skilled in the treatment of the serious forms of illness from which they suffer. Anyone in the city of Cleveland who has a mental problem to solve may then be made to feel that this hospital and its out- patient department stand ready to give their aid. Such problems may arise in adults and be recognized by their families or by themselves, or they may arise in children and be recognized by those responsible for their care or instruction. They may come to attention only when anti-social conduct has brought them to the courts. They may complicate other difficulties in per- sonal or social adaptation in which they play an important but secondary part. For the solution of all such problems, whatever their nature, the city will have in such a psychopathic hospital as that which has been dis- cussed, the best type of medical resource that has yet been devised. Mental Diseases and Deficiency 459 Wards for Mental Patients, Cleveland City Hospital — Child in Ward for Alcoholics and Drug Addicts. 460 Hospital and Health Survey Provisions for Mental Cases in Other General Hospitals Lakeside Hospital — This important teaching hospital has no place for even the temporary care of mental cases. In Cleveland, as elsewhere in the United States, the virtual exclusion of patients with mental diseases from general hospitals is due to a fundamental defect in medical education which trains students in physical disorders and practically ignores disorders affect- ing the mind. Dr. Pearce Bailey, in a recent article*, inquires ^vhy problems in mental medicine have not received the attention which problems in general medicine have, and answers his question in the following words: "One significant answer to this question will be found in the indifference on the part of the medical profession to nervous and mental diseases. What medical school today, what general hospital, gives any but the most meagre and grudging representation to neurology and psychiatry? Our medical faculties have done so little to encourage interest and knowledge in these subjects that some of the most important social features connected with them have been brought to public interest by laymen. Indeed, we are so be- hind hand in these matters that there is a question if American neurology and psychiatry will ever attain the position they should have unless there is established a special foundation for research and teaching, to do for the menace of nervous and mental disease what is being done as a matter of course for physical diseases. It really seems that a care-free foundation were the condition for the firmer, broader, more scientific grasp of the sub- jects which bring us into closer relation with human nature than any others. Trained men are wanted everywhere, a wider dissemination of knowledge is wanted. Men trained in mental medicine are needed at the state hos- pitals, in the Public Health Service, in the courts and the schools, to carry on the principles of the few psychiatric clinics thus far established. Where are they to come from? What medical school is in a position to train them? A great field of preventive medicine is before us, asking for action. Perhaps in the past the proofs of the need have not been plain enough. That ex- planation no longer holds good. The public health importance of nervous and mental diseases no longer permits of evasion." The facilities for teaching mental medicine in the Medical School of Western Reserve University are neither inferior nor superior to those found in practically all American colleges. The academic status of psychiatry — an unimportant division, combined with neurology, of the department of general medicine — is in harmony with the meagre clinical facilities available and the small number of hours devoted to the subject in the curriculum. The only wards in which mental patients can be studied by medical students are those at the City Hospital, where the most striking thing to be seen is the neglect with which mental cases still can be treated in an institution devoted to the relief of the sick. A rather striking local occurrence which shows how little can be accomplished when psychiatry is taught under such conditions was afforded by a trial in which the testamentary capacity of a wealthy man was the issue. A recent graduate of the Medical School, when placed upon SMental Hygiene, Vol. 4, No. 2, April 1920. Mental Diseases and Deficiency 461 the witness stand, attempted to describe the patient's mental disease in a confused medical jargon, instead of stating what it was that he saw and heard which led him to make a diagnosis of mental disorder. The impression made on the court was that of a person attempting to describe something he knew nothing whatever about. A few minutes later, however, a bank clerk who took the stand gave a clear, simply-worded account of his deal- ings with the patient, evidences of failing memory, of delusions, misidentifiea- tion of persons and other evidences of a disordered mind. The authorities of the University and the Medical School are fully aware of the deficiency which their school shares with so many others, and an active movement is under way to include a modern well-equipped university psychiatric clinic in the new Lakeside Hospital. When these facilities are available, mental cases will be admitted to the wards set aside for them with as little formality as to the general medical or surgical wards of the hospital, and students will learn their mental medicine in the same atmosphere of science and kindly care as that in which they learn to diagnose and treat all other types of illness. With such provisions, those who graduate from this medical school in the future will have an attidude toward mental disease very different from that of those already graduated, who are carrying into the homes and hospitals in which they practise a conception of insanity that belongs to a different century. The benefits of the university psychiatric clinic to others are even greater than those which come to the future phy- sicians. The training school for nurses of the parent hospital which has a psychiatric department gives special consideration to mental nursing, all pupil nurses spending a definite period of their course of training in the mental wards. The social service department of a university psychiatric clinic enables the environment to be studied as a factor in the causes of disease, its manifestations or its outcome. Thus, the hospital is brought into con- tact with the school and the home and when such relations are established between the social environment in which mental illness has its origin and the psychiatric hospital in which it is studied and treated, a real and positive mental hygiene becomes possible. Fairview Park Hospital — The medical staff of Fairview Park (formerly the German) Hospital is headed by a neuro-psychiatrist. A limited number of patients are received in private rooms where they are cared for skillfully under his direction. A mental hygiene clinic is about to be opened. Mt. Sinai Hospital has this year appointed a neuro-psychiatrist to its staff and inaugurated a mental hygiene clinic. St. John's Hospital is able to take in a few mental patients, who offer no special difficulties in treatment, but it has no out-patient department for mental diseases and no psychiatrist. Lakewood Hospital also receives a few mental patients, the physicians who bring them into the hospital being responsible for their care. Other General Hospitals — There are no beds for mental patients in the hospitals not mentioned above, except the Marine Hospital in which there are a few beds for mental patients among beneficiaries of the Bureau of 46 , -2 Hospital and Health Survey War Risk Insurance, but most of them have neuro-psychiatrists on their con- sulting staffs. In none, however, is there a regular psychiatric service or clinic. The neuro-psychiatrists act as consultants and are called in only when some one feels that their special services are needed. How little this need is ap- parentlv felt is shown by the fact that the neuro-psychiatrist of one of these hospitals made his last visit before he left to enter the army and it was not known at the hospital whether or not he had returned to Cleveland since the war. In another hospital no psychiatric consultations had been held or demanded within two years. Dispensaries There are no dispensaries for psychiatric cases in Cleveland. Were it not for the psychological clinic maintained by the Board of Education and the work done by Miss Claire Walters in connection with the Boys' Home and the Juvenile Court, it would be necessary to say that no organized facilities existed for the examination of mental patients in out-patient clinics. It is well recognized that the psychological clinic can deal with only one phase of the problems of mental diseases and mental deficiency. With the great shortage of institutional provisions that exists in Cleveland the need for dispensaries is much increased. There is urgent need for several well equipped and well staffed psychiatric dispensaries not only to aid the psychological clinics in rounding out their work with children but to bring medical aid to many who can be most successfully treated in that way and to others who need institutional care but who can be tided over temporary difficulties by the help that they can receive in a well-conducted psychiatric dispensary. The out-patient department of the proposed City Psychopathic Hospital will be one of its most useful activities but to deal with such special problems as those presented in the schools and courts and homes, "outposts" must be established which can give as many hours or days a week as are necessary to these special tasks. With a personnel consisting of a psychiatrist, a psychologist and a social worker such "outposts" can become extremely valuable diagnostic and therapeutic agencies, especially when they have behind them the wards and laboratories of a modern psychopathic hospital. Another such dispen- sary which should also maintain its share of "outposts" should be established at the Lakeside Hospital where it will greatly increase the usefulness of the proposed university psychiatric clinic. Private Sanitaria for Mental Cases The number of patients in private institutions in the different states bears a general relation to the extent and character of state care. Where state care is maintained at a high level of efficiency, persons avail themselves freely of it, but when it is poor in extent or quality every effort is made, even by those with very limited means, to provide some kind of a substitute. It is not surprising, therefore, that with its overcrowded state hospitals operated at a very low cost, Ohio should have a relatively large proportion of patients in private institutions. Mental Diseases and Deficiency 463 In most other states the insane and mentally defective, whether in public or private institutions, are at all times regarded as wards of the state. This is a practical survival of the ancient custom which made all minors and incompetent persons wards of the Crown. In Ohio no license whatever is required to conduct a private sanitarium for the care of voluntary or com- mitted cases of mental disease. In spite of the efforts of a former member of the State Board of Charities, who was a psychiatrist, to bring such institu- tions under state supervision, any person can start a sanitarium, advertise, receive patients, lock them in strong rooms or restrain them in beds without any authority of law. These sanitaria are not inspected, in fact, are scarcely known to exist, except by physicians. Judges occasionally order patients to such institutions which receive them on that specific order, but thereafter the state exercises no supervision. Practically the only control which any state official has over these institutions is that exercised by the Fire Marshal who may declare the premises unfit for the purposes for which they are used and order the reception of persons and patients discontinued on the ground of fire hazard. This lack of supervision over what is generally recognized to be an ac- tivity in which the state has a very definite responsibility, may be contrasted with the provisions for licensing and inspecting private institutions which exist in New York. In that state a private institution caring for mental cases must secure a license which is granted only after a careful inspection by the psychiatrist who is Medical Inspector of the State Hospital Commis- sion. The physician-in-charge of a private institution must have had at least five years' experience in the treatment of mental diseases in an insti- tution for the insane. All cases under treatment in an institution must have been received as voluntary patients under the laws regulating this form of admission or must have been committed by one of the methods provided by law. Such institutions are frequently inspected and they must make the changes and improvements ordered by the State Hospital Commission, in personnel as well as in physical facilities, or be in danger of having their license revoked. Nothing that has been said above regarding the necessity for supervising and inspecting private sanitaria for the care of mental cases should be taken to minimize the valuable part which the best of these institutions, even though run for profit, play in the treatment of mental diseases. It would be difficult to devise any other substitute for patients who require con- tinued care and are able to pay more for it than the cost of maintenance in the state hospitals. There are certain disadvantages in the lack of a large staff, laboratories and facilities which characterize the modern state hos- pital, but the surroundings of the good private institutions are similar to the patient's usual environment. Much more individualized work is carried on in behalf of those who have disorders of long duration, but with prospects of ultimate recovery, than is possible in the state hospitals, in which prac- tically all therapeutic effort is concentrated for a short period upon a rela- tively small proportion of patients. Several of the sanitaria for mental diseases, which receive patients from Cleveland are excellent institutions, have staffs of competent physicians and nurses and are able to provide prac- tically all the facilities for treatment which modern standards demand. On 464 Hospital and Health Survey the other hand, others which often charge as high or higher rates provide only custodial care which, in many instances, is inferior to that provided by a state hospital. There is urgent need of a change in legislation which will enforce in Ohio the provisions of the Fifth Amendment of the United States Constitution, which makes it illegal to deprive any person of "life, liberty or property, without due process of law. " Private sanitaria for mental patients and men- tally defective children should receive their cases by voluntary admission, commitment for observation, or regular commitment, as is the case with public institutions. Such institutions should be licensed, preferably for a year at a time, after an inspection of the plant and facilities by a competent psychiatrist and after approval by the Bureau of Hospitals of the State Department of Health. Every such institution should be subject to expert inspection not less frequently than four times a year and during such inspec- tions every patient should be examined to see that he is either a voluntary patient or held under proper legal authority and to determine whether he is receiving the treatment which his condition demands. A provision should also be inserted in the law which will make it mandatory for the medical head of each such institution to possess certain experience in the care of mental disease. It should be within the power of the licensing board to revoke or fail to renew at any time the license of any private institution which does not maintain a satisfactory standard of treatment or which re- ceives patients through illegal methods of commitment. Places Other Than Hospitals for Detention or Care County Jail — The county jail provides for a small number of mental cases. In the cell section there are two beds in which prisoners who are quite ill physically or are thought to be mental cases are put for short periods. For- merly this was the only provision available for those who after their arrest seemed to present evidences of abnormal mental condition. Largely through the efforts of Judge Alexander Hadden of the Probate Court, a room off the sheriff's office was secured and provided with eight beds. Men who are apparently insane, epileptic or mentally defective are now put into this room. Before prohibition went into effect more than fifteen had been housed in this room at one time, mattresses being placed on the floor and the patients placed two in a bed. Since prohibition this number has been greatly decreased so that sometimes for several days at a time there has been no new mental case admitted. When the jail was visited there were two patients in the room, one a man who escaped from the State Hospital at Massillon, and the other a young negro awaiting investigation. These patients are kept segre- gated from criminals, and everybody at the jail seems to realize that they should have some special attention. Usually after one night spent in the jail hospital mental cases are examined by one of the neuro-psychiatrists attached to the Probate Court and when their cases have been considered by the court they are transferred to the City Hospital or other disposition made. Women are taken to the matron's floor where they have the freedom of a good-sized room during the day. At night they are put in cells. Mental Diseases and Deficiency 465 In spite of the best provisions, insane persons who are unable to give an account of themselves or who suffer with disorders of conduct are extremely likely to be picked up by the police. With a law which permits the admis- sion of all such persons to psychopathic wards for observation, it is not neces- sary for such cases to be detained in jail at all. In fact, in several states, provisions of the insanity law directly forbid the placing of an insane person or one in whom insanity is suspected in a place for criminals or even in a place in which are to be found those accused of crime. Prisoners who are await- ing trial or who exhibit evidences of mental disease during their imprison- ment should be transferred at once to the psychopathic department of the City Hospital for observation. This applies to alcoholic cases and drug addicts whose arrest cuts off the supply of the drug to which they are ad- dicted. It is very evident that the jail is regarded in Cleveland as a wholly unsuitable place for persons suffering from mental disease and, very properly, no provision is made there for other than the most temporary kind of care. Mentally defective prisoners are very unlikely to have their condition recognized at the jail unless they are very low grade defectives, when they usually take the course through the Probate Court followed by those suffer- ing from mental diseases. With the routine mental examination of a person admitted to a jail, such as is the practice in many cities and is rapidly extending to others, it will not be necessary to depend upon the untrained judgment of the sheriff and jailers as to the mental state of prisoners. City Farm — On a large tract of land at Warrensville, a short distance outside the corporate limits of the city, is the City Farm which was acquired upon the suggestion of Dr. Harris R. Cooley, at one time Director of Chari- ties and Corrections. It was Dr. Cooley's plan, as part of a general system of parole and reconstruction, to attempt to reclaim prisoners in the House of Correction by giving them an opportunity for industrial training on the farm. The tract of land is so large that some of it was soon used for other purposes. There are now on this tract in addition to the House of Correc- tion, the Tuberculosis Sanatorium (described in Part IV. of the Hospital and Health Survey), the Girls' Home and the City Infirmary. The City Infirmary — This institution provides for about 500 patients, most of them advanced in years, with chronic illnesses. Some are able to be about and help to a certain extent in the institution, but most of them are too infirm. Cases are received upon the order of the Superintendent of Out-door Relief after being referred to that official by the families of pa- tients, district physicians or other physicians. The building is new and clean. There is only one resident physician and few nurses, so the standards of scientific care are not high, although there are many evidences of kind- ness and interest on the part of those who are in contact with the patients. Specialists from the Probate Court make periodical examinations of the whole population of the Infirmary for the purpose of discovering and having "probated" those suffering from mental diseases. The last such visit was in November, 1919, and another is expected in the near future. The exami- 466 Hospital and Health Survey nation of seventy cases indicated that a number of patients with well-defined psychoses will be found and, in addition, many others with simple senile deterioration who are usually not transferred to the "insane wards. " These "insane wards" consist of two buildings of modern construction, but show no evidence of having been planned especially for the purpose for which they are used. When visited there were seventy-nine male and eighty-nine female patients. Windows are guarded and doors locked. In general, the wards were clean and not unattractive. Patients are not received directly to these wards, but, in all cases, transferred from the City Hospital or from other wards of the City Infirmary. Theoretically, all are awaiting reception by the State Hospital as soon as vacancies exist. Actually, they will spend many months or years in the institution, for vacancies in the State Hospital are used for the reception of more acute cases. These patients have no specialist in mental diseases to direct their care and no trained nurses. At- tendants who are paid from $42.00 to $50.00 per month, with maintenance, are employed. These attendants, as is so often the case, make up in kind- ness and thoughtfulness much that they lack through not having had special training. These "insane wards" are purely custodial. They represent another period in the history of the care of the insane, and exist only because, pending the state's tardy recognition of its duty in the matter, Cleveland is content to allow some of its citizens wjio suffer from serious diseases to be held in a custodial institution without treatment. Sane patients are sometimes trans- ferred from the other wards of the City Infirmary to the "insane wards" for "discipline," a practice unfair alike to the insane and to those who are trans- ferred. Mental Diseases and Deficiency 467 State Facilities for Diagnosis and Treatment IN every state the care of mental diseases is very largely dependent upon legal and administrative mechanisms set up by the legislature. A community may possess an enlightened and humane conception of its duty toward its mentally ill but such a conception can be expressed only through such mechanisms. In all other diseases no such situation exists. It is for this reason that a study of the facilities for dealing with mental diseases and mental deficiency in Cleveland must take into consideration the laws, administrative agencies and institutions that the state of Ohio has provided. State Board of Administration The form of institutional administration and supervision in Ohio is that known as the "State board of control system. " In this system all authority is placed in the hands of the few men constituting the central board, and the institutions have no local boards of managers. In Ohio this board is called the State Board of Administration. It is a bi-partisan body consisting of four members, each of whom receives $5,000 a year for full-time service. The term of office is four years. Members are appointed by the Governor with the advice and consent of the Senate. In spite of the fact that by far the larger number of persons in the twenty-one institutions under the control of the Board are suffering from serious forms of illness, the law does not re- quire that a physician shall be one of the members, nor even for any medical consultation in the work of the Board. The medical superintendents of state institutions are directly under the Board. When the medical profes- sion demanded representation, a physician was appointed to the Board. Business administration is centered in the Board so there are no stewards in the hospitals. This places a heavy burden of business detail upon the medical superintendents of these institutions. There is no provision for coordinat- ing the scientific work of the hospitals, no central institute for research and training and no feeling on the part of the Board that it is responsible for leadership in the very important and complex relationships which mental diseases and mental deficiency bear to social, health and educational prob- lems. A harsh and unwieldy commitment law is permitted to remain on the statute books as far as any action initiated by the Board is concerned, and the whole system of administration is based upon the conception that the duty of the state toward its citizens with mental diseases and mental deficiency begins and ends with institutional administration. Of course the period of institutional treatment represents only one phase of a life-time prob- lem in the insane and mentally defective, and no administrative mechanism which limits its interest to the institutional phase (and practically only to the business side of this phase) can establish clinics, develop social service and after-care for patients and take leadership in practical work for preven- tion. In states which have special medically led commissions to direct the state care of the insane and mentally defective, all these activities constitute a large part of the service rendered, while at the same time business adminis- tration is competently directed. At present many states are firmly committed to the "Board of Control Idea," but in several, efforts are being made to cor- rect the serious deficiencies of such a system by appointing physicians as •468 Hospital and Health Survey special advisors in the part of their work that deals with mental diseases, mental deficiency and tuberculosis. Even with such modifications this sys- tem does not permit the kind of work in treatment and prevention that modern conception of mental diseases and mental deficiency makes obligatory upon a state that faces these problems squarely and seeks to do more than temporize with them. Laws Relating to the Insane, Mentally Defective and Epileptic Insane — The laws of Ohio require that when any person is believed to be insane, or because of insanity is "dangerous to the community at large," a formal complaint be made, a warrant issued for the apprehension of the alleged insane person, and the accused brought before the court or examined by the Probate Judge out of court. This procedure emphasizes the legal side of mental disease, adding a considerable burden to the already troubled minds of the unfortunate patients, who often are perplexed that they should be arrested when they have committed no crime. As stated, the judge may review the case at the residence of the patient or elsewhere, but naturally this is seldom done. The judge obtains such evidence of the patient's in- sanity as he deems necessary and must cause a certificate to be made by two medical witnesses. Being satisfied that the person is insane, the court applies to the superintendent of the state hospital, asking that the patient be received. Lpon notice from the superintendent, the judge directs the sheriff to transfer the patient to the state hospital. A suitable female assistant must accom- pany him if the patient is a woman. If there is a vacancy in the county's quota at the hospital, the Probate Judge may commit an acute case without notice. If the relatives of an insane person desire to take charge of him they may do so with the court's approval. Voluntary commitments are permitted for not more than sixty days, and no hospital is permitted to care for more than five voluntary patients at one time, nor for any if the county's quota is already full. There is no provision for emergency commitments. Patients may be allowed out on trial visits not exceeding ninety days in length. These visits are made under rules prescribed by the Board of Ad- ministration, but the decision, except in criminal cases, rests in the hands of the superintendent. When an insane criminal is in condition suitable for discharge, the prosecuting attorney of the county whence he came must be informed. The question of insanity may be introduced as a defense in crim- inal actions and determined by the jury sitting in the case or by jury specially called, in which event the prisoner is usually transferred to the jurisdiction of the Probate Court so that he may be placed in a state hospital. The trial judge may commit him if his release is deemed dangerous to the public peace or safety. Similarly if a person before a court in any capacity appears to be insane, a jury may be empowered to decide his mental state, or he may be transferred to the Probate Court for its determination. The latter is the usual procedure. Criminal, convict, dangerous and "incorrigible" insane who cannot be conveniently cared for at other hospitals for the insane, and insane persons who have previously been convicted of certain serious crimes are cared for at the Lima State Hospital for the Criminal Insane. Mental Diseases and Deficiency 469 None but residents of the state can be received into a state hospital, except upon order of the State Board of Administration. The Ohio law does not reflect, as the laws of many other states now do, the great changes in medical and public opinion regarding mental illness and those who suffer from it that have come about during the last genera- tion. The provision for a quota for each county legally recognizes failure to provide free state care. The requirement of personal appearance before a judge imposes the hardships of a quasi-criminal procedure upon sick people. The provision limiting the number of voluntary cases to five is not observed by most hospital superintendents. In the absence of vacancies for cases awaiting admission after court commitment such a provision serves, never- theless, to restrict the use of the most desirable type of commitment pro- cedure. The laws relating to the insane should be thoroughly revised so as to permit personal appearance or even service to be waived, to provide for emergency commitment and commitment for observation, and to remove the restrictions thrown about voluntary admission. The law should provide for attendants from the state hospitals going to the homes and bringing in new patients, thereby eliminating the sheriff entirely. Mentally Defective and Epileptic — Proceedings in committing the feeble-minded and epileptic are practically identical with those followed in cases of insanity, and there is the same emphasis on a hearing before a judge. There is the same provision for the reception of epileptics as voluntary pa- tients, and parents and guardians may voluntarily ask that their charges be admitted into the Institution for the Feeble-minded at Columbus, Ohio. The Board of Administration may also make commitments to that institu- tion. Medical certificates for these institutions and the state hospitals are alike. With the mentally defective and epileptic, as with the insane, the object of the commitment law should be to make the institutions readily accessible to those who need their services, throwing around the procedure only such safeguards as experience has shown to be necessary to prevent abuse. The self-respect and welfare of those committed should be the chief consideration. In the care of the. mentally defective and epileptic, voluntary commitment should be so provided for as to become the method of election. State Hospital for Mental Diseases There are six civil state hospitals and an institution for the criminal insane in Ohio. Hamilton County (Cincinnati) has a hospital as large as one of the state hospitals, which is owned by the county but maintained by the state. The state hospitals at Cleveland, Columbus, Dayton and Toledo receive nearly all their patients from the cities in which they are situated. In many states the great public institutions for the insane are remote from large cities. The Ohio plan has several marked advantages. Few states in the country have an arrangement whereby a system of state psychopathic hospitals forming departments of existing state hospitals could be put into 470 Hospital and Health Survey operation so readily or be likely to operate with as much success. The favor- able location of these hospitals not only renders them readily accessible but also makes it possible to carry on after-care supervision with great facility. The over-crowding, understaffing, low per capita allowance for maintenance, and the unsympathetic control by a board of business administration, makes it impossible, however, to take advantage of these favorable circumstances. The Cleveland State Hospital owes its origin to a gift of a tract of 100 acres lying within the city limits by Thomas Garfield and his wife, for the purpose of establishing a hospital for the insane. The reception of pa- tients commenced in 1855. The growth of the city has made land so valu- able that the hospital cannot expand. As the buildings are old and in poor repair it would be sound economy to abandon them, retaining only a recep- tion hospital, acute medical and surgical hospitals and a diagnostic clinic. Such a center for intensive medical treatment of not more than 500 beds would provide facilities for an institution of 1,500 which should be situated within twenty miles from the city where land is cheaper and more outdoor life possible. The experience of states in which full state care is provided shows that the ratio of patients to population under such conditions is approxi- mately three to one thousand. In states like New York and Massachusetts in which full state care has been provided for many years and people make the fullest possible use of the state hospitals, the ratio rises to four per 1,000. Every group of 500,000 people requires a state hospital of 1,500 beds. There- fore the district in which Cleveland is situated (Cuyahoga, Lake and Geauga Counties) requires a second state hospital, which, like the first, could be utilized for the intensive medical treatment suggested. With the growth of the city these hospitals could be increased in size to 2,000 each or possibly to 2,500. When the latter number is reached, with the intensive treatment group, there will be 5,500 beds, which would provide for a city of 1,650,000 population. No provisions short of these will relieve the situation that exists and end the reproach of detaining mental patients in such places as the City Infirmary, because the state has made too little provision, and of sending them back to their homes because the courts will deal with only such cases as can be provided for. Cleveland gets but little relief from other state hospitals. When visited by the Survey investigator the Cleveland State Hospital had 1,737 patients. There were only 55 patients from Cleveland in all other state hospitals, except that for the criminal insane at Lima, where there were 219. The ratio of patients to population in the whole state was one to 423.5 and the ratio of patients from Cleveland to the population of the city, one to 497.3. It is obvious that Cleveland has 17 per cent fewer beds than its quota in the state hospitals. The 1,737 patients in the Cleveland State Hospital were occupying space alloted to 1,450, causing an overcrowding of nearly 20 per cent. The original allotment is based upon a distressingly small floor space and it is not difficult to picture the conditions that exist when this space is occupied by 20 per cent more patients than the number for which it was designed. Even to maintain the population with this amount of overcrowding and to receive new cases it is necessary to send out many patients still unrecovered. No policy could be more unsound economically than this. The number of physicians in comparison with the number of Mental Diseases and Deficiency 471 patients in this hospital is one to 485, one of the lowest ratios in the United States and little greater than that of physicians to the general population in the city of Cleveland. If one disregards entirely the need of physicians to treat the mental diseases from which the patients suffer, he can gain some idea of the standards of medical work possible, when he realizes that these patients are so ill physically that 10 per cent die each year. The population of a hospital gives a less adequate idea of the amount of medical work that has to be done than the admission rate. In 1919, 617 patients were admitted to this hospital. No state hospital of the same size in the whole country re- ceived so many. The superintendent, who is a well-trained physician, re- ceives only $2,500 a year, which is less than the amount received by a recent graduate in medicine as junior assistant in some other states. The appropri- ations for maintenance are in proportion. Few institutions in the United States spend as little for their patients' maintenance and care. In 1919 the rate per annum per capita for medical, surgical and laboratory supplies was 19.4 cents. In this hospital approximately 180 patients die every year. If the entire appropriation for medical, surgical and laboratory supplies had been expended last year upon these 180 patients, each would have had $2.20 worth of such sick room necessities during his or her last illness. The super- intendent is trying in the face of these conditions to make his institution a hospital in fact as well as in name. He plans to re-institute a training school for nurses, develop a system of after-care and make the best possible use of his meagre staff and equipment. He will inevitably fail if the people of Cleveland are unable to induce the legislature to change the policy of neglect that keeps its work upon the asylum level. State Institution for the Feeble-minded The "Institution for the Feeble-minded," the only one in the state, was established in 1857 and opened in August of that year in rented buildings in Columbus, Ohio. It removed to its present location in West Columbus in 1868. In 1898 the legislature appropriated funds for the purchase of the Custodial Farm of 1,248 acres at Orient. June 30, 1918, there were 2,264 inmates. Additional buildings about to be opened and others immediately constructed will care for 864 more, giving accommodation for 3,128. This is the largest institution of the sort in the world. The state of Ohio is hardly doing more than touching the surface of the problem of mental deficiency. With a population of 5,393,000, a conserva- tive estimate would place the number of feeble-minded in the state at at least 21,000 (four per thousand), of whom not less than 10,000 require care in special institutions. Provision is made for less than one-third of this number. What of the other two-thirds who should have such care? Many of them, as feeble-minded children in the public schools, juvenile courts, reformatories and orphanages, or as feeble-minded adults in the county jails, state prisons, criminal courts, venereal clinics and almshouses, are yearly a source of vast expense and the cause of untold sorrow. 472 Hospital and Health Survey With an estimated population of about one million, Cleveland District has about 4,000 feeble-minded persons, each of whom possesses potentiali- ties for delinquency and dependency that justify a serious effort on the part of public authorities to recognize and deal properly with the problems these individuals present. The advantages of early recognition and diagnosis, intensive special class training, and either wise and careful supervision out in the community or adequate institutional care, should be offered to each feeble-minded child in the state. It is not enough to place these defective children in special classes for a few hours of the day over a period of a few years, and then suddenly dump them into the community without proper oversight or supervision in early adolescence — the most unstable and critical period of life even for those not so handicapped mentally. The sad combination of the defective's childish mind and his adult years inevitably brings him into conflict with laws and rules of conduct which have been devised for persons whose minds as well as bodies are those of adults. Much of the benefit to be derived from special classes in Cleveland is being lost through lack of proper oversight after school hours and adequate supervision of the child in the community. The special class should be used not merely to relieve the grades of a drag and the regular grade teachers of an apparently hopeless burden, not for awakening interest and developing the general intelligence of the child, but to prepare and fit the defective to do something useful in life. Some state authority should be charged with the supervision of all mental defectives who are in need of, but not receiving it. On leaving the special class, employment suited to his vocational interest and aptitudes should be secured for each of these children. All those unable to profit by special class training or incapable of being adequately supervised in the community, should receive institutional care, but those defectives whose character, make- up and personality give them a definite community value, who are self- supporting, and are neither a danger to themselves nor the general public, can and should be handled satisfactorily under outside supervision. The fact that many high grade defectives, after prolonged institutional life and occupational training, can be paroled with perfect satisfaction into the community, has now been well demonstrated by Dr. Fernald at Waverley, Dr. Wallace at Wrentham, Dr. Bernstein at Rome, and many other leaders in work among the feeble-minded. Dr. Fernald recently made a study of all male patients paroled from Waverley in the last twenty-five years. It was found that the great majority of these boys had never been arrested, never been in court, never had children, but were law-abiding, self-supporting citi- zens. Few had married. The economic saving through a well-developed parole system is enormous but it is necessary to emphasize the point that such super- vision must rest upon a carefully made diagnosis by experts. With this a period of institutional training is usually, but not always, required. Mental Diseases and Deficiency 473 Two outstanding needs deserve mention: (1) identification and special class training, with proper after-care and supervision for all children in the state who are capable of receiving it; (2) increased institutional provision. The first requires a comprehensive mental deficiency law for the state and the careful upbuilding of the local mechanisms by which such a law may be made effective. The appropriation of $650,000 which is available will procure the site, provide for water supply, sewage disposal, power plant, administrative and service buildings for a new institution, but at least $1,350,- 000 more will be needed for an institution housing 2,000 patients. With such provisions Ohio will still be behind other states in the number of beds compared to the general population, but, with two such "parent" institu- tions, extension by means of colonies may be cheaply and efficiently made. State Hospital for Epileptics The Ohio Hospital for Epileptics at Gallipolis, opened in 1893, was the first institution in this country for the care of epileptics. The example was followed in many different states. The census of this institution at the end of the last fiscal year was 1,587. On April 2, 1920, there were 191 patients from Cuyahoga County. This number represents a ratio much less than that which the population of Cleveland bears to that of the whole state, but cities have many resources in their dispensaries and clinics for the treatment of epilepsy, and in the absence of full state provisions it is not unfair that the cities should have a smaller proportion of the beds available in state institu- tions than rural communities. Additional provisions for 456 patients are here being made. A second institution of this kind is already needed. Formerly a special class for epileptics was maintained in Cleveland, but it was discontinued for reasons that could not be ascertained. Epileptic children have needs that cannot always be met in the special classes for the mentally defective. Although many of them are mentally defective from birth or are dulled intellectually by their disease, there are others suffering from epilepsy w T ho are normally bright. Their seizures make it necessary to exclude such children from the grade classes, as nothing is much more dis- tressing for other children to witness than a severe epileptic convulsion, but they are capable of carrying on grade work. The result is that many leave school altogether at an early age and, in addition to the heavy burden of their epilepsy, carry the additional one of illiteracy. It would seem that in a school population of 144,197 several special classes for epileptics would be amply justified. Bureau of Juvenile Research The Bureau of Juvenile Research was established on July 1, 1914, under the following broad provision of law: "All minors, who, in the judgment of the Juvenile Court, require state institutional care and guardianship, shall be wards of the state and shall be 474 Hospital and Health Survey committed to the care and custody of the Ohio Board of Administration, which Board thereupon becomes vested with the sole and exclusive guardian- ship of such minors." (Ohio G. C, Section 1841-1.) The Board of Administration commits these minors to the Bureau of Juvenile Research for study and classification and is required, after their condition has been determined, to "then assign the child to a suitable state institution or place it in a family under such rules and regulations as may be adopted.'' The Board of Administration has authority to transfer minors from one institution to another upon proper cause with the proviso that "except as otherwise provided by law, no person shall be transferred from a benevolent to a penal institution." This permits the Board to transfer a child from the institution in its jurisdiction to the Bureau of Juvenile Re- search and later to re-transfer him. Further provision is made for the re- ception by the Bureau of minors from public institutions not supported by the state, from private charitable institutions, or from the custody of legal guardians, upon terms deemed proper. The counties liable for the support of these minors are required to pay the expenses of their transportation. The special defect of this generally admirable law is that it provides for the review of cases that have already been passed upon by the courts. Obvi- ously, the examinations are most needed before trial rather than after com- mitment. It will be noted that only cases which require institutional care are to be sent to this Bureau by the Juvenile Courts. This restriction is undesirable, for the hope of correcting delinquent trends in the mentally defective and of dealing successfully with psychopathic or psychoneurotic chil- dren, lies in making the greatest efforts in the early stages before departures from normal behavior are so striking that they are easily recognized, and be- fore it is certain that institutional care is the most desirable measure. Those interested in the problem of conduct disorders in childhood desire to have all Juvenile Court cases examined with regard to the mental factors in their delinquency. The present director of the Bureau, Dr. H. H. Goddard, has well said: "In a great many cases, the first offenders are as feeble-minded or psy- chopathic as others and there is no good reason why we should wait until they have made a second or third attempt before we should recognize their condition and proceed to treat it." The Board of Administration and the Bureau of Juvenile Research in- terpret this law in the broadest possible way and endeavor to render as much service as possible to the children sent by parents or institutions. The work of the Bureau has been much handicapped by insufficient funds. Good buildings with a capacity for 150 patients exist but there is sufficient money to care for only 40 at a time, and at present there are less than that number at the Bureau. Its work is. very much embarrassed by the fact that the Institution for Feeble-minded is overcrowded, so that a mentally defective child must wait, after his examination, until there is a vacancy before he can be admitted, and further embarrassment is due to the fact that there are no facilities in the state for the treatment of psychopathic and psycho- neurotic children. Mental Diseases and. Deficiency 475 The Director supplies the following concise statement of the personnel in his organization. "The organization at present is as follows: director, chief psycho- clinician, who is responsible for all under mental diagnosis; two associate clinicians, who are next to the chief in ability and also capable of making diagnosis; then two assistant psycho-clinicians of somewhat less experience, but able to make accurate mental tests and submit recommendations or suggestion on diagnosis; a physician and two nurses for the care of the physical side; a chief clerk, record clerk, three stenographers, one superintendent of cottages, superintendent of grounds, two attendants and the night watch." We have much doubt as to the wisdom of dismissing so lightly the "phys- ical side" of such complex problems as those which come to the Bureau of Juvenile Research for solution, and of dealing with all the mental factors from a purely psychological approach. Even if the defectives present no special problem with which the psychiatrist is best equipped to deal, the psychopathic, psychotic and psychoneurotic children must present many difficulties upon which mental medicine has some light to throw. It will be most unfortunate if this highly important experiment station fails to render the service of whicL it is capable through lack of sufficient funds. When one contrasts the few thousands of dollars required for its maintenance with the millions that are almost blindly expended in dealing with the consequences of our unintelligent way of approaching conduct disorders of childhood and adolescence, it is obvious that considerations of economy alone would demand generous support of this Bureau. 476 Hospital and Health Survey Courts and Correctional Agencies MENTAL diseases and mental deficiency differ from other problems of health and medicine because of the fact that their diagnosis, management and, to a very large extent, the success with which they may be dealt by physicians, teachers, nurses and social workers is de- termined by courts and correctional agencies. There is no doubt that these disorders come to attention much more frequently for other reasons than that of disturbance of conduct. Such disturbances, when they do occur, however, are so important socially and sometimes so tragic in their con- sequences that mental disorders generally are dealt with by a legal mechan- ism suitable for only a small percentage of all persons who are mentally ill. The physician, therefore, has to call upon the courts when mental cases are brought to his attention, even though there is no question whatever of public order or safety. Very often, in other cases, the courts have gone a long way in determining the future of mental patients before the advice of physicians is sought at all. Courts Probate Court — The Probate Court is especially charged with the duty of dealing with mental patients. The Commitment Law of Ohio has already been referred to (page 468). When an affidavit alleging insanity has been presented, the Judge orders a "suitable person" usually the sheriff or a deputy, to bring the patient to court. Patients are also referred to the Probate Court from other courts in which they have been found to be insane but which are not empowered to commit to institutions. In such cases the function of the Probate Court is only that of commitment, the issue of insanity having already been decided. In order to protect himself from ill-advised or improper applications for the commitment of a patient the Probate Judge has attached to his court two examining physicians who have had experience in hospitals for mental diseases. These psychiatrists interview the friends of the patient, examine the patient personally, and make a report, usually verbal, to the Judge. The Women's Protective Association sometimes makes social investigations for the court. If this preliminary examination shows that the patient suffers from a mental disorder, the psychiatrists make out a medical certifi- cate and the patient is committed forthwith. If the Judge deems that such action is inadvisable the case is dismissed. If the examination is inconclu- sive and observation is required to establish the diagnosis the Probate Judge commits the patient to the "Detention Hospital," that is, to the mental wards of the City Hospital, (page 446). Previously this was not possible, but some years ago when the wife of a lawyer went through the trying ex- perience of commitment the law was amended so as to permit this practice. The Detention Hospital is used not only for such observation cases but for those "whose insanity is likely to be temporary" and all "insane persons who cannot be committed to or received into the State Hospital." The overcrowding at the Cleveland State Hospital makes the latter procedure necessary in many cases, but the overcrowded and unsatisfactory state of the Detention Hospital often makes it difficult to find any place for those Mental Diseases and Deficiency 477 who urgently need care. The result is that people are advised to take their mentally ill relatives home again and thus treatment is deferred — a tho- roughly uneconomic and unsound practice. The Probate Judge may also commit to the department for mental patients in the City Infirmary at Warrensville (page 465) or, in criminal cases, to the jail hospital (page 464). It is often the case, when the law is harsh and public facilities for observation and treatment inadequate, that kindness and sympathetic cooperation on the part of those who administer the law minimize the distress and humiliation that come to patients. This is the case in Cleveland. The Probate Judge is considerate, realizing the heavy affliction that mental disease brings to the patients or to their families but, although he attempts to soften the phases of commitment that smack of criminal procedure, the fact that a person "suspected" of having a mental disease is produced in court and usually brought there by a sheriff creates an atmosphere that in many other states has been eliminated from the admission to hospital of persons suffering from mental illness. When a patient is committed the Court becomes a supplicant to the State Hospital in the effort to secure admission. The superintendent of the hospital exercises full jurisdiction in this. Preference is given to patients who are having the greatest difficulty in getting on in the community. Those with mild mental disorders are rarely received when application is first made. Practically no other course is possible but the great disadvantage of this method of solving the difficulty lies in the fact that mild and early cases afford the most promising field for successful treatment and many of the severe and late cases that become a permanent charge upon the state could make a full or a "social" recovery were treatment available in time. The Cost to the city of the medical examinations and other services rendered in the commitment of mental patients in the Probate Court is not ascertainable from any published reports. The Clerk of the Court kindly permitted the examination of the check book stubs for the period of three months ending September 10th, 1919. This quarter is somewhat lighter than the other three and so an estimate of the yearly cost based upon this examination would give a total less, rather than more, than is actually the case. Medical fees during the period amounted to $2,209.00, an annual rate of $8,836. If these examinations were made in the mental wards of the City Hospital under such conditions as those that may be expected to exist when that institution is transformed into a real City Psychopathic Hos- pital, such a contribution would go far toward paying the salaries of all the full-time psychiatrists needed. In such a hospital expert observation would yield medical and social facts of great value in determining the best action to be taken in each case. If the present difficulty in securing prompt ad- mission to the state hospitals continues, as it must for several years in spite of the most energetic efforts to correct it by new building, the selection of cases for commitment or for return to their homes, with or without out- patient supervision and treatment, would be done in a more efficient manner than is possible with the facilities that now exist. As it has been held that the mental wards of the City Hospital constitute a place to which insane patients may be legally committed, the physicians there cannot, obviously, 478 Hospital and Health Survey take part in the commitment of people to their own institution. In order that the proposed City Psychopathic Hospital in connection with the City Hospital may operate to the greatest advantage, it is necessary that this and other provisions of the law be changed so as to permit commitment there only for observation and temporary treatment on physicians' cer- tificates or the orders of any magistrate. This method of commitment is followed with conspicuous success in New York City in the psychopathic wards of Bellevue and Kings County Hospitals in the commitment of more than 4,0Q0 patients a year. The sheriff receives $1.71 for each patient conveyed to the Cleveland State Hospital. There were 567 such patients during 1919, for whose trans- portation he was paid $969.57. For each mentally defective person sent to the Columbus State Institution $22.83 is paid. Twelve patients were con- veyed there during the same year at a cost of $273.96, the remainder of the total of eighty-six being taken by relatives. Twenty patients were taken to the State Hospital for Epileptics by friends and six by the sheriff at a cost of $247.38 or $41.23 each. The warrant to arrest a patient entails a fee of $1.64. The number of such warrants issued was not ascertained. To those who are accustomed to methods more in accordance with those used with other sick persons, this handling of children and adults with mental diseases, feeblemindedness and epilepsy by sheriffs and court attendants is abhorrent. It is a relic of a period in the development of the public attitude toward illness that has no more place in an enlightened community today than Salem witchcraft. The simplest, kindest, and least expensive method is to have nurses and attendants from the institutions to which patients are to be committed come for them and convey them there by the skillful and kindly methods that their training so admirably fits them to use. No other method would be tolerated by those who had seen the one suggested in actual operation. Municipal Court — Only a relatively small proportion of all offenses for which people are arrested are serious ones. This is true of those committed by mentally defective or psychopathic persons as well as by those with nor- mal mentality and so the lower courts, which in every city deal with a vast amount of delinquency, have to do much more than the higher courts with persons whose asocial conduct is dependent upon abnormal mental states. In the Municipal Court of Cleveland the relationship existing between delinquency and psychopathic conditions are not so fully appreciated as in some other cities nor do they receive as much weight in procedures of the court and in the dispositions made of offenders. The work of the Municipal Court is evidently carried on with earnestness and a broad spirit of toler- ance but few persons brought before it receive an expert psychiatric examina- tion. When insanity is offered as a plea or some abnormal mental condition is apparent to the court or to the social workers, patrolmen or others con- nected with it, prisoners are sent to the Probate Court for disposition and there they receive a psychiatric examination. There seems to be a belief that laymen can pick out individuals who require a mental examination and that insanity or mental deficiency that does not manifest itself in ways thus Mental Diseases and Deficiency 479 apparent does not require to be taken into consideration. During a visit to this court a girl who had escaped from an institution in Michigan was under examination. Although to a psychiatric observer there seemed to be indica- tions of mental deficiency which would warrant a careful examination, the Court and the Probation Officer were quite confident that the girl had excel- lent intelligence and was simply "sulky" and "tough." It is asserted that such conclusions are founded upon long experience in dealing with delinquent types but it must be remembered that this experience is not checked by studying the results of examinations made elsewhere by those specially trained and it is difficult to see how it can do any more than to crystallize connections of normality and abnormality already formed. In Boston, Chicago and Philadelphia psychiatric clinics in connection with the Munici- pal Courts have been in successful operation for a considerable period of time and, in the opinion of the magistrates presiding over those courts, con- stitute a practical adjunct of the greatest value. The Probation Officer, Mrs. Callaghan, realizes that her work would be aided in many cases by access to psychiatric advice. She has charge of all persons placed on probation, paying special attention to the women, and renders other assistance to the court when women are concerned. Mrs. Callaghan has many cases examined by Miss Claire Walters who conducts the psychological examinations at the Boys' School and in cases that are to be sent to the Probate Court she makes notes that are very helpful to the psychiatrists attached to that court. In a city as large as Cleveland a psychiatric clinic in connection with the Municipal Court would be able to render valuable service. Nothing is more wasteful and ineffective than the method of dealing with permanent mental deficiency or psychopathic conditions by repeated trial and commitment to correctional institutions. Where the actual results of this method have been carefully studied it has been found that, in many instances, the cost to the community of dealing with one such individual by these methods i s greater than that of maintaining an efficient psychiatric clinic for a period of years. With a modern City Psychopathic Hospital as a center for all such activities, a psychiatric clinic could be established in the Municipal Court which would have back of it all the scientific resources of the Psychopathic Hospital and its facilities for investigation by those specially trained in this kind of medical social work. Parole Board — The Parole Board which consists of the Director of Public Welfare and the Probation Officer deals with skill and discrimination with cases that come before it. From ten to fifteen prisoners come before this Board each week and there are usually about seventy-five cases on parole. This number of cases requires more time for thorough investigation than one probation officer can give, and the work of the Board would be much aided if the probation officer had more assistance. In the numerous instances in which mental deficiency or some psychopathic condition is the cause or a very important factor in the delinquency of prisoners who come before the Parole Board there is no psychiatric report. The great value of such reports in dealing with these prisoners would amply justify provisions for mental 480 Hospital and Health Survey examinations as a routine measure in all persons committed by the Courts to the House of Correction. When a modern City Psychopathic Hospital is established there should be stationed here another psychiatric "outpost" consisting of a psychiatrist, a psychologist and a social worker who could give from one to three days a week to this work. Juvenile Court and the Detention Home — The Juvenile Court of Cleveland has long been known as a progressive agency conducted in accord- ance witb enlightened ideas regarding the management of delinquency among children. The present judge who, in addition, presides over the Domestic Relations and Insolvency Courts, has been at the head of the court for more than twenty years. It is housed, unfortunately, in the same building as the criminal courts, but in the new Criminal and Juvenile Court building which is being erected it will have a separate entrance and contact with the criminal courts will be avoided to a large extent. Many avenues are open to the Juvenile Court for securing information regarding the children brought before it. Social workers investigate the family and personal histories and the Clearing House cooperates in securing such information, especially regarding dependency or delinquency among families. The important relationships that juvenile delinquency bear to mental deficiency and other disorders of the nervous system are well under- stood and many efforts are made to secure psychiatric and psychological examinations that will throw light upon this subject in individual cases. Miss Claire Walters who is attached to the Boys' School makes intelli- gence tests. At her suggestion the services of the psychiatrists attached to the Probate Court are employed, children often being sent to them for mental examinations. At the Boys' School and the Detention Home (dis- cussed below) children are observed while their cases are pending or while awaiting placement but, of course, this observation is not made by those trained to detect the most significant alterations in behavior. The Bureau of Juvenile Research is by far the most valuable facility possessed by the court in dealing with issues, but, as was stated in the discussion of that institution, it receives children for scientific study after instead of before the issue of institutional commitment has been decided. The Juvenile Court can dispose of children brought before it in a number of different ways. Warning or reprimanding the children, warning or fining their parents and parole to a parole officer are the methods employed in by far the greater number of cases. Boys may be committed to the Boys' School, the State Industrial School for Boys, or to the Cleveland Farm School. Girls may be committed to the House of the Good Shepherd or to the State Industrial School for Girls. These institutions will be described a little later. They receive many mentally defective children, sometimes those of relatively low grade, and, in consequence, the tasks for which they were created are less efficiently performed. This is largely due to the absence of fully adequate facilities in the court for scientific mental diagnosis but were such facilities available many children Would still have to be disposed of in this way on account of the very inadequate state provisions for institu- Mental Diseases and Deficiency 481 tional care of the mentally defective and the lack of a mental deficiency law under which an effective system of extra-institutional supervision and guard- ianship can be constructed. When it is apparent from the histories and the results of psychiatric and psychological examinations that children are mentally defective and require institutional care the Judge of the Juvenile Court makes every effort to secure admission to an appropriate institution. He can transfer the case to the Probate Court for commitment, to a state hospital (which is rarely done), commit directly to the State Institution for the Feeble-minded, the State Hospital for Epileptics, or to the custody of the Board of Administra- tion for transfer to an institution upon recommendation of the Bureau of Juvenile Research. This court needs a psychiatric clinic to help it deal with the perplexing and enormously important problems in human conduct that come before it. Here are to be observed the first difficulties that subnormal or psychopathic- children experience in making the adaptations that are required for socially acceptable behavior. Upon the methods here employed for checking un- desirable adaptations and substituting desirable ones depend not only the future happiness of children and of the families of which they are members, but the success or failure that the community will later achieve in dealing with much adult delinquency and crime. , The time has long since passed when it was necessary to defend utilizing to the utmost in Children's Courts the sciences that have to do with the deep springs of conduct. Practical demonstrations by this time, extending over a number of years, justify the statement of one Judge of a Juvenile Court that he would not be willing to continue his work if deprived of the services of his psychiatric advisor. The maintenance of a psychiatric clinic for the Cleveland Juvenile Court should constitute one of the broader "outpost" duties of the proposed City Psychopathic Hospital. Backed by the resources of such a hospital, with its highly trained personnel, ward service for children, laboratories and well organized social service, such a clinic in the Juvenile Court would be much more useful than a small clinic acting independently. Detention Home — An indispensable adjunct to every Children's Court is a place where children may be safely detained while their cases are under investigation or while they are awaiting disposition. In Cleveland this is provided by the Detention Home, consisting of offices in a remodelled frame dwelling and quarters for the children in a fireproof addition. The building- is sanitary, well designed for the purpose that it serves and regarded as very satisfactory. Recreation rooms in the building and a playground outside have been provided. Adjoining property has been purchased so that depend- ent children may be placed in a building entirely separate from that in which delinquents are quartered. Changes must be made in this structure to eliminate a fire hazard but, even with present facilities, dependent and delinquent children are provided for separately. The total capacity of the Detention Home is 135. The usual population is from 100 to 140. On April 1, 1920, there were ninety -nine present — sixty-nine boys and thirty 482 Hospital and Health Survey girls. On that date fourteen boys and six girls selected at random were carefully examined mentally. Nine, or 40 per cent were found to be men- tally defective. The stay of the children in the Detention Home is necessarily short as they are detained only while their cases are pending. During this brief period, however, education is not neglected. Boys attend the Boys' School, close at hand, and girls receive instruction in the home building. Academic subjects are taught and some instruction given in domestic science and manual training. There are many evidences of kindness, sympathy and understanding on the part of those responsible for the operation of this institution. When a psychiatric clinic is included in the resources that the Juvenile Court has at its disposal, the observation of special cases in the Detention Home will yield very important psychiatric information. Correctional Agencies The public correctional agencies of the state were not examined in this survey. For children there are the Girls' Industrial School near Delaware and the Boys' Industrial School near Lancaster. The Boys' Industrial School receives boys between the ages of ten and eighteen. They may be retained until the age of twenty-one. The Girls' Industrial School was established in 1869 for "the instruction and reformation of incorrigible girls between the ages of nine and eighteen. " A report published by the Bureau of Juvenile Research in 1915 showed that more than 50 per cent of 1,000 children ex- amined in the two schools were mentally defective. House of Correction — The House of Correction, situated on the same reservation at Warrensville as the City Infirmary, the Tuberculosis Sanatorium and the Girls' Home, is a modern building, clean, sanitary and well conducted. All Courts, except the Juvenile Court, commit to the House of Correction. Only misdemeanants are received, the maxi- mum sentence being one year's imprisonment and a fine of $500. Prisoners may be paroled at any time in the discretion of the Director of Public Wel- fare. During 1918, 4,986 men and 695 women were admitted. In the year following the male admissions fell to 3,002 and the female admissions to 408. The greatest number in the institution at any time was 662 men and 88 women in 1918 and 748 men and 81 women in 1919. It is seen that the greatest decrease in 1919 was in prisoners serving the shortest terms. This is ascribed chiefly to prohibition. During the last six months it has been still greater than previously and the average daily population is less than forty. On the women's side with a capacity of 150 the average daily popu- lation in 1919 was only fifty-two. The best use to make of the vacant parts of the building is receiving much thought. There are many agencies that could make use of increased institutional facilities but few care to use a penal institution. It has been suggested that it be used as a convalescent hospital for patients from the City Hospital, for an isolation hospital for venereal patients, and for the care of feeble-minded women of child- Mental Diseases and Deficiency 483 bearing age pending proper provision by the state. The desirability of the city making provision for the mentally defective is open to serious question. However temporary these provisions may be intended to be, experience shows that they are exceedingly likely to be permanent. There is general agreement that the institutional care of the mentally de- fective is the function of the state. Granting that some increased provisions by the state will soon be made available, it is certain that if Cleveland makes the provisions at the House of Correction suggested, the new beds in state institutions will be used first for residents of other localities in which it may be assumed that the pressure for room for such patients is quite as marked as in Cleveland. By far the wisest thing to do during the period of waiting for the state to meet its deficit is to increase the facilities for community supervision and guardianship. If as much progress in this direction is made as the experience of other communities shows is possible, the need for insti- tutional provisions may be found to be less than it would be if 1,000 or 2,000 additional beds in state institutions were suddenly made available at the present time. Some of the statistics obtained regarding prisoners admitted to the House of Correction suggest a relatively high proportion of mentally defec- tive individuals. The changing character of the population resulting from the great decrease in the number of prisoners convicted of intoxication and minor offenses growing out of alcoholism is indicated by the marked differ- ence in the percentage of illiterates between 1918 and 1919. During 1918, when there were 1,123 admissions for intoxication — or 20 per cent of all admissions — the proportion of illiterates was 8.3 per cent. During 1919 only 471 prisoners were committed for intoxication, constituting 14 per cent of the total number of admissions. In that year the proportion of illiterates was 16.9 per cent. It is evident that formerly alcohol played an important part in the failure to make social adjustments which brought people to the House of Correction but that, in the absence of this causative agent, crime and delinquency are committed by persons less typical of the entire com- munity. In such a group the feeble-minded will always be found in the highest proportion. This bears out the experience of other communities which have seen their problems of crime and delinquency chan^estrikingly during the last ten years, first by the wider use of probation and ffc-ole which greatly shortens the terms of normal-minded prisoners without affecting in the same degree the mentally defective, and more recently by prohibition which lessens the number of accidental criminals and delinquents but does not affect in such a marked manner those whose offenses are due to more deeply seated causes of unacceptable social behavior. Forty-seven men and seven women, taken at random and representing presumably the average population of the House of Correction, were examined mentally. Of this number five were found to have definite mental diseases and twenty to be mentally defective. Here, then, as in other types of insti- tutions for the socially inadequate, we find a heavy proportion of those whose difficulties are due to mental defect or disease. It is obvious that it is use- less to expect an institution of this sort, however efficiently administered, to accomplish much with individuals who have severe and often permanent 484 Hospital and Health Survey defects of the brain. Although there are no routine psychiatric examina- tions to determine the real nature of the mass of asocial humanity dealt with in this institution, there is a rough and ready practical recognition of the existence of an important problem in mental deficiency by those who actually come into contact with the prisoners. Many of the features in the daily routine of institutional life which experience has shown to be desirable indi- cate quite clearly that the limited capacity of the feeble-minded has been taken into account in the development. Farm School — Near Hudson, twenty-three miles from Cleveland on electric and steam railways, is the Cleveland Farm School. After some early difficulties this school got under way in 1903. It is conducted by the Depart- ment of Public Welfare. All commitments are made through the Juvenile Court. Usually there is a waiting list (twenty at present) and it is necessary to hold boys who have been committed to the Farm School at the Detention Home (page 481) where they remain under the jurisdiction of the Court and attend the Boys' School nearby (page 486). When children are admitted to the Farm School from the Detention Home all information that has been gathered regarding them is sent at the same time. The school is a cottage institution, each cottage being under the charge of a master and a matron. The eight frame cottages were designed to accom- modate 120 boys, but the present census is 150. The superintendent, who was formerly a teacher in the East High School, is energetic and progressive but is much hampered by insufficient funds. Academic instruction is under the direction of the Cleveland Board of Education. Four teachers, three men and one woman, are employed at an average salary of $1,480 a year. School work continues throughout the year. Manual training and' country sports provide work and recreation. It is said that it is possible to get on successfully with much more liberty than is feasible at the State Industrial School at Lancaster and that the results have been exceedingly good. At first it was thought that a short period of institutional life and a long parole would prove the best method but recently the period of institutional care has been lengthened with much better results. In connection with the Farm School is a well organized Placement De- partment which not only places boys from this school but from the State Industrial School at Lancaster. Principals of schools have been instructed not to receive boys directly from either institution but to refer them to the Placement Department. The follow-up work thus provided for is carried on as efficiently as the funds and personnel available permit. The Girls' Home — This is a wooden structure with a capacity of thirty- nine which is usually exceeded. An effort is made to receive only delinquent girls who are not sexually immoral. The matron and the teacher, who are doing notable work, are aware of the importance of detecting feeble-minded and psychopathic girls and modifying their training in accordance with their special needs, but are without the expert advice which is so essential. The practical type of instruction carried on is very well suited to the require- Mental Diseases and Deficiency 485 ments of subnormal types if a careful mental examination were possible in order to indicate the kind of training most likely to be useful in each case. The examinations made indicate that such girls constitute about 20 per cent of those received. In this home, as in most such places for the tempo- rary care of young people who are delinquent or dependent, the mentally defective require an undue amount of the attention from those in charge, and they do not receive a corresponding amount of benefit. Such institutions feel the full weight of the state's failure to provide adequately for the mentally defective. If the extra work, anxiety and interference with broad aims for individual reconstruction which is due to the burden of feebleminded- ness in such homes, refuges and shelters throughout the state, were fully known the legislature could not fail to be moved to make the provisions that have been promised so long. House of Good Shepherd — The House of the Good Shepherd is situated on Carnegie Avenue at 30th Street and is one of the notable institutions of the same name to be found in many large cities throughout the world. The girls received are divided into three groups. The group composed of delin- quent girls committed by the Juvenile Court is the largest group, and when the institution was visited, numbered 120. Dependent girls form the next largest group and numbered sixty -five. There were forty girls in the "Mag- dalene" group. The institution is conducted in accordance with a very definite point of view regarding the problems presented. It is felt that the atmosphere of religious influence and kindness which has been created by the devotion of the Sisters who conduct the institution can be depended upon to bring about better living and, in order to intensify the impression upon the minds of the girls that their entrance into the home is the fresh starting point, each girl receives a new and fictitious name by which she is known to everyone. Of course this renders it impossible to trace individuals through previous de- linquent experiences or to establish their school records. The past histories of the girls are never discussed. There is great reluctance to have the diag- nosis of mental deficiency or psychopathic conditions made and the children transferred to special institutions unless serious disorders of conduct makes such a step necessary. This is due to the intense devotion to their tasks which the Sisters have and a belief that no effort should be spared to bring about reformation even in those who seem the least promising. It results not infrequently in achievements in individual cases that would not be thought possible by those whose early and only recourse in difficult cases is the insti- stitution for the mentally defective and it represents the literal carrying out of a very honest and deep-seated conviction as to the basic factors in immoral conduct. Twenty of the delinquent girls were examined mentally. One was found to be suffering from a psychopathic condition and eight were mentally defective. If the same proportion exists in this entire group the percentage of mentally defective girls is forty-five. Thirteen of the dependent girls were examined of whom five were found to be mentally defective and one suffering from a 486 Hospital and Health Survey psychopathic condition. This would indicate the same proportion in the entire group as in the delinquents. None in the "Magdalene" group were examined. Academic instruction is carried on with training in domestic science, especially laundry work. Many girls who have been admitted to the home have gone out to live useful and orderly lives. Boys' School — The Boys' School, situated on Clinton Avenue at 29th Street, was organized in 1876 for "truant and incorrigible boys." At first it was called the "Special Unclassified School" and the object of its establish- ment was to segregate boys who "because of immoral conduct were a detri- ment to work of the regular classes." Later the present name was adopted. For a time the classes were conducted in several different buildings, but in 1904 they were united in the present building. There are two sources of admission — the city Board of Education through a certificate of the Assistant Superintendent of Education, upon application of the principal of the school which the boy attended, and commitment by the Juvenile Court. Boys sent from the Board of Education are known as " incorrigibles " and are a charge upon the city while those sent by the Juvenile Court are known as "detention cases" and are a charge upon the county. Upon admission to the school each boy is first studied by the Placement Department of which Miss Claire Walters is the head. Miss Walters com- menced her work as a teacher in the Boys' School in 1902. Since 1907 she has been attached to the Juvenile Court and since 1912 has been fitting her- self by summer study for psychological work. The findings of the psycho- logical tests constitute the chief factor in the subsequent disposition of the boys. Those who seem to be mentally defective are referred to the psycho- logical clinic of the Board of Education for examination by Dr. Luckey and placement by Miss Steinbach. If not suitable candidates for the special classes they are assigned to classes in the Boys' School and observations upon their conduct are carefully made. There are eight grades and two classes for the subnormal. Besides the usual academic branches, manual training, weaving, printing and knitting are taught. The printing classes have been especially successful, many boys securing part-time employment outside. Sale of the products of the manual training shops provides funds for the pur- chase of materials. There are also night classes and the school term extends throughout the year. Most of the children from the Juvenile Court reside in the school and most of the incorrigible boys live at home. There are no psychiatric examinations of the boys in spite of the growing body of information that is accumulating regarding the relation that exists between certain psychopathic conditions and disorders of conduct in chil- dren. Here is another favorable place for an "outpost" of the City Psy- chopathic Hospital when it is established. Mental Diseases and Deficiency 487 Other Homes Sixteen orphanages and other homes conducted by private agencies were visited. Although maintained chiefly for dependent children all have their problems of delinquency with which to deah In all the institutions for delinquents visited the total census on the dates that visits were made was 1,975. |Of this number 375 children, chosen for the most part at random, were examined mentally by the psychiatrists and psychologists associated with the Survey. Fifteen of all those examined were found to have some psychopathic condition and fifty-six to be mentally defective. If the proportion of psychopathic and mentally defective chil- dren was the same in the total population of these institutions there were not less than 374 individuals who presented a demonstrable mental disorder or a definite mentally defective condition, by far the greater proportion of whom could have been cared for in special state institutions with advantage to themselves and to the community. It is doubtful whether any other institutions are as greatly impeded in their work by the presence of a large component of persons utterly unsuited for the environment in which they live as these homes and schools established and maintained for the care and training of dependent and delinquent girls and boys. Sometimes these insti- tutions are harshly criticized for the quality of their work, but few people stop to realize that they are carrying a burden which the state should carry, and that many if not all the deficiencies in their work are due to this, the fact that a large part of all their slender resources has to be devoted to a task that is not primarily theirs at all and was not in the minds of those whose gener- osity made these institutions possible. It is easy to say that all mentally defective and psychopathic children could be excluded from institutions that were not intended for them, but no one who has seen the plight that many of these children present, coming as they do so often from homes presided over by feeble-minded parents, would have the heart to advocate closing the only doors that are open to them. But for the patience and humanity of those who work day and night with these children the real tragedy of the state's neglect to provide for the mentally defective would be far more appar- ent than it is. The imbecile girl, often with her illegitimate baby, the psycho- pathic boy with gravely delinquent traits that make him an unsafe companion for other children, the irritable epileptic child, all are taken into these homes and cared for in spite of the fact that their presence interferes seriously with work that would be difficult enough under most favorable conditions and that it is well known to the authorities of the home that little or nothing will be accomplished by methods that have been carefully devised for the train- ing or social rehabilitation of the normal minded. There are but two remedies for this condition which is to be seen in the institutions for dependents and delinquents in nearly all large American cities. The first is careful psychological and psychiatric examination and classifica- tion of all applicants for admission and the second is an adequate system of state institutional care and community supervision for those who are rendered socially inadequate on account of mental deficiency or unstable mental make- up. 488 Hospital and Health Survey Mentally Atypical Children in tne Schools Special Classes for the Mentally Defective CLEVELAND has provided instruction in special classes for the men- tally defective since 1905, when four classes were organized for "defec- tive pupils," it being recognized that the provision for "backward children" made in 1893 was not suitable for those with more serious men- tal defects. At the present time such classes are well conducted under the general supervision of Miss Charlotte Steinbach who has had special train- ing for this work. The psychological examinations are conducted by Bertha M. Luckey, Ph. D., with the assistance of Miss Florence Durst, a specially trained teacher. Some of the special class centers are poorly provided for. They have only one or two rooms while others have four or five rooms which permit satisfactory classification. Each class has from 12 to 15 pupils. There are about 1,000 children in all the special classes. This constitutes somewhat less than one per cent of the total school population.* Cooperation between the special class teachers and the grade teachers is good. When a child appears to the grade teacher to be atypical, incapable of doing the regular work and is being passed for promotion, the child is reported to the principal of the school and the name of the child sent to Miss Steinbach's office. The names come in at intervals, in long lists. Children are also referred by the Juvenile Court, the Humane Society and other welfare organizations, paro- chial schools and parents. These children are referred to Dr. Luckey, who conducts a careful psychological examination, usually in the dispensary of the school which the child attends. Children in whom a diagnosis is not possible with such an examination are brought to the office for special study. In such cases a carefully prepared history blank is sent to the school to be filled with all the information that can be obtained by a personal investiga- tion. The careers of these children are followed as thoroughly as possible. In this the "Clearing House" in the building of the Associated Charities, under the Welfare Federation, is able to render valuable assistance by report- ing, usually within three days, the names of other members of the family who have received relief or have been dealt with by the courts. During last year about 1,400 of the 2,916 children examined were found to be mentally defective. Investigation of these cases, through the Clearing House, showed that members of the families of the mentally defective children had Juvenile Court records in 466 instances. In 173 of these cases there had been two or more appearances in the Juvenile Court. Some of the children who are of very low grade mentally are sent to appropriate institutions, when vacancies exist, without being placed in special classes at all. About half of all the children examined are thought to be simply cases of slow development or children in whom other causes than mental deficiency are responsible for failure in school. The rest are assigned to the special classes that seem to fit their requirements best. It is well un- derstood that a single examination is not always conclusive and the lack of •Division of Health Report, March, 1920: public schools, 108,000; parochial schools, 36,197. Mental Diseases and Deficiency 489 time for making repeated examinations is much regretted. Careful observa- tion in the special classes by experienced teachers compensates in part for this defect. An effort is made to have it generally understood that admission to these classes does not necessarily imply a positive diagnosis of mental deficiency. The teachers of the special classes are enthusiastic over their work and feel convinced that they are accomplishing something of real value. Some of the principals are a little out of sympathy with the special classes and express the opinion that more children who are "simply backward" should remain in the regular classes, even though larger and older than their class- mates and that, for the others, the special classes are an inadequate substitute for permanent institutional care. The general impression in visiting the special classes is that there are many defective children in them who should be in state institutions and that their removal would enable the special classes to do their work with others more successfully. In the absence of proper state facilities, however, no one would seriously recommend that such chil- dren be excluded from the special classes. When more adequate state pro- visions exist and more defective children can be admitted to proper institu- tions, at least for a period of training, the classes will undoubtedly do better work and have more success in their highly important task of fitting the less defective children to take a useful part in the life of the general community with their defect in intelligence partly compensated for by having learned to do skillfully a few simple kinds of work for which there is a demand. The salaries of the teachers in the special classes are the same as those of grade teachers, with the exception of head teachers who are responsible for the work of several others. These receive from $50 to $100 a year additional. At least ten of the special class teachers are on the regular substitute list and receive from $4.20 to $6.00 a day for their services, which is less than that received by grade teachers. The entire cost of the special classes during the year ending September, 1919, was $71,989.70 for teachers' salaries and $106.33 for supplies. It is doubtful whether any educational activity of the city yielded larger returns for the money expended. More special classes, extra pay for teachers and better classification at special class centers are needed. In addition, more complete diagnostic facilities should be supplied. Although the schools have been fortunate in securing the services of so well trained a psychologist as Dr. Luckey, it must not be forgotten that more than a psychological examination and social in- vestigation is needed to deal satisfactorily with the complex problems pre- sented by a child whose mental development is defective or retarded. These conditions depend upon brain defects but not usually upon this cause alone for there are many closely related changes in the body as a whole and in other organs which have a great deal to do with both the rate of mental develop- ment and the degree to which it may progress. The assignment of a child to a special class is an event of great importance in the life of the child and of no little importance to the community. The examinations that precede such a step should be conducted in a clinic equipped to deal with both mental and physical issues. The great importance of disorders of the "ductless glands" (thyroid, thymus, pituitary, testicles and ovaries) makes it essential -tOO Hospital and Health Survey that a complete physical study should play a large part in such an examina- tion. The fatalistic attitude too prevalent toward all mental defects has excluded many a child from treatment which might have materially modified the mental and social picture presented upon a superficial investigation. A thorough-going study of each child, from a psychiatric as well as a psycho- logical point of view, in which are considered the child's personality, his special abilities and interests and the possibility of psychotic or psycho- neurotic trends is the only basis upon which future mental health and limits of adaptability to a social environment can be judged in an individual still in the developmental stage. Such a complete study is the function of the psychiatric clinic. Work Permits for the Mentally Defective The truancy law of Ohio provides that boys of such subnormal mental capacity that they are unable to get past the sixth grade may receive special permission to go to work upon attaining fifteen years of age, and girls of six- teen, having passed the seventh grade may also receive permission. At six- teen any boy or girl may leave school. Boys of sixteen may go to work with- out permits, but girls of normal mentality who have not passed the seventh grade cannot have permission to work in factories until eighteen. A mentally deficient girl may have a work certificate before eighteen. It is believed that the law requiring school attendance should be more flexible in the case of mentally defective children. It should give the school enough power to hold the child when advisable in individual cases or to recom- mend that children be allowed to leave before they have completed the attendance now required. Often defective children leave school too soon, when the teachers feel that they have just reached the point where something can be done for them. It is suggested that in cases where subnormal children are not able to receive benefit from academic instruction and are approaching the age at which they can receive work permits, they should receive technical training in a school or shop, or in domestic economy, where, working under the supervision of expert teachers they can gain the knowledge and skill that will be helpful to them in securing and maintaining employment whicli will command a living wage. In this way the fundamental and non- remediable mental defect may be compensated for by intelligently directed training. It should, however, be kept in mind that if the equipment of the shop or school is unusual or out of date and instruction is given only with such apparatus, re-education may be necessary when the boy or girl takes up employment. Work permits are issued by the truant officer and the subnormal child's mental age is recorded on the card. Some people feel that this handicaps the child in obtaining advantageous employment, but most of those concerned believe that the mental age should be so recorded as the card is not widely displayed but is filed with the employer and knowing the child's limitations he can protect the employe and himself. As a matter of fact the feeble- Mental Diseases and Deficiency 491 minded easily secure employment and sometimes receive very good wages. Many anecdotes are told, one concerning a seventeen year old boy whose "mental age" was six years, earning $4.20 per day cleaning cork in a factory. He was taught by a substitute teacher who received exactly the same amount for her services. A review of permits issued during a recent period of six months showed 'that 8.6 per cent of the boys and 4.8 per cent of the girls were definitely diagnosed as feeble-minded and had their mental ages recorded upon their work permit cards. The following tables, prepared by Miss F. V. Ball, show in detail the in- formation contained in the health records of these children and an analysis of the industries in which those who were working were engaged. The kinds of work in which they were occupied do not differ materially from those in which all working children are engaged. Hospital and Health Survey UOIJ -03JJO3 -131JV U3Air) JlUIjaj pssnpx >-( t-. lO H co ^1- cn co -i CO *o H N * IO H ^h 00 00 CN i-H > > E X X 65 65 6< 65 65 65 uon * oo t^ i£> [ "^ -03JJO3 -I31JV cn >3- o CO ^H aaAiQ iiuijajj r ~ l 1 tN 65 6S pasnjajj ^ 00 o\ ,_, CN }iuii3> XI & 6? M133X id _ CN VO lO CO t> C CO •* CN CO £5 65 UOtSIy\ CN CN 1-1 IS) KO 65 uoiiuiriM CO ^C ir <£3 o CM cr U~ CO lO CN 65 +j O CM V£ O CN o H lO o c C* —i o CN IT o < co o to H C >-* § > > X I-H X X Mental Diseases and Deficiency 493 65 65 CO ro O 0> r-~ c o +J CO lO 00 io >- o H CM .-< i-H tv o ,H V a 6? 1 b-p 8 s - o CM i-H r- o ■* o CM 65 | 65 ST CO **■ «3 O CM i- 1 ° CO " : 1 CM °3 ■M 65 1 65 h o n ci o\ ^ 1 ° h r-l O CO CO 00 P" o iH CM i-H »-« f o i) a a 8 s - ? § CM C"» .-H !>. i- oo o o N lO H O •- r>. 1 t— 1 ■— CO 5 in * -CJ4 ^ 1 &5 s° ,h r- **■ VC oo K£ H iO * u- c^ '" ! " 1 CO u 3x 8 s - 1 ^ * a i-H CM CM CM t> f-c CM CM CM VC "* "* . 1 CM 03 CO co eo J "O g T) s « S « 3 wing Tr oolen M etal Tra :tail Sto: inting T iscellane "3 o •• £ § K iH § 494 Hospital and Health Survey Special Types of Atypical Children Unusually Bright Children — By means of group psychological tests, supplemented by individual tests, a number of children classified as "unusu- ally bright" have been picked out and the school authorities have formed some special classes and devised methods of giving these children special work. A physical examination is made of these children but no psychiatric examination. So important is the latter in determining whether or not a child shall be placed in this group that, in the opinion of the writer, the harm likely to result to unstable individuals if purely psychological tests are em- ployed will offset the good that comes to others if the experiment is continued without such aid. It is in this group that some of the graver psychiatric problems are often found. An ordinary physical examination in such cases is far from conclusive and often throws no light upon the psychiatric situa- tion. Properly conducted such an experiment is certain to yield important results. Much has already been done for these children whose needs have so long been overlooked. Often astonishing progress is made in the special classes for the "unusually bright." Handicraft and domestic science play a large part. Folk dancing and various games fill part of the time. A model store is conducted with great success. As there is only a "four-period day," some of the children work after hours. It is, however, a field to be entered only with full appreciation of the complex factors with which it will be neces- sary to deal. Psychopathic Children — Cleveland has not yet been able to give spe- cial attention to psychopathic children in the public schools. These children usually possess normal intelligence but have volitional or emotional diffi- culties or psychoneurotic trends that interfere seriously with their family and social adaptation in later life. It is among such children that the fore- runners of grave mental disease are often found. Juvenile or adult delin- quency, vagrancy and the development of many asocial compensations for personality defects, make wrecks out of much human material that early in life might have been dealt with successfully. In such work it is indispensable to conduct careful psychiatric, psychological and social studies and to co- ordinate the findings, with the element of treatment always uppermost. Speech Defects — The essentially mental basis for speech defect, together with the great frequency of this condition among school children, makes its consideration important. Since the educational survey of Cleveland in 1915, forty-eight special classes have been organized for treatment of speech defects. The work was started by fifteen teachers, each teacher having three classes — a kindergarten class, a phonetic class and a stuttering class. Some are conducted in school hours and some out of school hours. At the present time there are four teachers each teaching ten classes per week, each class having one hour of instruction per week. These teachers receive extra com- pensation of $200 per year for this work. Seventeen other teachers give in- struction outside school hours and receive $1.50 per hour additional for this work. The work is conducted under the general direction of Miss Williams who devotes to it half her time, for which she receives $1,880 a year. For the other half of her time which is otherwise occupied, she is compensated. Mental Diseases and Deficiency 49.5 The teachers are not particularly attracted by the increase in compensation but are especially interested in the work and would prefer to do it exclusively. Since this work has been going on teachers in the school have become more watchful for speech defects and recognize them more quickly. If teachers were available, the number of pupils enrolled could be doubled at once. It is claimed that one-third of the kindergarten children have speech defects (lisping most common), and it is hoped finally to give each kindergarten class teacher some training for speech instruction. A good deal of research concerning the essential elements in difficulty in speech and the basic facts underlying plans of treatment has recently been carried on. Much excel- lent work in treatment has already been done, but an important fact often overlooked in speech classes is the psychoneurotic basis for the condi- tion in many cases. Without correcting the handicaps found in the psycho- neurotic child, little in the way of permanent results are to be expected. If the subject had been taken up from a psychiatric approach this would have been readily comprehended. It is important that this factor receive atten- tion or else much time and money will be used in attaining temporary results. After-care and Supervision Too often attention is fixed upon the phase of the lives of mentally de- fective children that is passed in school without realizing that in the more serious affairs of adult life the mental defect will persist but the protection of the special class will not be present. Many a teacher sees the end of the period of school life approach for her charges, especially the girls, with dread. The transition is often dramatically sudden. One day the defective child is in an environment especially created for her safety and protection, watched over and guided by those who well understand the limitations of the mind arrested in its development. On the following day this individual with a child's mind in a woman's body goes into a world which knows nothing of "mental age" or "limited responsibility" and has inexorable standards of conduct which do not take such factors into consideration. Thanks to the practical instruction given in the special classes, such chil- dren are often better fitted than some of their normal minded schoolmates to earn their living at simple work and have had habits of industry developed by the careful training that they have received. Nevertheless they have still only the judgment and control of impulses of a child. In many instances they are handicapped by mentally defective parents so that those who should prove their protectors are but an additional handicap to them. There is urgent need for a system of community supervision that will throw around these grown-up children some of the special protection that is thrown around those who are children in years as well as in mind. First, it is necessary to have a mental deficiency law that recognizes the need of spe- cial guardianship and provides a practical means for supplying it. Such laws, modeled in most instances after the "Mental Deficiency Act" of England 496 Hospital and Health Survey have been enacted in several states and when they exist and there is an efficient system of registration and community supervision the work of the special class is supplemented in such a way that the feeble-minded can and do live happy, useful, harmless lives instead of inflicting much damage upon society and being themselves harmed by a social environment created for people with normal minds. Mental Diseases and Deficiency 497 Welfare Organizations AMONG the voluntary agencies for social work is to be found a very keen appreciation of the part played by mental factors in the problems with which they have to deal . None see more clearly than the workers in these agencies the full effects of the failure of the state to provide adequate facilities for caring for the insane, the mentally defective and the epileptic. Weary of waiting for relief from this quarter, from which, how- ever, it must ultimately come, these agencies are devising for themselves some makeshift methods of dealing with certain phases of abnormal men- tal conditions. The general hospitals to which they may refer all other classes of sick persons for help have nothing to offer to those whose illness is mental. Psychiatrists in private practice give as much time as they can afford to the examination of special cases but social workers are reluctant to make use of this means of securing help except in especially urgent cases. It is of interest to review briefly what some of the social agencies have done to provide means for solving some of their problems. American Red Cross — This organization serves those who have been in the naval and military service of the United States during the recent war, and their families. The society has organized a medical committee made up of various consultants, including psychiatrists; has employed a psychiatrist, and, on January 9, 1920, opened a neuro-psychiatric clinic. The organiza- tion already has a record of 238 cases and believes that this number will be much enlarged when the clinic is further developed. From January 6th to April 6th, 158 examinations had been made, the psychiatrist personally ex- amining about 100. Social workers bring the patients to the clinic and re- port on the family, economic and neighborhood situation as well as giving attention to personal histories and the facts which led to the request for examination. The social workers receive instructions at the clinic which assist them in becoming better qualified for this special work. On questions of general physical health consultations are obtained at various prominent hospitals or with members of the mental committee. The Red Cross main- tains an Army and Navy Club where the psychiatrist lives and where several quiet mental patients may be cared for. Members of this organization report that they are much embarrassed by the fact that the Government makes inadequate provision for ex-soldiers with mental and nervous disorders. There are thirty in the neighborhood who need hospital care, which at present is unavailable. The Associated Charities — This organization finds that with the widen- ing of its field beyond the supplying of necessities of life such as food, fuel, clothing and shelter, its work now includes health, education, employment, recreation and spiritual development, the last having for its objective the development of "a working philosophy of life" that will help to make the adjustments necessary for living in a modern community. Of the 2,000 families cared for by the Associated Charities less than 600 receive material help, the other 1,400 being able to work out their own problems after receiv- ing advice and personal assistance. 498 Hospital and Health Survey In carrying out this program a psychological approach to the problems of the individuals concerned is, of course, necessary. A survey of 1,960 families under the care of the organization during March, 1920, disclosed 359 in which abnormal mental condition was an important element in the social problem presented. In these 359 families there were 574 individuals listed. The number of individuals is probably smaller than the actual number because the list was made conservatively, especially in regard to the number of indi- viduals with mental difficulties. It is believed that if a psychiatric clinic were available for closer study of these famiKes, a larger number of mentally abnormal members would be found. Among these 574 individuals, however, 46 are already in hospitals for the insane and 19 in institutions for the feeble- minded. It was thought that 56 more should be in such hospitals and 136 in institutions for the feeble-minded. These data are shown in detail in the following table. FAMILIES AND INDIVIDUALS UNDER CARE OF ASSOCIATED CHARITIES WITH MENTAL DISORDERS Group 1; — Diagnosed Cases Families Individuals Mental Diseases and Constitutional Psychopathic States 88 95 Mental Deficiency ..-.. 107 148 Epilepsy... '. 12 12 Group 2 — Well-defined Mental Cases, but not Diagnosed Families Individuals Mental Disorder 29 41 Mental Deficiency . 28 76 Group 3 — Mental Disorder or Mental Deficiency Strongly Suspected, but not Well-defined Families Individuals Mental Disorder , 41 64 Mental Deficiency 54 138 Total of the three groups 359 574 It is stated that there is great difficulty in securing the commitment of mental patients unless the condition from which they suffer is severe and that uncured patients are too freely paroled from the hospitals. The commitment of the feeble-minded is extremely difficult because of the lack of institutional space. The association is deeply interested in preventive work and the treatment of cases in early stages to avert further development of mental disorders. Mental Diseases and Deficiency 499 In the absence of any special provision for mental hygiene work it is doing what is possible by means of its own workers. Humane Society — The Humane Society found that in its work it was frequently necessary to have mental age and capacity of children and adults tested, but no local agency was available to give this assistance. Such in- formation is needed in order to reach an opinion as to whether a father can take and keep a position and whether a mother is able to maintain a home and supervise and rear her children. The information is essential in order to determine the proper form of assistance in any particular case and to de- termine what disposition and care shall be given to children. Help has been received irregularly from the workers of the Bureau of Juvenile Research located at Columbus, and the Humane Society had one of its workers trained to make intelligence tests. Welfare Federation — This organization is most desirous of having suitable provisions made for mental patients now in the various orphanages and other institutions in which it is interested. The officers of this organiza- tion also feel the need of psychiatric clinics to which they can turn for help. The Women's Protective Association — This is a private association supported from the Community Fund. It is associated in its work with the Police Department, having an office at the central police station. Some members of the Association are special investigators without power, but carry this title to facilitate the discharge of their duties. The Association takes charge of girls and women, usually between the age limits of fourteen and twenty. The police often turn over to them the insane and obviously mentally defective girls whom they do not wish to place under arrest, and cases in which there is not enough evidence to go into court. This Association makes home investigations for the superintendent of the institution for the feeble-minded and obtains reports on his parole cases. It also makes investigations for the Probate Court. A woman to be charged with the offense of being a common prostitute must have been arrested before. The so-called "golden rule" method of handling these cases is to have the girl sign a confession when arrested, promising to refrain from further delinquency, after which she is given a warning or placed under the care of the Protective Association. The Asso- ciation maintains Sterling House (described in another section of this report) for the detention of girls in their charge. A prominent psychiatrist makes mental examinations on occasion, the Probate Court gives its cooperation, and Miss Walters of the Boys' School assists. Nevertheless, these facilities are too limited to afford the type of help needed. Mental cases must be picked out by laymen and referred for examination afterward. Recently it was necessary to send two feeble-minded women to the county workhouse as they could not be kept in the home on account of venereal disease and evidently could not be committed to an institution for the feeble-minded. The probation officer of this Association suspects that at least 75 per cent of those who come under her care are sub- normal and that many others are psychopathic. The obviously feeble- 500 Hospital and Health Survey minded are sent to the state institution at Columbus, but are readily released on parole at the request of relatives or friends, because of the crowded condi- tion in the institution. Mental Test Registry of the Associated Charities — The Associated Charities maintains a mental test registry which consists of a card index of the results of the mental tests of children, made by psychologists and psychia- trists for the Probate Court, for the Board of Education and for the Juvenile Court. There are records of 9,000 families, including frequently more than one individual per family, usually the children. The assembling of these records was begun in 1914. The cost has been moderate and the results of the work have been of great benefit in the administration of relief for families in which mental deficiency or disease was the chief factor in family depend- ency. This registry has provided a storehouse of information for research, education and for propaganda purposes. Cleveland supports the welfare agencies mentioned above in a liberal manner with full appreciation of the part they play in the social life of the city. How much further would every dollar contributed to their work go if their efforts to bring about better individual and social adjustments could receive the aid that a careful mental study of each individual gives? It is certain that when the proposed City Psychopathic Hospital comes into ex- istence and establishes its "outposts" where they may be of the greatest service, the first to derive benefit from the new facilities will be the welfare agencies which now have to deal with some of the most complex human prob- lems without the information regarding the deep springs that regulate the conduct of the human beings concerned that can be gained only in the psychi- atric clinic. Mental Diseases and Deficiency 501 Prevention — Mental Hygiene DURING the four months in which this study was in progress practi- cally every institution in Cleveland which deals with dependents, de- linquents or persons who for any reason require special care and super- vision by the community was visited by members of the Survey staff. Social workers, court officers, teachers, physicians and others whose work brings them directly into contact with the socially maladjusted of the city were inter- viewed repeatedly and in many instances their daily work was closely observed. In twenty-nine of the institutions visited children and adults under care re- ceived a careful mental examination. Altogether these institutions had a popu- lation of 2,978 on the days on which they were visited and 541 individuals were personally examined by the Field Consultant or his assistants. Among those examined, who in all cases were taken at random from the group under study, there were found 119 persons who presented mental disorders, consti- tutional psychopathic states, mental deficiency or epilepsy of such a degree of severity that institutional care was required. If the same percentage ex- isted in the whole population of the institutions visited, and there is no reason to believe that it does not, there were in Cleveland at the time the survey was made 651 mental patients receiving temporary or permanent care in institutions designed for entirely different purposes. In these unsuit- able institutions they were not only constituting a serious drain upon the institutional resources but were interfering with the specific objects for which the institutions were established and conducted, At some time, the remote- ness of which depends chiefly upon the strength and the insistence of the demand made by the people of the state, adequate institutional facilities for these cases will be provided but if, today, it were possible to admit every- one of them to an appropriate institution, a survey made six months hence would find nearly as many others in their places. The investigation made by the Survey merely dipped into the stream of unadapted human beings which flows continuously through the schools, courts and institutions of Cleveland, and ascertained the fact, already known by many and suspected by others, that disorders of the central nervous system were in very large part responsible for the volume of this stream. The stream can be diverted into other channels but what can be done to dry up its source? Are mental disease and mental deficiency inevitable accompaniments of the life of American communities, or can they in any considerable measure be con- trolled? It is most important that this report, which of necessity is devoted so largely to the institutional provisions for those with mental disorders and mental deficiency, should not convey the impression that we have to do with a problem which can be handled in different ways according to the skill, enlightenment and resources that we bring to bear upon it but which, never- theless, must always continue to exist in the same dimensions. Mental diseases and mental deficiency are preventable, to a less extent than the infectious diseases but to a greater extent than most of the degenerative physical diseases. It is beyond the scope of the report even to outline the field of mental hygiene or the practical measures of prevention, but it is de- sirable to suggest that the agencies which deal with health, education and the care of dependents and delinquents in Cleveland institute organized efforts to bring about practical work in mental hygiene. 50 t 2 Hospital and Health Survey Much of the prevention of mental diseases lies in other fields of preventive medicine. General paresis, which is responsible for one-fifth of all the male admissions to hospitals for the insane, is a manifestation of syphilis and its prevention lies in the prevention of the primary disease. Mental diseases dependent upon alcohol and drugs are prevented only by the legal and social measures which can be directed against the particular evils from which they come. Much mental disease is the result of general physical illness and its prevention depends upon the success with which the general health of the population is maintained. Mental deficiency has its most important single cause in heredity, and the control of unfavorable heredity is the practical field of eugenics. As far as those disorders which have been mentioned are concerned mental hygiene consists obviously in directing the attention of those responsible for other organized health movements to the relations which their work bears to mental disease and mental defect. Nevertheless, there is an important field of prevention which no other agencies than those spe- cifically devoted to mental hygiene can hope to enter successfully; that is, the control — largely during childhood — of those factors acting within the mental life of the individual which are recognizable early as slight deviations from normal thinking and living, and which ultimately may result in disastrous anti-social reactions or in the production of grave forms of mental disease. There is, in addition, a great field in mental hygiene which has for its objects the protection, supervision and special training of people with impaired or naturally limited ability to adjust themselves so that through the skillful efforts of others their lives may be successful and useful, socially if not bio- logically. Facilities must be organized for dealing with those incipient stages of severe disorders at the very beginning. A conception of the part of the school clinic much wider than that of classifying children with reference to intelligence must come into existence. The mental hygiene activities of many unrelated welfare organizations and city and state departments must be coordinated by an organization specifically established for this purpose. This is the task of the mental hygiene society.* * Important and recent reprints on the subject of mental disease and care can be had by application to the National Committee for Mental Hygiene, 50 Union Square, New York City. Mental Diseases and Deficiency 503 Summary of Recommendations I. Dealing with state legislation and local ordinances or charter changes. A. State 1. State administration and supervision of the institutional care and treatment of persons with mental diseases, mental deficiency and epilepsy, and of their guardianship in the community. Legislation is recommended that will accomplish the following objects: a. Establishing a special State Commission on Mental Diseases for the per- formance of the functions mentioned above ; such Commission (headed by a physician experienced in dealing with the institutional and social aspects of mental disorders) to administer the state hospitals for the insane, the State Institution for the Feeble-minded, the State Hospital for Epileptics and the Bureau for Juvenile Research and to concern itself with the broad medical and community relationships of these disorders as well as with the business administration of the institutions. b. Establishing a bi-partisan State Institutional Development Commission composed of the head of the special Commission on Mental Diseases recommended in the preceding paragraph, members of each house of the Legislature and persons not in the service of the state who can bring special knowledge to the task; such Commission to formulate a ten-year program for the development of the state's institutions for mental disorders in accordance with a comprehensive plan for remedying the existing serious inadequacy and to present to the Legislature, at the beginning of each session, definite recommendations for appropriations for the ensuing two years. c. Licensing and inspecting private institutions for the care of mental patients. 2. Commitment, care and parole and discharge of persons with mental diseases. Legislation is recommended that will accomplish the following objects: a. Removing present restrictions as to the number of voluntary patients that can be received in state hospitals. b. Committing patients for observation for a period of ten days to state hospitals, psychopathic hospitals and psychopathic wards in general hos- pitals. c. Prohibiting the detention of persons awaiting commitment in jails or alms- houses and placing the responsibility for their care pending commitment and reception in state hospitals in the hands of health officers, except in cities where suitable facilities are otherwise provided. d. Discontinuing the personal appearance of mentaj, patients in court. e. Admitting patients to state hospitals in emergencies upon the certificate of two physicians, such admissions to be followed within ten days by discharge or court commitments. 504 Hospital and Health Survey f. Committing to state hospitals any persons under trial in whom mental disease is suspected upon order of any trial judge, such commitments being for observation only and for a period not less than ten nor more than thirty days. g. Authorizing sending nurses and attendants from state hospitals to bring from their homes or places of temporary detention patients who may have been committed and are awaiting transfer, thus eliminating the services of sheriffs and police officers. h. Authorizing counties to pay examining physicians salaries instead of fees for their services when mental examinations are made in psychopathic hos- pitals, psychopathic wards in general hospitals or mental clinics main- taining satisfactory standards. 3. Commitment, registration, care, training, parole and discharge and com- munity guardianship and supervision of the mentally defective. Legislation is recommended that will accomplish the following objects: a. Committing children and adults for observation for a period of ten days to state institutions for the feeble-minded, state hospitals for epileptics, psychopathic hospitals, psychopathic wards in general hospitals or the Bureau for Juvenile Research. b. Committing mentally defective children and adults to guardianship, with provision for transfer from this form of commitment to institutions and vice versa. c. Encouraging the development and coordinating, under the proposed State Commission on Mental Diseases, organized facilities for the regis- tration and community supervision of the mentally defective. (See IV A- lb.) d. Eliminating the age of consent in mentally defective women and girls who have been committed to institutions or to guardianship. e. Authorizing sending nurses and attendants from state institutions for the feeble-minded and state hospitals for epileptics to bring from their homes or places of temporary detention patients who have been committed and are awaiting transfer, thus eliminating the services of sheriffs and police officers. f. Authorizing counties to pay examining physicians salaries instead of fees for their services when mental examinations are made in psychopathic hospitals, psychopathic wards in general hospitals or mental clinics main- taining satisfactory standards. g. Authorizing the proposed State Commission on Mental Diseases to in- spect places for the temporary detention of mentally defective persons and homes and schools in which delinquent or dependent children are maintained. Mental Diseases and Deficiency 505 h. Requiring the establishment and maintenance of special classes for mentally defective children in every school district in which fifteen or more such children are found, authorizing the payment by the State Department of Education of a fixed sum to the local school authorities for each such class maintained, requiring satisfactory mental and physical examinations of all children before admission to such classes and author- izing supervision of such examinations by a psychiatric advisor to the State Department of Education. 4. Other state legislation affecting the insane, mentally defective and epileptic and furthering work in mental hygiene. Legislation is recommended that will accomplish the following objects: a. Developing the Bureau for Juvenile Research so that its original objects may be accomplished, permitting it to receive children for observation before as well as after they are committed to the state institutions or to the custody of the Board of Administration. b.j Requiring the Juvenile Court and authorizing other courts to maintain mental clinics or to make arrangements with other clinics for the routine mental examination of juvenile and adult offenders. B. City Such changes in local ordinances and city charter are recommended as will permit the establishment of the facilities recommended in the following sections. II. Dealing with departments of state and city government. A. State The following recommendations are made for developing existing state facilities for dealing with mental disorders and promoting mental hygiene. Some of them involve both legislative and administrative action -and others only administrative action: 1. Institutional provisions for the treatment of persons with mental diseases. a. Providing a new State Hospital for the insane, to be constituted by adding a new department in the country to the Cleveland State Hospital and dis- tributing functions between the two departments so that the city depart- ment (the present institution) will be used for receiving and intensive treatment center, infirmaries for terminal conditions, hospital for acute general and surgical diseases, diagnostic clinic, laboratories and adminis- tration and the new department (which would be the larger) for patients in good physical condition who require long, continued care and who will profit by the facilities for industrial training and re-education. b. Providing adequate salaries for superintendents of state hospitals (who now receive lower compensation than in any other state) assistant physi- cians, nurses and occupation instructors in order that more efficient treat- ment services may be built up. .506 Hospital and Health Survey c. Providing Clinical Directors of Psychiatry in all state hospitals to be responsible for the scientific work and for the supervision of all training. d. Providing training schools for nurses and for attendants in all state hos- pitals and a Supervisor of Nursing in the proposed State Commission on Mental Diseases to supervise and standardize such instruction. e. Instituting active after-care and social service so that more patients may be paroled and, by following their supervision into the community, the durability of recoveries and remissions increased. (See IV A-lb.) f . Instituting a system of mental clinics in the district of each state hospital for after-care and preventive work, and, in cities, cooperating with exist- ing mental clinics so that after-care patients may be seen by the physicians who have them under their care while in state hospitals. g. Providing stewards at state hospitals so that superintendents will be relieved from the administrative details that now occupy a larger part of their time than supervising and developing medical activities. h. Effecting liaison with the proposed City Psychopathic Hospital (Psycho- pathic Department of the City Hospital) for the purposes of training medical and nursing personnel and carrying on joint work in psychiatric . research. 2. Institutional provisions for the treatment of persons with mental deficiency and epilepsy. a. Providing a new state institution for the feeble-minded to which persons of both sexes and all ages will be admitted and attaching to this and the existing institution colonies for the care and training of boys and men in good physical condition and of relatively high mentality. b. Providing adequate salaries for superintendents, assistant physicians, nurses and teachers of the State Institution for the Feeble-minded and the State Hospital for Epileptics in order that more efficient treatment and training services may be built up. B. City The following recommendations are made for developing existing city facilities for dealing with mental disorders and promoting mental hygiene: 1. City Hospital. a. Replacing the present deplorable facilities for the reception, observation, diagnosis and early treatment of mental patients with a modern City Psychopathic Hospital (Psychopathic Department) of from 150 to 200 beds with a full-time medical staff and all modern facilities for treatment — including occupational therapy, physiotherapy, hydrotherapy, etc. b. Providing the proposed City Psychopathic Hospital with a dispensary at the hospital and developing under its control and leadership, besides the Central Mental Dispensary, special mental clinics in the Children's Mental Diseases and Deficiency .507 Court, the Municipal Court, the Boys' School and other agencies which require the services of psychiatrists, such "outposts" being supported directly by the agencies served or by appropriations to the City Hospital for these specific purposes and constituting part of the Mental Clinic in the proposed Downtown Dispensary. (See IV B-l.) (This arrangement prevents the establishment of a number of small, weak and unattached clinics and permits the facilities in personnel and laboratories that a strong Psychopathic Hospital would possess to be widely employed.) c. Including nursing in the City Psychopathic Hospital in the nursing department of the City Hospital, pupil nurses in the training school being required to spend three months in mental nursing and the physicians and supervising nurse of the Psychopathic Hospital assisting in the instruction of nurses in the training school. d. Forming affiliations with other Nurses' Training Schools in the city and elsewhere so as to give special instruction and experience in mental nurs- ing and, in return, secure the services of pupil and graduate nurses. e. Strengthening the Social Service Department of the City Hospital by the addition of psychiatric social workers. f. Utilizing to the fullest possible extent the teaching facilities of the City Psychopathic Hospital, not only for medical students and physicians but occupation instructors, social service workers and others. 2. Board of Education. a. Providing a greater number of special classes for backward and mentally defective children and improving the accommodations in special class centers. b. Increasing the compensation of teachers of special classes so that this work will be placed upon a higher professional plane. c. Developing the present psychological clinic of the Board of Education into a School Mental Clinic in which psychiatrists, psychologists and psychiatric social workers can bring to bear upon the mental problems of school children all the resources of psychology and medicine instead of only those which deal with the measurement of intelligence. d. In such a clinic, widening the scope of the study of unadjusted school children to include other mental problems than mental deficiency and making the aim of treatment as prominent as that of diagnosis. e. Systematically encouraging teachers and parents to make use of the School Mental Clinic recommended in the preceding paragraph for the diagnosis and treatment of psychoneurotic and psychopathic children and those presenting conduct disorders of any kind (lying, pilfering, sex delinquencies, truancy, etc.). 508 Hospital and Health Survey f. Correlating the work of special classes for "exceptionally bright" children and for the correction of speech defects with routine examinations and individual studies in the School Mental Clinic. g. Including in the instruction given, in teachers' institute and other train- ing courses, information regarding mental deficiency and the psycho- pathic disorders of childhood. h. Arranging for the postgraduate instruction in Cleveland or elsewhere of teachers who desire to fit themselves especially for work in special classes. 3. Parochial Schools. a. Encouraging the formation of special classes for backward and mentally defective children and the free use of the School Mental Clinic recom- mended above for diagnosis and treatment. 4. Courts. a. Establishing in the Juvenile Court a mental clinic staffed by psychiatrists, psychologists and psychiatric social workers from the proposed City Psychopathic Hospital and the Downtown Dispensary or, in case that difficulties in making satisfactory arrangements arise, an independent but closely affiliated clinic. (See IV B-ld.) b. Including in the work of such clinic the routine mental examinations and individual studies of children in the Boys' School, the Girls' Home and the private agencies to which children are sent by the Children's Court for temporary detention or placement. c. Establishing as another "outpost" of the Psychopathic Hospital a clinic in the Municipal Court which should also conduct routine mental exami- nations and individual studies of persons in the House of Correction. (See IV B-ld.) d. Replacing the present system of mental examination in the Probate Court by examination by the staff of the Psychopathic Hospital, such services to be paid for by appropriations or allotments made by the Probate Court to the Department of Public Welfare for this purpose. (See I A-2h and I A-3f.) III. Dealing with private agencies by groups. The following recommendations are made for more effective work in dealing with mental disorders and promoting mental hygiene by private agencies : A. State 1. Mental Hygiene Committee. a. The newly organized Committee for Mental Hygiene should receive the support of all those who desire to see the state assume the duties that rightfully belong to it so that local agencies need not continue devoting a large part of their resources to the performance of tasks that arise chiefly Mental Diseases and Deficiency 509 from the state's negligence. Not until the state has met its obligation to provide for the mentally defective and epileptic will the local agencies — both public and private — be able to devote themselves exclusively to the work for which they were created and are maintained by public funds or private philanthropy. A strong State Committee for Mental Hygiene, with definite objects and strongly supported by public spirited citizens, can do more to accomplish these ends than any other type of private agency. B. City 1 . Hospitals. a. Western Reserve University and Lakeside Hospital. (See IV B-2a, b, c, d.) b. In order to carry their share of the burden of mental illness the various hospitals that aim to be general hospitals in fact as well as in name make provisions to care for a few mental patients, especially those arising in the hospital in the course of other illnesses ; make more use of the neuro-psychiatrists on their visiting and consulting staffs and make provisions for mental patients in their dispensaries. 2. Orphanages and Homes. a. Private charitable institutions, especially those which deal with dependent or delinquent children, wayward girls and unmarried mothers will find that light can be thrown upon some of their most difficult problems by making the freest use possible of such clinics as those recommended. Institutions receiving only delinquent children should secure such aid in every case whether it seems to be especially indicated or not. IV. Dealing with new agencies or private facilities to be established. A. State The establishment of the following new agencies is recommended: 1. Agencies that can be successfully instituted only under the special State Commission on Mental Diseases recommended. (See I A- la.) a. Forming a joint purchasing committee composed of representatives of the proposed Commission on Mental Diseases, the Board of Administra- tion, and superintendents and stewards of hospitals and institutions in the "mental disease group" the "charitable group" and the "correctional group" so as to effect all possible economies through joint purchase without requiring the present administrative union of entirely different kinds of state activities. b. Organizing, in the proposed Commission on Mental Diseases, a Bureau of Mental Hygiene that will have supervision over state mental clinics, after-care, parole and social service work, community supervision of the mentally defective and intensive experiments in the prevention of mental diseases and mental deficiency. 510 Hospital and Health Survey c. Organizing directly under the Commission on Mental Diseases at one of the State Hospitals or at the Bureau for Juvenile Research a central Psychiatric Institute for study and research into the causes, nature and treatment and prevention of mental diseases, mental deficiency and epilepsy, and for direction and coordination of the scientific work of the hospitals and institutions. B. City The establishment of the following new agencies is recommended: 1. Mental Clinic in the Downtown Dispensary. a. Establishing in the Downtown Dispensary, that has been recommended in various sections of the Survey, a large and fully staffed and equipped Mental Clinic that shall be a branch of the City Psychopathic Hospital (Psychopathic Department of the City Hospital) and conducted by that institution. b. Providing for the closest cooperation between this Mental Clinic and the other departments of the Downtown Dispensary and the dispensary of the proposed Psychiatric Clinic of Western Reserve University. c. Providing for carrying on mental clinics in connection with the Juvenile Court and other agencies, except the School Mental Clinic of the Board of Education, as "outposts" of the Mental Clinic of the Downtown Dispensary. (See II B-4a, b, c.) d. Utilizing the teaching facilities of the Mental Clinic of the Downtown Dispensary in the same way as those of the City Psychopathic Hospital. 2. Western Reserve University and Lakeside Hospital. a. Establishing a University Psychiatric Clinic of from 40 to 60 beds as an integral part of Lakeside Hospital for the reception, treatment and study of mental diseases, especially those types most frequently seen in general medical and surgical practice and most likely to be benefited by treatment under the conditions that exist in such a psychiatric de- partment of a general hospital. b. Establishing in connection with the University Psychiatric Clinic recom- mended in the foregoing paragraph, a dispensary particularly for the same types of cases as those received in the clinic. c. Utilizing to the greatest possible extent the facilities of the University Psychiatric Clinic and Dispensary for medical students and those in other departments of the University who would be aided by the study of psychopathology under clinical conditions. d. Effecting close cooperation between the University Psychiatric Clinic and the City Psychopathic Hospital and its various "outposts." Mental Diseases and Deficiency 511 3. Welfare Organizations. a. Organizing a Cleveland Mental Hygiene Committee, in which all other welfare organizations should be represented to coordinate all the activi- ties of voluntary social agencies that deal largely with mental hygiene problems, to conduct the "mental test registry," to aid public agencies (especially the proposed City Psychopathic Hospital and its various mental clinics, and the School Mental Clinic) and to cooperate, in measures affecting state institutions or state policies, with the Ohio State Committee for Mental Hygiene. THE CLEVELAND HOSPITAL AND HEALTH SURVEY REPORT List of Parts and Titles I. Introduction. General Environment. Sanitation. II. Public Health Services. Private Health Agencies. III. A Program for Child Health. IV. Tuberculosis. V. Venereal Disease. VI. Mental Diseases and Mental Deficiency. VII. Industrial Medical Service. Women and Industry. Children and Industry. VIII. Education and Practice in Medicine, Dentistry, Pharmacy. IX. Nursing. X. Hospitals and Dispensaries. XI. Method of Survey. Bibliography of Surveys. Index. The complete set may be obtained at a cost of $5.50 plus the postage and single parts at 50 cents each plus the postage, from THE CLEVELAND HOSPITAL COUNCIL, 308 Anisfield Building, Cleveland, Ohio Printed by The Pkemieh Press Cleveland, O. Industrial Medical Service Women and Industry Children and Industry Part Seven Cleveland Hospital a rj'd Health Survey Copyright, 1920 by The Cleveland Hospital Council Cleveland, Ohio Published by The Cleveland Hospital Council 308 Anisfield Bldg. Cleveland - Ohio Preface The Hospital and Health Survey of Cleveland was made at the request of the Cleveland Hospital Council. The Survey Committee appointed to be directly responsible for the work and through whose hands this report has been received for publica- tion consisted of the following: Malcolm L. McBride, Chairman; Mrs. Alfred A. Brewster, Thomas Coughlin, Richard F. Grant, Samuel H. Halle, Otto Miller, Dr. H. L. Rockwood, Howell Wright, Secretary The staff responsible for the work were: Haven Emerson, M. D., Director, and the following collaborators: Gertrude E. Sturges, M. D., Assistant Director; Michael M. Davis, Jr., Ph. D., Director of the Hospital and Dispensary Survey; Josephine Goldmark, B. A., Director of the Nursing Survey; Wade Wright, M. D., Director of the Industrial Hygiene Survey; Donald B. Armstrong, M. D., Director of Tuberculosis Survey; S. Josephine Baker, M. D., D. P. H., Director of the Infant and Maternity Survey; T. W. Salmon, M. D., Director of the Mental Hygiene Survey; W. F. Snow, M. D., Director of the Venereal Disease Survey; Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey. The expenses of the Survey and of the publication of the report have been met by appropriations received from the Community Chest, through the Welfare Federation, of which the Hospital Council is a member. The report as a whole, or by sections, can be obtained from the Cleveland Hospital Council. A list of the parts will be found in the back of this volume, together with prices. TABLE OF CONTENTS I. Industrial Medical Service Page Introduction : 525 The Industries of Cleveland.... 525 Medical Service in Industry- Industrial Physicians 526 Industrial Nursing ._ 529 Visiting Nursing... 531 Clerical Personnel... __ ._ _. 532 Dispensary Equipment . 533 Cost of Service 533 Administrative Relations : 534 Medical Service in Non-industrial Establishments 535 Medical Service Beyond the Plant 536 Industrial Medical Records _. 537 Absenteeism Due to Sickness 541 Physical Examinations 542 Special Services Industrial Psychiatry.... 544 Industrial Dental Service. 545 Industrial Ocular Service 545 Tuberculosis 546 Venereal Diseases. 547 Rehabilitation of Industrial Cripples 547 The Small Establishment ..I 550 Industrial Hospitals.... _ : 552 The Training of Industrial Physicians and Nurses 552 Public Health Authorities and Industrial Hygiene. 553 Recommendations 554 II. Women and Industry Introduction .. . _ 557 Conditions in Various Occupations Employing Women Industrial Establishments The Metal Trades _ 559 Textile and Knitting Mills 561 The Garment Trades 1 561 Candy Factories : _ 562 Miscellaneous Industrial Establishments 562 General Observations Hours of Work... 563 Earnings __ ; 564 TABLE OF CONTENTS— Continued Page Additional Benefits 564 Recreation 1 564 Vacations . 565 Supervision . . ~ 565 Physical Conditions of Work 567 Mercantile Establishments.. 568 Public Service Organizations Laundries... , 569 Hotels : 570 Restaurants — . 571 Public Utilities 571 General Discussion Night Work..... 571 HomeWork 1 573 Day Nurseries , 574 Mothers' Pensions 575 Recommendations 575 Community Interest— 576 III. Children and Industry- Introductory 579 Legal Provisions for Children 15-18 Going to Work 581 Statistics for Children in Industry in Cleveland, 1919 583 Where Children Work Occupations Employing Children. . 588 Manufacture of Confectionery 590 Manufacture of Hosiery and Knit Goods... 590 The Metal Trades 591 Printing and Publishing 592 Retail and Wholesale Trade 592 Telephone and Telegraph Work — 593 Street Trades .- 597 Agricultural Work and Domestic Service 602 Health of Children at Work Medical Examinations of Children for Work Permits.. 603 Suggested Content of Ohio Law re Health Certificate 607 Subnormal Children in Industry 608 Summary of Standards of Physical Fitness for Children Enter- ing Employment — 610 Education's Responsibility _ — 613 Junior Vocation Departments - 615 Suggested Plan of Organization for a Vocational Guidance Bureau 617 Summary of Recommendations 619 Appendix Tables 622 REPORT OF THE INDUSTRIAL DIVISION PREFACE In an industrial city such as Cleveland it is not possible to make a com- prehensive study of the health of the community without consideration of the relations of health and industry. Certain of these relations are the matter of this report. The Industrial Division of the Hospital and Health Survey has been concerned with three fields of industrial activity: medical, surgical and nursing service in industry; the employment of women and the employ- ment of children. These three subjects are discussed separately. All recommendations and for the most part the discussion of various topics relate specifically to conditions as observed in Cleveland, though it is true that many other industrial cities present similar problems. The Survey is indebted to the Committee for the Study of Public Health Nursing Education for designating Mrs. Anna M. Staebler to aid in the study of industrial nursing and to the Consumers' League of Ohio which contributed the services of Miss Florence V. Ball, who has conducted the study of children and industry. The Survey wishes also to acknowledge its appreciation of the coopera- tion and assistance offered by the industrial organizations of Cleveland and by numerous individuals and agencies in the city and state which have freely aided in these studies. Health and Industry Industrial Medical Service By Wade Wright, M. D. INTRODUCTION IN undertaking to study existing measures for the safeguarding of the health of industrial workers it was fully realized that detailed consideration of working conditions, of sanitation, of accident hazards and of industrial health, was not possible in the course of a brief survey. It has been the purpose of those conducting this inquiry to obtain certain essential data regarding the medical organization which various industrial and mercantile establishments have developed for the care of the health of their employes, to estimate as accurately as might be, the probable efficacy of such organiza- tion and to present in this report the findings of such an inquiry together with an expression of opinion regarding the merits of certain features observed, and ways and means for the remedying of the more outstanding defects. It is to be remembered that the Survey was without legal authority to enter and inspect industrial or other establishments and that this study has been made possible only through the courtesy and cooperation of the em- ployers of the city. The information here presented was obtained by questionnaire, by visit and by conference. It was not practicable to visit all of the large industrial establishments, but the great majority of plants employing over five hun- dred persons in which medical service is rendered, were visited by one of the four members of the staff of the Industrial Division. In all, about one hundred organizations of various sizes were carefully studied and information secured in some detail regarding many more. For the purpose of this report certain observations relating to industry will be separated from those concerning mercantile establishments, the con- struction trades and the public utilities. THE INDUSTRIES OF CLEVELAND The statistical studies of the number and size of industrial plants were based upon the "Directory of Ohio Manufacturers" issued by the Indus- trial Commission of Ohio in 1918. The information there published has been corrected by data more recently obtained, and though the resulting figures are not accurate they are probably a fair approximation of the facts. In Table I., published in the appendix, is shown the division of 1,521 industrial organizations into several size-groups, together with the group- total number of employes, the average number of employes per establish- ment and the percentages of establishments and employes in each group. Approximately 74 per cent of the city's industrial workers are engaged in establishments employing 200 or more, organizations of this size constituting ,>26 Hospital and Health Survey only 12 per cent of the total number of industrial organizations. 57 per cent of the employes are engaged in establishments employing 500 or more, 5.3 per cent of the organizations; and 43 per cent of the employes work in establish- ments employing 1,000 or more, 2.6 per cent of all organizations. It is evident, with so great a portion of all industrial operatives employed in a relatively small number of large establishments, that medical service would reach a very considerable number of workers if it were rendered in the larger plants. MEDICAL SERVICE IN INDUSTRY Table II. presents the findings relating to medical service in industrial establishments of various sizes. It was perhaps inevitable that in certain instances the information obtained from organizations was inexact. This was true of some statements regarding the place of the medical department in the scheme of administration and its relation to the rest of the industrial organism and regarding the status of physicians employed part time and on call. It has been necessary in consequence that the staff rather freely in- terpret some of these statements. In estimating the number of firms furnishing medical service a rough standard of adequacy has been accepted. The presence in a plant of a first-aid cabinet which might be supplemented in the event of a serious emergency by the attention of a neighborhood physician has not been reck- oned as "medical service." Those plants employing trained nurses for dis- pensary work have been rated as furnishing medical service even though physicians were seldom called in. The quality of medical service rendered in the establishments which have been considered as furnishing service undoubtedly ranges between widely separated extremes. In comparatively few instances has it been found to be of a high order, judged by the best standards of industrial medi- cine and surgery as practiced in this country. It is noteworthy and most creditable, however, that about one-half of the industrial workers of the city are upon occasion receiving some sort of medical attention in industrial plants. The dressing of industrial injuries of course demands immediate atten- tion and it is true and to be expected that there is a concentration of person- nel and service to meet this first need. A relatively small amount of time and service is devoted to other than surgical work. No effort has been made by the Survey to appraise the quality of surgical work done by industrial surgeons in the city, but there is much evidence that Cleveland is fortunate in having a group of interested, conscientious and able surgeons giving their time especially to industrial cases. Industrial Physicians In Table III. are tabulated data concerning the medical department personnel of establishments rendering medical service. Health and Industry 527 The Survey has knowledge of but seven physicians employed upon a full- time basis in the industries of Cleveland. There is a much larger group, numbering over twenty, who are identified almost exclusively with indus- trial practice, including a number of surgeons who are each engaged on a part-time or visit basis by several firms. There has been an interesting and important development of medical partnerships which purpose to render comprehensive service to their clients, including dispensary administration and health supervision as well as indus- trial medicine and surgery. There is much to be hoped of this type of organ- ization, especially in connection with small establishments, with contracting and construction work and those firms not in a position to command the full service of an industrial physician as the administrative officer of a medical department. Industrial medical service as at present conceived is comparatively new, crudely developed and far from being standardized. Industries have drawn into their medical departments a variety of types of physicians. In Cleveland there are a few highly skilled industrial physicians, trained to consider the intricate inter-relations of medicine and industry, possessed of wide technical knowledge of their special field. There is another group of physicians doing little but casualty surgery, some of them eminently capable and many of them less so. As a. rule these men are frankly interested in nothing but surgical conditions, but many will consent nevertheless to submit opinions upon any matters relating to health and sanitation, including obscure poisonings or involved questions of indus- trial hygiene. A third class includes men who have been drawn into industry from gen- eral practice, not infrequently in a sense, against their desire. Often the basis of selection of such physicians was curious. They were in many in- stances the attending family physician of plant executives. They are apply- ing in industry methods very similar to those which they formerly employed in private practice, with probably the same degree of conscientiousness and scientific honesty which characterized their work previously. Many of them become capable executives and well qualified industrial physicians. They are, however, strikingly indicative of the lack of comprehension among those directing industrial establishments of the importance of selecting for plant physicians, men technically equipped to render a technical service and who are possessed of proper personality and ability to develop with and be- yond assigned tasks. Another group, happily diminishing, is made up of incapables, men who have not succeeded in general practice, who have drifted near financial rocks and who eagerly welcome even the small salaries or fees which they may secure in establishments administered by those who still are of the impression that any doctor is a good doctor, and if secured cheaply, a better one for their purposes. There was a time, not long ago, when industry diligently sought for the struggling young physician and, finding him, offered him employment. 528 Hospital and Health Survey Usually the salary was very small, but the collateral inducements glowing. The young man was informed that despite the low salary he would be able to secure a splendid income by the simple means of developing a private practice among the company's employes. The glowing prophecy has been fulfilled and the physician, perhaps no longer young and struggling, has a splendid income, practising among the employes. The public views with alarm and suspicion and reads editorials about, public officials who personally benefit through their positions, but industry has sought and welcomed the physician who comes to advise and remains to operate. Industry does not aim to employ superintendents or treasurers upon such a basis of remuneration, why physicians? Cleveland is not without numerous industrial physicians whose incomes are very appreciably augmented from the personal practice worked up in industrial dispensaries. The cough which takes a laborer to his plant dis- pensary may carry him rather unexpectedly still farther to the company doctor's down-town office and a tonsillectomy operation, and beyond that into a dazed state of financial stringency. Or by a particularly fortuitous arrangement, one involving many thousands of operatives in Cleveland, the company physician or surgeon may collect within the company dispensary his personal fee for professional services rendered. It is not dishonest or unethical practice, any more than is that of the concessionaire who sells pie by the plant gate, and there are honorable and able men engaged in it. But it is of questionable value to any employer with whom the health of his employes is a matter of real concern. Indus- trial physicians should be employed to render specific services. If it is the feeling of the management of an industrial establishment that they do not wish to undertake the care of disabilities other than those arising out of industrial injuries, the services of physicians in their employ should be restricted to such cases. Under no circumstances should physicians be permitted to recruit private patients under the guise of their official posi- tions as company servants. Such employes as need care beyond that fur- nished by the company should be referred to competent practitioners not on the company's medical staff. The situation of an industrial physician in an industrial dispensary is quite analogous to that of a physician on the visiting staff of one of the many reputable hospitals which forbid staff physi- cians to receive dispensary or hospital cases as private patients except under very special circumstances. The temptation to enlarge a personal practice in this manner is compli- cated by other obvious evils, such as unnecessary treatment or operations, intrusions upon the practices of fellow physicians and inevitable exploitation of workers. Health and Industry 529 The Survey recommends that industrial physicians be selected with regard for their professional and executive abilities and that only the well qualified be chosen; that they be remunerated upon a basis commensurate with the amount and character of services expected of them ; that they be not permitted to combine with their official duties personal practice among the company personnel. Industrial Nursing Industrial nursing is perhaps less standardized than industrial medicine, for the duties assigned to plant nurses vary with plant physicians, types of industries and of employes and the purposes and fancies of plant executives. Of these several factors the last is probably the most potent. Rarely is a capable nurse selected and encouraged to develop and extend her field of usefulness. She is frequently added to the payroll in much the same spirit with which such employes as doorkeepers or telephone operators are added. The great majority of industrial nurses in Cleveland are registered trained nurses. Most of them have entered industry after a period of private duty nursing, others directly from hospital training schools. It is of course to be expected, as in the case of physicians, that the degree of excellence of training varies. Again, as with physicians, some are well qualified to do industrial work and are intensely interested in the progress of the new pro- fession; some have sought the short hours and freedom of the industrial world, rather than the strain and uncertainty of private duty nursing; and others among the least capable of the nursing profession have drifted in. A small portion of industrial nurses in the city are not registered nurses and are not graduates of hospital training schools. A number have had short courses in first-aid, others gained their knowledge of emergency surgery as dressing assistants. Some of them are very able and others obviously masquerading in nurses' uniforms and are probably more of a liability than an asset to the firms employing them. One may safely venture the assertion that in certain instances executives employing untrained nurses are not aware of their real professional status. There is undoubtedly a place in industrial medical service for practical nurses or nurses' assistants, serving with and under the direction of compe- tent medical or nursing authority. At present practical nurses are found in almost eyery instance in charge of their own departments. In establishments where there is no organized medical service certain duties ordinarily assigned to a nurse are assumed by matrons or by members of the clerical forces. Such an arrangement is warranted only in a small organization. The progress of industrial hygiene has been due in large measure to the contributions of industrial nurses. The truth of this may be readily evi- denced if one endeavors to withdraw from the fabric of industrial organiza- tions the threads representative of the services, the influence and the person- alities of able industrial nurses. It is the industrial nurse in many instances 530 Hospital and Health Survey who stands in the minds of employes as the most kindly, most wholesome human element in a big industrial machine. Her achievement, however, must depend in great degree upon the intelligent support and guidance of the plant administration. It is to be expected that the personality, abilities and ambitions of indus- trial nurses should in general be in keeping with the types of industrial organizations which employ them and the purposes for which they are em- ployed. It is as idle to criticize many an industrial nurse for failure to real- ize fully her opportunities for constructive health work as it is to condemn the surviving old type contract surgeon who is competent simply to bask on the sunny side of the payroll as "a doctor," quite as content as his employ- ers are to have him there. Not infrequently the nurse gives far more service than is expected of her, little though that service may be. She finds slight stimulus to better effort. If she writes a poor report, it serves as well as a good one, for it doubtless receives but a casual glance from an uninterested front office executive. Perhaps, as in one plant, she finds no official who considers it his duty to review- that report, so she submits none. She may attempt to extend her usefulness, as in another Cleveland establishment, but the employes make such increased use of her department that she is retired to her own reserva- tion, instructed to remain there. If the professional advice she offers is unsound, there is no one the wiser, certainly not the recipient of the advice. If she has had fairly good training, is reasonably decorative, has a ready suggestion for the relief of the general manager's indigestion and the em- ployes like her, she may be an eminent success as an industrial nurse in almost any one of the large group of plants where physicians are employed part time or on call. The employment of nurses with little or no medical supervision has led in Cleveland to a lowering of accepted standards of nursing and medical practice regarding medication. With the exception of instances so rare as to be practicably negligible the industrial nurses of the city are freely ad- ministering drugs for the relief of minor ailments without individual or standing orders of physicians. There is constant and free use made of various sedatives for the relief of headaches, coughs and divers pains and of cocaine for the removal of foreign bodies in the eye. Though it is not to be questioned that many or most nurses are qualified to use these drugs with discretion, the fact remains that indiscriminate medication of this kind is not in accordance with modern standards of medical treatment and unauthor- ized, as in these instances, it is in direct violation of the medical practice act of the state. Isolated, as most industrial nurses are, from professional associations, confined to their duties for the entire weekly working period, they naturally tend to become somewhat limited in conception of their duties and their opportunities. They are pioneers in their respective establishments often, Health and Industry 531 each one endeavoring to work out her own problems, a difficult task when no precedents are at hand and no competent advice readily available. There is urgent necessity in Cleveland, as in other cities, for some' means of carrying to industrial nurses the counsel and technical assistance which most need and many desire. The present Industrial Nurses' Club is presum- ably of real value in this connection but its services are quite inadequate. It would be much to the advantage of organizations employing industrial nurses to contribute to a common fund devoted to the maintenance of a center for gatherings of industrial nurses; of a good library on industrial hygiene, including related periodicals; of a series of conferences and of one or more well salaried counseling industrial nurses. Such a counsellor, wisely chosen, rendering an expert technical consultation service, could be of unques- tioned assistance to industrial nurses and plant executives and would in no sense conflict with established relations of authority and responsibility. Visiting Nursing It has been difficult to determine with any exactness the number of firms whose nurses make visits to the homes of employes. In a small num- ber of establishments visiting nursing is an accepted part of the medical department routine, in others, visits to the homes of sick workers are made infrequently. A total of 22 firms are recorded as providing at least occa- sional visiting nursing services; 13 of these firms employing 1,000 or more; 7 firms employing 500 to 1,000, and 2 firms from 200 to 500 employes. In no instance does a visiting industrial nurse do bedside nursing, at its best the purpose of her visit being rather to determine whether or not the sick or injured worker is receiving proper care. Industry has made occasional use of nurses furnished by the Visiting Nursing Association. A more extended utilization of such an established service might be advantageous. In Cleveland a considerable number of nurses employed in industry for visiting do not report to the medical department but are responsible to employment officials. Their task is to visit the homes of absentees to de- termine the cause of absence and to exert such influence as they may to induce the delinquent to return to work. Such service, valuable though it may be, is not visiting nursing, is not a part of medical care or supervision and the employment of nurses for this work is frequently a transparent subterfuge of employment departments used to mask the real purpose of such visiting. It rarely fails to discredit the organization responsible for the activity and to lower the respect of employes for the plant nurses. With good reason employes resent the com- ing to their homes unasked of women who wear the uniform of nurses but who in purpose and in fact belong to the company espionage service and not to its health department. 532 Hospital and Health Survey It is obvious that absence follow-up can best be done by visitors who are qualified to discern illness when it exists, but nurses are so few and absentee- ism so prevalent that it is of doubtful wisdom to assign nurses to routine absence follow-up instead of to visiting of the known or suspected sick. In any event, visiting nurses should be considered as medical department per- sonnel and their reports should be part of the medical department records. RECOMMENDA TIONS The survey recommends that: Industrial nurses be graduate, registered nurses. That they be employed in the practice of nursing or in the maintenance of the physical welfare of establishment personnel. That industrial nurses be carefully chosen for professional fitness and for such qualities of personality and character as will enable them to fulfill their many responsibilities. That practical, untrained nurses be employed only under competent medical or nursing supervision. That industrial nurses in establishments where they are directly and wholly responsible to executive officers rather than to industrial physicians be granted such authority and receive such support as may be necessary for the development of their fullest usefulness. That industrial physicians re- member that the industrial nurse must be more than a handmaiden of the medical profession. That medication without the individual or standing orders of a physi- cian should be prohibited in industrial establishments as it is in law. That encouragement and assistance be offered by industry to industrial nurses in their efforts to maintain contact with progressive movements in their rapidly developing profession. That visiting nursing be considered as a normal function of industrial medical service to be exercised as required or desirable. That industrial visiting nurses be rated as medical department personnel. That they visit the known or suspected sick and be not employed for routine absence follow-up from employment departments. Clerical Personnel Clerical personnel of medical departments in Cleveland is limited. It is about as rare and found in about the same places as adequate dispensary records. Seven firms employ a total of fourteen clerks in connection with industrial dispensaries. Efficient health administration is as dependent upon proper dispensary records as efficient production and sales methods upon proper cost accounting. In all industrial dispensaries there is need of some clerical work. Nurses and physicians are trained for medical service. If clerical work is excessive it should be performed by clerks and not by the medical or nursing staff. Health and Industry .533 Dispensary Equipment No detailed consideration of the equipment of industrial dispensaries is included in this report. Excellent work can be done with meager equip- ment and worthless work in the midst of much white enamel. It has been a matter of some interest that with a few exceptions the medical departments rendering the best service in the city are in poor quar- ters and possessed of inferior dispensary" fittings. The equipment of many of the most elaborately furnished suites has apparently exhausted the inter- est and thought of those responsible for medical administration. It is certain that an efficient staff will be aided by adequate and convenient equipment as well as by quarters which are accessible and sufficiently large for the number of cases to be handled. Most of the industrial X-Ray work in the city is done by hospitals or firms specializing in this service. A small number of firms have installed apparatus for such purposes as radiographing teeth or minor injuries. Sev- eral establishments have apparatus enabling them to do practically all grades of X-Ray work. Few dispensaries have even limited clinical laboratory facilities. There are probably not more than five such laboratories in use. One private ambulance has been ordered by a large industrial organiza- tion. The inadequacy of ambulance service in the city is not infrequently a source of annoyance and even danger in the transfer of injured workmen to hospitals. Especially apparent is the need of trained ambulance attendants. There is much reason for believing that the industries of Cleveland could be served much more satisfactorily than at present by a centralized ambulance call system, the cars of such a system to be operated by a single agency or controlled jointly by the hospitals of the city. Cost of Service Though many of the results of industrial medical service must be reck- oned as intangible, there are ways in which the quality of service which is rendered may be checked, as well as certain effects upon employment and insurance costs to be noted. Through these means may be obtained an approximate estimate of what the service is worth. It is more simple to secure accurate figures regarding the cost of service. There are several plants in Cleveland efficiently applying cost accounting to medical departments and it is in these few plants alone that there is definite knowledge of the total outlay for medical work. Other firms may roughly calculate the cost by guessing at the value of medical supplies purchased or on hand and adding to that amount the salaries of personnel. In most establishments there is the greatest vagueness regard- ing costs of service, occasionally combined with a fanciful exactness regard- ing the benefits derived. 534 Hospital and Health Survey A number of firms stated the cost to be in the neighborhood of five dol- lars a year per employe, but this amount, it is interesting to note, is rela- tively constant, independent of the size of the plants, nature of products, types of workers or the extent and quality of service rendered. In one large establishment the cost is $10.92 a year per employe and in another $11.23. Such amounts are probably not excessive at the present time if the service secured is comprehensive and of a high order. Administrative Relations The ultimate utility of a medical department is certainly to some extent determined by the place which the department occupies in the industrial organization, though it must be recognized that all plants are not conducted along the lines prescribed in the schematic plan of administration. If a medical department is to develop and render more than relatively insignifi- cant service it must have at its head a responsible executive in whom is vested suitable authority. As it is the function of this executive to conduct operations relating to the maintenance of a healthy staff of employes, it would seem reasonable to select for the office a properly qualified physician. Not infrequently medical departments are administered by laymen who direct the activities of subordi- nate physicians, a practice which may be compared to the employment of a good foundryman to superintend a draughting room or of a capable pipe fitter to direct the tuning of a piano. If it is not feasible in any particular industrial organization to make the medical head of a medical department directly responsible to a general executive, he should at least have authority to control the policies and methods within his own field. In Table IV. are shown the administrative relations of a number of industrial medical departments in Cleveland. Reasonably accurate infor- mation regarding fifty-six organizations has been tabulated. In certain establishments the duties of executives are not well defined and it has been necessary to determine rather arbitrarily the classification of the adminis- trative relations of a few medical departments. Under "Administration" are included medical departments responsible to general administrative bodies as executive boards and to general managers. "Production" is inclusive of factory managers and superintendents. "Em- ployment" includes welfare departments, service departments, employment and industrial relations managers. "Claims" includes pension and acci- dent departments. Almost half of the medical departments classified are responsible to some form of employment service, 78 per cent are responsible to either such em- ployment service or to general administrative officers, while only 17 per cent are responsible to production. In an extensive study of industrial medical service by C D. Selby in 1919, 41 per cent of a group of medical departments Health and Industry 535 were found to be responsible to production, 16 per cent to labor relations and 18 per cent to administration. Though conditions within individual organizations must in great measure determine the relation of medical departments to various executives, it has appeared that the best developed medical services have been in departments headed by full-time physicians directly responsible to general administrative officers. It is to be accepted that such departments must cooperate closely and harmoniously with related plant activities. If no full-time physician is employed the medical department may well come under the supervision of the company officer or executive charged with labor relations. The heads of two medical departments are also in charge of the service departments of their respective establishments. Such an arrange- ment may be successful, as in these instances, under favorable circumstances and when the chief surgeon and service head is an able executive, but it is not one to be commended as generally applicable or desirable. MEDICAL SERVICE IN NON-INDUSTRIAL ESTABLISHMENTS Certain mercantile establishments of the city and a number of public utilities have developed medical services which are so similar to those found in industry that they may be considered as within the scope of this survey. In Table V. of the appendix is set forth a summary of the statistical find- ings covering these groups. Contrary to the condition prevalent in manu- facturing establishments, mercantile medical service is concerned more with the health of employes than with accidents. It affords an excellent oppor- tunity for a demonstration of the value and possibilities of medical service as distinguished from that essentially surgical. Medical departments have not to this time been developed in the con- struction trades though the health and accident hazards are notable. A beginning has been made in Cleveland, though not, however, by a Cleveland construction firm. There are in Cleveland about twenty thousand workers in the construc- tion trades. For many of these the work is arduous and hazardous and demands continued exposure to inclement weather. Both health and safety of construction labor are frequently imperiled. Small injuries are numerous and serious accidents common. Extensive construction enterprises involve the housing of workmen and necessarily special problems of sanitation. Wages in the construction trades are high and the time lost by injured workers is a costly factor. The loss incident to the absence of men from their jobs, sent away for the dressing of small injuries is alone great. To this must be added the cost of turnover from more serious accidents and from ill health, and the burden of numerous fatalities. 536 Hospital and Health Survey There could be developed on construction jobs medical service somewhat similar to that of the army in the field. Portable dispensaries could be in- stalled where needed, suitable light equipment provided and medical and surgical care thus made available for sick or injured workmen. It is a matter of great concern to individual workers, to construction firms and to public health authorities. MEDICAL SERVICE BEYOND THE PLANT Industrial medical departments are in most instances established and manned to furnish surgical care for industrial injuries. As previously indi- cated, there has been relatively slight development of service purposed to care for the health of operatives. There has been in Cleveland almost no consideration of the health of employes beyond the confines of plant prop- erty except through the ministrations of a few visiting nurses. It is of course difficult to determine the limits of the social orbit of an employe, an orbit touching many interests, work, home, church and recrea- tion. In this connection it is of interest to consider the curious philosophy of many employers who rather belligerently assert that they have not con- cerned themselves with the health of their employes because that is a private affair; that if the men received good working conditions and good wages they receive enough; and that besides there are in the city men who have secured training for the medical profession, implying that in consequence the community is in duty bound to support these physicians regardless of their merits. Yet the same employers turn to show proudly their company cooperative stores where food and clothing are sold at cost, or at a trifling profit, food for the worker and for his family. The implications in this case are probably that food and clothing are not to be regarded as private affairs and that the community does not owe storekeepers a living. The employer who has joined with his employes to enhance the purchas- ing value of wages by sharing in the operation of a cooperative store has but few mental steps to tread till he faces an opportunity to secure for his em- ployes that which is as necessary in their lives as socks and canned tomatoes —a fair chance for health and for competent medical care at a reasonable cost. It should be possible for employers and employes together to arrange for the establishment of industrial dispensaries, for the securing of medical and nursing personnel and for the conduct of such dispensaries upon a mutually satisfactory basis. A dispensary of this nature might be limited to the full medical care of employes or might increase its resources to include the care of employes' families. The extent of medical and nursing service and the apportionment of cost are details which any representative fair- minded body could readily determine. There are in Cleveland at least two mutual benefit associations which participate in the administration of plant medical service. One is. in its Health and Industry 537 plan, but little above the level of the old-time lodge practice, the other is the most promising industrial medical service in the city. One of these mutual benefit associations employs a physician whose office is provided by the com- pany and who for a small annual sum contributed by each member renders service to members of the association, services necessarily limited. Em- ployes who are not members of the mutual benefit association may consult this physician, but upon a fee basis. In the other organization cited, the plan is to render comprehensive medical service of the highest type, employing physicians and nurses in such numbers as may be required to insure adequate and prompt treatment of employes. It is contemplated that later, service shall be available for the members of employes' families. INDUSTRIAL MEDICAL RECORDS There is such a thing as accumulating useless statistical material, of multiplying indices and cross indices, just as there is the considering of prob- lems by guess work when they are considered at all. There is also such a thing as keeping an accurate record of important facts and of summarizing the data so made available in such a manner as to render them possible of intelligent interpretation. It is a safe assumption that the industries of Cleveland have not attained their present eminent position by the universal application of the sort of administrative methods which are generally found in their medical departments. There are several establishments in Cleveland in which essential data regarding injuries and illness incurred by employes are recorded and the findings so tabulated as to be of significance and great value. There are numerous establishments with thousands of records so inadequate, confused and inaccessible that they are practically worthless; and there are others which keep no records worthy of mention, yet expend a total of many thousands of dollars for the purpose of safeguarding the physical welfare of employes. The conditions in various plants, such as the type of industry, of organ- ization, of personnel and of medical service, all enter into the consideration of dispensary records and forms for records. It is probably futile and not desirable to hope for general adoption of any uniform record system, but there are a few minimum standards for good industrial medical practice just as there are for good hospital practice. Industrial medical records should indicate the recognition of such standards. It is not within the province of this report to set forth dogmatically a list of standards for industrial medical records, but several suggestions may, however, be submitted. Records concerning individuals should be so filed as to be readily acces- sible. This may entail a cross index by name if records are filed by case number or shop number. Individuals may well be identified by name, number, department, nationality and address. It is very desirable to state the actual process upon which an employe is engaged. 538 Hospital and Health Survey Dates of injury, illness, treatment and discharge should be set down. Adequate, though possibly brief statements should be made regarding treatment, such as dressings or medication. Progress notes are valuable. Accurate diagnosis, by standard nomenclature, should be required. "Deferred" and "provisional" diagnoses should be supplemented by more accurate opinions. Condition of the case at discharge should be stated. Whether the record form be a card filed separately or in a folder or a sheet bound loose-leaf fashion or filed folded or flat is a matter for each organization to consider. Good records are kept in any one of these ways. There is much to be gained by filing all of the data relating to an indi- vidual in one place. A fairly preva'ent custom is to make out a new form for each new accident or illness without reference to the previous history of the individual concerned. In many instances the custom can be well justi- fied but in general it is not good practice, especially in regard to medical cases, to ignore an available case history. Ample evidence warrants a gentle caution against indiscriminate "elimi- nation of paper work." A certain amount of paper work is a good thing; it saves other kinds of more arduous work. Industrial medical department forms are of practically unlimited variety as to shape, filing system, purpose, content and degree of usefulness. The forms collected in Cleveland in connection with this survey may be roughly classified into several groups. (•a) Forms used to get injured or ill workers from the plant to the dis- pensary. They include passes from timekeepers and foremen, with or with- out provision for record of time elapsed in transit. Some include space for description of the accident incurred. In large plants it may be found very desirable to have some sort of a check on the time consumed by employes in coming to the dispensary and in returning to work. An ingenious shirker can occupy several hours in negotiating the short distance between his de- partment and the plant dispensary. It is to be remembered, however, that as little difficulty as possible should be thrown in the way of patients which might deter them from making free and prompt use of the dispensary. In- fections and prolonged disabilities are the penalties. Official statements re- garding the percentage of industrial injuries in Ohio which have become infected and regarding the influence of infection on the production of perma- nent disability offer matter for serious and thoughtful attention. A bulletin of the Industrial Commission of Ohio published March 1, 1917, stated that of 73,525 industrial accidents for which awards were made by the Com- mission for the year ending June 30, 1915, infection was reported in connec- tion with 7,073 cases, approximately one-tenth of all accidents. Of these 7,073 cases 39 resulted fatally, 161 in permanent partial disability and 6,873 in prolonged temporary disability. Health and Industry 539 (b) Forms used for follow-up to insure the return of cases needing continued dressings or treatment. These include hospital passes and cards patterned after the conventional time card, used in racks, one for a case, and "pulled" by the dispensary nurse when a patient has received his ap- pointed treatment. (c) Forms for case records, medical, surgical, dental, ocular or for spe- cial studies. They range from simple cards to elaborate forms upon which positive findings may be indicated by signs. (d) Forms for physical examinations. Such forms vary with the pur- pose for which physical examinations are performed. They also vary with the training and the professional hobbies of their medical authors. (e) Forms for preliminary and final reports on cases. Usually for the purpose of informing compensation departments regarding the nature of injuries and the progress or termination of cases. Occasionally include a statement of professional fees. (f) Forms for periodic reports to executive departments. They, for the most part, present a somewhat curious selection of data and, as with the case of many other forms, are of unknown executive origin. Industrial. accidents and disease, as well as non-industrial accidents and illness, are important and costly matters concerning employes and their employers, affecting as they do not only the well being and income of indi- viduals but also operating costs through lowered morale, absenteeism, in- creased turnover, lowered production, faulty goods, medical care and insur- ance rates. It would appear to be a subject of genuine interest to progres- sive employers, but the supposition is not borne out in the records of many industrial medical establishments. Even though ample material may be at hand in the files of the medical departments it is seldom summarized and tabulated in monthly or other periodic reports in such fashion as to furnish responsible executives with sound bases for comparative judgments. For example, there is rarely careful discrimination between numbers of individuals, numbers of cases and numbers of dressings, treatments and visits. There is rarely a comparative statement of accident and illness inci- dence based upon some common factor, such as a hundred or a thousand full-time workers. A relatively small department of a plant showing ap- parently a low accident incidence may in fact have a very high accident rate. There is rarely in periodic reports a differentiation between trifling and seri- ous accidents, yet more important than the frequency rate is the severity rate indicating the time lost. This may be illustrated by the machine trades in which the number of accidents causing an immediate loss of time of less than one day is much greater than the number of serious accidents, perhaps ninety to ninety-five per cent of the total. Though an important group of injuries, these trivial cases are not reportable to the Industrial Commission and do not figure in an estimation of the severity rate. Thus the machine trades, having a fairly high accident severity rate, have a still higher accident frequency rate because of numerous accidents, each causing disability for a short period. ■540 Hospital and Health Survey These more accurate reports of medical department data do not demand the attention of skilled statisticians. They can be very satisfactorily com- piled by industrial nurses or clinic clerks with possibly occasional supervision or assistance. There is much to be gained from the general adoption of some uniform basis of reckoning for accident and sickness statistics, and at the present time there appear no more authoritative standards than those employed by the Bureau of Labor Statistics of the United States Department of Labor. These include the standards of the Committee on Statistics of the International Association of Industrial Accident Boards and Commissions regarding tabulable accidents, diseases and injuries; what shall constitute a full-time worker; the computation of the number of man-hours worked in an establish- ment and a scale of time losses for weighting various industrial accidents. According to these standards the accident frequency rate expresses the number of tabulable accidents incurred per 1,000 full-time workers, a full- time worker being one who works ten hours a day, three hundred days a year. The accident severity rate expresses the number of days lost through tabulable accidents for each full-time worker per year. The utilization of this method of tabulating accidents and illness would enable executives to estimate accurately the losses from these sources by departments, by processes, by various time periods, by day and night shifts, by nationalities, or in other ways; would enable them to compare their losses with other similar establishments or with other industries. Complete and recent reports of accidents in Cleveland have not been available, but a bulletin published by the Industrial Commission of Ohio in 1915 presents an analysis of reportable industrial accidents occurring in Cuyahoga County from July to December, 1914. Computations based upon the figures of this report indicate an accident frequency rate of 93.7 accidents per 1,000 workers per year, and an accident severity rate of 4.53 days lost per worker per year. (Table VL, Appendix.) Through the courtesy of the Industrial Commission advance figures have been received indicating the number of reportable accidents occurring in several groups of plants located within selected important industrial areas of the city during the period of June 1, 1919, to November 30, 1919. The industries represented were quite diversified, though for the most part they were engaged in the manufacture of metal products. These figures, which are presented in Table VII. of the appendix, indicate for a total of 54,091 employes, an accident frequency rate of 201.7 accidents per thousand workers per year, and an accident severity rate of 2.6 days lost per worker per year. Detailed information regarding the computation of accident and illness frequency rates and severity rates may be obtained from the Bureau of Labor Statistics in Washington. Health axd Industry 541 ABSENTEEISM DUE TO SICKNESS There is little question in the minds of those deeply concerned with problems of industrial health that the greatest present need in this field is for the accumulation of accurate and extensive data regarding absenteeism due to sickness and non-industrial accidents. It is not always easy to obtain. In one Cleveland plant unusually satisfactory reports of illness are obtained by conditioning a portion of an attendance bonus upon the prompt report- ing of cause of absence, with a penalty for false reporting. In another establishment all absentees are questioned by the employment department upon their return to work regarding illness or other cause of absence. In another organization all employes absent over a certain period return through the medical department. Numerous plants obtain much valuable information regarding absenteeism due to sickness through follow-up person- nel, either nurses or visitors working from the employment offices. It is necessary that there be close coordination of the medical and employment departments, and of importance that all facts secured be recorded and in- corporated with the records of individuals in the medical department. The subject is one which has been rather studiously neglected by employ- ers who customarily state that non-industrial sickness is not of their concern and, like the medical care of such illness, is wholly a private affair of employes. This is questionable. In recent years there have been numerous careful investigations into the incidence and duration of absence due to non-industrial accidents and illness of industrial workers. These studies have shown that there is an average time loss per worker usually ranging upward from six days per year. Seven days of lost time a year is probably a conservative estimate for all industries. One set of authoritative figures, based upon consideration of over half a million workers, places the time loss at nearly nine days per year per worker. These are averages. In certain trades and among certain nationalities the loss may be less or greater. If to a time loss of seven days for non-industrial accidents and illness there be added an estimated loss of four days for industrial accidents, there is a total loss among the industries of Cleveland of approximately two and a fifth million days a year. When to the two hundred thousand industrial workers are added the many thousands employed in the public utilities, in mercantile and commercial establishments, in the construction trades and in transportation, there is a most impressive total of time loss, with its attendant economic loss to employes, employers and the community as a whole. This loss is not of wages' and production alone for to it must be added the burden of medical and social care placed upon numerous individuals, physicians, nurses, hospitals and other institutions. Estimates of actual time lost must be supplemented by consideration of the intangible but noteworthy losses due to non-disabling poor health and 54-2 Hospital axd Health Survey physical and mental defects. The findings of the examiners of draft regis- trants in 191? and 1918, indicating 46S men per thousand with important physical or mental defects, are significant. It is reasonable to believe that these evidences of sickness and accidents could be materially reduced by applying intelligent and simple preventive measures and by providing a better mechanism than now exists for the care of ill health. Even were the burden so evenly distributed that the ardent champion of the rights of the individual might justly argue that each citizen bore only his proper share and so should be responsible as an individual, there would -till be ample reason for developing health and safety education and better means of providing medical and nursing care. The burden is not evenly distributed. An illustration may be found in Table YIII. of the appendix where are compared the accident incidence of the construction trades and that of the metal trades in Cuyahoga County. as published by the Industrial Commission. This comparison indicates an accident frequency rate in the construction trades over twice that of the metal trades, and a severity rate four to eight times as great, the variation being dependent upon various assumptions as to the length of the working day for workers in the construction trades. It may be pointed out that industry presents an unparalleled opportunity for the detection and remedy of defects, for the observation of disease in its earliest recognizable stages and for the institution of measures for the treatment of such disease. In no other way than at work are so many persons brought frequently together in groups, each group constituted of individuals living much the same sort of life under similar conditions. It is recommended by the Survey that industrial, mercantile and other establishments proceed to collect data regarding the incidence and nature of sickness and accidents among employes causing absence from work. This information may later be analyzed with great profit by individual organiza- tions, and the findings of individual establishments may be available for consolidation and study by such groups as associations of employment man- agers, industrial physicians and other interested agencies. PHYSICAL EXAMINATIONS It is essential for efficient public health control that there be knowledge of the community's physical constitution, of its defects, of menaces to the public health. So does efficient control of the health of the individual rest upon knowledge of the physical condition of the individual. It is of course possible without this knowledge to maintain r-ertain general safeguards, but they are of necessity inadequate and probably frequently misdirected. If men and women, and especially children, are to labor under conditions which do not work undue detriment to their health it is of the greatest im- portance that there be such continued observation of their physical state as will lead to the prompt institution of eorrective measures following detection H E.A L T H AND INDUSTRY 548 of ill effects. This can no more be done without initial physical examina- tions than can the running time for a race be recorded when the moment of starting is not noted. There has been much opposition to compulsory physical examinations exerted by organized labor, usually the expression of feeling that the exami- nations might be made an instrument for discriminative action against indi- viduals considered by employers to be undesirable. Without doubt physical examinations have been at times the occasion of injustices, but there are now thoughtful men in the labor group who have affirmed their belief in the value of physical examinations when fairly conducted and not instituted for the elimination of defectives. Ohio manufacturers are unusually strengthened in their position of being able to accept practically all labor applicants, by the operation of the Work- men's Compensation Act which does not penalize the employer of a defec- tive workman who incurs by accident a loss to a single remaining paired member, by charging against that employer's compensation account a claim for the total, double loss. The findings of the Survey are that eleven industrial organizations in Cleveland conduct compulsory physical examinations. A small additional number offer optional examinations. It is of importance that in practically every instance the only bases of rejection were of the following nature: (a) Communicable disease. (b) Conditions which would render the applicant, if employed, liable to per- sonal injury or harm. (c) Conditions which would render the applicant, if employed, a menace to the health or safety of fellow workmen. (d) Unreasonable lack of personal cleanliness. The second and third reasons for rejection have not been frequently operative, partly because of the labor shortage and partly because in large establishments there can be found suitable work for almost any defective. There are in the files of the Survey the names of scores of firms employing cripples and persons handicapped by orthopedic conditions, deaf and dumb, partially and totally blind and even pronounced and recognized mental defec- tives. Selective placement is not always made with desirable precision, but it is in a general way the purpose of numerous large establishments. Ohio law requires that "no person suffering from or afflicted with tuber- culosis, a venereal or a contagious disease, shall be employed in or about any part of a restaurant or its kitchen or handle foodstuffs or products used therein." In the course of this study but one establishment among the leading hotels and restaurants of the city has been found in which physical examina- 544 Hospital and Health Survey tions are conducted, and that a department store restaurant. Various managers evinced genuine interest in examinations, but found their labor so. highly mobile and scarce as to deter them from pursuing the matter. There are, however, many deaths reported from tuberculosis among cooks, bakers, stewards and waiters, a sufficient number to suggest that existing active cases are widely distributed among the members of these occupational groups. One large group, of food handlers, apparently recog- nizing that many of its members were suffering from or afflicted with com- municable disease, appealed for the cooperation of the Survey in an effort " looking to a clearing up of the situation." It would appear to be a wide field of endeavor for the department of the State Fire Marshal, to which department the Legislature in its wisdom has committed the administration of these matters pertaining to the public health. It is recommended that the responsibility for the maintenance of health among food handlers in restaurants be transferred to the State De- partment of Health. Many persons are daily imperiled because of defective vision or other disability, physical or mental, in those who operate taxicabs or other motor cars, trucks, cranes and elevators. Few of such operators are examined. The safety of that portion of the public which boards street cars and rides therein or has occasion to cross tracks is daily entrusted to a large corps of men, none of whom are examined to determine their freedom from infirma- ties which might disqualify them for certain types of work. The municipal government of Cleveland is the largest single employer of labor in the city, having on its payroll approximately 10,000 men and women. As such its responsibility in connection with the maintenance of health among working people is not only a great one but very immediate. It is also grossly neglected. It is a responsibility shared by each tax-paying citizen. The Survey recommends that the City, through its Division of Health, provide for its employes an initial and subsequent periodic physical examina- tion with such medical and surgical care from time to time as may be deemed necessary and advisable. It is wholly reasonable to expect of the city government a service for its workers comparable with the best medical services provided by large indus- trial organizations. SPECIAL SERVICES Industrial Psychiatry As one of the outgrowths of careful study of the causes of industrial unrest there has come new knowledge of psychology as applied to industry and even more recently the beginnings of industrial psychiatry. Psychology and psychiatry are terms often used somewhat carelessly and it is of importance that they be differentiated. Psychology may be defined as the study of Health and Industry 545 states of consciousness, but is ordinarily limited to consideration of normal processes. Most psychologists are not physicians. Psychiatry is the study of abnormal, pathological mental processes and conditions. Most psychiatrists have been trained as physicians. Military surgeons during the war found that men whose mental equip- ment was not such as to permit them to withstand military discipline and routine had not infrequently checkered industrial histories, having held many jobs and no job for a long while. Carefully studied, in many instances these individuals proved to be of psychopathic type. In industry they had prob- ably been called unruly, inefficient or lazy. When upon deficient mentality are thrown the burdens of fatigue, of unhealthful working conditions, of real or fancied injustices and of economic uncertainties, it is rather to be expected that unrest results. In a realm of science so beset with difficulties as is psychiatry, complicated in an industrial environment by many different factors, progress will likely be slow, but the development of this field warrants earnest consideration by industry. It is not a subject to be approached by the inadequately trained or by the casual enthusiast. There have been in Cleveland at least two employers who have made extended use of psychometric tests and over such a period of time as to justify, apparently, the continued use of these aids to employment and place- ment. In neither organization have the tests been considered as other than one of several gauges of the fitness of applicants. Industrial Dental Service The public in recent years has come to realize in some degree the impor- tance to health and self-respect of good teeth and high standards of mouth hygiene. This interest has been reflected in the development in industry of dental clinics and in the importance which is attached in many establish- ments to the care of the teeth of employes. While a casual inspection of the teeth is a part of every reasonably thorough physical examination, several firms have installed dental chairs and employ capable dental surgeons to inspect the teeth of all recent employes. Four manufacturing and one mer- cantile establishment in the city maintain dental service. The amount and kinds of work performed vary with the establishment but are in every in- stance limited to nothing more costly than amalgam fillings. The cost is borne either entirely by the employing company or shared by the employes who pay a moderate sum for materials used. It is a service which is generally enthusiastically endorsed by the organiza- tions which have installed it and it is one which merits wide adoption. Industrial Ocular Service Several industries in which fine work demands good vision have found it sound practice to secure for their employes the services of competent oculists, not only to determine the grade of vision at the time of employment, but also 546 Hospital and Health Survey to re-examine workers from time to time to secure by glasses proper correc- tion of refractive errors. Five firms maintain oculists for work of this nature, but many more make use of oculists as consultants or refer to them serious eye injuries. In far too few instances are these serious eye cases promptly referred. Inquiry recently made indicates that a large portion of industrial eye injuries referred to ophthalmologists had been previously mishandled. Industrial Commission figures for the state at large have shown that eye injuries made up 22 per cent of the cases of permanent total disability,. 8.9 per cent of cases of permanent partial disability and 10.9 per cent of the cases of temporary partial disability. In a study of the influence of infection upon disability, it was found that 18 per cent of the cases of total or partial loss of vision were due to infection. The neglect of vision begins early in many industrial plants. The Snellen chart as generally used is one of a number of false gods before which a suc- cession of company officials reverently bow. If the chart is veiled in dim obscurity, the almost superstitious regard for its subtle values is the greater. Snellen charts hang in sunny offices or in half -lighted basements; some illuminated at the top, some at the side; some by glaring light, some by moribund filaments. There are in Cleveland a number of able oculists who are greatly interested in industrial eye injuries and a number in the safeguarding of the vision of industrial workers. More use should be made of them. There is no hospital in the city devoting a special service to the care of eye cases, though such cases are occasionally received in seven general hos- pitals. One hospital only regards certain beds as belonging to the eye serv- ice, holding four beds in a surgical ward for this purpose. Five hospitals have magnets for the removal of metallic foreign bodies. Cleveland is greatly in need of an eye hospital and the almost unanimous and generally emphatic statements of the oculists of the city regarding the desirability of such an institution warrant a favorable response from the community. Tuberculosis In an industrial population as large as that of Cleveland it is certain that there are a considerable number of cases of tuberculosis, yet in the establish- ments conducting physical examinations the number of cases observed is almost negligible. They have presumably been overlooked either because the examinations have been made too casually and hastily or because they have been made by physicians ill qualified to examine for pulmonary disease. Reports of the municipal Division of Health offer evidence that large numbers of industrial workers are dying of tuberculosis. As no data are available regarding the numbers of reported cases for occupational groups or detailed information concerning the numbers of various types of workers in the city, no fatality or mortality rates can be given. Health and Industry 547 It is to the interest of those afflicted as well as their companions at work that reasonable measures be taken to identify persons with this disease and to assist them in securing proper care. The incipient cases must be sought with special diligence, for in such cases there may be slight evidence of ill- ness to attract the attention of foremen or fellow workers. The physician who conducts examinations must have sound knowledge of chest conditions or the examinations will be more or less futile. Not all physicians have this knowledge and while it is in a sense unfair to general- ize, it is safe to say that a very large portion of the surgical group of the pro- fession and a somewhat smaller portion of the medical group know little about the diagnosis of pulmonary tuberculosis, except possibly in its well advanced stages. It should be wholly practicable, however, for industry to make frequent use of expert consultants who might review groups of doubtful cases selected by plant physicians. The opportunity of industrial medical services to cooperate in the reduc- tion of tuberculosis is a very valuable one. In Cleveland little utilization has been made of it. There is awakening doubt of the blissfulness of igno- rance in regard to this preventable disease which is alone the cause of a fifth to a quarter of all the deaths occurring in the working-age groups. Venereal Disease The activity during the war, of the United States Public Health Service, in connection with its extensive program for the combating of venereal dis- ease unfortunately did not stimulate a sustained interest in the subject among employers. There are probably not more than two or three establish- ments in Cleveland in which venereal disease is of more than trifling concern. Yet Cleveland is not a community distinguished for its freedom from venereal disease and from the conditions which foster it. Nor is venereal disease without influence upon the efficiency of working people and upon absentee- ism. Like defective vision, and tuberculous lungs, venereal disease has been considered a personal affair of the worker, another inviolable right of the individual. Though much of the traditional prejudice against frank and honest care of venereal disease has fortunately passed, it is still in practice difficult either to secure reporting or to conduct the treatment of cases in industrial dispensaries. There are, however, no insurmountable difficulties in the way of tactful and straightforward educational work with advice regarding the accessibility of centers for diagnosis and treatment. This is a reasonable function of industrial medical service. The Rehabilitation of Industrial Cripples The analogy of industrial casualties to those of war has frequently been pointed out. Though this has long been a matter of comment and there -c faj ~ II «5 s .548 549 550 Hospital and Health Survey has been a lively interest in the care of military cripples, govermental agen- cies have been slow to evince any realization of the economic and social folly of scrapping the cripples produced in industry. There has been scant development in Cleveland of methods for the treat- ment of industrial injuries calculated to restore the injured to the fullest possible function in the shortest period of time compatible with good surgical practice. There has been limited application of the knowledge gained else- where in recent years of rehabilitative methods and devices. There has been in the community and in its leading medical centers an unfortunate neglect of orthopedic surgery with consequent loss to the community of services of a special nature which the community has reason to expect. Medical cen- ters, teaching and others, hold a public trust. THE SMALL ESTABLISHMENT The employer of less than two or three hundred workers seldom feels justi- fied in making the expenditures necessary for a plant dispensary installation and for the maintenance of the needed personnel, even though he realizes that his employes are exposed to certain hazards, and when ill or injured do not receive proper care. Considerations of economy may lead him to aban- don his desire to have physical examinations of applicants for employment, suitable placement of the less fit, prompt and efficient medical and surgical attention, visiting nursing service and health supervision in his plant. Ninety-four per cent of the industrial organizations in the city employ less than five hundred workers each, a total of 83,711. (Table I., Appendix.) Eighty -eight per cent employ less than 200 each, a total of 51,682. Eighty percent employ less than 100 each, a total of 41,000. The need of great numbers of these smaller organizations for medical service of a high order could be met by the establishment of industrial dis- pensaries at various points in industrial districts, carefully selected with regard for accessibility from the plants which each dispensary would serve. The greatest agglomeration of small industrial establishments in Cleve- land is in the heart of the city. Within a radius of a mile of the Public Square there are 536 establishments of various sizes, employing a total of 34,131 workers. Of these plants, 459 employ less than 100 each; 505 shops employ less than 200 each, 94.2 per cent of all establishments in the area, 53 per cent of the employes, an average of 36 workers per establishment. Basing an estimate upon Industrial Commission figures for accidents occurring in plants of this group, there is an annual time loss for industrial operatives from reportable industrial accidents of approximately 16,000 days, an annual total of 22,400 accidents of all grades; and a time loss from all accidents and illness of over 250,000 days. Plant medical service now reaches less than 8,000 of the operatives in this area through eight dispen- saries employing a total of ten industrial nurses, two full-time and four part-time physicians. Health and Industry 551 Quite comparable for density of industrial population with this central area of the city is the region about Forty-fifth Street and St. Clair Avenue. Within a radius of half a mile of this point are employed a total of 21,100 operatives in 114 establishments. Of these plants, 71 employ less than 100 workers; 89 employ less than 200, being 77 per cent of all the shops in the zone, employing 22 per cent of the employes, an average of 53 in each plant. The estimated annual time loss for industrial operatives from reportable industrial accidents occurring in this area is 38,345 days. There is an esti- mated annual total of accidents of all grades of 53,340, with a time loss from all accidents and illness of 186,000 days. Plant medical service now reaches a little over 7,000 employes in this region, through eight plant dispensaries and the services of four industrial nurses and eight part-time physicians. The area of density of industrial population extends southward from this -region about Forty-fifth Street for a depth of three or four miles from the lake front. Statistics similar to those presented might be furnished for other circumscribed areas within this belt. Though there are many physicians practising within this large zone and in other parts of the city which are thickly set with industrial plants, there is at present no industrial dispensary conducted upon an essentially coopera- tive basis. It would be the recommendation of the Survey that the general adminis- tration of such a cooperative dispensary as has been suggested, or of such dispensaries, be in the hands of a commercially disinterested body associated with a controlling board representing employers, employes, physicians and the administrative organization. The administration might be the respon- sibility of a general hospital or of any one of several recognized and trusted public agencies of which the local chapter of the American Red Cross may be considered an example. Such a dispensary should be self-supporting, and though paying salaries and fees sufficient to command the services of able personnel, should not be conducted for profit in the customary sense. It should have such profes- sional supervision as would assure the rendering of efficient service. The first requirement of the dispensary would be the care of industrial injuries, with surgeons and nurses in attendance in such numbers and at such times as might be needed. It > would be wholly feasible, however, to extend the service to include, if desired, physical examination of applicants for employment or of employes, mental examinations, medical care of indus- trial and non-industrial sickness, dental service, ocular service and visiting nursing. The cost of installation and maintenance should be guaranteed by the industrial establishments participating, but it would in part be returned by the Industrial Commission in payments for service rendered under the Work- men's Compensation Act. 552 Hospital and Health Survey If established for a group of two thousand employes the cost of main- tenance would be approximately that of medical service in a single plant employing a similar number of workers, between five and ten dollars a year per employe, though of course the amount would vary with the range of services offered. INDUSTRIAL HOSPITALS Cleveland is at present greatly in need of additional hospital beds. With the consequent demand, it is wholly to be expected that serious industrial accident cases are frequently peddled about the hospitals until a vacancy is. found. As the larger part of such cases come within the provisions of the Workmen's Compensation Act, enabling the Industrial Commission to pay for certain surgical and hospital services, and as the amount customarily paid by the Commission approximates, in most instances, half or less than half of the actual cost of maintenance in hospital, it naturally follows that a financially pressed institution offers the injured workman its minimum services which may or may not be adequate. Xot all industrial surgeons hold staff positions in the hospitals of the city and some who do not have experienced difficulties in performing the services for- which they are employed because of the necessity of relinquishing their responsibilities to the hospitals with which their patients are placed. Inquiry made by the Survey has confirmed an impression that there is a field in Cleveland for one or more hospitals to be established and maintained for the care of industrial cases exclusively. It is suggested that such a hos- pital could best be administered either by some present existing hospital organization in which there is general confidence or by a board of control of representative character. It is of importance that the professional stand- ards of such an institution be high for the medical, nursing and laboratory services, and that the hospital be open to all qualified industrial physicians who are willing and able to practise according to the established standards. Conducted for industrial cases, staffed and visited by skilled industrial physicians and surgeons, such an institution should make available a type of service needed but not at present found in the city. The opportunities which would be presented for attention to such matters as ambulance service, the use of interpreters, the treatment of industrial eye injuries, of severe burns, the development of physiotherapy and other rehabilitative measures, would alone commend the project to many persons who have had occasion to follow the progress of cases of industrial injury under existing hospital conditions. THE TRAINING OF INDUSTRIAL PHYSICIANS AND NURSES It has been evident, perhaps, that industry makes certain special demands upon the physicians and nurses who serve therein, demands with which most physicians and nurses not in industry are unfamiliar and which they are not trained to meet. Health and Industry 553 There is a rapidly growing need for the services of industrial hygienists, men who have studied the toxic effects of various poisonous substances such as are now used in many industries; men who are competent to consider such problems as those of the effects of dusts and fumes, of ventilation, of illumi- nation, of fatigue and of factory sanitation. These are matters which most industrial physicians are not qualified to handle intelligently and thoroughly though they may from experience be able to express a valuable common sense opinion. While the nurses who are graduates of good hospital training schools may quickly become proficient as dispensary nurses they are by no means prepared to assume readily the duties and to comprehend the many respon- sibilities which are now properly those of a well equipped industrial nurse. Special instruction is required for the rapid training of industrial physi- cians, hygienists and nurses, and it is to be hoped that the existing facilities of the Western Reserve Medical School may be expanded and supplemented to permit of such instruction to graduate physicians and nurses within the coming year. Certain portions of the instruction offered to physicians might be made available to nurses in addition to courses arranged to meet their special requirements. The industries of the Cleveland district would unquestionably profit greatly by the establishment of such a school of industrial hygiene, not only through the services of the skilled physicians and nurses which it would pre- pare for their employ, but through the development of research facilities which would be at their ready disposal. It is an undertaking deserving of their deepest interest and of their support and cooperation. As a part of the reorganized hospital and dispensary service of the city there is contemplated a clinic centrally located to receive emergency cases and to offer facilities for consultation. In connection with such a consulta- tion clinic it is the belief of the Survey that there should be established an industrial clinic where ailments of industrial origin might be thoroughly studied, to which plant dispensaries might refer doubtful cases for diagnosis and to which workers in the various industries and trades might go for authoritative medical advice. It would be of advantage to associate this clinic closely with the prospec- tive school of industrial hygiene in order that each might profit by the re- sources of the other. PUBLIC HEALTH AUTHORITIES AND INDUSTRIAL HYGIENE The Industrial Commission of Ohio is vested with broad powers to safe- guard the health and safety of working men and women. It possesses con- siderable police authority. The Division of Industrial Hygiene of the State Department of Health is endowed with certain powers of inquiry but is unable to institute obligatory corrective measures. The activities of this division are unfortunately not closely correlated with those of the Industrial Commis- 554 Hospital and Health Survey sion whose inspectors are especially concerned with questions of safety and conditions of employment other than those relating to the health of opera- tives. Adequate as are the powers of state authorities to make inquiries and issue orders regarding matters pertaining to the safety and health of indus- trial workers, there would be much gained to the industries and to the work- ingmen and women of Cleveland through the establishment of a Bureau of Industrial Hygiene within the municipal Division of Health. It could serve in an advisory and consultant capacity, aiding in the planning of fac- tories and work rooms and in the solution of problems concerning industrial hygiene. Such a division might well be charged with the conduct of medical service for the municipal employes such as was recommended in the section of this report relating to physical examinations. It in no sense need conflict with or duplicate with the activities of the state authorities. Cleveland is an industrial community; the greatest common interest of her people is in her industries and those of her people who labor therein are the life of the city. The future of Cleveland depends upon the well being and the happiness of her industrial workers and to secure and safeguard their health is the_vital task of industrial medical service. SUMMARY OF RECOMMENDATIONS It is the recommendation of the Survey — That industrial physicians be selected with regard for their professional and execu- tive abilities; that they be remunerated upon a basis commensurate with the amount and character of service expected of them; that they be not permitted to combine with their official duties a private practice among the company personnel. That industrial nurses be chosen for professional fitness and such qualities of person- ality and character as will enable them to fulfill their many responsibilities. That untrained nurses be employed only under competent medical or nursing super- vision. That industrial nurses be granted such authority and receive such support as may be necessary for the development of their fullest usefulness. That medication by nurses without the individual or standing orders of a physician be prohibited. That encourage- ment and assistance be offered industrial nurses in their efforts to maintain contact with progressive movements in industrial medicine. That visiting nursing be considered a normal function of industrial nurses. That industrial nurses be rated as medical person- nel. That they visit sick or suspected sick and be not employed for routine absence follow-up from employment departments. That sufficient clerical personnel be employed in industrial medical departments to free physicians and nurses for professional service. That industrial dispensaries be furnished with adequate and convenient equipment which need not be elaborate. Health and Industry 555 That some municipal or cooperative industrial service be undertaken providing efficient ambulance transportation of sick and injured to the hospital from industrial establishments . That there be applied to industrial medical departments efficient cost-accounting systems. That administrative relations of industrial physicians permit of free and direct ac- cess to general executives; that wherever possible physicians and not laymen direct the activities of the health service in industrial plants. That employers and employes together arrange for the establishment and maintenance of cooperative industrial dispensaries. That industrial medical records conform to recognized standards of adequacy and that they be filed in such manner and so summarized as to make possible their intelligent in- terpretation. That there be a general adoption of some uniform system of reckoning for accident and sickness statistics. That there be study of absenteeism due to sickness and non-industrial accidents, among the employes of industry. That physical examinations be generally adopted as prerequisite to employment, not for the purpose of the elimination of those not physically fit, but for guidance in the proper placement of labor applicants; that the conditions found in such examinations be followed up by subsequent periodic examinations. That responsibility for the maintenance of health among food-handlers in restaurants be transferred from the department of the State Fire Marshal to the State Department of Health, or preferably, if possible, to the Division of Health of the City of Cleveland. That there be compulsory physical examination of all applicants for positions as oper- ators of public conveyances. That the municipal government maintain within the Division of Health, for the serv- ice of all its employes, an adequate health service or bureau which shall be charged with the conduct of physical examinations of applicants for civil service positions, with annual periodic medical examination of all city employes, and such further medical service as may be' deemed necessary. That there be a study of the problem of abnormal mentality among industrial workers, particularly in its relations to vocational guidance and unemployment. That there be an extension and development of industrial dental service. That there be more extended use made of the services of skilled oculists, both in the care of industrial injuries and in the conservation of the sight of industrial workers. That there be more extended use made of able consultant diagnosticians in connec- tion with suspected cases of tuberculosis. That there be a revival of interest in educational work directed against venereal disease. o.56 Hospital and Health Survey That there be proper consideration devoted to cases of permanent disability resulting from industrial injuries with particular regard to the development of methods for functional rehabilitation. That there be developed among groups of small industrial establishments some form of cooperative dispensary to operate under the joint direction of employers and employes and some commercially disinterested organization. That there be established one or more industrial hospitals exclusively for the care of industrial cases, such a hospital to permit to practice any industrial physician able and willing to meet the requirements, which should be of high standard. That there be developed within the Western Reserve University Medical School fac- ilities for the training of industrial physicians and nurses. That there be established in connection with some central dispensary a consultation diagnostic industrial clinic. That there be established within the municipal division of health a bureau of industrial hygiene. Health and Industry 557 Women and Industry By Marie Wright INDUSTRY has become interested in the health of employes. The con- crete expression of this interest takes different form in almost every establishment. One executive enthuses over rest periods, another shows every visitor the immaculate new dispensary, still another expatiates upon the benefits to be derived from hot food at noon. Any or all of these features may contribute to the well-being of the working force. They are represen- tative of various activities which are reasonably those of industry, not to be considered mildly extravagant novelties, but essential equipment and services giving to the workers the opportunity to lead a healthful life at work as well as away from it. There is a tendency to attribute much of the ill-health of working people to conditions under which they live when not at work. Important as is the relation of the home life of workers to their health, it must be remembered that the character of the home life is largely the result of influences growing- out of their work. Home life and working life are closely inter-related. The hours of work determine the amount of leisure for improvement and appre- ciation of the home. Wages determine to a large extent the choice of neigh- borhood, of building, and often of furnishings and food. Visitors to the homes of working people are at times dismayed by their clutter and apparent lack of cleanliness, but these conditions are not necessarily productive of disease. No matter what the home of an employe may be, his employer has the responsibility of providing a work place reasonably clean, well venti- lated, and with suitable conveniences. The work should, if possible, be without special hazard, but where there is danger of accident or illness as a result of any process, the employe should be informed of the risk and encouraged to guard against it in every way. The relative susceptibility of men and women to fatigue and special hazards is a matter of opinion at present only partially substantiated by fact, but the employment of women should be safeguarded at least as well as that of men. Because of the important relation of women to present and future generations, it is generally considered that they should have especially favorable surroundings where possible. Another reason that the working environment of women should be wholesome and their occupations health- ful is that they are less likely than men to spend their margin of leisure time in healthful recreation. Many girls do their washing and ironing and make or mend their clothes in the evenings. Married women and widows often work harder at housework than they do during the day. Since in so far as employers endeavor to promote the health of employes they are promoting the public health, and since work under adverse circum- stances is one of the greatest detriments to health, especially for women, a study of the work which women are doing in Cleveland and its probable relation to their health has been included in the general survey of the health situation of the city. 558 Hospital and Health Survey In order to learn the nature of the various occupations in which women are engaged, visits were made to most of the firms known to employ women in considerable numbers. Realizing that, in general, conditions in small shops are not as good as in large ones, it was nevertheless considered advis- able to study conditions affecting the major part of the working women. As has been pointed out, in Cleveland seventy-nine per cent of all industrial operatives are in establishments each employing over one hundred persons. The remaining twenty-one per cent are distributed throughout a large number of small shops averaging about thirty-three employes each. (Table I, Appendix.) This condition is even more apparent among mer- cantile establishments. During February, March, and April, 1920, visits were made to seventy- nine establishments employing a total of 22,906 women. . While the study was primarily concerned with the industrial field, other types of organiza- tions employing women were found to have problems so similar that a number of them were included. Of the employes in the establishments visited, 12,613 were in industrial plants, 6,730 in mercantile establishments, 1,458 in organizations of public service and 2,105 in public utilities. There are no recent figures available as to the number of women gain- fully employed in Cleveland except those in the Directory of Ohio Manu- facturers (Industrial Commission of Ohio, 1918), and as the employment of women has fluctuated since this report was issued, its figures were not found accurate in all cases. Consequently no totals can be given for the numbers of women in various occupations for comparison with the figures from the establishments visited in the course of the Survey. Information was obtained by means of interviews with managers, super- intendents, or other executives in touch with personnel problems, and was usually supplemented by a visit of inspection through the plants. While information so obtained is general and often not exact, the collection of repeated impressions by an impartial observer is so far almost the only means of judging the subtle factors which enter into the making of a good place to work. While the attitude of executives varied, there was in general a manifest interest in the well-being of employes and an appreciation of the fact that knowledge of methods for maintaining and improving the health of workers should, by the interchange of ideas and experiences, be made available for all industry. The value of health is appreciated at a time when labor is scarce. INDUSTRIAL ESTABLISHMENTS It is not a new thing for women to be in industry. The war focussed so much attention upon women who were doing the work of men in factories that it is frequently forgotten that women have had a place in Cleveland's nut and bolt shops and other plants making small metal products since those concerns were first established — a matter of thirty to forty years. In the textile and knitting, garment and candy trades, women have always been a predominant labor element. Health and Industry 559 During the war more women went into factories than had ever done so before. Increased demand for the regular products of essential industries enabled manufacturers in those branches to hold and increase their forces, while women for the making of munitions were usually recruited from the "non-essential industries" or from that large body of women who had not worked before but whose patriotism enabled them to undertake successfully the new and often heavy work. Most of these women left the factories upon the completion of government orders and have not returned. The^ "non- essential industries" have reclaimed many of their former employes, and by now readjustment is about complete. There are a few factories which, as a result of their war experience, have continued to employ women although they had not done so before. In the six factories where it was learned that this was the case, six hundred women are employed. Two of these factories have continued to employ the women who started to work there during the war, but as they drop out men are hired in their places, and consequently the number of women is dwindling. In another plant there are very few women com- pared with the number employed during ,the war, and the women are giving up machine work for bench work of a light type. Within the past two years there have been established four new factories, employing a total of 698 women. Neither the retention of women in plants which had not formerly employed them, nor their employment in new fac- tories, is sufficient to account for the present shortage of female labor. The checking of immigration and the return of many foreign workers to Europe, is a partial cause of a general shortage of both men and women. The fact that wages for men are higher than ever before means that many women do not have to work now as they did formerly, and in many cases this new independence has apparently resulted in an unfortunate attitude toward work, with a greater absenteeism and a tendency to float from job to job. In the face of this labor shortage the cry for increased production has aroused feverish efforts on the part of employers to get help in one way or another. The alluring advertisements of "Help Wanted" contribute to the prevailing unrest, and the readiness to try a new job upon the slightest dis- satisfaction with the old. Applicants from such sources do not prove satis- factory. Instead of advertising, several firms are now paying a bonus to employes who bring in friends who will continue to work for a certain period of time, recognizing the principle that a satisfied employe is the best advertisement in the labor market. The Metal Trades The largest group of industrial establishments studied was in the so- called metal trades, where the product varies from a small piece of machined steel to an assembled oil stove or an electric lamp. 3,691 women were employed in the twenty-three plants visited. The operations included bench work and assembly, as well as operating such machines as drill presses, punch presses, screw machines, lathes, and a variety of machines adapted for special processes. 560 Hospital and Health Survey Most of the work is not heavy, and the girls are instructed to lift not over ten to fifteen pounds, although they not infrequently disobey this rule. Where girls are on machines requiring gear shifts, special efforts have been made to favor ease of operation. However, there is considerable effort in the running of any screw machine or lathe, and in general it has seemed better practice for men to do that work. Punch presses and drills are usually guarded, and relatively few acci- dents to women have been reported. Although no data are available as to the carefulness of women in operating machines compared with men, there is a prevalent impression that they are more careful than male operatives and that, freely accepting risks of operation, they make little complaint when injured. Nineteen of these twenty-three establishments provide medical service. Bloomer uniforms are required in five plants and are optional in several others. The uniform has fallen into disfavor since the war, and effort is needed to enforce its use at machine work and to maintain any degree of uniformity and safety by the avoidance of jewelry, fluffy collars and ties. High-heeled shoes for standing work should also be opposed where possible by making it easy for the women to get sensible working shoes reasonably priced. Individual steel lockers are provided in twelve plants and hooks in dressing rooms in most of the others. The increased feeling of well-being and self-respect of the worker who changes from street clothes to working clothes and back again is worth emphasizing by employment or service departments. Although several of the plants have physical examination for men, only one organization was found to give to girls anything which might properly be called a physical examination. There seems to be little realization of the impossibility of judging by appearance as to a girl's fitness for fatiguing work. With a high degree of conscientiousness, several employment departments have taken a timid attitude in this matter. The fear that girls will object to physical examinations properly conducted is with slight foundation, as they are in general use in similar establishments elsewhere, and where used in Cleveland meet with little or no opposition. If physical examinations are conducted on a reasonable basis of rejection and if their purpose is frankly explained, it is, as a rule, only the undesirable worker who will raise any objection. The dirt and grease of machine shops, which in the minds of many people render them unsuitable places for the employment of women, are in fact not objectionable if there are provided proper washing facilities and oppor- tunity to use them. Such facilities must include hot water. The noise and vibration from different kinds of machinery are of rela- tively greater importance. There is about many machine shops a wholesome attitude toward work which is very appealing to the sturdy, independent type of girl, frequently encountered in this industry. Many girls who worked in munitions factories testified that they had never been so happy before. Health and Industry 561 Tables XI and XII of the appendix present the findings regarding hours and starting rates for the various industries studied. The usual working day for women in the metal trades is from seven to half past four. Although piece-work is prevalent, a certain minimum daily wage is guaranteed in fifteen plants, while three others pay a guaranteed minimum wage for the learning period. There is little or no seasonal variation, but the supply of work frequently varies with orders. Some factories employ American girls almost exclusively, others only foreign born or those of foreign parentage. Usually all nationalities are represented, but for heavy, dirty work the foreign women of peasant type are in greatest demand. Colored women are employed in two plants in con- siderable numbers. Textile and Knitting Mills The female operatives of the textile and knitting trades constitute an important group of working women, numbering 4,642 in the eleven estab- lishments visited. The knitting mills seem in almost every case to be work- ing beyond normal capacity. In a number of instances mills were working under great pressure upon goods for delivery a year hence. Supposedly as a result of the increased activity, work-rooms were cluttered with piles of unfinished work, and there were evidences of poor factory housekeeping. The numerous exposed overhead belts furnishing power to circular knitting machines seem to' be an unnecessary accident hazard for the opera- tives who are constantly obliged to move about under them. The brightly colored fluff from the yarn is everywhere on the machines, and at times adheres noticeably to the faces, arms, and hair of the girls. Occasionally they develop sore hands or arms, said to be caused by the dyes. In one plant mention was made of the numerous sore throats, but they were attributed to "late hours and dances." As only four plants in this group have medical service, and only one employs a physician, there has been little definite study of health problems within this industry. The working hours are forty-nine and one-half or fifty in all but two establishments, as may be seen in Table XI. The working day is usually seven-thirty to five or five-fifteen. Most of the women employed are either foreign-born or are of Hungarian, German, Austrian, or Polish parentage. Although most of them are between twenty and thirty years of age, they are of a mature type, appearing much older. The Garment Trades In the seven garment factories visited, 2,700 women are employed. Much of the work is power-machine operating, with the usual varieties of finishing work. The great problem of the garment trades is the regulariza- tion of employment, or elimination of seasonal variations in production. As a result of the attention which has been given to this problem, three 562 Hospital and Health Survey firms reported that they had work steadily throughout the year. One re- ported work for at least forty -eight weeks. Two large establishments operate through a .fifty -week year, and of the remaining two weeks, one week is "layoff" and one may be vacation with pay. Another firm has a fifty-one-week year, and the whole factory closes for one week of vacation. As is shown in Table XI, weekly hours are. forty-four or forty-three and three-quarters, in all but two shops, where they are forty-seven. One plant uses an allotment system — workers going home when the day's task is completed, and seldom working even the possible forty -four hours. Two firms work an eight and three-quarter-hour day five days a week, with a full holiday Saturday. Another firm, after trying the same plan, is strongly in favor of the eight- hour day and a half-holiday on Saturday. In the ladies' garment trade the wages are usually set by the union wage scale agreement, under which the minimum is $14 per week. Comparative starting rates may be found in Table XII. Bohemians, Italians and Hungarians are the leading nationalities in each of several factories visited, with various Slav peoples also represented. In several factories there are more than one-third or one-half American born. Two factories will hire no one who does not speak English. The use of routing systems and time study has made the modern garment factory a very different place from the old-style tailor shop. Candy Factories. Candy factories are as a rule relatively small establishments. The six visited had a total of 371 women employes. The demand for candy is seasonal, and there seems to be no way to regularize its manufacture, since it should be sold within a short time after it is made, unless stored under most favorable conditions. Two firms reported that they never laid off any help, as their forces automatically decreased in slack seasons when workers who left were not replaced. Most of the girls were American born, and as a group were young, although older women are used for sorting and other work since girls have become scarce. As little skill is required, except that natural to young fingers, there are many floaters who find in the busy seasons of the candy trade the brief employment which satisfies them. Such workers are apt to be careless about their work, and their persons, and require care- ful supervision, especially in the making of a food product. This super- vision was generally found, but several establishments could well improve their standards of cleanliness as well as their equipment for the comfort of employes. Miscellaneous Industrial Establishments Of those establishments listed as miscellaneous, some of the paper-box factories are small but quite progressive in policy. Two tobacco factories revealed an interesting general situation. The tobacco industry of Cleveland finds itself on the decline largely because of Health and Industry 563 scarcity of skilled labor. In Cleveland no American girls and very few young foreign girls will work on cigars. As a result the workers are practically all foreign born and mostly foreign-speaking, and with the realization of their dwindling numbers have become very independent. One executive said that his plant is kept open fifty hours a week for the convenience of his employes, but none of them work so long, as they come and go at their pleasure. Several firms which began business in Cleveland have found it necessary to take most of their work elsewhere, and now have large tobacco factories in New York, Pennsylvania and Texas. These are said to be model factories as the workers speak English and appreciate the good work- ing conditions provided. The firms apparently realize that the Cleveland factories could be made both mOre attractive and more healthful. Learning to make cigars requires several weeks, during which time most of the material handled is waste and cannot be reclaimed. The cost of teaching a new maker is said to be $350, even at the starting rate of $12 a week. When $15 and $16 a week is offered to an unskilled girl in other industries, there is little incentive for her to learn a difficult trade, even with the promise of high piece-work earnings later. General Observations on Industrial Establishments. Hours of Work Reference has already been made to the weekly hours in several trades. (Table XL) In the course of the Survey, little overtime work was reported. Only ten firms admitted that they had any overtime for women, and that was said to be only occasional or optional. It seems probable that over- time is more frequent in clerical work than in industry. While, to the knowledge of the Survey, regular rest periods are arranged for in only one factory, there are four establishments in which women are allowed fifteen minutes about nine o'clock in the morning for the purpose of eating part of their lunch. This is an interesting acceptance of the custom of many women who go to work with little or no breakfast, and consequently feel the need of food before the regular lunch hour. Another establishment has two five-minute rest periods which are optional, and consequently not extensively used. One firm had discontinued rest periods during the day but dismissed all employes twenty minutes before the accustomed closing hour, granting pay for the full day. Rest periods may be of additional value as a means of improving ventilation by open windows. Many workers object to fresh air if it must be admitted near them. Few people fail to appreciate a room full of fresh air replacing what has been vitiated, especially when there are present fumes or odors incident to an industrial process. It is probable that in many factories where the work is monotonous and exacting, much might be gained by instituting rest periods. Both before and after the introduction of such a measure, it is important that careful obser- vation be made of the physical condition of workers as well as of production rates. 564 Hospital and Health Survey Earnings It was hoped at first that figures might be received from payrolls show- ing actual earnings of a group of workers over a suitable period in order to obtain a fair conception of the relation of earnings to the cost of living and the opportunity for health. This was not found practicable, however. Wage rates are misleading, and as some are by the day and others by the hour or piece, comparison is difficult and often unfair. The starting rates reported have been tabulated in Table XII. Some establishments raise the rate at the end of the first week, some after two weeks or a month, and in many cases the rate stands until the piece-work earnings are higher, which may be in a few days or a matter of months. Estimated averages for the various establishments and their maximums are obviously so inaccurate in most cases that they have not been presented in this report. In several cases where averages of actual earnings have been made and analyzed, the results have been at variance with previous estimates — additional evidence of the futility of accepting approximate figures regarding actual earnings even from persons familiar with establishment pay-rolls. A dditional Ben efi is — Cafeteria Practically all industrial establishments provide either a cafeteria or a lunch-room. The cafeteria may serve a full meal approximately at cost or may provide food to supplement the lunch brought by workers. Most plants arrange that coffee or other hot drinks may be secured free or at slight expense. In six plants the employes eat in work-rooms, in certain instances the company providing coffee. Several of these establishments have rooms which are called lunch-rooms, probably in the hope that they may thus fulfill the requirements of the law. The benefit of a change of environment together with good food at meal-time, is generally recognized, and many factories are planning better equipment in new buildings which they have in prospect. Cooperative buying is another way of increasing the purchasing power of wages, which has been undertaken in several Cleveland factories with much success. Group life insurance carried by the company is an advantage offered by many firms. Only eight industrial establishments reported benefit associations or some form of sickness insurance for women employes. Several other firms have benefit associations but women are excluded from membership, the reasons not always being clear. Recreation In twenty-one establishments there was found some sort of group recrea- tion instituted and supported by the employes, with or without the co- operation of employers. In certain establishments this is merely an informal banding into social clubs. In others there are carefully managed parties and entertainments for the employes and their families. A number of organizations have bowling clubs, baseball or basket-ball teams. Some firms have employed recreation leaders who direct setting-up exercises and Health and Industry • 565 games at noon. Where this is done, at the request or with the sympathy of the workers, excellent results have been obtained, but no person wishes to be coerced into play. The field of recreation offers an excellent opportunity for the development of employes' organizations upon a sound basis. The experience gained in deciding upon the form and direction of such activities is excellent preparation for consideration of more serious issues which may confront employes in their industrial relations. The value of group meetings is realized by many establishments as a result of their liberty loan rallies. Feelings of comradeship and friendship among employes are incentives to contentment in labor, and so become the modern equivalent of the spirit of craftsmanship. Group activities which foster these friendly relations and promote the feeling of solidarity among employes are to be encouraged. Vacations Many firms have a definite vacation policy. Four factories in the metal trades closed last year for two weeks during July or August. In one instance wages were paid for one week; in another plant, during a shut-down of four weeks, payment was made of two weeks' wages. Another firm offers one week of vacation with pay as a bonus to any employe who has not been absent during the year, except with a physician's certificate of illness. Several establishments reward old employes with vacations. One knitting mill has adopted the policy of one week of vacation with pay after one year of service. Another closes ten days during the year without pay. The garment fac- tories generally give one week with pay after one year, although in one case days of paid vacation are reckoned by periods of service completed. Of the candy factories, two give one week with pay after one year, one gives ten days and another two weeks with pay. Other establishments recog- nize the desirability of vacations and permit leave of absence for the purpose. Only two establishments were found in which Saturday was not at least a half holiday; two garment factories have no regular work on Saturday. Supervision There is no uniformity as to methods of employment in the various plants, but in many places the modern principle of having all applicants pass through one office has been adopted. This office is responsible for definitely hiring workers for all departments, and with the advice of foremen usually decides questions of adjustment, discipline and discharge. For the purpose of the Survey an establishment has been considered as having centralized employment when the authority to hire or reject all applicants is vested in one person or office. (Table XIV.) In eighteen of the plants visited women were in charge of hiring women employes, and in some cases men also. The plants of Cleveland are recognizing more and more the value of having women in a supervisory capacity where women are employed. 566 Hospital and Health Survey The number and size of plants having supervisory women appear in Table XV which under this term includes: employment managers, welfare directors, and those who are in some measure responsible for conditions affecting the work of women in factories. Nurses have not been included unless when concerned primarily with such responsibilities rather than nursing. Foreladies have been omitted as their sphere is usually limited to direction of the performance of manufacturing operations. When there is no other woman in supervision, a forelady often successfully handles social problems and acts as intermediary between the girls and the management. As the duties of supervisory women are often not clearly defined, it has been necessary to make rather arbitrary classifications in some instances for the purpose of tabulation. In each of three establishments work of this nature is so extensive that there is a well-organized department staffed by a number of women, each with well-recognized duties. There is clearly an important place in industry for the woman who has by training adapted her common sense and personality to seeing fairly the problems of human relations and interpreting them in the everyday adjustments of factory life. The question of health supervision for women includes a special problem discussed here rather than in connection with general health supervision. In almost every case where plant nurse, employment manager or other executive was asked about the policy in regard to the employment of preg- nant women, the reply was that each case was decided upon its individual merits. There is need, however, of a certain well-defined standard of pro- cedure, for if left to themselves, many women work longer than they should, and in their eagerness to conceal their condition may do themselves harm. Usually the executive in charge of personnel is eager to have any woman who is pregnant leave work as soon as or before her condition becomes notice- able. This is often desirable where numbers of girls and men are employed in the same departments, for comment cannot be avoided and is frequently unwholesome. Several cases were noted where special effort had been made to place favorably, pregnant women who were badly in need of money so that they might continue to work until about the seventh or eighth month under supervision of the factory nurse. It was generally believed that ordi- narily a woman should not continue factory work after the sixth month. None of the executives interviewed wished women to return to work within six months or a year after childbirth, and except with foreign women it is seldom that any worker endeavors to return so soon. In plants where foreign women are employed without careful questioning or an effort to learn of home conditions, it may not infrequently happen that mothers of small children will be at work when they should be at home. Although it is not feasible to generalize for all processes and industries regarding the limita- tions which should be placed upon the employment of pregnant women, because of variations in the hazard of continued employment, thoughtful consideration should be given to the problems presented in individual cases, and in no event should pregnant women knowingly be permitted to work within two weeks before, or four weeks after childbirth. Health and Industry 567 Physical Conditions of Work Light, air, and to some extent sanitation vary largely with the age of the plant equipment. Many Cleveland firms are planning to build new factories with model installations and feel that they should not be judged on present facilities meanwhile. Cleanliness is more difficult to maintain in an old plant than, in a new one, but it can always be achieved by dint of special application to the problem and is important for its moral effect as well as for physical comfort. Toilet facilities were usually found to be ade- quate and in compliance with the legal requirements, but in several cases were not entirely partitioned off from the main work-room, which is a very undesirable arrangement. Washing facilities varied greatly, but on the whole were adequate except for a somewhat too limited supply of hot water. Drinking water was usually provided by bubble fountains, or water coolers. Several common drinking cups were seen, as will always be the case when the workers must provide their own. Facilities for the seating of workers were found to be of great variety, ranging from a barrel top or a box to the most modern steel chairs, adjustable for height of seat and back. The law requires that individual establishments "shall provide a suitable seat for the use of each female em- ploye and shall permit the use of such seat when such female employes are not necessarily engaged in the active duties for which they are employed, and when the use thereof will not actually and necessarily interfere with the proper discharge of the duties of such employes, constructed where practicable with an automatic back support." In practice, while chairs are generally provided for at least occasional use, the phrase "interfere with the proper discharge of their duties'* may be broadly interpreted to prevent the use of chairs at any operation, and has not resulted in the general realiza- tion that chairs can now be designed for use in connection with almost any type of work. The law also provides that, "No female under the age of twenty-one years shall be engaged or permitted to work at an employment which com- pels her to remain standing constantly while on duty." Knitting, weaving and spinning are not considered standing work because the operator walks about her machine. As it is difficult to judge the ages of girls eighteen to twenty-one, this law is all but impossible of enforcement. A campaign for education concerning better seating and its use is needed for both employers and employes. It is true that employes often will not choose to sit at their work, and old employes frequently object to new types of chairs with backs. Operatives can usually be won over to acceptance of an appliance which is really to their advantage by a patient and persistent demonstration of its merits. Lockers are another institution which often cause the employer to weary of well-doing, for keys are lost and many workers will not use locks when they are furnished. Twenty-five establishments reported that they had lockers, usually of steel, one for each person. Other firms use racks in a dressing- room. Only two cases were found where clothing was hanging in the work- room. 568 Hospital and Health Survey Couches were provided for women employes in thirty-two establishments. This might mean a single couch in a room crowded with wraps, or a com- fortable bed in a silence-room or dispensary. Many plants have, in addi- tion to a dispensary bed, a room with several couches to be used for rest when needed. The plant which has no cot available for an emergency is not properly equipped to care for women employes. MERCANTILE ESTABLISHMENTS In the seven mercantile establishments visited, 6,730 women are em- ployed. Department stores have uniform closing hours, giving them forty-eight hours per week, except a few that remain open an extra half-hour on Satur- day. During July and August a number of the stores are closed all day either Saturday or Monday. The vacation policy varies slightly, but all stores grant a week with pay after a certain period of service, which may be three, six, nine, or twelve months, and usually two weeks with pay is given after a longer service. Department stores have developed a special service for employes in their educational departments. It is helpful to a new employe to have the necessary information as to store policy and department relations pre- sented in definite fashion. Through careful observation, the ability of the individual may be directed into the most fruitful channels. There is in many mercantile establishments opportunity for advancement, and effort is encouraged by the knowledge that many buyers and executives have worked their way up through the store. Classes in salesmanship give added zest to selling as well as increased earning in commissions. Efficient employment is an important preliminary to the work of the educational department, and the health of employes as well should be carefully considered. Several of the stores are now giving attention to the development of adequate health departments. Starting rates vary with the age and ability of the worker. For the stock, cashier and inspection departments, two stores have a minimum of $10 per week, while others do not give less than $12 or $13. For selling on a com- mission basis, the usual minimum is $15 per week. Several stores have women elevator operators who are said to be more satisfactory than the men who are obtainable. Where doors are arranged to open easily, little physical effort is required, but adequate opportunity for rest should be provided to relieve the nervous strain of constant atten- tion to an important duty, while at the same time treating passengers with courtesy and answering questions. Rest periods are provided in practically all establishments by the use of a relief operator. Except in one-way ele- vators standing is usually constant in busy hours, but suitable seats should be available for use upon occasion. Health and Industry 569 Women also operate elevators in several hotels and public buildings. This is another kind of work on which colored women are frequently employed. $14 per week is the lowest of the wage rates reported for elevator operators. PUBLIC-SERVICE ORGANIZATIONS Laundries It is unfortunate that conditions for workers in laundries at present seem to be in some ways poorer than in the past. The services of a woman supervisor have been given up in one place, use of lockers, cafeteria and recreation in another. Labor cost is fifty per cent of the cost of laundering, and as the public resents increased prices, it is difficult for laundries to raise their wage rates to a point of competition with factories. Consequently the scarcity of female labor is severely felt in laundries. Some plants were so short-handed that managers and executives had to take the places of absent workers. Porter service was most inadequate and often the laundry housekeeping was poorly done. The attitude of laundry men toward their workers varied greatly. Some were indifferent to the objectionable features of the work. Others maintained that standing was not harmful, that high humidity was beneficial, and that marking soiled clothes was a particularly healthful occupation. In one laundry there was an effort made to seat all employes so far as possible. New machines, often designed so that the worker could be seated, were being- installed beside old ones, showing the advances in this direction and suggest- ing further improvements that should follow if the comfort of workers is to receive the same consideration in laundries that it does in most factories. Ventilating devices were generally used, although often they were ineffec- tive. It would seem that much of the steam could be kept from the general work-room by partitioning off the section used for washing, and mangles could also be installed in separate rooms, although there is no excuse for a noticeable escape of steam from mangles when excellent exhausts are, avail- able. The nature of laundry work makes it particularly desirable that em- ployes' wraps should not be left in the work-room, that separate lunch- rooms should be provided, that toilet and washing facilities should be ade- quate, but this was not always the case. It is interesting that even the less progressive laundry men speak of the laundry as a type of public service, and feel a responsibility to serve their customers faithfully, especially when there is much general sickness as was the case this winter. One manager considered that the importance of getting the work done outweighed the importance of good working conditions for laundry workers so long as there was no violation of the law. Often the law's minimum is considered the only reasonable maximum. The scarcity of labor has resulted in the use of colored girls in three of the commercial laundries visited, and three of the hotel laundries. Separate coat rooms, toilets and eating facilities were usually provided. The colored 570 Hospital and Health Survey workers were generally considered less efficient, and much slower to learn the work — which was given as the reason for their lower wage. Colored girls started at $10 where white beginners received $13. In two laundries white girls received $14 for a starting rate, in another, $12. The average for laundry workers seemed to be about $17. The variation of busy and slack days has been largely eliminated from laundries by daily collections of clothes from patrons. There is said to be no overtime for women. Two plants work fifty hours, one forty-nine, and two. forty-seven hours. Hotels In spite of the inclusion of the word "hotel" in the Industrial Com- mission's definition of "shops and factories," there seems to be doubt as to whether hotels do come under the supervision of the Industrial Com- mission, especially since enforcement of "Laws Providing for Inspection and Licensing of Hotels and Restaurants" has recently been entrusted to the department of the State Fire Marshal, although with no mention of kinds of work or hours for employes. The hotel department heads were of the impression that some restrictions existed but were vague as to their nature. Hotel and restaurant workers are said to be confirmed floaters. Some of the women live in hotel dormitories, with board in addition to their monthly wage; some live outside, receiving two meals daily besides a weekly wage;, and others live outside and carry their own meals. Earnings depend in part unon tips and cannot be accurately estimated. They are often larger potentially than in reality, especially for chamber-maids. The stated sum paid for similar work in different places varied, and in general there seemed to be little opportunity for increases based on efficiency or length of service, a'though one hotel has groiro insurance and a bonus as incentives to continued employment. The decentralization of responsibility in hotels rather surprises the inquirer who must go from department to department to learn of the various types of workers and the conditions of their employment. The hotel manager has two problems — serving the public and maintaining a staff of employes to render that service. As catering to the public is the fundamental pur- pose of a hotel, it receives most of the manager's attention, and the demands of the public are so varied that a great amount of detail is involved. The problems incident to maintaining a staff of employes are left to those in charge of the several departments, which are conducted quite independently of each other. The effectiveness of such an arrangement depends, of course, noon the efficiency of department heads. As stewards and hotel house- keepers are somewhat temperamental, and invariably complain of the un- reasonableness of their employes who stay only a short time, it seems pos- sible that the present method of hiring and dealing with employes in hotels might be replaced to advantage by an organized central employment service similar to that used in industries, in many of which the requirements for different types of employes are as varied as in hotels. Health a n d Indus t r v 57 1 Restaurants Waitresses are one of the few groups of women strongly unionized in Cleveland. Their wage scale of $12 to $18 per week in addition to meals and tips, prevails in the city. They work eight hours for six days per week, but often the day is broken in two parts with the afternoon hours free. These cannot be well utilized, and the union is about to campaign for all straight watches of eight continuous hours. By using the shift system some managers have practically all of their waitresses working continuous hours. While restaurants and cafeterias in many cases seem slow to provide facilities for the comfort of employes, some progressive managers have taken these matters into consideration, and are also planning centralized employment, employes' organizations, and medical service for workers. PUBLIC UTILITIES The difficulties of poor telephone service are well known to the public, but the reasons back of it require special study. Operators are scarce, special urging is often needed to induce girls to enter this field, and many of them stay for but a short time. The low wages paid have been one very evident reason. Changes have recently been effected in Cleveland, but comparison with most industrial work is still unfavorable. The nervous tension under which the work must be performed is trying to many tem- peraments. This has been recognized to a degree by the provision of a fifteen-minute rest period in each three and one-half or four hour period of duty. Whether this is sufficient for relaxation from such work is something that should be carefully studied and every effort made to preserve the routine so that no matter what the pressure of traffic may be, the rests need never be omitted. Rather than deny the nervous strain of telephone work, it would seem that companies might well devote themselves to special study of methods for lessening the strain on operators. The public should be better informed as to the conditions under which operators work, in order that they may cooperate with telephone companies to improve service by properly signalling operators, carefully giving numbers, and displaying a reasonable patience. , The telegraph companies employ several hundred girls as telegraph operators. Others are in the telephone department. All of this work requires a keen mind and a combination of speed and exactness in opera- tion that would seem to deserve better pay than is generally given. GENERAL DISCUSSION Night Work The difficulty of securing an adequate supply of female labor has already been discussed. One of the results of this labor scarcity has been to cause several manufacturers, under pressure of unfilled orders, to see in night work the simplest solution of their problem. There are women eager to 5 72 Hospital and Health Survey work at night, and many firms report that women are turned away from the night shift though they cannot be secured for work by day. These women have families of small children for which they must care during the day. At night their husbands come home and assume the responsibility of family care so that the mothers may go to the factory. Here they may work from five o'clock to ten, or more likely from three to eleven, five to twelve, or six to two, and in one plant from six to half past four in the morning. It is hard to believe that after a day's housework and the care of small children a woman is in any condition to be a good factory operative, but many employers seem to feel that night work is very satisfactory. As most of the night shifts have begun in the past six months, the effect of a woman's holding two jobs has not become apparent in the quality of her work. The result will be sooner evident in her home, for even a sturdy woman of the European peasant type cannot long stand such double duty without impair- ing her physical condition, the first effect of which will be upon her children. A hard-working mother with insufficient sleep is apt to be irritable, and even if she is conscientious enough to feed and clothe her children properly, their tempers are apt to reflect her own. Of real home life there can be none when father and mother scarcely see each other, and the inculcation of American ideals under such circumstances is a barren hope. The Survey has a record of 980 women who were working on night shifts in fifteen Cleveland factories on April loth. Of these 652 were employed in the textile and knitting mills and 328 in the metal trades. Aside from the effect upon home life, and the street dangers at night, the night work in the factory itself is not so pleasant as it is by day. Factory illumination generally is none too good. 'At night with only artificial light- ing it is usually worse. Other parts of the building are dark, and there is a sense of the uncanny about being at work when naturally one should be asleep. In factories where there are cafeterias, and dispensaries for the use of the day force, these facilities are seldom available at night. Often there is no definite pause for eating, even in a seven or eight-hour shift. There is almost never the same supervision at night that there is during the day, and where both men and women are employed there is even more reason for it. Night work is possibly but a temporary measure. The experience of England during the war and, before that, the feeling that led six European countries to agree to prohibit night work for women, should make our people consider the institution carefully before we sanction its use even in an emer- gency threatening the life of the nation — and such an emergency does not now exist. So long as there is no hindrance to the establishment of night shifts for women, there will be temptation to meet orders by this means rather than by improved management, routing and planning of work. It would be well for Ohio to record on its statute books its opposition to the employment of women at night. At present there is not even an avenue for learning the full extent of night work, as there is no requirement for reporting night shifts to the Industrial Commission and no method for its control except through chance visits of state inspectors. Health and Industry 573 The telephone and telegraph companies employ a few women at night, and there is an occasional small restaurant with night waitresses. Girl ushers are used in several of the theatres and moving-picture houses, but in small numbers. Aside from factories the largest number of women who work at night are those who clean office buildings. They usually work eight hours, and it may be at any time of the night or early morning, although the shift from five to twelve o'clock is most popular, leaving, as it does, a little of the night for sleeping. The women are usually hired by the fore- lady in charge, and are in large proportion foreign. They frequently bring neighbors to work with them to avoid the journey home alone. These women speak their native languages, and enjoy the informality of the work, though there is no question about the fatigue in connection with scrubbing and carrying heavy pails of water, frequently with no elevator service. In April a night cleaning woman was killed while on the way to her home in a Cleveland suburb and robbed of her pay. Home Work . A means of adding to the day's output utilized by a number of factories is homework. Parts of sweaters are frequently joined by a stitch done by* hand, and use of factory space for this work is avoided in many cases by sending the work to the homes of women who have spent a few days in the factory learning the work. It is estimated that at least 225 women work on sweaters and other knit goods in their homes. Except for the delivery and collection of material by some of the firms, there is no overhead expense in connection with home work, so that it is difficult to understand why rates for this work should be so low. A number of factories have established small branch factories, occasion- ally located in connection with a dwelling, but under the law considered work- shops only when they are the assembly place for workers other than those living in such a dwelling. Between this type of workshop and the service rendered by women sewing by hand in their own homes, there is another type of industrial service performed by the women in whose homes a com- pany has installed a power machine. While the Industrial Commission inspects the main factories and the smaller branch shops, it is not practicable for inspectors to maintain adequate supervision of the conditions under which work is performed in the homes of individual workers. There is a variety of home work. An occasional garment factory sends out cuffs to be turned. The carding of snaps and fasteners employs about one hundred women. This work is done entirely in the homes, and the workers must carry supplies back and forth to the factory. The earnings seem very little for the time required, but the work is light and many women have probably been able to earn in this way who would otherwise not have been able to do so. Stringing of sales tags is another type of home work done mostly by children, some of whom object to the low rates of pay. In season there is also the home trimming of tailored hats, which are delivered by the case. A few women work on brushes at home. .574 Hospital and Health Survey While the advantages of home work for crippled or convalescent patients has given interest to its possibilities in special cases, the general increase of home work, due to current high prices on the one hand and the demands of employers for labor on the other, must be carefully watched. The repeti- tion of such abuses of home work as were revealed by studies of conditions in New York should be avoided. . Not only in this country but abroad has it been observed that more unfavorable conditions for the children are created where their mothers do industrial work in their homes, than result from other forms of work under- taken by married women. Carmagnano, in Pediatria (March, 19*20, XXVIII, Xo. 5), believes that we should go so far as to provide legal measures to protect prospective and nursing mothers who are engaged in wage-earning or piece-work at home, as we protect them in factory work. Day Xurseries In almost every establishment visited, more married women were em- ployed than ever before. Many of these were young women with few home 'responsibilities, for it was frequently said that in these days working girls return to the factory or store a few days after they are married. Many, however, are women with families who find even the fairly good wages of their husbands insufficient for the family needs, or those who wish to pro- vide for the future by laying something aside now that wages are high, or others who are helping to pay for a home or sending money to suffering relatives in Europe. Many complaints come from the schools that children of school age are kept at home to care for the younger members of the family, or in other cases that mothers are either leaving the children to run the streets or lock- ing them in their houses while the mothers are at work. .More than one child left in this way has been burned to death. Whether mothers of small children should be permitted to work is a difficult social problem. They cannot be legislated into their homes, nor should they be encouraged to evade responsibilities by day-nursery facilities. On the other hand the children cannot be permitted to be neglected. Day nurseries have provided care for some children whose mothers are obliged to work. 337 such children were cared for by the Day Xursery and Free Kindergarten Association last year. The day nursery, however, is an expen- sive institution, and we have little information from which to judge its net social worth. If working women were to be charged one dollar per day per child, which is the approximate cost of nursery care, probably few women would use day nurseries. Should the community then contribute to the support of the families of those mothers by supplying nursery care for a slight fee, encourag- ing the mothers to work outside their homes and leave their children for the group care of the nursery? If such' is to be the case the community Health and Industry 575 must insist that this care be of the best and that preventive health measures for the young child be used to ward off later illnesses and defects so far as possible, in order that the eventual economic cost to the community may not be too high. Mothers are working at the present time. The care that should be given to their children is a community health problem with economic and social aspects so important that each community should give careful study to its own situation. Mothers' Pensions The provision of mothers' pensions has been a partial approach to the same problem, but is applicable only in cases of widows who are mentally and morally sound and whose legal residence is established. Even where mothers' pensions can be granted, they are most inadequate. $15 per month for the first child and $7 for each additional child, is the maximum per- mitted. This maximum is always granted in Cuyahoga County, but is so inadequate that in numbers of cases the pension must be supplemented by the Associated Charities. In some counties, however, no pensions are given, and in others the amount is very small, so that great effort will be required to arouse sufficient public opinion through the state to secure legislative increase of the maxi- mum. The court takes the stand that no mother may receive a pension if she works more than three days a week, which means that a widow with four children is faced with the alternatives of receiving a pension of $36 per month or of earning a living for the family. RECOMMENDA TIONS It is the recommendation of the Survey — That industrial and other establishments bring to the attention of employes the health value of suitable working clothing, with special regard for the advantages of proper footwear for women who are much upon their feet, and for the safety of women in machine trades. That in establishments where there is routine physical examination of men, women employes be admitted to an examination of similar nature. That uncertainty of the adequacy of piece-work earnings be obviated by a guaranteed minimum wage-rate when practicable. That the industries of Cleveland devote special consideration to the elimination of hazards of accident and illness where women are employed. That various industries endeavor to eliminate seasonal variations in employment through regularization of work. 576 Hospital and Health Survey That special effort be made to interest both employers and employes in the use of seating suitable for different operations, and that where possible chairs be adjustable for height of seat and back. That every establishment employing women provide one or more couches for the use of such employes. That the municipal department of health maintain careful supervision of laundries with special reference to the comfort and health of employes. That the public be more adequately informed regarding the technical difficulties incident to maintenance of a telephone service, to the end that its cooperation be secured in a reduction of the hazard of nerve strain for telephone operators, and a consequent improvement of a service which at present is essentially dependent upon the high efficiency of a human factor. That night work of women be prohibited by law, except in essential public utilities. That greater publicity be given to provisions of the laws of the State of Ohio governing conditions of employment. That the number of women inspectors of the Industrial Commission assigned to the Cleveland district be increased in order that the conditions attending the employment of women and children in individual establish- ments may be observed more frequently than at the yearly intervals at present prevailing. INTEREST OF THE COMMUNITY The hope of solution of the various problems in connection with the employment of women lies in the interest of the community. The Young Women's Christian Association has, through its Industrial Extension De- partment and more recently through the Industrial Women's Club, taken an active part in recreation for working girls, and has also attempted, by educational means, to prepare these girls to think out their problems for themselves. The Vacation Savings Club has been effective in the encouragement of thrift among working people, especially women. The Girls' City Club has been recently established by the League of Women Workers, with the aid of secretaries of the Vacation Savings Club, and affords a downtown social club for girls, with a variety of recreation and classes. The local branch of the Consumers' League has taken an active interest in the various aspects of the work of women, and is cooperating with other agencies in an effort to learn actual conditions of work in relation to present and proposed legislation, and to learn the opinions of thinking working women concerning their own problems. Health and Industry 577 The State-City Free Employment Bureau is interested in the work of women from the practical point of view of placement. The worth of such a central agency for employment has been demonstrated in many places, and its usefulness grows as it is used. Where working women play so important a part in the industrial life of a city as they do in Cleveland, there is reason to hope and believe that the people of the city will consider and protect their interests. When a Feller Needs a Friend - By BRJGGS York TrtbTnio It.- DECLARATION OF DEPENDENCE mU^m That childhood 15 endowed with certain inherent and. inalienable rights among which are jgjjBgii freedom* from toil for daily bread, Jlslll^BB the right to play and to dream - the right to Hie normal 5leep or the night' season; the right to an education that we rpay have equality of opportunity for develop ing oil that there' 15 in us of mmd and. h^art" */<• tip/way Courtesy Neu Yorlf Tribune and The Cleveland Pr 578 Health a x d Industry 579 Children ana Industry By Florence V. Ball INTRODUCTORY A STUDY of children and industry is included in the report of the Hos- pital and Health Survey because the health of the large portion of the city's population who are going to be its industrial workers depends largely upon what provisions are made for their welfare during the period when they are 15-18 years old. The years from 15-18 are the adolescent years, and children of this age face especial health problems which must have care- ful attention. Out of the children who go to work are developed the future industrial workers and citizens of the city. If only a few of the children in the community were going to work it might not be important from a health standpoint to consider their interests so carefully. But at 17 years of age 75% of the children of Cleveland are already at work, and many of them have been at work for two or three years previously. They are no longer under the direct care of school medical authorities. Neither are their especial needs studied and provided for in industrial medical service. Unless special supervision is provided for children of these years, their passage into industry is unguarded and unguided, and irreparable damage may be done to their mental and physical well-being, which will have serious results both in their own future and in that of the community. Nor is the sound health of this group of children assured by considera- tion of their physical wants alone. Their problem is a psychological as well as a physiological one. The degree of adjustment between children and their first jobs, the success of their transition from school into industry, the amount of preparation which they have had for industrial life, are all factors of great power in determining their development from childhood into sound maturity. A study of children and industry from a health standpoint involves three general considerations: first, measures taken to protect the health of chil- dren upon entrance into industry, by the adoption of requisite health stand- ards; second, regulation of their industrial careers until they reach matur- ity, which means a study of legal restrictions of children's work as well as a study of present conditions under which they work; and, third, the more indirect but no less important relation between educational preparation, adjustment with the job and sound health. Under what circumstances are children going to work? What measures have been taken to develop their bodies and make them physicially fit to enter industrial life? What kind of work are children doing and what kind of a chance does it offer them for future industrial competency? What hap- pens to children at work who are not normal, mentally or physically? What in education has prepared children for the shift from school to eight hours of labor daily, at work quite different from the sort of activity which has char- 580 Hospital and Health Survey acterized their school life? What is going to be the effect of such a radical change on growing boys and girls, whose physical and mental instability at this time is marked? Childhood naturally falls into several distinct periods, the prenatal period, infancy, the pre-school period, the school period and the adolescent period. Each of these periods is important in the welfare of children. To those interested in one particular stage of a child's development, that one may seem of paramount importance. Probably not until all periods are equally emphasized will children have a full chance for development. However, the successive needs of childhood may be viewed, no one will deny the need for careful instruction and guidance during the adolescent years. All of the care which has been given to children's health in earlier years will prove to have been futile if they are allowed to go free from guidance and protection in these later years before they are competent to take care of themselves. The physical and moral difficulties which approaching maturity thrusts on them, require for children assistance and advice and often medical care, in order to safeguard their health, as well as to complete the training and prep- aration which have been the work of society for the 14 or 15 preceding years. These are the years of transition from supervised childhood to indepen- dent maturity. Opinion is divided as to the advisability of allowing chil- dren to go to work during this period. One point of view sees always the child in the developing boy and girl and desires for the child the maximum of care and protection. This protective care can go too far and, in extreme, smothers the springs of initiative and self-reliance needed in the man. The other point of view, more hard-headed, believes that participation in the work of the world cannot begin too soon for sturdy development. In its interest in independent character it tends to lose sight of the fact that too early work stunts a child's development and that a sound mind should be combined with a healthy body in order to realize its greatest powers. Another point of view, the commercial one, of the dollar value of child labor, should not be seriously considered. Obviously the industry of this country does not have to depend on the work of children for its income, although it is chiefly to combat the commercially-minded that it is necessary to make such strictly defined child-labor laws. Otherwise, it would be possible to make laws elastic, in order to meet more easily the individual needs of chil- dren. It is our belief that the efforts made on behalf of children of adolescent years, regarding their passage from school to work, should be directed towards individual adjustments. In concern for the child, the man in the developing boy should not be overlooked, neither should the child be allowed to enter the adult's world of work too soon. There is great variation here in individual children. Some children mature much sooner than others and are ready sooner to make the transition from school to work. Methods must be developed by which allowance can be made for individual variation. Health and Industry 581 Considerable antagonism is aroused towards the present regulation of children's work, by the hardship caused in individual cases. Even though hardship in individual cases is no argument for the abolition of restrictions on the age of children going to work, it should be possible to originate some methods for making distinctions in individual cases, which will not be loopholes for unscrupulous and destructive evasion of the laws designed to protect the health and best interests of children. Such distinctions can be worked out on the basis of the physical ability of the individual child, determined after careful medical and mental examinations. It is purposed to bring out the possibilities of such a method in the following sections. This study is a survey of the present relation between children and in- dustry in Cleveland, presenting information not so much comprehensive, as representative of the situation. The regulations limiting children's work which are at present in force are considered first, and next, the information which has been available regarding the number of children at work, both legally and illegally. Discussion, in some detail, of the kinds of work in which children are found employed follow. The questions of their health and the measures taken to safeguard it are considered separately. There is included a brief report on the mentally subnormal children known to be at work. One section of the report considers the relation between industrial training, educational preparation, vocational guidance, and health and efficiency. The conclusions reached at the end of the study and the recommendations made are summarized in the last section. The study was made during the spring of 1920. It had been the inten- tion of the Consumers' League of Ohio to make some such research into health in the industrial field in Cleveland. Upon hearing the comprehensive plans contemplated for the Hospital and Health Survey, the Consumers' League decided to support the services of a special worker who would be under the direction of the Survey, rather than to carry on an independent research. Such an arrangement was effected for the present study, which has been made by a member of the staff of the Industrial Division of the Hospital and Health Survey, the subject of Children and Industry being especially appropriate to the long continued interest of the Consumers' League in work- ing children. LEGAL PROVISIONS FOR CHILDREN 15 TO 18 GOING TO WORK In order to understand the situation as it is in Cleveland for children of working age, a review of the existing legislation relating to children of this age is essential. Who are children? When does a boy become a man, and a girl a woman? The Ohio Child Labor Law says that a girl is an adult when she is 18, and may work the same hours and under the same circum- stances as any woman, save that she cannot work at night until she is 21. According to the Child Labor Law a boy of 16 may work longer hours than an adult woman may work. After he is 18 this law considers him a man in every respect, able to work any number of hours, day or night, and under the same conditions as govern men's work. 582 Hospital and Health Survey Research has shown that boys mature more slowly than girls, but the Child Labor Law says that a boy may go to work a year earlier than a girl, and that he may have a year's less schooling than a girl. On the other hand, the common law of the state does not consider a boy a man until he is 21, when he may for the first time exercise property rights and the right of franchise, and get a marriage license without permission of his parents or guardian. Following is a summary of the essential provisions of the Child Labor Law of Ohio, and of other laws relating to children of 1.5 to 18 years going to work. Age Requirements Employment of boys under 15 and girls under 16 years of age is strictly forbidden. iVge and schooling certificates are required for all boys under 16 and all girls under 18 years of age. Boys under 16 and girls under 18 years of age may not legally be emdelrpo more than eight hours daily, 48 hours weekly, before 7 in the morning, not after 6 in the evening, nor more than six days in any week. Boys under 18 years of age may not legally be employed more than 10 hours daily, .54 hours weekly, before 6 in the morning or after 10 at night, nor more than six days in any week. Girls between 18 and 21 years of age may not legally be employed more than nine hours daily (except Saturday in mercantile establishments, when 10 hours is the limit), .50 hours weekly, before 6 in the morning and after 10 at night, nor more than six days in any week. Certain occupations involving physical and moral hazard are prohibited for all women. Girls under 21 cannot work at employment involving con- stant standing. No boy or girl under 18 can be employed at extremely dangerous occupations to health and morals, eighteen such occupations being specified in the law. Xo boy under 15 years of age and no girl under 16 years of age can be employed at all, save in agricultural work or in domestic service. Xo boy 15 to 16 can be employed at dangerous machinery or where his health may be injured and his morals depraved, or at the tobacco trades. Thirty- two other occupations are prohibited to boys in the law. Educational Requirements 1 . The age and schooling certificates required for all boys 15 to 16 years of age, and all girls 16 to 18 years of age must show that every boy has passed a sixth grade test, and that every girl has passed a seventh grade test. If upon examination and by school record a child proves to be below the nor- mal in mental development and unable to pass this test, he may receive a school certificate at the discretion of the issuing officer. Health and Industry 583 2. Every boy 15 to 16 years of age must return to school if he ceases work and does not find other work. No provision is made requiring girls 16 to 18 to return to school if not at work. Health Requirements A certificate is required from the school physician or some properly qual- ified physician showing that a child is physically fit to be employed in any of the occupations permitted by law for a child between 15 and 16 years of age, provided that if the records of the school physician show such child to have been previously sound in health, no further physician's certificate need be required. Special Vacation Certificate Boys 15 to 16 years of age and girls 16 to 18 years of age may have vaca- tion certificates to be employed in occupations not forbidden by law, even though they have not passed the required school grade, provided all other requirements for a certificate are complied with. Street Trades No provision is made in the Ohio State Law which covers street trades. There is a city ordinance, not enforced, regulating this kind of work. This will be further discussed in a section of the report on newsboys. Juvenile Court Provision is made through the Juvenile Court and probation system for dealing with delinquent young people of all ages who can be classed as juve- niles. The offending street trader, or truant from school, here receives less severe handling than in regular law courts, and is dealt with by persuasion rather than by punishment. Enforcement of Present Laws This comes under the School Attendance department of the city schools and the department of Factory Inspection of the State Industrial Commission. These two agencies cooperate to keep track of all children of the ages in question. The adequacy of their working force and their success in enforcing these regulations will be discussed at the end of the next section. STATISTICS FOR CHILDREN IN INDUSTRY IN CLEVELAND, 1919 There are three sources of information from which to ascertain how many children there are in Cleveland, of what age and of what sex, how many of them are working and how many are in school. 1. The school census, taken every spring by the Census Bureau of the Board of Education, enumerates each child in the city from 6 to 20 years of age, whether he is in school, out of school or at work. .584 Hospital and Health Survey 2. The Industrial Commission of Ohio obtains annually from all employ- ers records of the occupations and wages of all boys and girls under 18 whom they employ. 3. The work certificate office, at the Board of Education, keeps on file the name, age and sex of every child who, after complying with certain re- quirements, secures from the office an age and schooling certificate, which entitles him to go to work. It was possible to obtain information from these three sources for the same period of time, the year of 1919. The school census of May, 1919, was analyzed so as to obtain information for boys and girls separately, the records of the work certificate office for the school year, September, 1918, to June, 1919, were secured and, through the courtesy of the Industrial Commission, their statistics for 1919, which are not yet published, were obtained and analyzed. The information collected in this way for the number of children at work is somewhat surprising to compare. Following is the summary of results. The full tables for this information may be found in the Appendix, Tables XVI. to XVIII. TABLE XIX. Comparison of Three Tables for Number of Children at Work ix Cleveland in 1919. Boys Girls Total School Census, 15-18 years of age..... .9,068 (15-18) 6,778 (16-18) 15,846 Industrial Commission of Ohio, 15-18 years of age 1 2,957 (15-18) 2,072 (16-18) 5,029 Work Certificates Issued, 15-16, 16-18 years of age 1,444 (15-16) 2,057 (16-18) 3,501 Of the three records probably the records of the School Census more nearly approximate the truth as to the number of children actually in indus- try. Their figures were obtained in a house to house canvass of the whole city and were then checked up with the existing school records at the Census Bureau of the Board of Education, where a school child's card contains as well, a record of the whole family of children, whether of school age or not. The figures of the Industrial Commission were obtained from employers, and it may well be that they recorded only the certificated children whose permits were on file in their office, which would be boys 15 to 16 and girls 16 to 18 years of age. The boys 16 to 18 employed are only estimated in many cases. Not all employers keep age records of their employes. Fur- thermore, the Industrial Commission records are not complete, as a number of employers have not yet made their reports to the Commission for 1919. The work certificate office figures included only those children who went to work through the legal channels. Health and Industry 585 4. Illegal Child Labor and Law Enforcement. Comparison of these sets of figures shows the great extent of unlicensed labor on the part of girls 16 to 18 years of age. Almost 5,000 girls are at work in Cleveland with no check on them in any way to see that the health and educational standards considered essential for them are maintained. In addition, these figures take no account of the extent of work among children who are under the legal age for employment. Reports have come in on all sides as to the number of under age children who are at work regularly, as well as at work part time after school and on Saturdays. It has been exceedingly difficult to verify these reports, save for scattered individual cases. There is undoubtedly truth in the prevailing opinion. The school census bureau is freely used by a number of employers to verify the ages of young children applying for work. Records were kept by the school census bureau office for several weeks of such calls from employers, and disclosed actually at work, or applying for work, 168 boys and girls who were under the legal age for employment. Ages and Number of Children Applying for Work Age Boys Girls 11 1 12 5 13 25 13 14 34 41 15 1 48 Total. 66 102—168 42 of the boys and 73 of the girls were regularly at work, the remaining num- ber, 23 boys and 28 girls, had applied for work. 22 employers were repre- sented in this list. One department store was responsible for 60 of the viola- tions, the majority of which were for girls, and one manufacturer of metal products was responsible for 18 violations, most of them for boys. The facility with which these figures were collected is an indication of the extent of illegal employment of children. In addition must be reckoned those chil- dren working after school and on Saturdays without permits. Some of these children had been out of school for months, two or three as long as two years. One boy had been injured and his case brought into court. Another boy of 15 was working with a paper company without a permit. An accident brought this case to the notice of the school authori- ties. The boy's hand was crushed in a machine. His school record showed him to be defective, of a mental age of 9 years according to the test. If this boy had gone to work through the work permit office where his physical and .586 Hospital and Health Survey mental condition would have been determined, his employer would have been notified of his mental disability, and the boy protected from an accident hazard. The Child Labor Law of Ohio is often cited for its excellence. If the law is not enforced, its excellence is without virtue. One explanation of this illegal employment is to be found in the depart- ments of School Attendance and of Factory Inspection. For it is their joint responsibility to see that the school and child labor regulations are enforced. Both these agencies work at a disadvantage. One truant officer must keep track of 10,000 children. Boston requires one attendance officer for every 6,000 children. Obviously, one officer cannot cover all of the cases of irregu- lar attendance which occur among 10,000 children. As it is now, the truant officers devote only a small part of their time to following up children of working ages. If a child has come into the office and obtained a permit for a job, but has left that job, the permit then coming back to the office from the employer, he should return to school. This is not followed up. No one knows what becomes of the child. A list of such children was once started but the list grew so rapidly that it was impossible for the attendance officers to keep up with it, so the matter w r as dropped. This means that either the children are not working and are not in school, or they are working illegally without a permit. There is no question of the efficiency of the present force. School prin- cipals and others interested have spoken most highly of the work of the attendance department, saying that the officers are untiring in their efforts and most cooperative. With such a small force something has to be neg- lected and the children of working age have been ready to take advantage of the light authority imposed on them. This situation is true also for the State Department of Factory Inspection of the Industrial Commission. There are for the 88 counties of Ohio eight women visitors to see to the enforcement of the child labor law and others. The several counties surrounding and including Cleveland have the full services of two inspectors, who do splendid work, but who, obviously, could not be expected to be responsib'e for full enforcement of the law. Cleveland industry alone employs tens of thousands of women and young people and needs the supervision of several inspectors in order that industrial plants may be visited more than once annually. Undoubtedly one source of illegal child labor is the tremendous labor shortage which has prevailed throughout the present year. This shortage was mentioned almost without exception by every employer visited. "We can't get help. Ordinarily our rule is never to employ anyone, boy or girl, under 18. But we have been forced to make exceptions to this rule because we can't get enough help otherwise." The attitude of foreign parents is antagonistic also. They wish their children to go to work as soon :\s possible and will resort to any subterfuge Health and Industry 587 in order to evade the law. It should be pointed out that economic necessity is by no means always the explanation of their attitude. Foreigners have a different attitude toward their children from that of most Americans. Chil- dren represent so much potential earning power which must be utilized for the family income at the earliest possible time. The sense for property, owning a home, is strongly developed in European peasant people, and they will make every sacrifice of themselves and even of their children, in order to acquire a little land and a house, having no thought for the possible physi- cal harm they are bringing on themselves. The strong constitution which is the inheritance of the European peasant does not always endure for his children. Life in an American city offers less opportunity for the de- velopment of a rugged physique able to withstand heavy toil as well as the high power, top-speed existence characteristic of city life. Extension of school hygiene and general health education will in time eliminate this attitude on the part of parents towards their children. But meanwhile the laws designed to conserve the health and welfare of children are the only defense available to protect them from their own ignorance and the ignorance or short-sightedness of their parents or employers. But one of the principal causes of so much illegal employment of children is the fact that the children know they "can get away with it." Otherwise there would never be so many applications for work from such young chil- dren. Inadequate supervision on the part of the truant officers on one hand and of the Factory Inspection Department on the other, leaves too many loopholes for children to slip through. If it is impossible to enforce these laws with the present organization and personnel of the school and state departments, then their methods should be improved and their personnel increased to cover the city adequately. No city of the size and importance of Cleveland can afford to allow large numbers of its children of the ages of 12 to 16 years to enter industry, unre- stricted and undirected, their physical fitness to perform the tasks which they pick out for themselves, in no way ascertained, nor their capacity to stand up under continued years of industrial life assured in any degree. More supervision must be provided both by the school authorities and by the State Industrial Commission, in order to check up on this illegal employment. This is vital. No prerequisite health standards for children at work can be established and maintained until it is certain that every child going to work goes through the work permit office, where he is medi- cally examined and must show physical fitness before he can obtain a permit for employment. It is recommended that at least three more women inspectors be assigned to the Cleveland district by the State Industrial Commission and that the number of attendance officers in the School Attendance Department be in- creased from 13, the present number, to at least °2(). •588 Hospital and Health Survey WHERE CHILDREN WORK 1. Occupations Employing Children Boys and girls are employed in greatest numbers in manufacturing, retail and wholesale trade, and in telephone and telegraph work. Table XX. in the Appendix shows the distribution of boys and girls in the various trades, as shown in the Industrial Commission's report. As before stated, the statistics of the Industrial Commission are not numerically complete, but they are sufficiently extensive to be representative of trades employing children in Cleveland. The information obtained through personal visits to 50 different establishments employing children in some numbers, corroborates in every instance the evidence of the Industrial Commission's figures. The last published report of employment by the Industrial Commission of Ohio for Cleveland is for the year of 1915. A total of 3,299 children under 18 were employed in that year, as against 5,029 employed in 1919, showing an increase of about 1,800 in four years, or 35%. Table XXI. in the x^ppendix shows the distribution of children in the various trades for these two years, 1915 and 1919. There are several noteworthy changes. Telephone and tele- graph work in 1919 used 463 girls under 18. In 1915, 35 girls were so employed. On the other hand, the employment of young girls has fallen off considerably in the manufacture of clothing, hosiery and knit goods, and woolen and worsted goods. The employment of boys has increased, mainly, in the manufacture of electrical machinery, foundry and machine shop products and sewing machines. Their employment has decreased in steel works and rolling mills. Both boys and girls are employed in greater numbers now in the retail and wholesale trade than in 1915. The largest numbers of both boys and girls are employed in manufactur- ing, in round numbers 3,000 boys and 900 girls. The majority of these are wage earners, as distinguished from clerical workers. This is true of all employment for children. The classification of the Industrial Commission includes three groups of employes: clerical workers, wage earners and sales people. 23.7% of all children accounted for are clerical workers, 72.8% are wage earners and 3.5% are sales people. Boys and girls are scattered throughout the manufacturing trades, being- found in greatest numbers engaged in the manufacture of men's and women's clothing, hosiery and knit goods, the metal trades and printing and publish- ing. 39 manufacturing establishments were visited. In all, 50 establish- ments employing young people were visited and information collected re- garding hours, wages, nature of work, opportunity for advancement, educa- tional requirement, medical service and general conditions of work. The opinion of each employer was obtained as to the employment of junior help. Medical service is described in detail in the first section of the Industrial Survey report, andconditions of work in the second section, therefore, no further discussion will be made of these two subjects in this report. In all places where girls are found at work women are employed as well, and conditions Health and Industry 589 of work are identical for both. This does not apply equally to boys. It must be remembered, as pointed out earlier in the report, that boys do not work under the same supervised conditions of work which the law insists upon for women and girls. Boys must use those toilet and dressing room facilities which are provided for the men, and must eat their lunch under the same circumstances that men do. This often means a cold lunch. While many factories provide a cafeteria where girls and women may obtain a hot lunch, not all of them provide the same service for boys and men. A. Hours of Work The law limits the hours of work of boys 15 to 16 and girls 16 to 18 years of age, to 8 daily and 48 weekly. So far as it was possible to ascertain the facts on this point, the law is observed. Employers who wish to use the services of children, find no difficulty in arranging their schedule of hours to accommodate an eight-hour shift for the children. Employers who can get along without the services of children state that they employ no one under 18, because of the difficulty of arranging a separate 8-hour shift. B. Wages Table XXII. in the Appendix shows the rates of wages paid to children in all occupations. 2,635 of 5,029 children listed by the Industrial Commission report receive from $10 to $15 weekly. 648 children receive less than $10 weekly. Figures obtained by visits in the spring of 1920 run very slightly higher, 22 establishments pay between $13 and $15 weekly, 18 establishments pay $15 or more weekly and 15 establishments pay less than $13 weekly. In all cases where employers were questioned as to wages, the beginning rate has been quoted, as the character of the information for regular wage rates varies greatly. Some employers use hourly rates, others weekly, some esti- mate wages on a piece work basis, and others use a straight time rate. Even a payroll would not give exact figures, for the result of the labor scarcity of the past few months has been to make labor very independent, working only a few days in one place, or at one time. As one employer said when inter- viewed, "The girls come and go as they please. I don't dare say anything, or they put on their hats and leave. All I do is to carry the key." Wage rates are slightly lower in retail and wholesale trades, and very definitely so in telephone and telegraph work, where the rate is $10 to $12 weekly. Manufacturing pays more, especially to boys. More boys receive from $15 to $21 per week than from $10 to $15 per week. Wages for boys are generally higher than for girls. This is true of all occupations. The present wages paid to boys in the various shops classed under metal trades work have been so high as to make boys a scarcity in all other kinds of work open to them. On the whole wage rates for children are high, due to the fact that many children are doing adults' work because of the labor shortage. 590 Hospital and Health Survey C. Nature of Work and Opportunity for Advancement These vary in almost every trade for boys and girls. In the industrial held proper the manufacture of men's and women's clothing offers to girls good opportunity to learn a trade and advance to higher positions. Boys in this trade run errands, or work in the shipping room. Their greatest chance for a job with some future is to become an apprentice to a cutter. In the six establishments visited, girls learn the trade in a school maintained in the factory or from instructors, and require from two to eight weeks in which to learn. They may start in at once on power machine operating or begin by examining or packing the finished product. One instructor states that young girls are not strong enough to do machine work and so are started in on hand work. The sewing trades offer a very good opportunity to girls. Girls should be carefully watched, however, against undue eyestrain. One factory has the eyes of girls regularly examined by an oculist, and insists on glasses being obtained if prescribed. The physical condition of each girl should be determined before she is allowed to begin power machine operat- ing. This could be done by the company physician or by the examining physician at the office where she obtains her permit to work, and a recom- mendation put on her permit as to her physical ability to essay heavy work. The Manufacture of Confectionery This is a seasonal industry and attracts girls of the floater type who never stay very long anywhere, or who wish to work only occasionally and do not wish to work where they have to spend time learning a trade. Chocolate dipping is the only operation for women in this trade requiring any skill, and very few of the younger girls are found at chocolate dipping. The em- ployment of boys in this trade is negligible. The Manufacture of Hosiery and Knit Goods This industry employs boys and girls in about equal numbers. In most instances it is no longer a seasonal industry. The work is easy to learn and in- struction is given by other workers or by foreladies. Some of the boys and girls work on knitting machines, but most of them handle the finished product in the stock room, doing inspecting, folding and packing. In addition, boys are em- ployed to run errands. There is little or no opportunity for advancement in this kind of work. An increase in wages is the most that can be hoped for. Considerable standing is necessary. The law states that no girl under 21 shall be employed at an occupation requiring her to stand constantly, and that seats must be provided for every girl and woman employed. Seats are usually provided and sometimes made use of. The average girl needs instruction in health education. Some standing is necessary in all occupa- tions, but many employes stand constantly, even though their work does not require it. On the other hand, many tasks are done standing which could be done seated, if employers would devote a little thought to the mat- ter. Numerous machines are now operated from seats, which formerly re- quired a standing position. It is very essential to the health of young girls Health and Industry 591 that they be not subjected to the strain of continued standing. No small function of the medical service in industrial plants should be the instruction of employes, especially the younger ones, in the application of common sense to their daily living, in such matters as alternate sitting and standing at work, changing of posture while at work, the wearing of practical working- clothes which will give freedom of movement and the maximum of comfort, the necessity for nourishing diet, plenty of sleep, fresh air, and other related subjects. The Metal Trades Of the 23 metal trades establishments visited, nine employed boys and a few, girls. 294 boys and 9 girls under 18 were found at work. The girls were for the most part engaged in packing and sorting parts and in making small pasteboard boxes. In no case was their, work difficult and in every case they were seated at benches. For boys the metal trades offer exception- ally good opportunities for learning a skilled trade. In eight of the nine plants they were found working in machine shops under the supervision of skilled workmen, making good pay and having every chance to apply them- selves and get ahead. Very few of these boys, however, were under 16 years of age. Employers almost universally stated that it was their rule to employ no boys under 16. "They are a nuisance." Much of the machinery involves too great an accident hazard for such young boys, and there is nothing much they can do but run errands. Even boys from 16 to 18 years of age are looked upon with disfavor. Whatever the explanation may be, it is true that the dissatisfaction of employers with boys of this age is general. "They are hard to get and no good." A number of firms were visited which had been known to employ boys of this age, but no longer do so, having made a strict rule to employ no one under 18, boys or girls, because they had proved to be such unsatisfactory help. As a group, the metal trades seem to be above the average in plant organization for the welfare of employes. Medical service is provided, equipment is good, hot food nlay be obtained at noon, and some recreation is provided. This is well worth noting because of the large number of boys it affects. 1,119 of the 2,090 boys employed in indus- try proper in Cleveland are in the metal trades. In the plants visited 115 of the boys were employed as apprentices. This means that they were systematically learning a machinist's trade and in addi- tion were occupied part of each week in study and class work, either at East Technical High School or in classes conducted in the plant. The superi- ority of this method of inducting boys into industry cannot be emphasized too strongly. It will be discussed in more detail in a later section. There are only a few shops in Cleveland where a modern or in fact any system of apprenticeship is now made use of. A number of employers stated that they have plans for it in mind, but that with the present scarcity of boys, it is not possible to establish such a system now. In the two plants where an apprenticeship system is well established, great satisfaction was expressed as to the results obtained. .592 Hospital and Health Survey Printing and Publishing This is a trade which is largely unionized in all its branches, even in the binderies, which make use of girls and women. For girls, in practically all work done by them outside of the binderies, there is no job with a future. Feeding presses is the commonest sort of a job. This is easy work, is safe, is done sitting, but is very monotonous. Employers frankly say that it is blind alley work and it is very difficult to hold girls at it any length of time. Boys have always the chance to learn the printer's trade or to become pressmen. This work they may learn through the apprenticeship system which is directed by union rules. Union rules require four years' time spent as an apprentice before a boy is able to qualify as a skilled worker. Non-union shops claim that the work can be learned in a year and a half. Union rules require, in the case of pressmen, that there can be only one apprentice to every five pressmen in a shop. The employer in this trade states that there should be an allowance of one apprentice to every three pressmen in a shop. As the union rule works out, it is difficult for a boy jto become an apprentice, as there are few openings. No relation is made be- tween school and shop. No part of the boy's time is spent in class work. Working conditions in the printing trades are fair. There are definite lead hazards in most branches of the trade, and as yet union organization has not recognized this hazard in relation to young boys who are especially susceptible to lead poisoning. No provisions are made to protect boys from a lead hazard. In European countries boys are not permitted to work in occupations which expose them to lead fumes or dust. Boys in American shops have been found doing the dustiest kind of work, cleaning and brushing linotyps machines and gathering up lead scraps. Under section 13337-4 of the State Child Labor Law the State Board of Health has power to forbid the employment of boys under 18 at any process injurious to their health. This authority should be used to exclude boys from employment on those processes in the printing trades involving a lead hazard. Retail and Wholesale Trade Seven large department stores were visited. In this group 105 boys and -266 girls under 18 are at work. They are apparently employed in about equal numbers. Here again opportunity differs for boys and girls. Boys are employed in the stock room as messengers and as "jumpers" and wagon boys in the delivery department. Many boys who are still in school engage in this kind of work after school and on Saturdays. This is not difficult work for an active boy. It is done in good surroundings, for the most part. The modern department store, of which there are a number in Cleveland, serves hot meals and uses care and thought in arranging for the welfare of its employes. The chief objections to this kind of work for boys are that it does not get anywhere in giving training for a trade, and the law regulating the hours of work for young boys is often disregarded in the delivery service. It is common experience to have a package thrust in a house door late in the evening by a small boy, especially on Saturdays and in a holiday season. H E A LTH AND INDUSTRY 593 Girls are welcomed into department store organization very readily. One employer says, "We cannot get along without our junior help." Another says, "We give careful attention to the young girls coming to work for us, for in them we look for our future material for salesmanship." At least four of the stores visited have an educational department, where girls receive a certain amount of class instruction as training for store work. Girls under 18 rarely start in as saleswomen. They are employed as branch cashiers, as wrappers and in inspecting merchandise. In time they may graduate into salesmanship work, where there is greater opportunity both in salary and for responsible positions. The New York State Factory Investigating Commission considers there is a definite health hazard for young girls in much of department store work. "The nervous tension of the work of parcel wrappers and of floor cashiers has been found to be of a serious character." Telephone and Telegraph Work Telephone Work. About 400 girls under 18 are employed in telephone work. This is a marked increase over the number in 1915, when only 35 girls were listed for both telephone and telegraph work. The telephone companies have in the past endeavored to limit employment to girls over 18, but their inability to get sufficient operators, with the resulting unsatisfactory telephone service, has led them to seek younger girls. . No report of the trade of telephone operating can be made without careful consideration of the nature of the work. Telephone officials stoutly insist that there is no nervous strain in operating, that it is pleasant and healthful work. Some of them base this statement on their own experience of years in the service. And in appearance these women justify their contention. However, in comparison with other types of work open to girls there is con- siderable difference. Girls work in "tricks" of four hours; having during that time one 15-minute relief period, when they can leave the switchboard. This 15-minute relief period is a regular part of the routine. However, when a supervisor is short of workers it is not infrequently impossible for her to arrange this relief period. The rest of the four-hour period operators must sit steadily in one position before the switchboard. There is no op- portunity for them to move around and change their physical position, as is the case in most other occupations. During this period girls are sitting with their arms stretched out before them or reaching upward, and their eyes must be continually on the switchboard. White and colored lights are con- tinually winking on this board in front of them. In addition, operators must listen and talk against the constant buzz and noise created by a large number of people talking in one room, even though the noise from talking has been scientifically reduced to a minimum by the construction of the switchboard mechanism. While the noise in the operating room of all exchanges does not compare with the roar in the average machine shop, the difficulty is that in a telephone exchange almost continuous conversation is necessary with subscribers, requiring close and sustained attention from 594 Hospital and Health Survey operators. It is often difficult for a subscriber to retain his poise and calni during a fifteen minute period of telephone communication. How much more exacting it is to expect the same of an operator for four hours at a time. Telephone work is learned in a training school, requiring attendance from two weeks upwards, part of which time is spent in the class room, and part at the switchboard. A salary is paid to the student while attending school. The same excellent lunch and rest room facilities are provided for students as for regular operators. There is good opportunity for advancement to supervisory positions for a girl who likes telephone work and will continue in it. There is also con- siderable opportunity in the commercial field for private branch exchange operators. This kind of work pays well and often leads to other opportuni- ties. The average duration of service of telephone workers is not long. Sta- tistics for Cleveland are not available on this point, beyond the statement of officials that their labor turnover is high. However, in the report on tele- phone work just made public by the New York State Industrial Commission, it is stated that of every three applicants registered for telephone training one does not finish training, one stays less than one year, and one stays more than one year. As a girl is an expense to the company until she has been employed one year, this means that the loss on operators is high. The telephone companies make every effort to cut down the high labor turnover by means of careful selection of operators, improved conditions of work and well developed welfare features. That the rapidly shifting working- force may be due to the exacting nature of telephone operating seems not to have been so carefully considered. While medical service is provided for all plants of the companies, it is not adequate. The facilities of the medical department should be expanded to give operators a periodical as well as an initial physical examination, and complete medical records should be main- tained, in order to obtain reliable information as to the degree of nervous strain experienced, and its effect on the health and efficiency of operators. • That there is a distinct health hazard in telephone work for younger girls seems undoubted. Up to the age of 18 years a girl's nervous organism is none too stable in any case, and it is questionable whether it should be sub- jected to the peculiar nervous strain of telephone operating in an urban community. The Ohio Child Labor Law prohibits to girls under 18 certain occupations dangerous to their health. It is recommended that a careful study be made of the effects on the health of young girls of this kind of work, and that if the results of this study warrant it, telephone operating be included in the occupations forbidden to girls under 18 years of age. As the tele- phone companies, in Cleveland as well as elsewhere, are coming to rely more and more on the services of younger girls, this is a question which should have immediate attention. Health and Industry 595 Telegraph Work. As organized in Cleveland at the present time telegraph work has few places for girls under 18 years of age. The only work open to them is mes- senger work in the operating room. When a girl becomes 18 years old, howr ever, she may go the company school and take a several weeks' course in tele- graph operating. There is in this work a trade with some, if not a consider- able future, and it involves no great health hazard. Telegraph business makes use of boys in large numbers, 140 being em- ployed as messengers by the two companies in Cleveland. Their work is easily learned, familiarity with the city being about the only requirement. There is no real opportunity for advancement in messenger work. A boy might better make his initial contact with the industrial and commercial world through a job holding out some inducement to buckle down and learn a trade. Messenger work, like newspaper selling, can be done and is suc- cessfully in one company, by older men. Employers like the energy and hustle native to youth, but it is short-sighted to allow that energy to be dissipated in a job without a real future. D. Educational Requirement Throughout the trades there is no educational requirement, save in the case of apprentice schools, when a boy must have graduated from the 8th grade. The last group described, including telephone and telegraph work, endeavors to maintain an 8th grade requirement. Their need for workers does not always allow them to do so. Possibly the most striking comment which can be made upon the various tasks at which girls under 18 and boys under 16 are employed is that the mentally subnormal children found at work in the city almost without exception are engaged at the same tasks, upon which normal children are working. Apparently the tasks are so simple that it is possible for subnormal children to engage in them without difficulty. The work is easily learned. Few of the jobs upon which the younger people are now employed require any great skill. From the stand- point of learning a trade this is not always objectionable. For example, in department store work there are a variety of tasks for girls to become familiar with, no one of which requires any great skill for proficiency, but all contributing to a knowledge which is essential to the higher jobs opening up to girls later on in the profession. The same may be said of metal trades for boys. There is considerable preliminary work upon which a boy's time may be spent, which provides general training for machine shop work and which does not waste his time. From the standpoint of learning a trade, it is objectionable, however, to employ a boy or girl at work which utilizes youthful energy without yielding any training for future competency. The messenger work at which so many boys and some girls are employed in factories merely uses young legs because they are quicker than old ones, and so long as a man has at his disposala pair of young legs it is easier to use them than to think up some means of 596 Hospital and Health Survey getting along without them. The use of messenger and office boys is a holdover from the older, more inefficient methods of doing business when work was conducted without thought for the most economical organization of time and energy. In the labor shortage in Cleveland of the past spring, the job that was the hardest hit was that of office boy. It was the universal complaint that it was impossible to get an office boy, even when a largely increased salary was offered as inducement. When opportunity was open for other work, boys chose the job of office boy and messenger last of all. E. Comments of Employers Opinion differed somewhat as to the merits of boys and girls under 18. It was almost universally stated that the boy of certificate age, that is, 15 to 16, would be better off in school. Many employers thought all children under 18 were better off in school, but so long as it was possible to do so, they employed a few. A number stated that they intended to eliminate the younger help as fast as possible. F. Conclusions The trend of the comments of employers strengthens the conclusions reached after the study of children's employment, a brief summary of which is recorded in the observations made on the various occupations. These conclusions are first, that the presence of boys of 15 to 16 years of age in industry is not necessary and can and should be eliminated; and, second, that there must be more conscious direction into the industrial field of boys and girls 16 to 18. The blind way in which the average boy or girl gets his or her first job is one reason for their employment at casual work, learned today and forgotten tomorrow. Their work is unsatisfactory and they are unreliable because there is nothing about their jobs to wake them up to real effort. Their minds are elsewhere. Blind alley jobs in children's employment have been recognized for some time, and while not approved have been more or less condoned as unavoid- able. They are not unavoidable. The labor of children 10 to 14 years of age was once thought unavoidable and was condoned. It has been proved conclusively that such labor is not necessary. So long as children are allowed to drift about, as fancy dictates, from job to job, instability and unsatisfac- tory work will result. Methods should be worked out in connection with the certification of children for work, which will provide that a child's first job is selected with some care and thought. This selection should be determined by the inclination of the child as much as possible, but also by his physical and mental capacity, ascertained through the careful medical examination made. Unless especially pointed out in the description of the particular occupa- tion there is comparatively little health hazard for a normally developed child, 16 years of age, in the trades where he is found employed in Cleveland, provided the legal regulations regarding hours and conditions of work are Health and Industry 597 complied with. There is quite a definite health hazard, however, in the effect on a child of irregular and promiscuous jobs, or in work uninteresting in itself and holding no promise of a real vocation in the future. The opinion of the director of boys' employment of the Public Employment Bureau in Cleveland is of weight on this point. After several years' experience she states her conclusions as follows: "The freshness, interest and alertness of the boy seeking his first job are so much valued by employers that school boys seeking vacation work are readily hired, even though their services are temporary. Contrasting strongly with the keen forcefulness of these school boys are the sullenness and stolid disinterestedness of the boys who keep changing jobs. Employers have corroborated our observations that boys are, as a rule, less valuable at the end of one or two years' work than they were when they began their first job. The chief reason for this unfor- tunate but common state is that boys leave school anxious to earn money, and, because they have not thought about a trade or future advancement, they take the first thing they happen to find. This is usually a 'blind- alley' job which pays from the start a reasonably high wage. The boy is at first delighted and applies himself so well that his earnings, if on a piece- work basis, become higher. If he wishes to speed up and work overtime, he can earn more. Because of his high weekly earnings at this rate, if he has a chance on another job at a higher rate, he leaves to try that. After a year or so of this, the results noticed in him are definite physical deterioration, such as nervousness, enervation, drooped shoulders, sluggish bodily move- ments, and slow mental reactions. Boys who have shown great promise when their applications were first presented, but who have insisted on this kind of work, have been a real disappointment when it is evident what their work has cost them. The long, confining hours of industry, unless the boy is buoyed up by the stimulation of a future finished apprenticeship and a worthy goal of achievement, and the loss of nervous energy in high speed jobs stamp upon the face, figure and health of that boy the price he has had to pay." It is largely from a health consideration that more care is urged in the selection of jobs for children. Children have a right to work and in many cases the effect on them of employment is highly beneficial. But they are not adults and some supervision of their activities in industry is legitimate. Children are not wholly free agents in the selection of their school studies, and there is no reason why they should be in the selection of work until they have reached the age of maturity. Boys and girls of 16 have not reached the age of maturity. Left to their own direction they think of their health last, if they think of it at all. If they are directed into work for which they are physically and mentally qualified, the health hazard involved in allowing young children to work daily will be greatly diminished. 2. Street Trades There is no provision in the Ohio State Child Labor Law relating to newsboys, and other street traders. There is a Cleveland city ordinance, not enforced, containing these provisions: 598 Hospital and Health Survey No boy under 10 and no girl under 18 years of age may work at all on the city streets. I No boy under 14 years of age may work on the city streets before 5:30 in the morning and after 8 at night. No boy 10 years of age and over may work on the city streets, without a permit issued to him in writing by the mayor of Cleveland, or by his author- ized representative. The permit shall state that the boy is mentally and physically fit to perform this work. After a permit is secured by a boy he shall receive a badge, which he must wear while at work. This permit may be revoked if the provisions of this ordinance are violated. Trades which come under this ordinance are, selling of papers, periodicals, gum, pencils, candy, perfume and other commodities, in a public place. The Consumers' League of Ohio has campaigned for some time to secure the enforcement of this ordinance. Through interviews with public officials they secured the following promises: (a) Mayor Davis said that he would authorize someone at the Board of Edu- cation to issue permits and badges. (b) Superintendent Spaulding and Mr. Jones have promised that the Board of Education would issue the permits and badges, provided money could be raised to pay for the latter. (c) Chief of Police Smith has promised that he would instruct his squad in the enforcement of this ordinance. Judge Addams will cooperate. The Consumers' League states that the ordinance is not now enforced because — 1. The newspapers do not wish regulation, claiming they are making efforts to take care of the trade from within. 2. There is no money in the city license department to pay for badges (esti- mated cost $300.) 3. There is no money to pay special officers to be detailed to this particular work. Boys and a few girls enter these trades as young as six and remain in them throughout the years while they are in school. The majority of them sell newspapers. Anyone who will take the trouble to observe, may judge for himself as to the extent that newspapers are sold on the downtown streets and busy outlying street corners by small boys. Nor is it necessary to point out in any detail the undesirable nature of this work for children. Common sense alone will indicate the inadvisability of allowing children from six years of age up to spend time on the downtown Health and Industry 599 streets, in an atmosphere of great confusion and excitement, getting home after dark, going to bed late and having irregular and badly chosen meals. The fact that a progressive city like Cleveland will continue to allow its chil- dren to hazard their health and safety in this way is puzzling, although it may be an illustration of the extremes to which American sentiment for business independence will go. There is a very real appeal made by the small hustler who thrusts an evening paper at the passerby, which has been felt by everyone, but it requires only a little thought to realize that this appeal is not justified by the price which the child must pay in the end. For the purpose of securing some specific information as to the extent and general character of the newsboy trade, a census was taken in a downtown school adjoining the business district, of the boys in that school who were selling newspapers or other articles on the streets. There are about 800 pupils in this school, 400 of whom are boys. One hundred records were secured from boys and 10 from girls by a canvass made from room to room. A summary of these records is found in Tables XXIII., A and B, in the Appen- dix. As many as 20 boys under 10 years of age were found who sold papers. Six of these youngsters sold papers until after 8 at night. Fourteen of them earned less than 50 cents a day. Twelve of them were classed by their teachers as not having good health, and eleven of them were classed as having inferior mental capacity. According to the ratings of age and grade in use by the public schools, 59 of the 100 boys who sold papers were retarded in school one, two and three years. Eight additional boys were in a special "opportunity" class which was not graded. 17 out of the 100 boys were in open air classes. 34 of the 100 boys had a poor health record and 16 a fair health record, making, 50% of the boys whose health is only fair or poor. All of the boys sold papers on Saturdays, either for the same afternoon and evening period or all day. While it would not be justifiable to conclude that the physical and mental condition of these boys is due wholly to the fact that they sell newspapers, as there are probably other' contributing factors, such as home conditions, ignorance of foreign-born parents, and others, the fact should be emphasized that almost two-thirds of these boys are in no condition, physically or men- tally to justify their work of selling papers in their spare time after school and on Saturdays. Seventeen of the boys were found in open air classes. This means that they had been diagnosed as suffering from some degree of poor nutrition, and so were placed in special rooms where a maximum of fresh air is provided and the children are given the benefit of extra food. The teachers report that the children improve greatly in health when attending these open air classes. A number of stories of the newsboys found in these open air rooms are of interest. Arthur, age 9, in the third grade, sells papers every afternoon until 8 o'clock and Saturday the same time. Saturday morning he sells boxes which he picks up around the market. He makes about 50 cents a day. 600 Hospital and Health Survey He is only a fairly good student. As open air class boys rank, his health is fair. Joe, age 10, in the fourth grade, delivers papers from 4:30 until 7 in the morning. He sells papers after school until 6. On Saturday his hours are from 4:30 a. m. to 7 a. m. and from 9:30 a. m. to 6 p. m. He makes about 75 cents a day. Although he was regular in attendance at school, his physical condition is poor. He was a failure last year in school, and at present applies himself only fairly well. John, age 11, in the fifth grade, sells papers after school until 6. He is badly undernourished, and is only a fair scholar. He expects to get a job and work this summer. Peter, age 11, in the fifth grade, sells papers after school until 6 o'clock. He makes a dollar a day. He has been selling papers for a year, is markedly nervous and jumpy. He has been a truant from school and has to report to the truant office. He is bright, but he is not able to apply himself, according to his teacher. Martin, age 10, in the fourth grade, works after school until 6 o'clock, making 40 cents a day. He was sick and lying on a cot when interviewed. He is only a fair student. Amelio, age 11, in the sixth grade, sells papers until 7 every night and on Saturday from 10 in the morning until 8 at night. He has been selling- papers five years. He is regular in his attendance at school, but not very strong, and is very nervous. His health has improved greatly since going into the fresh air class. Mike, age 7, in the second grade, sells papers until 7 at night, "making 19 cents a day. He goes to the office with his brother for the papers. He is frail looking. His teacher reports that he is not at all well. Frank, age 8, in the third grade, sells papers from 7 in the morning until school time, and after school until 8. He makes 95 cents a day, including tips. His health seems fair. He is very nervous, talks very fast and stut- ters. He is in a special class for stutterers, and tries very hard to overcome it. Billy, age 8, in the second grade, sells papers until 10 at night. It takes him a half hour to get home from the downtown district where he works. The school nurse and doctor cannot find anything wrong with him, but they have not been able to understand his sleepiness. The teacher states that it has been a struggle all the year to keep him going. "He is so lifeless, bright enough and gets along well enough in his studies, but has no energy." Sam, age 11, in the fifth grade, delivers papers from 5 to 7:30 in the morn- ing and sells after school until 6. He makes a dollar a day. He has been Health and Industry 601 selling papers two years. He is small, nervous and of a high strung type. He is bright, a good student, and has been a truant, but not at the present time. Joe, age 11, in the fifth grade, sells papers until 7 o 'clock. Then every night and Sunday he watches tickets in a show until 9 o'clock. He gets 75 .cents a week for this. He is undersized and not strong. He is intelligent and a good student. Joe, age 12, in the fifth grade, sells papers after school until 7, making 40 cents. He has been selling papers for five years. On Saturday, from 8 in the morning until 4 in the afternoon, he sells boxes which he picks up around the market, making about $1.50. On Sunday he shines shoes from 8 to 10 in the morning, making 50 cents. He gives the money to his mother. She usually gives him a dime. He is very anaemic and not in good health. His scholarship record is poor. He does not apply himself, and his teacher considers that he has dull mentality. These cases, selected at random, show very clearly the kind of life which newsboys lead. While the amount of money they make varies in many cases, it is not worth the time spent making it. It should be noted that in every case where boys are working later than 6 o'clock their physical condi- tion shows the effect of their late hours and irregular meals. Their hours out of school should be occupied in a manner which will not drain their vitality further. The excitement of street life with its over stimulation of young nerves and energies requires sound health and strength to withstand its strain. Boys should not be allowed to engage in newspaper selling and other street trading unless they can show a clean bill of health and are up in their school studies. Boys like and enjoy this kind of work, in most cases. If they are allowed to engage in it only when they can com- ply with a certain standard of scholarship and physical ability, the desire to become a newsboy could be utilized as the necessary incentive to master school studies and develop health habits. It is recommended that the city ordinance regulating street trades be enforced, pending amendment of the ordinance or inclusion of these trades in the state law. Permits to boys to engage in this work and badges to be worn by them while at work, should be issued through the work certificate office of the Board of Education, where each boy will receive a medical ex- amination showing him to be physically fit for this occupation before he can obtain a permit. Early morning paper delivery should also be regulated by issuance of certificates based on physical fitness for this work. Although regulation of this trade does not come under the state school law, the enforcement of the existing city ordinance directly affects pupils throughout their school life and unless some effort is made tojteep watch of 602 Hospital and Health Survey the children in these trades, their unguarded pursuit of them will break down the work of the Board of Education in the medical and truancy departments. It is logical that children in the school system engaging in these trades should do so only under the direction of the Board of Education, so that the w T ork of the medical and truancy departments may not be nullified by the extra-school activities of these children. 3. Agricultural Work and Domestic Service Neither of these groups of work is included in the list of occupations employing children w r hich come under the regulation of the State Child Labor Law 7 . The number of children w r ho are employed at these kinds of work cannot even be guessed at, as no record is kept of them in any place. Un- doubtedly some of the 6,778 girls 16 to 18 years of age, listed by the school census as working, are employed in domestic service. Agricultural work for children under 18 does not affect any number of children in Cleveland except in one situation, w r hich is, how 7 ever, of consider- able importance. This is the case of children who leave Cleveland in the early spring and remain until the late fall to work in agricultural fields either in Ohio or elsewhere. The children are recruited by agents who are paid by the farmer who employs them so much a head for children recruited. These agents obtain individual children without their parents, or whole families, and transport them to the locality w r here they are to w r ork. Principals of schools in districts where there is an industrial population report that every spring about six weeks or two months before the close of school, or in April sometimes, there is an exodus of children and families from the district. One school principal reported that 20 families and some boys had gone from her district, taking about 100 children altogether, the majority of w 7 hom were her school pupils. They went to work in the beet fields near Flint, Michigan, and were signed up by agents who came into the district and went directly to the homes of the families. In this school dis- trict there are Italians, Slavs and Hungarian gypsies. The Italians do not undertake this kind of work, but many Slavs and most of the Hungarian gypsies go. This happens every spring. These people will return about one month after school begins. The children miss from two to three months of school and considerable retardation in school is the result. All of the children from 6 years of age upward work in the beet fields. According to the statement of this school principal even the little tots bring home as much as $150.00 for the season's work. The living conditions are primitive. The people live in shacks and very bad sanitary conditions pre- vail. The National Child Labor Committee has made considerable research into this form of work and has found very undesirable situations in every state visited. Health and Industry 603 So far as is known practically no boys are employed in domestic service. As before stated, it is impossible to make any estimate of the number of girls under 18 years of age so employed. In the canvass made of one school to obtain information as to the numbers of children working after school hours at selling papers, it was learned incidentally that quite a number of girls 14 years of age and under were doing housework after school and on Saturdays. Experts in industrial diseases state that housework contains more health hazards than are found in any other industry. There are no statistics avail- able to sustain this statement, but it would be wise to make a study of this occupation and accumulate more accurate information regarding it. It is questionable whether housework has any beneficial effects on the health of very young girls who engage in it. Both of these occupations should have age limitations and some super- vision of conditions of work, particularly agricultural work. There should be an age limit of at least 12 for these occupations and a limitation of the hours of work, similar to the limitations in hours for other occupations. A health certificate should be required of every child. Regulation of condi- tions of work may involve some difficulties needing the cooperation of other agencies, but examinations for a health certificate can be conducted in the same manner as for other occupations by the existing machinery, with- out great difficulty. By limiting the age and the hours of work of children engaging in these occupations and by requiring of them a certificate of physical fitness for this kind of work, their health will be better safeguarded. HEALTH OF CHILDREN AT WORK 1. Medical Examination of Children for Work Permits "Little has been done up to the present time in the United States to pre- vent children from going into work for which they are physically unfit, and practically no study has been made of the effects of early labor on the growth of the body. Many children who begin work between the ages of 14 and 18 are the children of least resistance in the community. They are in general the children of the poor, and in consequence are likely to be the ill-nourished, the undersized and the anaemic. Already handicapped, their growing bodies can offer no resistance to the exacting demands of industry on muscles and nerves. During these maturing years they are peculiarly liable to injury from overstrain and peculiarly sensitive to all sorts of industrial hazards. "A great deal of the work done by children is, moreover, totally unfit for them. It often involves too much sitting, or too much standing, the carrying of weights beyond the child's strength, the over exercising of one set of muscles at the expense of another, and, in certain occupations, the loss of sleep. Foreign investigations have shown that the sickness rate among juvenile laborers is alarming, especially during the second year of working life when the injurious effects of early labor upon already undeveloped bodies have had time to make themselves felt. 604 Hospital and Health Survey ^'A 'physical minimum' for children entering employment was provided in the standards adopted by the Children's Bureau Conferences held in Washington and other large cities in May and June, 1919. This minimum proposed that 'A child shall not be allowed to go to work until he has had a physical examination by a public school physician or other medical officer especially appointed for that purpose by the agency charged with the enforce- ment of the Jaw, and has been found to be of normal development for a child of his age and physically fit for the work at which he is to be employed.' It proposed also that 'There shall be an annual physical examination of all working children who are under 18 years of age.' (For the complete text of the standards, see pages 3, 4, 5 of Conferences Series 2, Bureau Publication No. 62 of Children's Bureau of the U. S. Dept. of Labor.) "But what constitutes 'normal development' for boys and girls of dif- ferent ages, and what indicates that a child is 'physically fit' for the employ- ment which he is about to enter? Only through exact observation and meas- urements can it be demonstrated that a child is unfit for certain kinds of work, or that too early and too exacting labor is endangering his physical development. The standards to be applied constitute a vitally important part of the problem of child labor." The above paragraphs are quoted from the statement of the Federal Children's Bureau made at the time of the appointment of its Committee on Health Standards for Children Entering Industry. It states very clearly the necessity for special care for children of these years who are going to work. In the descriptions of the various occupations in which children were found employed in Cleveland an effort has been made to point out the par- ticular health hazard, if any, present in each. There is, however, some health hazard in any kind of employment for growing boys and girls, unless their work is carefully supervised. Their physical and nervous organisms are not yet stabilized. They have less endurance, and they are more susceptible to fatigue and bodily strain. Postural strain is most likely to be overlooked unless a child receives some medical supervision after his initial examination for a certificate. The bony structure of a child is quite flexible. Children are peculiarly susceptible to deformities if subjected to unusual and pro- longed strain on one set of muscles, the use of which is especially required by the job at which they are employed. In the future, probably industry itself will exercise more supervision over the work engaged in by children in its employ. The attitude of many em- ployers at the present time is exceedingly intelligent and considerate, in so far as they have knowledge of the physical needs of children 15 to 18 years old. As the medical service in industrial plants develops there will be better facilities for close observation of children at work, and of the effect on them of different kinds of work. It will be possible to make finer adjustments between children and the tasks they perform which will definitely affect their health and efficiency. Health and Industry 605 Pending the time when industrial medical service can share this respon- sibility, the health of children in industry must be guarded by the public department which has the responsibility of examining the mental and physi- cal abilities of children applying for working certificates. In Cleveland this work is done in connection with the Department of Medical Inspection in Schools of the Board of Education. The present requirement in the Ohio School Law of a health certificate for every child going to work has been only superficially observed until the past year. The present director of the work has been at work since last June. Records have been in use only since September, 1919. Therefore, there are no data available for a longer period than one school year. Children are examined carefully as to eyesight, hearing, teeth, throat, lungs and heart, and are looked over for bodily defects, fallen arches, evidences of malnutrition. All children are measured and weighed. They are questioned on their previous health history and for any diseases from which they have suffered, such as epilepsy, rheumatism, contagious diseases, influenza, etc. This is quite a casual inquiry of the whole group being ex- amined. On the occasion when the procedure was observed 15 girls were being examined, and as the room is small there was some confusion. The girls took a personal interest in each individual examined, crowding around her until ordered back. f- The information obtained is recorded on each child's health record and filed. Separate files are arranged for records of children with serious physical defects, of children requiring correction of defects, and of children who are to be re-examined at a later period. The last named usually have conditional certificates. The medical officer spends about three hours daily in the office and a daily report is made up which is kept in the school medical inspection office. These records show the total number of boys and girls examined, the number considered defective and those who were relatively sound, the different defects found and the number of corrections effected during the 8' months from September to May. In the 8 months from September, 1919 to May, 1920, there were examined 2,348 children, 1,001 boys and 1,347 girls! 492 of the boys and 19 of the girls, or 1,111 of the children, had one or more physical defects. The. com- plete figures from these records will be found in Tables XXIV. and XXV.: in the Appendix. The defects from which children were suffering in largest numbers were carious teeth, defective vision and poor nutrition. 623 children had defec- tive teeth, of which number 367 were later reported corrected. 199 children' were handicapped by defective vision, of which number 109 were later re- r ported as having corrections made. 403 children were suffering from sorrie degree of poor nutrition. There was no record of treatment recommended 1 or received in these cases. 27 children were diagnosed as suspicious or 1 positive tubercular cases. '■'■ 606 Hospital and Health Survey The records of the large number of children suffering from decayed teeth, in many cases so bad that repair was impossible, from defective vision and from poor nutrition, indicate that the work of school medical inspection is not adequate. Children should not be allowed to reach the ages of 15 and 16 with such uncared-for teeth that many must be extracted. Poor nutri- tion may be due to a number of causes. More study of the subject of nutri- tion is necessary. The school medical department is already conducting experiments and classes in nutrition which it is hoped will lead to the diminu- tion of the undernourishment which handicaps so many school children. In some cities a minimum standard of nutrition is set, determined according to the height, weight and age of the child, as requisite for a health certificate. It is not within the functions of this department to do other than examine children and prescribe treatment for physical defects discovered. No medical or dental work is done. The child is sent back to his own physician for treat- ment. In case it is understood that the parents of the child are unable to pay for such care, the child is referred to one of the public dispensaries. In order to obtain prompt action on the part of parents in having the prescribed corrections made, certificates are usually refused until the work has been done or until the child can show evidence that the corrections are under way. A conditional certificate valid for a short period of time is often given to a child who is under medical or dental treatment for some remediable defect. At the end of the period for which the conditional certificate has been given the child must return to the office and show evidence that the defect has been corrected before he can obtain a permanent certificate. While this department has been organized less than a year, it is already fairly well established, and its work is proving its value. The officers are much interested in its development and the outlook is promising for an organization having a splendid influence on the health problems of children going to work. The department needs to be considerably expanded and its working force increased. Health standards for children going into industry should be formulated, patterned after those soon to be issued by the Federal Children's Bureau Committee already mentioned. A summary of the committee's preliminary report on standards is included at the end of this section. One of the functions of the department still to be developed should be sufficient contact with the industrial field to assure familiarity with the jobs in which children are employed, in order that the examining physicians may be able to decide intelligently as to the desirability of dif- ferent kinds of work for the various children examined. It is to be regretted that there are no health records available for a longer period of time than one year. It is not possible to learn from the records of one year only, the physical effects of employment on children, data which it is important to collect before conclusive statements can be made as to the desirability of this or that occupation for children. A prominent activity of this department should be the study of the various occupations which chil- dren enter, and the accumulation of evidence of the development of children after a period of months and years in these occupations. This information Health and Industry 607 can only be obtained by means of periodic medical examinations of children after employment has begun. The Ohio law relating to health certificates for work permits should be amended to require such periodic medical exami- nations. The law should be amended also to assure a medical examination in every case before a certificate is issued for a specific job. The pledge of the employer required in the present law should be amended to specify the exact nature of the work a child is to do, as otherwise a child may be trans- ferred to work, other than that for which he received his work certificate, which may be injurious to his health. The amendments to the present law can be made as in the suggested form of the law, which follows: 2. Suggested Content of Ohio Law re Health Certificate for Child Applying for a Work Certificate. Section 7764-1 (4) Health Certificate. A certificate from the school physician, or if there be none, from the board of health, and if there be no board of health within the school district in question, from a licensed physi- cian appointed by the board of education, showing after a thorough medical examination that the child is physically fit to be employed at the specific occupation for which the child makes application for a permit, such occupation to be one not prohibited by law for a child under 18 years of age. Periodical examination of children who have been granted one health certificate shall be provided for by limiting the period of time for which certificates may be issued to two periods of six months each and one period of one year successively. A thorough medical examination showing the child to be physically fit for the employment in which he is to engage or is engaged shall be necessary in every case, before a certificate may be issued. Certificates may be granted for shorter periods of time than six months or one year, successively, if the physical condition of the child warrants more frequent examination, or if the child is allowed to work while receiving medi- cal treatment for correction of remediable physical defects. A new certificate shall be required upon every change of employment. An adequate force of qualified physicians and others shall be provided for the work of examination and follow-up which may be necessary. (Pledge of Employer) (1) A pledge or promise signed by the employer or by an authorized manager or superintendent, specifying the exact nature of the work which the child is required or permitted to do, the number of hours per day during which the child is to be regularly employed, and the name and address of the employer, in which pledge or promise the employer agrees to employ the child in accordance with the provisions of this act, and to return to the superintendent of schools or to the person authorized by him to issue such certificates, the age, schooling and health certificate of the child within two days from the date of the child's withdrawal or dismissal from the employer, giving the reasons for such withdrawal or dismissal. 608 Hospital and Health Survey 3. Subnormal Children in Industry There are at present no means of ascertaining the mental capacities of all children wishing to go to work, other than the school record, which is too brief to furnish any information except the fact that the child has completed a specific school grade. Completion of the sixth grade is required of all boys and of the seventh grade of all girls. If it is decided that the mental capacity of a child is such that he cannot pass the required grade, that child may obtain a special permit to go to work, other requirements being complied with. School children who are suspected of being mentally deficient are tested by the examiner of subnormal children of the Department of Medical Inspection of the Board of Education. Only a small number of the subnormal children in the city are so examined. Such of those known deficient children as apply at the attendance department for a certificate to work, have on their school record the fact of their deficiency, and that fact is taken into consideration when the children are medically examined for a certificate. This information is invaluable in directing a child into the sort of work for which he is most suited because of his mental disability. A 15 year old boy went into the attendance department one day to obtain a permit to drive a truck for a construction company. He proved to be physically sound and during the time while he was being examined seemed normal. His school record showed that he was mentally deficient, having tested to a mental age of eight. The doctor promptly refused to grant him a permit for that job, as it did not seem wise to allow a boy of eight year old mentality to drive a truck about the city streets. There has been some discussion in the department as to the advisability of putting the statement of a child's mental deficiency on his school record, which goes to the work certificate office. Some officials felt that it was unfair to handicap the child in this way in finding employment. It is true that such a statement may not give a fair representation of the child's ca- pacity. The circumstances under which mental tests are given to a child may be such as to upset a not too well balanced mentality; that is, to a child in any degree uncertain of himself, it would be very upsetting to have to answer questions by strange people in the presence of his teacher and others who are strangers or of whom he is afraid. In such cases no child would give a very good account of his faculties. Furthermore, intelligence tests are still in the field of research, and not yet completely developed. It should not be so difficult to ascertain the mental capacity of an adult whose faculties have become somewhat crystallized, but it is questionable whether one group of tests as now used can set a value on the faculties of a growing child some of whose abilities are still latent. One employer, who has con- siderable sympathy for handicapped children, stated 'that he took three certificate boys who were mentally subnormal and put them to work in the machine shop. That was a year or so ago. Two of the boys were still there this spring, and one of them, his employer states, is making one of the best machinists in the shop and is an assistant foreman. It was his opinion that the tests which classed these boys as subnormal were too narrow in their scope, giving no indication of the fact that their ability might be entirely along ;i mechanical line. Health and Industry 609 Whatever the facts may be as to the adequacy of the tests as now given, their usefulness is undeniable and those in charge of them are exerting earnest effort to make the tests used complete, reliable and in step with the latest findings in this field of research. While more efficient tests may be worked out, those already in use are of great assistance in indicating, even if crudely, differences in mental capacities. Any knowledge of a deficiency in mentality of a child wishing to go to work should be communicated to his employer, as a protection both to the child and to the employer. In the visits to industrial establishments made during the course of this study, employers were questioned as to this point and the answer was invariably the same. "This information should be on the certificate of the child. It is of great assistance to us in deciding just Avhat the child shall do, and it protects us both from the chance of an accident." A study was made of all the records of the subnormal children applying at the work certificate office for working papers from September, 1919, to March, 1920. Of the 2,323 health records on file in the office for that period 148 were those of children whose mentality was deficient. According to these records 6.4% of all children having work permits are subnormal. This does not represent the total number. It represents only those children whose subnormality had been ascertained while they were in school. In close connection with the medical examination for work certifi- cates there should be facilities for determining more accurately the mental capacities of all children wishing to go to work. The data available from such examinations will be an exceedingly valuable contribution to the studies of employment for children which are now being made. A careful study was made of the 148 records of children of subnormal mentality. The work which these children were doing was analyzed, their physical defects tabulated and mental age recorded. In Table XXVI. in the Appendix the information thus obtained is shown in detail. There was more deficiency among the boys than among the girls, as the subnormal boys were 8.6% of the total number of boys who had obtained work certificates and the subnormal girls were 4.8% of the total number of girls. Twenty-seven of the boys and twenty-two of the girls had no physical defects. Poor nutrition and bad teeth were the chief sources of trouble for both boys and girls. In many cases the two went together. While the number of cases of defective vision was not great, it should be noted that what is described as mental deficiency in children is not infrequently retarded mental development due to bad vision. 13 girls and 8 boys who had tested subnormal in school came to the work certificate office with defects in eye- sight which should have been corrected before, in view of the fact that the children were thought to be defective and had proved to be so upon being tested. Not all of the children who had applied for work certificates were at work. Between a third and a half of the certificates had been returned to the office, <>1() Hospital and Health Survey showing that the children had left their original jobs. As the office has not followed up such cases, it is not known w T hether these children got other jobs and are working illegally or whether they are staying out of school at home. The jobs for which the children had certificates could be classified in three general groups, machine work, hand work and errand work. Almost half of the boys were doing errand work as messengers, wagon boys, etc. The machine work was of a simple sort, such as is done in a large knitting mill. Under hand work was grouped a large number of jobs in sorting and packing products, all of which require practically no skill and involve the repetition many times of one simple operation. Employers seem to have no objection to this group of workers. In many cases the work is very little different from that required of normal children. As before stated, the kind of work which many young children are doing is exceedingly simple, is easily learned and involves little or no mental effort. A question which requires study and which must be settled regarding such children, is whether or not they should continue in special schools where they can receive more training, or whether they should be more carefully inducted into industry where they can be under the stabilizing influence of regular work. Opinion differs on this point. Some teachers of backward children regret very much that they leave before 16 years of age, saying that it takes several years of special work to get any results with the children. Others believe that they are better off at work than in school and that the law requiring their attendance in school should be more flexible than it is, in order that such individuals may get to work as soon as possible. Such children can re- ceive their industrial training to better advantage in a shop than they can in a special class in school, where only meagre industrial equipment is pos- sible. In Cincinnati a special committee supervises the industrial careres of all such children. In Baltimore unusual boys are taken from school and put to work under the direction of a department having this special responsi- bility. The effect of carefully directed work on the character development of these boys has been noteworthy. An experiment of this kind is well worth trying. Too little is known of the possibilities which lie in the right kind of work for backward and unusual children. It is suggested that a special arrangement should be made in the work certificate offices whereby children of this group will be carefully studied and directed into employment and followed up after they are at work. i. Summary of Standards of Normal Development and Physical Fitness for Working Children (Tentative report of the committee appointed by the U. S. Children's Bureau to formulate standards for the use of physicians in examining chil- dren entering employment and children at work.) Health and Industry ■ 611 A. GENERAL RECOMMENDATIONS 1. Age Minimum for Entrance into Industry. Should be not less than 16 years. It is" important to protect a child from the physical and nervous strains of industry because of his general instability during the pubescent period. 2. Physical Minimum for Entrance into Industry. No child under 18 years should be permitted to go to work who is not normally de- veloped for his age, of sound health and physically fit for the work at which he is to be employed. 3. Physical Examinations for Children Entering Industry. A thorough medical examination for entrance into industry should be required and must show that a child is physically fit for industry. Before the examination is made the child must bring a promise of employment from his prospective employer stating the specific occupation in which he is to be employed. 4. Re-examinations for Children Changing Occupations. With each change of employer another examination should be made before the child is again permitted to work, likewise when a child is transferred in the same place to work differing in its physical demands and hazards from that for which a permit is issued. 5. Periodical Re-examinations for All Working Children. Yearly medical examinations should be required of all children at work up to the age of 18 years, or more frequently if judged desirable. These examinations shall take place either in the certificate issuing office or in the place where the child is employed. 6. Need of study by local administrative and medical officers of occupations in which children are employed and of their effect upon health. Occupations employing children should be especially studied by the examining physi- cian, who should also be required to familiarize himself with conditions of employment and the various health hazards of industry. 7. Need of authoritative scientific investigation. Considerable further study of the effects of different kinds of work upon the physique of the adolescent child is necessary, and especially with reference to: (a) Comparison of the rate of growth of children employed in different occupa- tions with that of children not in industry. (b) Comparison of morbidity among children employed in different occupa- tions with that of children not in industry. 612 Hospital and Health Survey (c) Comparison of mortality among children employed in different occupa- tions with that of children not in industry. (d) Fatigue in children employed in different occupations and industries. (e) Effect of employment in specific occupations at different stages of physio- logical development upon the growth and health of (1) normal children, and (2) children with certain physical defects. (f) Effect of employment in specific occupations upon the special functions and organs of adolescent girls and young women. (g) Types of work desirable for: (1) children with some mental defect, and (2) children who are suffering from some physical handicap. Considerable material for these studies could be obtained from public school medical records and records of examinations made for work certificates. All such records should be standardized so as to be statistically comparable. 8. Certain tentative minimum standards obtainable from results of scientific research already available. Although further study is necessary, there are sufficient data already on hand to justify the recommendation now of certain tentative minimum standards, which will materially safeguard the welfare of children entering industry while still immature. B. MINIMUM STANDARDS OF PHYSICAL FITNESS FOR CHILDREN ENTERING AND WORKING IN INDUSTRY 1. Standards of normal development. (a) Certificates should be refused to children who do not come up to the fol- lowing minimum standards of height and weight for specified ages, based on the most reliable present-day experience. Age Weight (in clothing) Height 14 80 lbs. 58 inches 15 85 lbs. 58 inches 16 90 lbs. 59 inches Exceptions may be made if other circumstances in the child's case, such as racial characteristics, warrant it. (b) Certificates should be refused to children who do not show certain unmis- takable signs of adolescence. 2. Standards of health and physical fitness for specific employment. (a) Certificates should be refused permanently to all children who have cer- tain specified defects. All such children should be referred to the appro- priate agency for whatever assistance may be necessary. Health and Industry 613 (b) Certificates should be refused to all children pending correction of all serious remediable defects. Such children should be referred to the ap- propriate medical agency for the necessary medical treatment. (c) All children who, for any reason, show a tendency to weakness or disease of any organ should be excluded from occupations which tend to aggravate that tendency. C. POINTS TO BE COVERED AND METHODS TO BE EMPLOYED IN PHYSICAL EXAMINATIONS 1. Items for Inquiry. (a) First examination should include a record of sex, race and nationality, age, intended employer (name and address), intended occupation and industry, school grade completed, family history of father, mother, brothers and sisters, previous illness and phys- ical examination. The physical examination should include the following: Nasopharynx Glands Chest, heart, lungs Abdomen Nervous system Summary of defects, as correctable and non-correctable. Certificate should be (a) recommended after first examination, or (b) refused, either per- manently or temporarily, pending correction of specified defect, or (c) recommended after re-examination (that is, after correction of defect). (b) In re-examinations the same points should be covered as in the first examination, and any changes noted in detail. 2. Record card and instructions for use of examining physician. The use of a uniform record card is recommended in order that uniformity may be obtained in administration and in statistical analysis. Such a record form is included in the report of the committee. (These standards in full may be obtained from the Federal Children's Bureau, Washington, D. C, upon application.) EDUCATION'S RESPONSIBILITY More educational preparation for the transition from school to industry is necessary. Upon the training provided in public education depends in a great measure the success with which children are guided out of the school period of semi-dependence into the industrial period of greater freedom and final independence when they must rely wholly on their own efforts. Height Maturity Weight Skin Physical condition Eyes Nutrition Ears Anaemia Mouth 614 Hospital and Health Survey It is generally agreed that education's prime function is that of training for citizenship in the complete sense. That this education must contain more elements which will connect it with industrial life is also generally agreed. When 75% of the children leave school shortly before the comple- tion of the elementary grades to go to work, it is necessary to plan a course of education which will supply the essentials within these grades. Indus- trial experts believe that vocational training should not be included in ele- mentary education except in the broadest sense, that schools supported by general taxation should not be expected to supply specific training for par- ticular jobs, that being the responsibility of industry. But the schools are not alive to their responsibility in getting children safely to work. Their influence should not cease as soon as the child goes through the school door. Authorities agree that partial supervision of the child should continue until the child is 18. His public school education should continue at least as long as that in some form. The problem of incorporating into the school program a sufficient amount of preparation for industrial life, of the right sort, is one of the most pressing and fundamental of the many questions which educators must face. Of the various experiments already being tried out none has as yet proved itself of sufficient value to justify its general use. The problem has many angles and requires considerable study and experimentation. The endeavor of the National Association of Corporation Schools to gather data on the subject and to develop experimentation in industrial training as well as in general education is a noteworthy instance of the many earnest efforts being made to throw light on a perplexing but interesting problem, interest- ing because it is of recent growth and is an index of the changing attitude of society towards industry. It has taken a long time for general thought to recognize that cultural education may include knowledge of the industrial world as well as of the world of letters and of science. . This problem cannot be solved easily. It is not within the province of a health survey to make specific recommendations as to how it shall be done, whether by more vocational training of a general nature in the school cur- riculum, whether trade apprenticeship in industry, or by the exten- sion of the establishment of continuation schools. The Smith-Hughes Act, passed by the United States Congress in 1917, has been a great incentive to the organization of some sort of vocational education in all of the states of the country. The local Board of Education or the Ohio state educational authorities should give this subject careful consideration in the near future and make more adequate provision for industrial training in the school pro- gram than exists at the present time. One element of training for industrial life which should be mentioned here is that of health education. Education for physical development and health maintenance cannot begin too soon. Knowledge of the elements of hygiene and sanitation should be thoroughly taught. For the child entering industry it is important that he shall know not only the value of physical and nervous energy and its conservation, but also the particular health hazards which he will encounter in industry. Trained to take into account Health and Industry • 615 health considerations just as he takes into account wages and hours of work, in determining the relative merits of possible jobs he will have learned a valuable lesson, and a most useful one. As reported in the section on Child Health Work (Part III.) there is no systematic instruction in hygiene and sanitation offered to the school children of Cleveland at present. A study of the subject brings out the necessity for such instruction for children who are going into the greater freedom of the industrial world, while they are still children. Every possible measure which can be taken to teach them to take care of themselves contributes towards their development into healthy adults. The Board of Education should provide at once for syste- matic and thorough health instruction throughout the grammar grades. JUNIOR VOCATION DEPARTMENTS Nor is there space in the scope of a health survey to do more than indi- cate the problem of actual industrial placement of children going to work at an early age. Sufficient industrial training before leaving school and care- ful selection of the first jobs in industry are both factors of influence in assuring the establishment of sound health in children of this formative age. Not only must a child be adequately prepared and physically qualified to go into industry; he must also get into the right place where his individual abilities have a chance for expansion. As pointed out previously a child cannot be expected to do this unaided. Many do and eventually make a success of their work, but it is not reasonable to expect that every child can do so, nor to assume that it is anything more than chance when a child does by accident, marked inclination, or repeated trials, land in a job which suits him and offers opportunity for development. Provision should be made for continuance during the early years of his employed life of the supervision by which a child is guided through school life. Some advice and individual consideration for each child going to work, given by a person familiar with the various fields of work open to children and having sympathy with and understanding of their desires and inclinations, can be of great service in effecting an early adjustment for the child with industrial life. Vocational guidance is still in the stage of experimentation, being one of the many prob- lems concerning children of working age which have only recently received attention. The whole problem of inducting children from school into industry, which has been considered in this study in its relation to the establishment of sound health in youth, can be met by the organization of Junior Employment Departments. England as long ago as 1910 saw the possibilities of central- ization, and made provision for it in the Education (Choice of Employment) Act. For the past five years even more care has been given to working children than provided for in this act. Children going to work have the benefit of individual advice regarding work, of consideration of their physical well-being, of educational opportunity to train for a vocation either before or after they begin work. It is considered to the nation's interest "that all children* receive a good chance of health and satisfactory employment." In England the juvenile labor exchange is under the direction of the school. 616 Hospital and Health Survey Junior employment departments or vocational guidance bureaus are developing in this country, and it has been found likewise advantageous to have the department closely connected with the school. When the activities for children of this age are closely related it is possible to unify the efforts of all and to be sure that all children are kept track of, and all information re- garding individual children made use of. There are numerous reasons which make advisable such centralization of activities. In Cleveland a free public employment bureau has been in existence for some years under the joint control of the state and city authorities. This bureau has conducted employment work for boys and girls for some time. The boys' work is in a separate department. The girls' and women's work has been combined in one department although previously separate. Careful investigation of the work in which young people are employed and of the establishments where they are to be sent has been a prominent feature of the junior employment work. The work of this department could probably be more effectively carried on in direct connection with the Board of Education department which has supervision of all children going to work. By such a central organization the process of guiding children from school to work would be a continuous one, under unified control and direction, making contradiction of purpose impossible. Free interchange of opinion and advice between those ascer- taining by examination the abilities of children and those directing them into industry would be possible and of great value. All of the data available, relating to the various phases of the employment of children, would be ac- cumulated in one place and their value for research and action be unequaled. Until such time as it is possible to effect a consolidation between the two departments it is recommended that their relations be made as close and direct as possible in order that the opinion of those examining the child who wishes to go to work, may direct the efforts of the employment bureau in finding the child suitable employment. Employment suited to a child's physical and mental abilities is essential. The degree of harmony attained between a child and his first job has no small influence in determining whether he will settle down and develop desirable work habits leading to a well ori- ented character or whether he is going to be dissatisfied in a short time and try another job, drifting about until his work habits become unsettled and his character unstable. An outline for such a Vocational Guidance Department is appended. It contains in the plan of organization the essential activities involved in deal- ing with the children of working age, all of which are properly included in a department functioning under the Board of Education in any city. Some features included have proved their value in similar departments already organized in this country and abroad. A plan of this character is appropri- ately a part of this report as it emphasizes ou opinion that the problem of the child going into industry is fundamentally one of health, and in order to protect his health adequately there must be a central bureau Health and Industry 617 which will serve as a bridge for his safe conduct from school into the industrial world. Proper consideration of a child's physical abilities comes first. This fact recognized and coupled with the other factors which must be considered, there is no reason why children should not benefit by their early industrial experience, rather than be permanently handicapped if not wasted to society by their ill-advised efforts at work, before they are equal to it or for which they are unfitted. A careful organization of the procedure of letting and getting children to work will give the health questions the important place which they should have, and will provide adequate machinery for continuing the task of supervision of children until they reach maturity. Suggested Plan of Organization tor a Junior Vocational Bureau of the Board of Education of Cleveland To include boys 15 to 18 and girls 16 to 18 years of age. This period of years is sug- gested rather than 15 to 21 years, because it is the division made by the State Child Labor Law between children and adults. Also it simplifies the division of children's and adults' employment into two offices, which offices can then be physically as well as officially separate. This organization will include all steps in the procedure of letting and getting a child to work, from the time when he is still in school and thinking of going to work, to the time when he is well established in suitable employment. /. School Connections. 1. Continuous record cards to be used, containing the medical, mental, scholastic and social (including family) history of the child, beginning with his first year in school and following him through the grades to -the office where he makes application for a work certificate. Such records have been used with great success in other cities. 2. Scholarship fund for children who otherwise would be obliged to go to work be- cause of economic necessity. 3. Vocational talks to children who are thinking of leaving school, emphasizing the importance of longer schooling, but also giving introductory information regarding indus- trial life. 4. Published leaflets on occupations open to children, to contain ^specific informa- tion relative to various occupations for the benefit of children making ^ready to leave school for work. //. School Attendance and Illegal Employment The school attendance and illegal employment of children of working age must be closely checked up in order to make certain that every child going to work does so legally by going through the work certificate office where he must undergo a medical examination before receiving a work certificate. 618 Hospital and Health Survey In order that all information relative to children 15 to 18 years of age may be utilized, the school census records should be available at this office. Special duties of one or more of the regular school attendance officers would be to follow up the school attendance of children of this age, to keep in touch with the State Factory Inspection Department regarding children at work, and to follow up all cases of children whose certificates have been returned, to see that they return to school if not at work. Correspondence has been successfully utilized to accomplish some of these ends. ///. Issuance of Work Certificates. 1. Establishment of birth and school records in accordance with the legal require- ments. 2. Medical examinations for health certificates, as required by law. The physician, nurses and clerks are to make and record medical examinations and follow up children whose permits are held up, until remediable defects are corrected, or are refused because of physical disability. These children must be kept track of, to see that they get medical assistance when necessary or return to school if not allowed to be at work. The school medical record of a child is of service here. • 3. Mental Tests — At present only marked subnormality is recorded in most offices. Intelligence tests are now used most effectively by many large corporations. Their use in this department is essential in aiding in the selection of suitable work for normal aS well as for subnormal children. IV. Vocation Bureau. 1. Continuous research in occupations open to children is necessary for the purpose of advising children wisely regarding work, and for the purpose of accumulating informa- tion, in respect to the health hazards for young people in various types of work. Too little is known on this subject at the present time. Such information must be available to the physician diagnosing a child's physical capacity for employment. 2. Placement and Guidance — Connects children who have received work certificates with jobs, and has the advantage of all the facts established by previous examinations as to the child's physical and mental qualifications, for use in vocational guidance work. V. Research. Through the many contacts which this bureau would have, and the large amount of information in its files, special studies of related questions would be of value, as well as periodical analysis of information in the files. VI. Advisory Committees. Note — In the two months which have elapsed since the field work for this report was completed, steps have been taken by the Cleveland Board of Education towards the formation of such a bureau. The Bureau of Attend- ance of the Board of Education has been enlarged and its functions extended. Health and Industry 619 Records have been established which will carry the medical, social and school history of the child from the time when he first enters school to the date when he leaves school to apply for working papers. Vocational advice to such children is to be provided, and the possibility of arranging for employ- ment work is being considered. Greater emphasis is being put on a child's physical status, ascertained by medical examinations, as the determining factor in deciding whether or not he shall receive a permit to work. SUMMARY OF RECOMMENDATIONS J. Recommendations Requiring Legislation. 1. The Ohio State Child Labor Law should be amended in the following particulars: Age Requirements — The employment of boys before they are 16 years of age should be forbidden. Age and schooling certificates should be required of all boys under 18 years of age at work. This makes the age requirements for boys and girls the same. In all cases in the law where an "age and schooling certificate" is mentioned the law should be changed to read "age, schooling and health certificate," inasmuch as the health certificate received by the child going to work is one of the most important factors to be considered in certifying a child for employment. 2. The Ohio School Code should be amended in the following particulars: Educational Requirements — Girls 16 to 18 years of age are not now required to continue school if not employed. The law should be amended to include this requirement and to make similar requirement for boys 16 to 18 years of age. Health Certificate — The section of the law relating to a health certificate for a child going to work should be changed. In no case should a child receive a certificate based on a previous record of the child's health. A thorough medical examination, made by a qualified physician, should be the requisite for every health certificate issued. These certificates should be issued in such a manner and for such periods of time as to insure periodical examinations of children over the two years from 16 to 18, or while they are employed on a certificate basis. Every health certificate should be issued for the specific job for which the child makes application for a permit. There should be included a pro- vision for an adequate force of examiners and assistants, for the work of examination and necessary follow up. Pledge of Employer — Added to this section of the law should be a clause requiring that the promise signed by the employer specify the exact nature of the work which the child is required or permitted to do. Agricultural Worli and Domestic Seroice are not now included by the Ohio Child Labor Law in the occupations under its supervision. There should be an age limitation of at least 12 for these occupations and a limitation of hours of work, similar to those limitations in hours of work in other occupations. A health certificate should be required of every child. Regulation of conditions of work may involve some difficulties needing the cooperation 6"20 Hospital and Health Survey of other agencies. Examinations for health certificates can be conducted in the same man- ner as for other occupations by the existing machinery without great difficulty. 3. The City Ordinance regulating street trades should be enforced, pending the inclusion of these trades in the State Child Labor Law. Certificates to boys to engage in this work and badges to be worn by them while at work, as specified in the ordinance, should be received from the work certificate office of the Board of Education, where each boy will receive a medical examination showing him to be physically fit for this kind of work, before he can receive a permit. II. Recommendations re Existing Departments, State or Local. 1 . Enforcement of the State Child Labor Law is under the direction of the Industrial Commission of Ohio. The law is not at the present time adequately enforced. Methods of work should be improved and the personnel for inspection increased, in order to elimi- nate the illegal employment of children, the extent of which the findings of this study indicate. 2. Enforcement of the State School L aw is similarly inadequate. It is under the direc- tion of the Board of Education. The number of School Attendance officers should be in- creased and the organization of the Attendance department and the Work Certificate Office revised. The School Census maintained by another department of the Board of Education should be more closely related to the department of Attendance, to aid in the work of checking up on the attendance of children, and especially those of working age. 3. Medical Examination for Work. Certificates — The present organization is under the direction of the Department of Medical Inspection of the Board of Education. It needs to be considerably expanded and its working force increased. Health standards for chil- dren going into industry should be formulated, patterned after those soon to be issued by the Federal Children's Bureau Committee on Health Standards for Children in Industry. One of its functions, still to be developed, should be sufficient contact with the industrial field to assure familiarity with the jobs open to children, in order that the examining physicians may be able to decide intelligently as to the desirability of different kinds of work for the various children examined. 4. Mental Examinations for Wor\ Certificates — There is at present no means of de- termining the mental capacities of children wishing to go to work, other than the school record, which is too brief to furnish any information except the fact that the child has completed the required school grade, except in the case of children who have been known in school as markedly subnormal. There should be in close relation to the work of medical examination for health certificates facilities by which to determine more accurately the mental capacities of children wishing to work, in order to aid in the selection of employ- ment for them. 5. Educational Training — More educational preparation for the transition from school to industry is necessary. It is not within the province of a health survey to make specific recommendations as to how this shall be done, but the Board of Education or the State educational authorities should give this question careful consideration in the near future, and make provision for more effective industrial education. In particular the Board of Education should provide at once for systematic and thorough health instruction in the Health and Industry 621 grammar grades. Knowledge of the elements of hygiene and sanitation is essential to the child entering industry as well as knowledge of the character of the health hazards which he will encounter in industry. 6. Junior Employment — The junior employment work at present under the direction of the Public Employment Bureau should be carried on in more direct connection with that department of the Board of Education having supervision of all children going to work, in order to have unified control and direction, making contradiction of purpose impossible. Until such time as it is possible to effect this consolidation it is recommended that the relation between the departments be made close and direct, in order that the opinion of those examining a child applying for a work certificate may direct the efforts of the employment bureau in finding suitable employment for the child. 7. Attendance Department — Plans have been made recently to enlarge and extend the functions of the Attendance Department of the Board of Education. Sufficient promi- nence should be given to the medical and mental examinations in all questions relating to the issuance of work certificates and to vocational guidance, as the medical and mental examinations, properly conducted, give unequaled opportunity to make adjustment be- tween the law and individual variation in capacity and physical development. More de- pendence should be placed on the results of careful examinations of children in deciding as to their employment in various occupations, thus lessening hardship or unfairness in individual cases. 622 Hospital and Health Survey TABLE I. Classification of 1,521 Industrial Organizations by Size Groups Including Employes Group by Size of Organization 1 ,000 and over 500 and over 400 and over 300 and over 200 and over 100 and over 1 and over Less than 1,000 Less than 500 Less than 400 Less than 300 Less than 200 Less than 100 1,000 and over 500 to 1,000 400 to 500 300 to 400 200 to 300 100 to 200 1 to 100 Totals 1,521 100.00 196,246 100.00 TABLE II. Medical Service in Industrial Organizations Group by Size of Total Number Total Total Per Per Organizations Number Organ. Number Number Cent Cent Organ. with Employes Employes Organ. Emps. in Medical in Recvg. in in Group Service Group Service Group Group Served Served 1,000 and over 39 32 84,359 72,196 82.05 85.58 500 to 1,000 41 30 28,176 20,786 73.17 73.77 200 to 500 102 7 32,029 2,118 6 86 6 61 1 to 200 1,339 3 51,682 365 0.22 0.70 Totals 1,521 72 196,246 95,465 4.73 48.64 1,000 and over 39 32 84,359 72,196 82.05 85.58 500 and over 80 62 112,535 92,982 77.50 82.62 200 and over 182 69 144,564 95,100 37.91 65.78 1 and over 1,521 72 196,246 95,465 4.73 48.64 Number of Organizations Per Cent of All Organiza- tions Number of Employes in Group Per Cent of All Employes All Groups Average Number Employes per Organ- ization 39 2.56 84,359 42.98 2,163.0 80 5.25 112,535 57.34 1,406.6 100 6.57 121,362 61.84 1,213.6 134 8.80 132,802 67.67 991.0 182 11.96 144,564 73.66 794.2 294 19.32 155,246 79.10 528.0 1,521 100.00 196,246 100.00 129.0 1,482 97.44 111,887 57.02 75.4 1,441 94.75 83,711 42.66 58.0 1,421 93.43 74,884 38.16 52.6 1,387 91.20 63,444 32.33 45.7 1,339 88.04 51,682 26.34 38.5 1,227 80.68 41,000 20.90 33.4 39 2.56 84,359 - 42.98 2,163.0 41 2.69 28,176 14.36 687.2 20 1.32 8,827 4.50 441.3 34 2.23 11,440 5.83 336.4 48 3.16 11,762 5.99 245.0 112 7.36 10,682 5.44 95.3 1,227 80.68 41,000 20.90 33.4 129.0 Per Cent Emps. Served of All Emps. Per Cent Organ. Served of All Organ 36.78 2.10 10.59 1.97 1.07 0.46 0.18 0.20 48.64 4.73 36.78 2.10 47.37 4.07 48.45 4.53 48.64 4.73 Health and Industry 623 TABLE III. Personnel of Medical Departments Number Organ. Number of No. of Full- Group by Size of with Me Organization Service 1 , 000 and over.. 32 500 to 1,000 30 200 to 500 7 1 to 200 3 Totals 72 95,465 93 No. of No. of No. of No. of No. of No. of Part- Phys. Trnd. Prac. Cleri- Employes Served Ind. Disp. Time Phys. Time Phys. on Call Nurses Nurses cal Pers. 72,196 53 6 41 8 69 12 14 20,786 30 1 16 8 18 7 2,118 7 4 1 6 365 3 1 1 1 62 18 93 20 14 TABLE IV. Administrative Relations of Fifty-six Medical Departments Group by Size of MEDICAL DEPARTMENT RESPONSIBLE TO Organizations Administration Production Employment Claims Total 1,000 and over 7 5 15 2 29 500 to 1,000 8 5 8 21 200 to 500 10 3 4 1 to 200 2 2 Totals 18 10 26 2 56 TABLE V. Medical Service in Mercantile Establishments and in Public Utilities No. No. Estab. No. of No. of No. of No. of No. of No. of No. of with with Dis- Em- Full- Part- Phys. Trnd. Prac. Vistg. Medical pen- ployes Time Time on Nurses Nurses Nurs- Service saries Served Phys. Phys. Call ing Mercantile 6 69, 107 1 3 2 5 2 2 Public Util 6 7 13,302 7 16 12 Totals 12 13 22,409 1 10 3 11 3 4 624 Hospital and Health Survey TABLE VI. Accident Frequency and Severity Rates for Cuyahoga County Based Upon Ohio Industrial Commission Report for July to December, 1914 For six months period: Accidents causing death 44 Accidents causing permanent partial disability.. 330 Accidents causing disability over seven days 3,892 Accidents causing disability two to seven days..... 4,571 Time Loss: Cases fatal (6,000 days each) _ 264,000 days Permanent partial disability 52,127 days Temporary disability, over seven days 103,976 days Temporary disability, under seven days 9 , 199 days Total time loss, all accidents, six months 429,302 days Accepting estimate of Bulletin 9 (1915), Industrial Commission, employes in industry numbered 185,000. Estimated number reportable accidents annually 17,344 Frequency rate (number per 1,000 full-time workers) 93.7 Estimated number days lost per year..... 858 , 604 Severity rate ( days lost per worker per year) 4.53 TABLE VII. Accident Frequency and Severity Rates for Groups of Operatives Employed Within Selected Areas Based Upon Reports Furnished by the Industrial Commission of Ohio Covering the Period of June 1st to November 30th, 1919 Group Number of Employes Accidents During Six 7 Days and Fatal Less Months More than 7 Days Estimated Yearly Total Freq. Rate Estimated Yearly Time Loss Sever- ity Rate I. 24 , 298 3 905 215 2,246 92.4 33,927 1.3 II. 19,600 6 2,147 520 5,346 276.3 74,345 3.7 III. 10,193 2 1,371 287 3,320 325.7 33,945 3.3 Totals 54,091 11 4,423 1,022 10,912 201.7 142,217 2.6 Time losses were estimated by reckoning a fatal accident as equivalent to 6,000 days. Employing average values previously published by the Industrial Commission, tem- porary disability of seven days or less was reckoned at 2.1 days; temporary disability of more than seven days, at 28.2 days. Health and Industry 625 TABLE VIII. Comparative Accident Frequency and Severity Rates in the Con- struction and Metal Trades Based Upon Statistics Published by the Industrial Commission of Ohio for Cuyahoga County, July to December, 1914 Construction Metal Trades Trades Number of employes 20 , 000 72 ,900 Accidents (6 months): Fatal 19 10 Permanent partial disability 30 71 Temporary disability 1 , 393 3 , 825 Total number accidents 1,442 3,906 Accidents (calculated for one year) 2 ,884 7,812 Accident frequency rate 144.2 107.1 Corrected for assumed 10-hour day, 200-day year 216.3 Corrected for assumed 8-hour day, 200-day year 270.3 Calculated time loss, days per year '. 290 , 868 246 , 858 Accident severity rate 14.5 3.38 Corrected for assumed 10-hour day, 200-day year * 21.0 Corrected for assumed 8-hour day, 200-day year : 27.2 The corrections above noted are made in consideration of the fact that many workers in the construction trades do not work a 3,000-hour year, which is the normal basis of computation of frequency and severity rates. The time losses given in this table were calculated from those published by the Indus- trial Commission, with the exception of allowances for fatal accidents, which were reckoned as each equivalent to a loss of 6,000 days. 626 Hospital axd Health Survey TABLE IX. Classification of 79 establishments employing women, presenting numbers of various establishments, numbers of women therein employed, and group totals. Group Industrial No. of Establish- ments 23 11 7 6 3 2 5 Group Total 57 Nature of Group Members Metal Trades No. of Female Employes ... 3,691 Group Total Knitting and Textile ... 4,642 Garment Trades ... 2,700 Candy Factories 371 Paper Box Factories 220 Tobacco Factories 375 614 12,613 Mercantile 7 7 Department Stores 6,730 Personal Service. . 6 3 2 11 Laundries Hotels Restaurants 505 708 245 - 1,458 Public Utilities 2 2 4 Telephone Companies Telegraph Companies 1,675 430 2,105 Totals . 79 22,906 Health and Industry 627 tn (-« Cn i-> l-» >-> CO m§ 38 _ i_i w -£> ~j in *-* •* . n » g. ft w N A i o 3 o ™ 00. ' g "1 O o C Ul 3 sr •o ^ 09 •4 o* °°. SB rt- 09 re W CD a •- r^W o 5' 5. 3 a h- » rl-' rt- c o < o O it a >1 H S[ > o v sr • ^s 3 3 >*» s » r* 3 99 w » A 3 o 5* (0 3" 3 o «2 •o 5' o* go. << a 5 w 09 o 628 Hospital and Health Survey XI - < S S - - a; ^q «-" — ■ §| J5 is •* "2 v G U *J JO S3 : o in <^ «> - J% •& H o 631 ^5 3 2 3 ss ^ V fig. 55? yi en _,^ Q ST d a 3 a d 3 a* » > 03 r 9 ?s ^ „.3 3 9 -.3 3 2 3 O d *9 h- in -3 3 2 632 Hospital and Health Survey TABLE XVII. Number of Children at Work, By Age and Sex From the Work Certificate Records, September, 1918 to September, 1919 Permits Vacation Total September, 1918 to Permits Number June, 1919 June-September, 1919 at Work Boys 1,444 581 2,025 Girls 2,057 546 2,603 Total 3,501 1,127 4,628 TABLE XVIII. Number of Children at Work, By Age and [Sex From the Records of the Industrial Commission of Ohio, 1919 Clerical Wage Sales Total Workers Earners People Workers Boys 617 2,248 92 2,957 Girls 573 1,416 83 2,072 Total 1,190 3,664 175 5,029 TABLE XIX. Comparison of Tables 16-18 for Number of Children at Work Boys Girls.. School Census Ages 15-18 Work Certificate Records. Ages 15-16 and 16-18 Ind. Commission Records. Ages 15-18 9,068 1,444 2,957 (15-18) (15-16) (15-18) 6,778 2,057 2,072 (16-18) (16-18) (16-18) Total 15,846 3,501 5,029 Health and Industry 633 TABLE XX. Occupations Employing Children Under 18, By Age and Sex Analysis of Records of Industrial Commission of Ohio, 1919 Trade, Telephone Construe- Manufac- Retail and and tion turing Service Wholesale Telegraph Total Boys — Clerical Workers 15 309 116 157 20 617 Wage Earners 67 1,778 56 316 31 2,248 Salespeople 1 3 .... 88 .... 92 Total..... 83 2,090 172 561 51 2,957 Girls- Bookkeepers 12 205 92 187 77 .573 Wage Earners 688 43 299 386 1,416 Salespeople 6 .... 77 .... 83 Total.-.. 12 899 135 563 463 2,072 Total- Clerical Workers 27 514 208 344 97 1,190 Wage Earners 67 2,466 99 615 417 3,664 Salespeople..... 1 9 .... 165 _.. 175 Grand Total 95 2,989 307 1,124 514 5,029 Per Cent of Total Number Employed of Each Group by Sex Clerical Workers Wage Earners Sales People Total No, Per Cent No. Per Cent No. Per Cent No. Per Cent Boys..- 617 20.9% 2,248 76.0% 92 3.1% 2,957 100% Girls™ 573 27.6% 1,416 68.4% 83 4.0% 2,072 100% Total 1,190 23.7% 3,664 72.8% 175 3.5% 5,029 100% 634 Hospital and Health Survey TABLE XXI. Distribution of Children in All Occupations and in Leading Manu- factures for 1915 and 1919 From the Records of the Industrial Commission of Ohio, 1915 and 1919 Boys Girls Occupation 1915 1919 1915 1919 Construction __ » 58 Manufacturing 1 ,638 Service 37 Trade, Retail and Wholesale _ 323 Telephone and Telegraph Work _ 44 83 12 2,090 859 899 172 6 135 561 299 563 51 35 463 Total 2,100 2,957 1,199 2,072 Leading Manufacturers Autos and Auto Parts Bolts, Nuts, Etc.... Clothing, Men's and Women's Confectionery Copper, Tin, Etc Electrical Machinery Foundry and Machine Shop Products.... Gas and Electric Fixtures Hosiery and Knit Goods Printing and Publishing _. Sewing Machines... Steel Works and Rolling Mills.. Woolen and Worsted Goods Total 849 1,423 580 686 Boys Girls 1915 1919 1915 1919 66 120 53 18 44 76 6 3 26 37 286 115 8 32 76 76 61 19 71 277 14 53 200 334 12 53 24 96 23 187 36 15 121 29 202 242 26 81 160 10 76 4 20 1 7 42 Health and Industry 635 TABLE XXII. Weekly Wage Rates for Children By Occupation and Sex From the Report of the Industrial Commission of Ohio for 1919 Trade, Telephone Construe- Manufac- Retail and and Weekly Wages tion turing Service Wholesale Telegraph Total Total 75 47 88 100 338 Under $5.00 — Boys Girls $5.00-$6.00— Boys 1 Girls .-„ $6.00-$7.00— Boys 7 Girls 1 $7.00-$8.00— Boys 5 Girls $8.00-$10.00— Boys 34 Girls $10.00-$12.00— Boys 14 Girls 1 $12.00-$15.00— Boys 11 Girls 5 $15.00-$18.00— Boys 4 Girls 2 $18.00-$21.00— Boys 2 Girls _. 1 $21.00-$25.00— Boys 3 Girls 1 $25.00-$30.00— Boys 1 Girls 6 2 1 5 14 58 $30.00-$35.00— Boys 1 Girls 1 20 4 29 1 54 2 2 17 21 13 3 23 1 41 4 2 6 8 5 35 2 57 1 5 24 31 31 11 19 5 71 14 7 8 29 87 23 74 11 229 47 9 49 4 109 268 43 109 12 446 201 40 177 328 747 567 49 138 10 775 3 71 33 172 86 667 473 16 87 6 586 178 14 83 20 297 424 19 40 485 57 14 23 8 103 154 4 2 163 18 5 7 10 41 42 1 44 6 2 1 5 14 3 1 3 8 2 2 5 1,193 1,442 883 588 204 Total..._ 95 2,989 307 1,124 514 5,029 5,029 636 Hospital and Health Survey TABLE XXIII. A Analysis of Records of 100 Newsboys in Cleveland, Showing Age, School Grade and Mental Capacity School Grade Mental Capacity \ge I. II. III. IV. V. VI. Total Good Fair Poor Total 6 4 .... .... .... 4 1 2 1 4 7 1 3 4 2 2 4 8 6 2 8 3 4 1 8 9 2 2 4 3 1 4 10 1 .... 2 5 4 12 7 3 2 12 11 1 2 5 12 1 21 11 5 5 21 12 (Special 2) 10 5 17 9 5 3 17 13 (Special 6) 2 5 12 25 8 11 6 25 14 .... 2 1 3 3 3 15 .... .... .... .... 1 1 2 2 2 rotai [ 7 11 10 10 34 20 100 44 31 25 100 TABLE XXIII. B Analysis of Records of 100 Newsboys, Continued, Showing Age, Health and Hours of Work at Night Health Age Good Fair Poor Total 6 3 1 4 7 1 3 4 8 4 1 3 8 9 1 1 2 4 10 6 2 4 12 11 8 3 10 21 12 8 4 5 17 13 17 3 5 25 14 3 3 15 1 1 2 Total 51 15 34 100 Work Till Night 5 6 7 8 9 10 Total 2 1 1 4 1 2 1 4 5 1 1 1 8 1 1 2 4 3 4 1 1 1 2 12 3 9 5 2 1 1 21 2 9 2 3 1 17 3 12 2 4 3 1 25 1 1 1 3 2 .... 2 19 40 14 14 100 Health and Industry 637; ffi W *ti § 3 Si (0 H n rt o nt C loye rs Gi EL W H o 03 < 8 X s n 3 3 X J ca r o c 03 3 n g > < H H M 3 H 9. 3 o. E, 03 a a O O <* s o a n n H o - 3 N3 v " > 2! d H > g M H Kl M O H a Z d o rt 2! U ►1 2d3 o n 03 o n T O rt t« rt J? 1 ■* SSi "■ J? 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'On "I* CO o CO CS I-H o I tf •a C a . off) 0. • CO w o O o © © 1 ° < 3 3 IS ao O o o o o c CB o CS © © © 1 e* go o W v> fcE"" W Q W 03 W «S C faS"" W Q 1 *o O o O 03 '- J ^5 o J - +-> a O 0, u CO ID f-. CO I— c o O 01 f u -H oo Ol ^H © 1 2 05 4) H H *d U u cj O £ < (4-1 c < c o o _o 1— < i— i VO o o « n- r-H m m CS © i m s- '- 03 u CB > O 03 U i> 1 ^ t 00 CS V >* 00 O ^-1 o © O 4-> si 2;^ CS CO CO co o s ^H m Ol ■<*■ I-H 1 S 00 *So m 03 >> ■M 1 m t^. m vo s 03 1 E CS X CS i ■*■ *3 o m 2 " ■* lH oe 5 CS cs 1—1 1 *o < 6 X o t^ 00 Ot o »H •g.aa J>» 00 C^ © •f si M< ** r-i "ffl 5?l?< 1-1 1— I "3 Pi ^^ 4- c cu- 4J o H h THE CLEVELAND HOSPITAL AND HEALTH SURVEY REPORT List of Parts and Titles I. Introduction. General Environment. Sanitation. II. Public Health Services. Private Health Agencies. III. A Program for Child]Health. IV. Tuberculosis. V. Venereal Disease. VI. Mental Diseases and Mental Deficiency. VII. Industrial Medical Service. Women and Industry. Children and Industry. VIII. Education and Practice in Medicine,| Dentistry, Pharmacy. IX. Nursing. X. Hospitals and Dispensaries. XI. Method of Survey. Bibliography of Surveys. Index. The complete set may be obtained at a cost of $5.50 plus the postage and single parts at 50 cents each plus the postage, from THE CLEVELAND HOSPITAL COUNCIL, 308 Anisfield Building, Cleveland, Ohio Printed by The Premier Press Cleveland, O. Education and Practice in Medicine, Dentistry, Pharmacy Part Eight Cleveland Hospital a n*d Health Survey Copyright, 1920 by The Cleveland Hospital Council Cleveland, Ohio Published by The Cleveland Hospital Council 308 Anisfield Bldg. Cleveland - Ohio Preface The Hospital and Health Survey of Cleveland was made at the request of the Cleveland Hospital Council. The Survey Committee appointed to be directly responsible for the work and through whose hands this report has been received for publica- tion consisted of the following: Malcolm L. McBride, Chairman; Mrs. Alfred A. Brewster, Thomas Coughlin, Richard F. Grant, Samuel H. Halle, Otto Miller, D,r. H. L. Rockwood, Howell Wright, Secretary The staff responsible for the work were: Haven Emerson, M. D., Director, and the following collaborators : Gertrude E. Sturges, M. D., Assistant Director; Michael M. Davis, Jr., Ph. D., Director of the Hospital and Dispensary Survey; Josephine Goldmark, B. A., Director of the Nursing Survey; Wade Wright, M. D., Director of the Industrial Hygiene Survey; Donald B. Armstrong, M. D., Director of Tuberculosis Survey; S. Josephine Baker, M. D., D. P. H., Director of the Infant and Maternity Survey; T. W. Salmon, M. D., Director of the Mental Hygiene Survey; W. F. Snow, M. D., Director of the Venereal Disease Survey; Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey. The expenses of the Survey and of the publication of the report have been met by appropriations received from the Community Chest, through the Welfare Federation, of which the Hospital Council is a member. The report as a whole, or by sections, can be obtained from the Cleveland Hospital Council. A list of the parts will be found in the back of this volume, together with prices. TABLE OF CONTENTS I. Medical Education and Practice in Cleveland. Medical College of Western Reserve University. - . • Page Position in Community 65 1 Present Problems of Construction '..1 1 '. ! 653 Endowment . 654 Community Relations 655 Discussion of Instruction Now Offered : 656 History of the College and the Distribution of its Graduates '..... 659 Post-graduate Instruction : 662 Medical Practice Classification of Cleveland Physicians by Specialties _ 663 Hospital Staff Service 664 Professional Organizations. 664 Discussion of Autopsy Service 667 Recommendations 669 II. Quacks and Patent Medicines, in Relation to the Foreign Born of Cleveland. The Picture The Immigrant — Susceptibility of foreign temperament 672 The Quack 672 How the Quack Reaches the Immigrant 674 The Objectives Means of Investigation and Prevention.. 676 Means of Prevention Education of Public 677 Regeneration of Foreign Language Newspapers.... 678 Counter Attractions 678 Recommendations 682 III. Dentistry in Cleveland Private Practice of Dentistry 683 Free Dental Work At public schools 684 At 3 health centers 684 At City Hospital 685 TABLE OF CONTENTS— Continued III. Dentistry in Cleveland — Continued Page Dental Service at College of Dentistry..... 685 Dental Service in Hospitals 686 College of Dentistry.... 1 688 The Dental Hygienist 689 Recommendations 690 IV. Pharmacy in Cleveland Number and Education of Pharmacists. 691 Laws Dealing with Pharmacy Enforcement of Law 692 Abuses Which Are Tolerated... 693 Cooperation of Pharmacists with the Division of Health 694 School of Pharmacy of Western Reserve University History 694 Buildings 695 Faculty _ _ 695 Finances...- 695 Needs __ 695 Proposed Manufacturing and Professional Service for Hospitals 696 Recommendations 697 Medical Education and Practice in Cleveland By Haven Emerson, M. D. SCHOOL OF MEDICINE OF WESTERN RESERVE UNIVERSITY WHERE there is but one institution of learning in a community, deal- ing with education in the liberal professions primarily concerned with the prevention and care of disease, the responsibility for pro- grams and accomplishment is easy to fix and the resources to be looked to for advancement are sharply limited. In Cleveland through eliminations, mergers and absorptions the Western Reserve University finds itself at the moment the only institution in Cleveland responsible for the preparation of physicians, dentists and pharmacists for the legal practice of these profes- sions. For nurses also the only agency offering education in the public health field is provided by the University. Since public service in the field of medical practice and in preventive medicine can not rise higher than its source, it is natural that where failures of imagination, scope, technic and standards in the professions are found the inquirer turns to the University to seek the cause. University education is subject to the same three main limitations as affect education in general and they are apparently, in the order of their importance, the ideals of the teachers, the character of administrative leadership and organization, and the material resources to provide the teachers and the facilities for their development. For the noticeably deficient recognition by the laity and by the medica profession of Cleveland, of many specialties in medicine which now demand long preparation, exclusive devotion and constant study in order to reap the benefit and provide the service' which modern knowledge permits, we can not but hold the policies of the medical teachers responsible. Under both medicine and surgery important and necessary special branches have devel- oped elsewhere which are not provided for in Cleveland. In tuberculosis, cardiology, neurology, psychiatry, urology, industrial and preventive medi- cine, and orthopedics, opportunities have been and are still lost which the medical school owes to students, practitioners and the sick of the city. There is much encouragement in the fact that during the past college year de- cisions have been reached which should broaden the field of surgery by pro- viding for a department of orthopedics having a large measure of independent development, and under the general head of medicine will arrange for a de- partment of psychiatry and neurology with obligations to provide for the necessary clinical teaching in these specialties. Much more could still be done to encourage and assist undergraduate students and recent graduates to cultivate new and special fields in research and practice as is common in other centers of medical education. 65Z Hospital and Health Survey The contact made with a wide circle of workers in medical and kindred fields, especially among those concerned with the social and preventive appli- cation of medical sciences in Cleveland, gradually developed the conviction among the members of the Survey staff that the regard, respect, dependence and affection felt by the public for the University fall far short of what one might expect. Little exact knowledge was found to be possessed concerning many of the important problems of medical and dental education by those in responsible positions as trustees and executives. In the Medical School the constitution and activities of the executive committee of the faculty seem to meet all the needs and yet contact between the faculty and the trustees is on an uncertain and unsatisfactory basis. Definite assignment of duties and responsibilities are not called for from the trustees. It is a matter of first importance that the appeal for support for education should be based on recognition by the public of eminent ser- vice given to it by the University, and upon entire confidence in the practical value of the training given and of the researches undertaken. In the words of the business salesman, the University has not sold itself to the Cleveland public. Leadership, organization and service are needed with this object in view. To this end it is suggested that much strength to the University organi- zation might be expected by enlisting the active interest and work of trus- tees who are still in the midst of the actual problems of industry, professions and public service, as well as those to whom the honor of trusteeship is rather a recognition of past accomplishments and of readiness to be generous in financial support. Among the trustees should be those chosen by the alumni of the various professional schools from their own professions, officially delegated to repre- sent the graduates. From no representative group of citizens will be found those who will serve the University more faithfully or bring to its councils more vision, ideals and influential support than from the body of graduates of the Medical School. As to the third element in determining a university's ability to meet its public obligations: namely, material resources for teaching and research, it is worth noting that at the present time when building costs are so exorbitant and teachers of all kinds are so ill paid, the simplest business logic will advise investment largely in men, brains and service with, for the time being, no more outlay on buildings than is necessary to give adequate facilities for the teachers, the classes and such research as can only be done within University buildings. Once the relative importance of the various financial needs which the professional colleges face is outlined, the generosity and pride of Clevelanders in their important public undertaking, the Western Reserve University, can be counted on to find the funds. Professional Education and Practice 653 Problems of Construction and Endowment In considering the relative importance of the two large undertakings which face the trustees : namely, the erection of new Medical School build- ings and endowment or more adequate financial support for the teaching departments of the Medical School, and the erection and maintenance of a University Hospital Group, a few fundamental statements of fact and ex- pressions of opinion are offered before presenting concrete recommendations for order of procedure, as suggested for the consideration of the Board of Trustees. In the first place, the University now controls at City Hospital, at Lake- side, at the Maternity Hospital and at the Babies' Dispensary and Hospital, such facilities for clinical teaching as meet the most ambitious needs for the highest grade of- medical education, and very broad opportunities for re- search in both laboratory and clinical branches of medical science. At Lakeside and at City Hospital 936 beds offering clinical material in medicine, surgery, pediatrics, contagious diseases, tuberculosis, venereal dis- ease and mental disease are available and under exclusive University control for 12 months in the year. Twenty-two beds for maternity cases and 1,500 confinements a year in in- and out-patient services are available for teaching purposes. With the proposed doubling of the capacity of City Hospital, to which the city committed itself by vote at the primary elections in April, 1920, the field for clinical study at that hospital will be still further increased. The City Hospital will probably always include groups of patients who can- not legally be cared for except in such a public hospital. The City Hospital will, in all probability, always have a larger group of patients available for clinical instruction in contagious diseases, tuberculosis, venereal diseases, mental and nervous diseases, chronic, incurable and inoperable medical and surgical cases than are likely to be or should be accommodated in any privately con- trolled institution, even if devoted exclusively to teaching purposes. The value of this asset in clinical teaching can hardly be over-emphasized. The close physical situation of Medical School buildings, in relation to the home of other faculties of the university departments, is considered very desirable, if not absolutely essential, for the broadest and most catholic relationship between the various teaching groups. The control by a university medical school of its own hospital, in order to permit of intensive study and special methods of education in groups of patients selected particularly for their value in medical education and re- search, is considered entirely desirable and the complete dependency of a medical school upon a public department for its sole hospital facilities is not considered safe in the present crude and politically precarious condition of municipal government in Cleveland, as elsewhere in the United States. The physical separation of the City Hospital from the Medical School buildings, which it may be presumed will ultimately be located in the vicinity of the University campus, would not necessarily put any particular inconvenience in the way of its use by medical students, although the time of medical 654 Hospital and Health Survey teachers might be wasted to a slight degree unless there were certain labora- tory or research facilities added to the City Hospital equipment at the ex- pense of the University. It is believed that the first project for which money should be raised and plans made for construction, equipment and maintenance, is a building or buildings for the Medical School, to include the various facilities needed for teaching and research, such as can be carried on outside of the immediate walls of the hospital. It is recommended that, at the same time that the project for Medical School buildings is undertaken, the trustees prepare a plan for the financial support, either by endowment or with annual pledges, which will provide adequately for the salaries and service needs of each department, so as to in- sure the provision of personnel to give the University a 100% return for its investment in its greatest asset — the brains of its teachers. It is recommended that the trustees of the University devote their best efforts to accomplish such changes as may be needed in the City Charter and such action as may be necessary from the officers of the city government as to insure the appointment of trustees selected from representative groups of citizens by the Mayor, to be responsible for the administration of the City Hospital. In support of this recommendation it must be said that the University has a greater stake in the permanency of policy, in the non- political character of administration, and in the standard of equipment, service and support given to the City Hospital than has any other group in the community. It would probably cost upward of $25,000,000 at present construction costs for the University to obtain, through private means, anything approximating the range of material for clinical teaching that will be available and at their service at the enlarged City Hospital. It must be noted that the value of this material in medical education is now and always will be jeopardized by political mischief or accident until the present method of appointing the superintendent of City Hospital and his responsibility practically direct to the Mayor, to whom alone he is indebted for his appointment, is replaced by a method of appointment and adminis- tration which resembles more closely the system found necessary to insure continuous and high grade hospital policies and administration in private institutions under boards of trustees. It is, furthermore, felt that the Uni- versity owes to the public the use of its prestige and influence to get the City Hospital out of politics, if for no other reason than that the sick poor at City Hospital are entitled to as constant and scientific medical service as the University would expect to provide in its own privately controlled insti- tutions. When the above three main accomplishments have been successfully carried to completion or have been brought, by the efforts of the University, within promise of accomplishment, and when funds have been obtained which would justify undertaking a building program, at a cubic foot cost for construction considerably less it is hoped than prevails at the present time, Professional Education and Practice 655 the plans of the University Trustees for a joint hospital project, involving the Babies' Hospital, Maternity Hospital and Lakeside Hospital should be carried through essentially as they are at present worked out but not neces- sarily as a single construction undertaking. There is good reason to expect substantial benefits to result from prosecuting all these projects at the same time, if the relative importance of the several undertakings is kept continu- ously in mind. Of the needs of the University Medical School and of the needs of the community for hospital beds it is quite clear that a hospital service for chil- dren of all ages is much greater than is the need for beds for maternity or for general medical and surgical patients. It is, therefore, recommended that as soon as funds can be provided the trustees proceed with the erection of the so-called Babies' Hospital project, which it is understood will provide for children of all ages to a total of 150 beds. The next in the order of im- portance, and the next by considerable margin of importance in terms of medical teaching or community need, would be the construction of a Mater- nity Hospital which is planned for 100 beds. In approximately the same position, but perhaps slightly less urgent as a need for medical education, though obviously needed by the community sooner or later, is the erection of the new Lakeside Hospital. As soon as funds can be provided, therefore, should come the construction of the proposed 500-bed hospital for general medical and surgical patients, including a pavilion for patients with mental and nervous disorders for the department of psychiatry. Community Relations Although the minimal hospital bed needs of the community indicate that Cleveland will require the additional 400 beds which the University Group project would provide for the total bed capacity of Cleveland, the Sur- vey cannot recommend that $12,000,000 be spent for this purpose when medical teaching needs do not demand more beds and when that number of beds could be provided for the city through additions to other hospitals at a half, and possibly at a third, of this expense, if built solely with the ob- ject of providing adequate hospitalization for the sick. Among the reasons often voiced in Cleveland for lack of full professional and public trust in and support of the Medical School is that, under the reasonable argument of needs for clinical teaching, the nomination of pro- fessional staffs of hospitals is permitted by the trustees of certain hospitals to rest with the faculty of the Medical School. Whether or not there is jus- tice in this criticism it is apparent that no asset accrues to the Medical School if it is in a position of exclusive control over facilities not really needed for teaching purposes. It is suggested that any formal affiliations with hos- pitals except those now maintained at the City Hospital and the three organi- zations of the University Hospital Group, (Lakeside, Maternity and Babies') be severed, unless the boards of trustees of the hospitals specifically request the University through its medical faculty to relieve them of the responsi- bility of selecting the members of the professional staff of their hospitals. Further than this it is thought that the funds and energies of the Univer- 656 Hospital and Health Survey sity and its teachers should not be devoted to operating public health ser- vices such as a city- wide prenatal and maternity service, to an extent greater than is needed in the teaching and research in medicine. To demonstrate rather than to operate in such public fields would seem the wiser role. Another matter of importance to the University in its relations to the public is its contribution of part-time service, supervision, and direction through members of its teaching staff to the work of various bureaus of the Division of Health. It is thought that it would be wiser for the University teachers to be held in an advisory capacity rather than in a financial relation as part- time employes of the city. The present relationship does not bring credit to the University although the services are of a grade which the city does not seem prepared to pay for at their true value. Any criticism of the public health service bears back upon the University teachers who share in the responsibility and in the emoluments. Curriculum, Instruction and Faculty Organization Now that there is such a strong and increasingly well-informed Current of public opinion in matters relating to preventive medicine and health development it would seem a particularly propitious time for the University to undertake in its Medical School, education of its medical students in their responsibilities to the public as quasi-health officers, as private practitioners and as students of the broad facts of epidemiology. There is no clinical subject, major or minor specialty, which is not susceptible of treatment to the end that preventive as w r ell as diagnostic and therapeutic objectives may be taught in each patient. Systematic instruction in public health problems and methods is now an obligation of every medical school, which can no longer be escaped on the plea of an overcrowded curriculum. • In proposing that industrial hygiene be developed as a department of the medical school or better as a separate small school under the wing of the medical school the particular local need of Cleveland's employers for trained medical officers in their plants and the great variety of industrial hazards not at present adequately studied and guarded against in the interest of the employes, are to be particularly emphasized. It would be unwise to confuse the training of industrial physicians with the training of physicians for careers as public health administrators. Details of a course of lectures, demonstrations and laboratory work have been given to the members of the medical faculty concerned, by the members of the Survey staff in charge of the Industrial Health Survey. Special reasons for urging endowment for a department of industrial hygiene will be found in the section devoted to industry, Part VII. Now: that orthopedic surgery and psychiatry bid fair to see special provision made for them, there remains among the major needs a special opportunity for urology under the aegis of the department of surgery. Professional Education and Practice 657 Generous praise must be given for the quality and scope, the leadership and product of the laboratory sciences as taught by the medical faculty. The study of physiology and functional pathology is well coordinated by special teaching in clinical study .a^ the bedside. While the department of anatomy has ample provision for staff and re- search and is particularly favored by the State laws under which a collection of material of very great value has been obtained in the course of many years of work, the fire risk of the present unsuitable quarters gives serious cause for anxiety. It is certainly unfortunate that the teaching of em- bryology and histology are not as well coordinated with general anatomy as are physiological chemistry and general physiology. The students do not at i present get the best that the teaching staff of this department and the modern conception of anatomical teaching permit. Full-time teaching positions for the head of the main clinical depart- ments and for the chief assistants in clinical instruction are much to be de- sired and would be welcomed in the department of medicine as they have been established in the department of pediatrics. Private practice ambitions will always run counter to the best tradi- tions and quality of medical teaching. . There is no organization of clinical departments for staff conference, and the result is a feeling of detachment and lack of interest, particularly among those whose teaching never comes under the critical and stimulating eye of the head of the department. Policies and standards of instruction where there are several hospital services used for teaching can only be put on a sound basis by frequent departmental staff conferences. With the ex- ception of the departments of pathology and physiology there is little, if any, contact established between teaching at the Medical School or Lake- side and the teaching at City Hospital. With the existing active executive committee of the medical faculty to relieve that body of the burden of business detail and to be ready for quick action when need arises, there is offered an excellent opportunity to democ- ratize and broaden the influence of the faculty and of the forces within it, by extending membership and vote to a larger proportion of the teaching staff. It is of great importance that those responsible for the various divi- sions of teaching meet for discussion and interchange of opinions as to general policies of the school. Although the so-called voting faculty of 24 might appear to give a broad and adequate representation, a little study of its' membership shows how restricted it is.. 658 Hospital and Health Survey Medical voting faculty consists of: Votes Members 1 President of the University . 2 Senior or emeritus professors, inactive, not teaching or in touch with the college work. 1 Research and elective teaching pro- fessor only. 20 Active in teaching. 24 Among the 20 active teachers are four who teach less than thirty-five scheduled hours a year. One associate professor in a clinical specialty has a vote but has no clinic and teaches only 16 hours a year. If there were departmental staff organizations so that the head of a department really represented his department with full knowledge of the opinions, teaching practices and so forth, of his colleagues and assistants, even this limited group (20) would give a good working representation, but there is much irrelevancy in the assignment of voting power apparently, for while the laboratory subject of bio-chemistry with an assistant professor is not represented, otology, gynecology and genito-urinary surgery have each a vote. There are four assistant professors who teach eighty or more hours each and yet have no voice in the faculty; not that representation should be based on the hours of teaching but that the faculty would be strengthened by the presence of men who are devoting so much of their lives to medical teaching, men whose youth and ambition is now rather a neglected asset. The danger of clique domination by clinical interests, where the great resources of hospital and college laboratories for private advancement are available, is always to be feared in medical schools, and to meet such a possibility prompt democratization of the voting faculty is recommended. Lack of sufficient junior assistants particularly at City Hospital forbids the thorough working up of the amazingly fertile material in clinical medi- cine, surgery and pediatrics. Diseases of metabolism, tuberculosis, cardiac disease and mental diseases appear to have but little consideration in the general plan of training of third and fourth year medical students. The teaching of surgery at Lakeside is almost exclusively carried out by the paid resident house officers, the head of the department confining his field to demonstrations and operative clinics. The surgery taught at City and at St. Vincent's hospitals is not brought into any definite or constant relation in the way of subject matter or sequence with the teaching at Lake- side. There is generous provision for research in both surgery and medicine. Professional Education and Practice 659 The teaching of obstetrics and of pediatrics in the fields of private practice and of preventive medicine is excellent. The department of pedia- trics lacks adequate dispensary service for children over three. The de- partment of obstetrics has more material than it needs for teaching pur- poses. If there is to be a truly modern and just division of responsibility between these specialties, the new born babe at the maternity hospital and in the homes reached by the out-patient delivery service, should be turned over at once to the care of the pediatrists. A baby should not be an ob- stetrician's responsibility once it is separated from the mother, and the most important age from the point of view of prevention of infant mor- tality is precisely the period when the babe is now under the care of the obstetrician. The Medical School lacks the attention and service for organization, development and coordination of its various departments and functions which are primarily the duty of the Dean of a professional school. The reason for this is not lack of understanding or appreciation of the problems, but the overwhelming occupation of the Dean in an absorbing and widely distributed private and hospital surgical practice, and in a considerable amount of clinical surgical instruction and demonstration. To attempt to maintain adequate direction of the intricate problems of the Medical School requires more time and undivided attention than can at present be given by the Dean. His rare and invaluable services in the field of surgical anatomy, pathology, diagnosis and operative treatment can ill be spared or his organ- izing ability be demanded at the expense of his professional career. History of the College and the Distribution of Its Graduates A brief summary of the important facts about the Western Reserve University Medical School and the part its graduates play in the professional life of Cleveland may properly be included here. Organized in 1843 this school officially joined the University in 1881. In 1914 there was merged with the Medical School of Western Reserve Uni- versity the Medical Department of Ohio Wesleyan University or the College of Physicians and Surgeons, itself a product of mergers of the Charity Hos- Hospital Medical College, which combined with the Medical Department of Wooster University in 1870, and the latter institution which merged with the College of Physicians and Surgeons in 1896. From 1814 to 1899, the Western Reserve University School of Medicine graduated 1,085 physicians. From 1900 to 1919 it has graduated 571 phy- sicians. There graduated in 1920, 45, and the attendance of the school during the academic year 1919-1920 was 223, divided by classes, first year 49, second year 34, third year 41, and fourth year 54. It is the policy of the school to limit its classes to fifty students. Laboratory facilities are inadequate for more. 660 Hospital and Health Survey The number of the teaching staff is 102 distributed by departments as follows : Anatomy ..._ 8 Biochemistry 2 Physiology 3 Pathology. 11 Hygiene and Bacteriology 3 Pharmacology and Therapeutics 4 Medicine _. 23 Pediatrics 9 Surgery. _ 37 Obstetrics and Gynecology 12 112 In 10 instances teachers hold positions in two departments. At Lake- side Hospital forty teachers hold staff positions, at City Hospital twenty- three, at St. Vincent's Charity Hospital nine, and at Maternity Hospital four. These also include ten duplications. Forty per cent of the clinical teachers are Western Reserve University graduates. The total required hours of work in the present four year course at the Western Reserve University Medical School are 5,136 hours, with electives 88 hours, or a grand total of 5,224. At Northwestern University at Chicago the total required is 4,322 horn's. At the University of Michigan it is 4,545 hours, and at Leland Stanford 4,182 hours. The following table shows the present distribution of graduates of^this school in the practice of medicine in Cleveland. Western 1 " Reserve University Graduates Remaining in Cleveland Years-Group No. of Graduates No. Practising in Cleveland Per Cent 1860-79 596 16 2.67 1880-89 523 38 7.26 1890-99 297 72 24.2 1900-09 239 90 37.6 1910-14 128 57 44.5 1915-19 204 58 28.4 Total 1987 331 16.6 Three hundred and thirty-one or 28.3% of 1,169 physicians in Cleveland are graduates of Western Reserve University Medical School. Of the 309 Professional Education and Practice 661 hospital staff positions in Cleveland, 75 or 24.2% are held by Western Re- serve University graduates and 31 or 10% by Western Reserve University teachers, graduates of other schools, or a total of 34.2% of hospital staff positions held by Western Reserve University graduates and teachers. The following three tables are of considerable interest to teachers and practitioners of medicine in Cleveland. TABLE I* Medical Department, Western Reserve University, Cleveland Year Estimated Popula- tion of City Classification by Council on Medical Edu- cation 3 "8 W £ V Z « +-» CO 3 co u Jffjffi u . , 0> ■5c 5 co 3. v Zb> .S CO C> jj Ml £o Executive Officer 1910 506,938 A 94 21 18 $130 $130 $130 $130 84 34 F.C.Waite, Sec . 1911 560,663 A 107-64 f 14 12 142 135 135 135 114 34 a a 1912 560,663 A 135-41 1 35 29 142 135 135 135 89 34 a a 1913 560,663 A- 144-1 7 f 22 21 162 155 150 155 96 34 " " 1914 560,663 A- 153-4f 30 30 162 153 150 155 90 33 a £ m a co c .6 O Ml c c rf C -2 o Ml U . .UU-wU.3^^^0 8 11. 1 .... 1 1 1 8 1 112 11 2 1 3 .. 2 16 .. .. 1 .. 2 3 12 13 .... 1 1 3 4 .. 3 13 11115 6 16 10 12 116 5 .. 3 8 .. 2 .... 3 -. 1 ... 3 ... 4 9 .. 2 .. .. 3 .. 1 1 4 .. 6 11 .. 1 .... 7 5 13 1910 14 2 Ill 1911 1 .. 1 3 1912 1 .. .. 3 1913 11 2 1914.. 1915.. 1916.. 1917 1918.. 1919 1 1 .. 1 1 1 .. 1 1 .. 1 1 1 5 1 1 6 2 3 5 1 2 2 3 2 2 2 2 1 1 .. 2 2.. 4 2 3 2 ..111 ..211 111.. .. 1 .. .. .. 1 .. .. .. .. 1 .. 1 1 ..11 1 1 1 1 1 .. .. 1 .. 1 1 1 1 1 .. 69 .. 2 139 .. 2 132 1 1 114 2 2 113 2 2 121 1 2 138 .. 2 130 .. .. 1 1 139 .. .. 1 2 136 94 171 176 161 157 169 178 165 181 180 'Copied from the Journal of the American Medical Association. 662 Hospital and Health Survey TABLE III.* Medical College Graduates Year Non- Sectarian Homeo pathic Eclectic Physio- Nonde- Med. script Total W. R. U. Grads. %of Total 1910 4,113 183 114 16 14 4,440 21 .5 1911 4,006 152 110 5 4,273 14 .3 1912 4,206 185 92 .... 4,483 35 .8 1913 3,679 209 93 .... 3,981 22 .6 1914 3,370 154 70 3,594 30 .8 1915 3,286 195 55 .... 3,536 38 1.0 1916 3,274 166 78 .... 3,518 49 1.3 1917 3,134 180 65 .... 3,379 32 .9 1918 2,454 114 42 60 2,670 46 1.7 1919 2,423 89 28 116 2,656 41 1.5 * Statistics compiled from Table VI. page 502, Journal of the American Medical Association, Aug. 16 1919, and Educational Numbers of Journal of the American Medical Association, 1910 through 1919 The Western Reserve University Medical School is classed as A, 1907 to 1919, by the Council on Medical Education Of the American Medical Association. Instruction for Graduates An important service undertaken by the Medical School during the sum- mer of 1920 has been the offering of systematic instruction to medical grad- uates in clinical medicine and surgery, including the necessary accessory training in anatomy, pathology, laboratory aids in diagnosis, and such co- operation from teachers in various specialties as is necessary. The concep- tion of the program is broad, the spirit of the teachers is of the finest and the fees are moderate, and there may be expected from the modest beginning of this year with a class of 23, such steady development and appreciation of the work as will go far to win generous professional support for the Medical School and its ideals. Once endowment is provided or annual support is assured for the teaching of medical undergraduates, there should be a public appeal made to support graduate teaching in the medical sciences, not alone in summer but as a necessary service for the University to provide for the profession throughout the year. Both the short courses in diagnosis and treatment such as are now being offered and courses leading to the proper training of specialists, taking one or two years of combined laboratory and hospital teaching, are urgently needed in this country. Professional Education and Practice 663 MEDICAL PRACTICE Physicians in Cleveland Classified by Specialty There arejl,169 registered physicians in Cleveland, distributed accord- ing to their^own statements among the different fields of practice as follows. General 878 Surgery- Surgery 87 Orthopedic Surgery 4 91 Internal Medicine 1 6 Tuberculosis 10 Neurology and Psychiatry Neurology 3 Psychiatry 2 Neurology and Psychiatry 7 12 Obstetrics and Gynecology Obstetrics 14 Gynecology 12 Obstetrics and Gynecology 4 30 Pediatrics 23 Ophthalmology, Otology, Laryngology and Rhinology Ophthalmology 12 Ophthalmology and Otology 3 Laryngology and Rhinology 4 Otology, Laryngology and Rhinology 21 Ophthalmology, Otology, Laryngology and Rhinology 15 55 Laboratory Specialties Pathology 1 Clinical Pathology 2 Roentgenology 9 Bacteriology 1 13 Anesthesia 3 Dermatology... 9 Urology 11 Public Health 1 Not in practice 14 Retired 3 1,169 664 Hospital and Health Survey Hospital Staff Service Estimating the number of internes and physicians retired£or|not prac- tising at 119 there is left a total of 1,050 physicians in active practice (one to every 758 of the population of Cleveland in 1920). Of this number 309 or 29.4% are on hospital staffs. 233 or 22.2% are on the staff of one hospital. 55 " 5.2 % " " " " " two hospitals. 15 " 1.4% " " " " " three " 5 " .5% " " " " " four 1 " .09% is " " " " five " (as pathologist). That 29.4% of all the practising physicians of Cleveland should control the opportunities of education and personal advancement afforded^by^80% of the hospital beds of the city is not entirely satisfactory. In Boston about 42% of the practising physicians enjoy hospita^oppor- tunities. In New York it was learned from a recent study that 51.6% of the registered physicians have hospital or dispensary affiliations (12.6% only dispensary affiliations, 12.8% both hospital and dispensary affiliationsjand 26.2% only hospital affiliations). Of 545 physicians who have served as internes in Cleveland hospitals chiefly within the past ten years, 196 or 36% are now practising in Cleve- land. These graduates who represent the best product of our present methods of medical education should be attached as soon as possible after leaving their hospital to some hospital service, at first in the dispensary or as assistants in the laboratory, but with a definite future of clinical oppor- tunity open to them through merit and the willingness to sacrifice some immediate financial gains for the sake of a higher professional training. Professional Organizations Professional organization in Cleveland resembles that of other large cities and has provided the resources in the shape of library and meetings which are a necessity in a rapidly developing profession and one in which criticism by one's fellows and discussion of results and scientific reports play so important a part. Cleveland Academy of Medicine Previous to 1902 there were two medical societies in Cleveland: the Cleveland Medical Society and The Cuyahoga County Medical Society. In 1902 the Cleveland Academy of Medicine was formed by the union of the two societies mentioned above. The Academy membership is approxi- mately 600. The general meetings are held once a month on the third Friday of the month in the auditorium of the Cleveland Medical Library Association. The Clinical and Pathological section meets on the first, and the Experimental medicine section on the second Friday in the month. The Eye, Ear, Nose and Throat Section has not met for some years. The Professional Education and Practice 665 Academy is the county medical society and is the local constituent unit of the Ohio State Medical Association and of the American Medical Associa- tion. Recently a more aggressive spirit has come over the Academy and with the services of full-time lay assistance, the officers have undertaken the pub- lication of a bulletin and have declared their intention to interest themselves and the rest of the profession in the modern problems of health insurance and legislation of various kinds affecting the professional and economic status of physicians in Ohio. The responsibility for the deplorable conditions which exist practically unchecked among the foreign born population, due to the exploitation of the sick and the well by quacks and patent medicine interests, rests to some degree if not chiefly with the indifference of the organized medical profession. The attention of the officers of the Academy of Medicine is called to the report on Quacks and Patent Medicines in Relation to the Foreign Born of Cleveland, which follows at the end of this chapter. Cleveland Medical Library Association In 1894 the Cleveland Medical Library Association was formed. Pre- vious to this time a considerable number of books, purchased from funds contributed by the County Medical Society, had been gathered in Case Library. In 1895 a contract was entered into with Case Library. The Library set aside space for the Association books and agreed to care for and bind them and, if reimbursed for the amount expended for binding, to de- liver the books to the Association upon demand. In 1898, on account of lack of space, it was necessary for the Library to terminate this arrange- ment. After due deliberation the property now occupied by the Library at 2318 Prospect Avenue was purchased by the Association. In 1906 a fire- proof stack-room and auditorium were added. In 1919 the property adjoin- ing on the west was purchased. The Cleveland Medical Library Association is incorporated under the Ohio laws. The management of its business affairs is in the hands of a Board of Trustees, who act through an Executive Committee. The traditional policy is the re-election of officers to ensure continuity of policy and con- servation in the handling of funds. The working librarian serves on a full- time basis. The hours are 9:30 A. M. to 10 P. M. To the general public are extended reading privileges. Only members are permitted to withdraw books. According to the Librarian's report for 1919 the total number of volumes is 24,312. 847 books were loaned during the year and 1,853 visitors to the Library were registered. The Library receives 166 different journals. The Library is supported by the dues of its members — about 260 in number — and the income of invested funds, the total of the funds being somewhat over $270,000. The funds are handled largely by two trust companies. 666 Hospital and Health Survey The Library is restrained from combining with any other society or organization by terms of the Allen gift, the principal of which is $200,000. . The Library which has capacity for doubling its present contents is used to only a small fraction of the needs of the profession. That less than six readers a day visited the Library and less than one book was borrowed for each medical practitioner of the city in 1919, is a commentary upon the acquisitiveness of the physicians in the field of modern medicine, and reflects also a lack of adequate advertisement and propaganda by the Library Asso- ciation itself of its own resources. The policies of the Library are liberal and its financial support sufficient to meet many more needs for medical references than seem to be felt by the profession in Cleveland. The Cleveland Medical Journal. The publication of the Cleveland Medical Journal was discontinued during the war and has not as yet been resumed. While the Journal was the official organ of the Academy it had no other relation with the Academy and was owned and published by a separate corporation as a public-spirited enterprise, not for profit. The Academy contributed to the Journal, each year, $2.00 per member. There seems to be no urgent need for the resump- tion of this journal at a time when every economy must be practised to per- mit the survival of those which serve a wider audience and offer space for most of the important contributions to medical science. Private Medical Organizations There are several private medical organizations serving to some degree social and scientific needs of the profession. Among these are the Cleveland Homeopathic Medical Society which was organized in 1865 (there are at present about 150 members), the Cleveland Colored Medical Society organized in 1916 (30 members, 18 of whom are doctors, 8 dentists and 4 pharmacists), and the Cleveland Public Health Association, a branch of the American Public Health Association, organized May 21, 1919 (the membership is 45, and is limited to those who are members of the national organization). Professional Opportunities The medical profession has suffered severely in its development in Cleveland by reason of the serious shortage of hospital beds. Visiting ser- vices which will be needed when the necessary increment of beds is added to existing hospital capacities should provide openings for most of the pro- fession willing and trained to give a high grade of service in hospitals. There is lacking in Cleveland that unity of spirit among the physicians which comes from a just distribution of equal opportunities and from generous support, encouragement and advancement of the young and ambitious by their seniors. Professional Education and Practice 667 A better trained group or with higher professional ideals would be hard to find than the recent graduates of the local medical school. They are entitled to a quicker recognition, particularly those who have dedicated themselves to various of the special fields of laboratory and clinical prac- tice, lines of effort not sufficiently appreciated in Cleveland. According to information obtained from those chiefly concerned with general medical practice and consultation work in internal medicine, there is a very unusual indifference among Cleveland physicians to the value of laboratory tests in confirmation of diagnosis or as checks upon clinical impressions and physical findings in the cause of disease. The use of the tests in medical practice now available in the fields of blood chemistry and immunology is practically unknown in Cleveland. Autopsies A comment which could not fail to come to the lips of any visiting- physician, particularly from European medical teaching centers, would certainly be that the use of the autopsy is not appreciated as, at the same time, the most valuable postgraduate education for hospital physicians and surgeons, and the cause of a respectful humility among teachers and students alike in the presence of the secrets of disease. During 1919 there were recorded 455 autopsies in the hospitals of Cleve- land, and it is fairly clear that autopsies are rarely performed outside of hospitals on private patients and about as rarely, in the honest meaning of the term, under the auspices of the Coroner's office. Of the 455 recorded autopsies it will be seen from the following list that 351 were performed in the hospitals where medical teaching is carried on: namely, at City, Lakeside, St. Vincent's and Maternity. Autopsies Performed in Cleveland Hospitals in 1919 City 209 approximately Fairview Glenville 1 or 2 Grace _ unknown Huron Road 5 Lakeside... 110 Lutheran Maternity. 8 Mount Sinai 50 Provident St. Alexis unknown St. Ann's. 20 orphanage children St. Clair... 1 St. John's 20 St. Luke's 5 St. Vincent's 27 Woman's Lakewood a few 455 668 Hospital and Health Survey Even at the hospitals where post-mortem study is urged and has its best chance in Cleveland the percentage of deaths which come to autopsy is piti- fully small as can be seen from the following list. Year 1914 1915 1916 1917 1918 1919 Year 1917 1918 1919 Lakeside Hospital Deaths Autopsies Percentage 226 85 38 243 107 44 284 114 40 273 97 35 350 64 18 317 City Hospital 110 37 Deaths Autopsies Percer 1,168 156 13 1,211 202 17 863 207 24 Year 1916 1917 1918 1919 5f. Vincent's Hospital Deaths Autopsies 131 16 182 178 331 18 21 16 Percentage 12 10 12 5 The pathologists of the hospitals are well aware of the neglect of the post-mortem as an invaluable educative resource, but interest is rarely as keen among the surgeons and physicians on duty. Public Health administration and the practice of curative medicine alike would be gainers if a post-mortem examination were required, in every death occurring in the hospitals of the city. It is distinctly a duty of the Hospital .Council to take a definite stand in this matter, see that hospital superin- tendents feel their responsibility for obtaining consent for autopsies from the family or friends of the deceased and apply this necessary control obser- vation to the clinical and operative services of the attending staff. No better statement as to the action it is desirable to take can be found than the following quotation from the writings of the leading pathologist of Cleveland. Professional Education and Practice 669 "Investigations of the cause of the general shortcoming of American medicine in studying the accuracy of clinical diagnosis lead to a variety of explanations and an equal variety of suggestions for improvement. The latter may be thus summarized: There should be: 1. Education of the public as to the importance of post-mortem ex- aminations to public health. 2. Improvement of legislation: (a) obviation of the necessity for written permission to perform a necropsy, and (b) recognition of the differ- ence between anatomic dissection and the necropsy. 3. Improvement of hospital regulations. 4. Increased development of the interest of physicians in the necropsy. 5. Encouragement of the selfish interest in post-mortems on the part of intelligent relatives of the dead. 6. Assignment, in large hospitals, of certain persons whose special duty it shall be to secure permission for post-mortem examinations. 7. Information given the family as to the conditions disclosed by the necropsy. 8. A request for necropsy in every fatal case in hospital or private practice. 9. Establishment in the hospitals of regular clinical pathologic con- ferences. We would suggest, in addition, that the subject is of direct importance to the devel- opment of industrial medicine and that those interesting themselves in this subject point out to the employers and employes the value to medicine and industry of post-mortem examinations. The suggested alteration of actuarial figures regarding life insurance is of similar importance to the so-called health insurance." RECOMMENDA TIONS It is recommended that: 1. New trustees who are still in the midst of the actual problems of industry, of the professions and of public service, be added to the present number of trustees or be ap- pointed when the terms of those trustees now serving expire. 2. One or more trustees, chosen by the alumni of the Medical School from their own number, be elected to the Board. 3. Medical School buildings be erected at a site which will permit of convenient contact between the medical faculty and the faculties of the other University schools. 4. In addition to its control of the exceptionally abundant facilities of the City Hos- pital for the teaching of clinical medicine to undergraduates, the University Medical School maintain such affiliations as it now has with Lakeside, Maternity and Babies' 670 Hospital and Health Survey Hospital, permitting medical research and study in methods of teaching which can hardly be carried out with such entire liberty in an institution of the public nature of City Hospi- tal, where political and financial difficulties may interfere occasionally with the best inter- ests of scientific medical teaching and study. 5. The trustees discontinue formal affiliations for the Medical School with other hospitals than the City Hospital and the three included in the University group, so far as systematic teaching activities are concerned. 6. At the same time that the project for Medical School buildings is undertaken the trustees prepare a plan for financial support, either by endowment or through annual pledges, which will adequately provide for the salaries of the teachers and the maintenance and service needs of each department of the Medical School. 7. The trustees of the University devote their best efforts to obtain such changes in the City Charter as may be found practicable and such action from the officers of the city government as may be necessary to insure the appointment of a board of trustees to be responsible for the administration of the City Hospital, such trustees to be selected from representative groups of citizens by the Mayor and to be appointed by him. 8. The building of the new hospital group, either as one construction undertaking (if ample funds are available) or in sequence (in the following order of preference — Babies' Hospital, Maternity Hospital and Lakeside Hospital) be commenced when the construction of Medical School buildings, the provision of endowment or adequate annual support for teaching and the removal of City Hospital from the probability of political mismanagement have been assured, or at least have been so planned for that their accomplishment will parallel, if not precede, the group hospital construction. 9. Neither funds nor the energies of University teachers or institutions be devoted to the operation of public facilities and medical services, except in so far as these can be made to contribute or are found necessary for the teaching and study of the medical sciences. 10. The University discourage the employment of its officers on a part-time basis in positions under the city government. 1 1 . Systematic instruction in the problems and principles of preventive medicine be included in the curriculum of undergraduate students without necessarily adding a new department or increasing the number of hours of instruction now given to medical stu- dents. 12. A department for the training of physicians in the field of industrial medicine be established as soon as adequate funds can be provided, this department and its func- tions not to be confused with such efforts as the University may undertake for the train- ing of physicians and others for the career of public health administrators. 13. The trustees push forward vigorously with the present plans for a department of orthopedics, under the general department of surgery, but free to develop its own teach- ing and research policies, with clinical facilities independent of those of general surgery. 14. A department of psychiatry with a similar independence under the general department of medicine be organized and provided with independent clinical facilities. 15. A department of urology be added to the independent special departments under the department of surgery. Professional Education and Practice 671 16. The extension of the principle of full-time teaching positions for the heads of the main clinical departments and for the chief assistants be undertaken as soon as salaries can be assured, adequate to attract trained teachers and to permit of their having ample time for research. 17. The medical faculty adopt the policy of having staff conferences in each depart- ment to provide for uniform teaching policies and practice in the various clinical hospital services used by these departments. 18. The voting faculty of the Medical School drop its inactive and absentee members and add not less than ten more members of the teaching staff, assistant professors, demon- strators and others, in order to make of this body a real academic forum, democratic in nature, and permitting a much broader representation from those carrying the major burden of the teaching work. 19. To the Department of Pediatrics be assigned the responsibility and care for new-born babies at the Maternity Hospital and in the maternity service of the City Hos- pital. 20. The trustees of the University encourage and give their active support to the new undertaking of the medical faculty in the field of medical education for graduate physicians. 21. The Hospital Council take an active interest in increasing the performance of post-mortem examinations for the sake of improving the quality of medical and surgical services in the hospitals. 672 Hospital and Health Survey Quacks and Patent Medicines By Mary Strong Burns THERE are many perils in being an immigrant in Cleveland, but one of the most disastrous to his pocket, health and native faith is the quack medical practitioner. With an estimated .513,000 of the city's 731,1.56 population either of foreign birth or foreign parentage in 1917, we have abundant opportunity to realize that it is not possible for the foreign- born with limited education and no English to pass unscathed through a labyrinth of new customs — good, bad and indifferent. The doctor, as popularly conceived by the uneducated, is a mystery at best, something of a magician from whom the patient dares expect only a small part of the truth and no explanation of it. The immigrant learns that the reputable doctor of medicine must have "M. D." after his name (even though it means as little to the immigrant as to the street gamin who "guessed it meant More Dope"), and when he pauses before an office door placarded "M, T. D., D. C, D. S. T., Ph. C." he may be forgiven for imagining that he stands before an even greater "Professor" than the law requires. He finds as wide a choice of doctors as of religions, and as he hesitates, bewildered, the more watchful and aggressive forces find him. Of these the quack doctors are most successful because they set forth in that particular foreign language newspaper which the immigrant reads as the one intelligible guide to his new country, a convincing statement of skill, learning and sympathy, promising (with reservations so deftly inserted as to be almost unnoticeable) health free or at minimum cost. Even though the immigrant feels well and in no need of medical care the quack's repeated message and the long list of "troubles and diseases" is ever present and suggestive, so that the susceptible imagination of the future victim is soon won over to a conviction of some bodily frailty. The quack, at the first examination, finds more serious ailments, the "cure" of which will generally necessitate an expenditure to the limit of the patient's resources and large enough to include the high cost of advertising. The foreign language newspapers derive from 30 per cent to 60 percent of their advertising income from the fraudulent statements of quack prac- titioners and patent medicine interests. It has been conservatively esti- mated that the Italian paper II Progresso and the Polish paper Ameryka Echo circulated here derive 60 per cent of their income from these sources. In one of these, one advertisement of "Parto-Glory, " containing 723 words, cost about $1 L 2.5. There are twenty-one newspapers not printed in English circulated in Cleveland, published locally. These are mostly papers of national circula- tion. There are also eleven foreign language papers. Taking all together, twelve different languages are used: Bohemian, German, Greek, Hungarian, Italian, Lithuanian, Polish, Roumanian, Slovak, Slovenian, Swedish and Ukrainian. The papers published here, with the exception of three, carry Professional Education and Practice 673 only advertisements of physicians and medical agencies doing business from a Cleveland office, and nearly one-third of their advertising income is derived from this source. The papers published out of town but circulated in Cleve- land are: four published in New York and one each in Chicago, Detroit, Jersey City, Middletown, Pa.; Pittsburgh, and Toledo. These do not con- tain advertisements of Cleveland quacks, although they are not limited to local advertising. They do, however, contain advertisements of 62 quack doctors from other cities, and of these only two from Detroit are duplicated in the list of out-of-town quacks who advertise in the foreign language papers published in Cleveland. Of the 25 physicians having offices in town and advertising in the Cleve- land foreign language newspapers, one uses papers in six languages, one, four languages, three, two languages and twenty, one language. Thirteen of these physicians advertise only their address and office hours. This is an admit- tedly ethical and legitimate procedure among foreigners. The doctor may thus announce his presence to people of his own race. Because of this prece- dent the quack practitioner may use a more elaborate form without arousing- suspicion, the foreign-born reader often getting the idea that the newspaper itself is setting forth the doctor's skill and goodness. Thus eight of the twenty-five physicians advertised to treat at their offices "all sicknesses of men and women, especially sicknesses of the blood, heart, kidneys, lungs, nerves, nose and throat;" two treat "blood and skin diseases," and two others treat "men only," evading a more open reference to venereal disease. In this class is the type of office whose apparent head, the quack doctor, is under the control of an unscrupulous business syndicate. This syndicate manages offices in a number of large cities, guaranteeing salaries and a cer- tain percentage to the doctor in charge, but claiming the fees of the patients. In one of these offices in Cleveland when business was interrupted by arrest, the receipts for the year were found to have amounted to $40,000. If illegal practice is detected the business manager of the syndicate appears, pays the fines, closes the office and spirits his doctor away to an office in another city where a new name and locality will make him more valuable than ever. After the affair has slipped out of the public mind, the syndicate opens its Cleveland office at a different address and in charge of a new agent and the game begins again. The agent of the syndicate may or may not be a licensed practitioner. He may have had his license revoked in another state. In any case his medical knowledge is less in demand than his skill at getting a cash return for any imitation of it. If a license is necessary to avoid sus- picion and the agent does not possess one, some unsuccessful, though once ethical, practitioner is lured into the game on the promise of a small regular salary, and when the crash comes he is usually left to be the scapegoat and serve the sentence. The eight out-of-town physicians advertising in foreign language papers published in Cleveland have offices as follows: one in Akron, one in Chicago, three in Detroit, one in Paterson, N. J.; one in Syracuse, N. Y. A private clinic in New York advertises in a German paper. The Hungarian paper published the notices of the Paterson and Syracuse doctors and of two from 674 Hospital and Health Survey Detroit; the Roumanian those of Akron and Chicago doctors, and one from Detroit. The advertisements of these out-of-town physicians show that five would treat "all troubles," one will treat "men only," one "rheumatism and kidney troubles," and one chronic diseases. One states that he will send medicines and advice; one offers a book, The Friend of Youth; one de- clares "Hundreds travel to see me, no treatment through letters;" another invites, "(Jome, or ask advice." The appeal of the quack is effectively adapted to the susceptible foreign temperament. In the picturesque phraseology of his own tongue the reader is tempted, cajoled, lured, warned and roused to fear; trading on his natural credulity, the wording of the advertisement is carefully managed so as to imply, rather than guarantee, a cure. The appeal of money saving is most frequent. "My advice is free;" "I will help you with the best medical care for such price as you can pay;" "I do not charge for examination if you are one of my patients;" "X-Ray examinations only $1;" "Pay after you are cured." This type of appeal is in constant use. Other types are here set down. The appeal of encouragement: "No matter what illness you have if you have failed to find health from others, come to me;" "With success I have cured many. What I have done for others I can do for you;" "Men and women my specialty." The appeal of fear, urging to prompt action: "Remember that neglect- ing your trouble makes it worse;" "I have saved hundreds from the operating table." The appeal through promise of a common language: "You can hold conversation with me in your own tongue;" "Come to me and be well informed about your sickness and understand how you can be cured;" "Here we speak Hungarian;" "We speak Polish," etc. The appeal of race: One florid description of sundry abilities is headed: "To my sick Roumanian Brothers;" "To my sick Lithuanian Brothers" — the nationality mentioned changing with the language of the paper. Another who still practises in spite of past fines and sentences uses this subtle method, "A message to the Italians. Sick Italians, do not be discouraged. Thou- sands of our countrymen have found health and happiness by going to see Dr. Landis. His treatments are simply marvelous!" The appeal of special skill and "method cures": "I use X-Ray and electrical machines and my own new methods of treatment. By these methods you will recover health in the quickest possible time;" "To save the stomach my practice is to inject the medicine directly into the arteries, which hastens considerably the process of restoring to health." The appeal to the imagination: "Formerly doctor to the Czar;" "A Polish doctor returned from U. S. Army Service in France. Come and place your confidence in me." Professional Education and Practice 675 The appeal to sentiment: "If you are well yourself, yet there are some who need help. Send us the names of others who are sick and save them while there is a chance." The type of appeal is more vivid and dramatic in Italian, Polish and Hun- garian papers; while that in Swedish, Lithuanian and German is more matter- of-fact. No fake advertising was found in the Greek paper, Atlantis. In addition to the appeal of the quack, the foreign language press abounds in advertisements of patent, or more properly, proprietary medicines offered by "medical institutes," "medical companies," drug manufacturers and retail drug stores. These usually claim in the newspapers to be remarkable cures for almost every disease that one may have, while the label on the bottle is more modest since that must conform to the food and drug act. This act, known as the "Pure Food Law," is supposed by many to be a seal of perfection, whereas it merely insists that the manufacturer shall make no false or misleading statement on the label of the bottle as to its contents or curative power. It does not affect products made and sold within the state. It prohibits the use of certain dangerous drugs unless their presence is declared, yet allows other dangerous drugs to be used and not declared. While the label must tell the truth the advertiser need not be so punctilious and in his hands the patent medicine takes on new power§. Some of the advertisements ask the patient to send by mail to the factory for medicine. Others would send medicine and instructions for treatment by mail. Still others announce that their product may be bought anywhere. The Roman Medicine Company announces, "Our institution is under the supervision of well-known medics from the old country. It was established to relieve our countrymen of their sufferings. Aher years of labor and research we dis- covered what is indispensable to cure our brothers of their sickness. Put a cross (X) on the illness from which you are suffering and send it to us. We will serve you free of charge with every necessity." Here follows a tempting array of "troubles," minor ailments and pains. One has only to choose. In addition to these perils by newspaper there are also perils by propa- ganda. Cards of reputable physicians have been sent out with prescrip- tions by retail druggists who implied that the doctor was also endorsing the sample of patent medicine enclosed. Recently a young woman, whose dress and manner suggested that of a public health nurse, was found visiting in the homes of women with families. She came ostensibly to advise them on the care of children and ended by selling a book in which patent medicines from several large wholesale houses were repeatedly recommended for treat- ment. These wholesale manufacturers of patent medicines employ clever lawyers at high salaries to protect their interests. If the preparation comes into disrepute under one name it may be used under another. Tan-lac has had several names. As a Dr. Cooper's Medical Discovery it was sold by a man in sky-blue uniform with buttons of five-dollar gold pieces, who drove through the country in an automobile. 676 . Hospital and Health Survey The Ohio State Medical Board is the instrument upon which Cleveland has relied for the detection of its quacks. There is only one state medical inspector for a city of nearly 800,000 people. This is obviously too great a task for one person. The State Medical Board publishes no report except for the Governor and the Secretary of State, on July 1st of each year. The following statement was submitted to us by the Board: From July 1, 1918, to June 30, 1919, certificates of four physicians and surgeons to practise medicine were revoked ; one certificate suspended and certificate of one limited practitioner revoked; nine applications for revocation are pending; 8 midwives were prosecuted and convicted; one acquitted. One hundred and sixty-three cases investigated; 28 convictions secured; 3 cases acquitted. There were two dismissals and one disagreement. Fifteen against whom charges were filed agreed to cease practice. Fifteen more left the state. Forty cases were pending on June 30, 1919; a number of these pending cases have since been tried and conviction secured. The state medical inspector for the city offered an informal account of her work, all records having been sent to Columbus as made, to await the compiling of the annual report in July. There have been a number of con- victions of doctors and midwives for illegal practice and criminal abortion, and other cases are being prosecuted. The work is evidently being done conscientiously and is as far-reaching as the efforts of one inspector can reasonably make it. However, a judicious and wider publicity of the ac- complishment of the State Medical Board might be of distinct educational value in the community. The patient victimized by the quack does not realize that his plight is the concern of anyone other than himself. It is difficult to state how large a number of Cleveland patients are treated through the mails by out-of-town quacks, but as practically every fraudulent scheme depends upon the mails at some time or other in its development, we are safe in believing that the Federal Authorities have not received complaints from all those who have been defrauded. The Federal Fraud Order Law, in use since 1914, gives the Post Office Department authority to close the mails to anyone using the mails in schemes to defraud. This may be an enormously effective weapon against quacks doing a large mail-order business. The post office collects evidence enough to be sure of conviction, then issues the Fraud Order. The quack, if he has not already vanished, has a right to refer to the court, but a reversed judg- ment has never been recorded. In a word, the Federal Post Office will only attempt cases w r hich it is sure of convicting. This law is also sharply limited because the Post Office Department cannot move until the mails have been actually used in an attempt to commit fraud. It must wait until it receives a complaint from someone who has been defrauded. Professional Education and Practice 677 The quack advertiser has purposely shaped his proposition to come within the letter of the law and to so avoid the attention of the Federal eye as long as possible. He knows his own danger and at the first symptom of detection collects his bounty and "skips the country," leaving the evidence powerless to convict and his victims without redress. The Fraud Order Law has proved" a radical cure for the cases in which it has been utilized, but the number of these is small. Its scope should be enlarged and its scheme of inspection made to include those who advertise with intention to defraud, for in this matter prevention is both education and cure. The value of this law depends largely not on its passive acceptance but on its aggressive enforcement. The patient who has been the victim should not be expected to make the complaint. There should be some unbiassed agency or group of agencies combining the knowledge of the Bureau of Immigration, State Medical Board and National Vigilance Committee of Advertising Clubs to receive the complaint and present the case to the Federal Authorities. Such an agency or bureau possibly and properly oper- ating under the auspices of the Cleveland Academy of Medicine, could be of untold benefit to the many cases of venereal disease who have so often be- come the prey of quack practitioners through lack of sufficient provision for treatment at hospitals and dispensaries. It could also furnish evidence of the need of further legislation to restrict the use of the mails from carrying advertisements relating to venereal disease. The American Medical Association has prepared and published a series of pamphlets on nostrums and quackery for the use of the public. These have a limited circulation among those who least need their warning. With discriminating field work this circulation could be increased. The priest, whose congregations have had sad experiences, the large industrial plants and their public health nurses, the libraries and popular magazines could be used to good effect. The emphasis in such education might be placed first upon the hallmarks of honest, intelligent treatment of disease, and second upon the fact that each one must stop — look — listen and then think for him- self before he trusts. Assuming the theory that the Acidemy of Medicine must not take any action on quack behavior, we might urge that dispensaries and prophylactic centers should feel free to teach as well as to practise the ethics of medical service, supplementing the mysteries of diagnosis and technic with a pro- gram of cheerful consideration for the patient and of eliminating the diffi- culty of an alien language by sympathetic and patient interpreters who are not too highly intellectualized to miss the human side in the medical interest of a case. The Americanization Committee of the Cleveland Bar Association has already become interested in the dealings of shyster lawyers with the foreign- born. This interest could be stimulated to secure valuable cooperation from the court when quack practitioners are being prosecuted and defended with unprincipled skill by their shyster lawyers. 678 Hospital and Health Survey The foreign-language newspapers cannot afford to give up their bad types of advertising unless they can get something equally remunerative to replace it. One small foreign-language paper refused quack and patent-medicine advertising to an amount of $1,500 a month because its people were being exploited and victimized. As a result it could barely pay expenses, but the editor declared he "felt at peace without stained money." It has, however, gradually resumed much of what it once refused — an instance of "the heroic for earth too hard." The American Association of Foreign -Language Newspapers was recently reorganized under the leadership of well known business men, one of its stated purposes being to improve the advertising in the foreign-language press of this country. They are pointing out to American advertisers the possibilities of the foreign-language paper as a medium for reaching new readers. In conjunction with the Better Business Association of the Cleve- land Advertising Club, this may be of assistance, providing the foreign- language papers do not have to surrender the control of their individual policy. The large foreign-born population is too valuable a field to be neglected by advertisers. The foreign-language press might offer to the future citizen the stimulus of the best the country affords of resources and responsibilities. At present its misuse amounts to almost a civic disaster. Should we be better satisfied to receive the immigrant who comes to our shores suspicious, distrustful, prepared to be duped and tricked both by Americans and fellow countrymen — who have had a chance to learn the ways of the country? Can we not look upon this "ignorance, gullibility, child-like credulity," or whatever we call his eager belief and wonder at our world, as something worth saving, precious because readily convertible into citizen- ship as loyal and even more fervid and spontaneous than our native New Englander, Texan or Rocky Mountaineer will feel free to express. The quack has conquered where the ethical practitioner has failed to attract, because the quack has taken the "infinite pains" of a genius to win his prey. As commercialist and practical psychologist he is an expert. The clean honesty of the ethical practitioner is not equally painstaking. It should not be asked of the ethical practitioner that he cope with quackery, but because he is pledged as his "brother's keeper," shall he not note in the successful appeal of the quack to his patient the things which are promised along with the cure — friendly consideration as a stranger, a sympathetic hearing and a frank diagnosis explained so as to be understood? These are of value whether the cure comes or not, for to the imaginative foreign tem- perament a serious illness sympathetically interpreted by the doctor is less ap- palling than some trivial indisposition left unexplained. Is it not possible to have some more flexible attitude on the part of the medical profession and some more aggressive attitude for ourselves as the public in the matter? Our health regulations no longer permit people to expose themselves un- necessarily to contagion. Is the menace of quackery to be ignored? We see in our midst a multitude of people from other worlds being fed with tales in their native tongue of fake cures by fake operators. We watch and think "It will be bitter bread for them." The doctors watch and think "It is all Professional Education and Practice 679 wrong but we may not speak." The foreign-language newspaper counts its advertising cash returns and prints on, thinking "The National Vigilance Committee of the Associated Advertising Clubs of the World allows it, the city of Cleveland allows it, the public does nothing, the income justifies it." Only the future warns: "The immigrant's instinct for belief in his new country is a tremendous asset to the nation and to the city of his choice. The opportunity of justifying this belief and for providing education and citizenship is open to the foreign language newspaper. It is the written word, the organ of authority, but those who control its policy are in turn controlled by larger business interests and these are prostituting its high office for commercial gain. Let the city waken and protect its right." Translations of Advertisements Shown in Facsimile on Page 680 1. 'TO MY SICK HUNGARIAN BROTHERS* If you have failed to find help, come to me, as I have practised many years and can give health with treatments to such men and women as are nervous or ill with complicated sickness, suffering because someone has given the wrong treatment or neglected it. With success I have cured such sick who could not get cured elsewhere. What I have done with others, I can do with you. Don't spend more time but come to me today. Advice free. If you suffer with chronic nervousness, blood, skin, or complicated trouble, or abdomen, stomach and liver trouble, rheumatism, back or muscles, headache, constipation, dizziness, eruptions, disease of the head, throat, nose — visit me. I have succeeded with such sick- nesses by treatment. Respectfully I will give you my opinion and after a good examina- tion will tell you what I can do. Get advice from me now as waiting is often dangerous. Don't forget that advice is free. Office hours from 9 a. m. to 8 p. m. — Sunday from 10 a. m. to 2 p. m. Dr. Kenealy, 647 Euclid Ave., 2nd Floor, Cleveland, Ohio. Over New Idea Bakery Republic Building Next Door Star Theater" •Translation of advertisement in Hungarian published in Szabadsag. 2. "CHRONIC AND NERVE DISEASES CURED* If you are afflicted with an upset stomach or kidneys or bladder, consult me today. Seek help where it can be found. Years of experience in the treatment of all nervous ail- ments, either chronic or complicated, have enabled me to give you scientific electrical treat- ments that will help you in cases where other methods have failed, and therefore many have been- freed from torture and danger of an operation. Remember: that delay and improper treatments are dangerous. Come to me if you wish to have the services of. an expert specialist. Dr. Lewis, Specialist Office hours: 9 a. m. to 8 p. m. — Sundays 10 a. m. to 2 p. m. 749 Sixth Avenue (between 42nd and 43rd Streets), New York City." •Translation advertisement in Italian published in II Progresso Professional Education and Practice ^ 681 3. "A MESSAGE TO THE ITALIANS!* Sick Italians, do not be discouraged if you have not been able to obtain the desired cure even after having been visited by different doctors, or been in many hospitals. Hundreds, or rather thousands, of our countrymen have found health and happiness by going to see Dr. Landis. Dr. Landis with his 25 years of practice in New York, having studied in the greatest universities and hospitals of America and Europe, is just the man who will put you on the road to health. His treatments are really wonderful. His office is equipped with the most costly electrical machinery, which cannot be found at all doctors' offices and which is indispensable for an efficient cure. Dr. Landis has experimented with a method cure of electricity which has given wonder- ful results and which allows individuals to get well without having to leave their work. If you suffer with pains in your back, or rheumatism, or sickness of the chest or blad- der, with weakness or anemia or any other illness, be it chronic or recent, consult Dr. Landis and you will certainly find a sure cure. All consultations are absolutely free. Remember that in any sickness to wait is always dangerous. Why wait? Go this very day. Italian is spoken. Dr. Leonardo Landis, 140 East 22nd Street, New York City. (Between 3rd and Lexington Aves.) Office hours: Every day from 10 a. m. to 7 p. m. Sunday from 10 a. m. to 1 p. m." "Translation of advertisement in Italian published in II Progresso. 4. "X-Ray examination $1.00.* If you are sick, notwithstanding what the nature of your sickness is, if you are dis- couraged, do not give up hope but come to me. I treat all sicknesses of men and women and especially sicknesses of the blood, skin, stomach, kidneys, lungs, nerves, heart, nose and throat by the assistance of X-Ray and electrical machines and my new methods of treatments. By these methods you will recover your health in the quickest possible time. I do not guess. The secret of my success lies in the careful research as to the cause of your sickness. I use X-Ray, microscope and chemical analysis and also all learned meth- ods to find the cause of the sickness. If you are bruised or injured, come to me and I will help you. My personal observation of the methods used in European clinics in Berlin, London, Vienna, Paris and Rome in my 20 years' experience with sicknesses that have grown old among men and women, gave me results that proved a success. I consider 605 and 914 great medicines for the blood. All treatments are absolutely painless. "Translation of advertisement in Polish published in Polonea W. Ameryce. 682 Hospital and Health Survey You can depend on an honest opinion, honest treatment, and the best treatments at the lowest prices that everyone can afford. If your sickness cannot be cured I will tell you. If it can be cured I will cure it in the quickest possible time. We talk in Polish and Slovak. Doctor Bailey, Specialist, 5511 Euclid Avenue, near East 55th Street. Office hours 9:30 a. m. to 8 p. m." RECOMMEND A TIONS 1. Legislation: (a) A more aggressive use and increased scope of the Federal Fraud Order Law. (b) A uniform Medical Practice Act between states, to be urged by the Cleveland Academy of Medicine. 2. Administration: (a) A Local Bureau organized to receive and act on complaints of medical fraud. This Bureau would make known its function to the public and to all Public Health agencies, who in turn would report such cases. (b) Increased Inspection and prosecution by the State Medical Board. (c) Development of the Americanization Committee of the Cleveland Bar Associa- tion for cooperation in prosecution. 3. Education: (a) Extended instruction in the ethics of medical service among medical students, and also to patients in hospitals, dispensaries, health centers etc. (b) General health education in popular courses (in a foreign language when neces- sary) in citizenship classes, industrial plants, churches, community centers etc. 4. Standardization of Foreign-Language Press: Fraudulent advertising to be replaced by advertising and general reading matter of good standard, through the assistance and supervision of the Chamber of Commerce, the Cleveland Advertising Club and other civic bodies, for the protection and education of the foreign-born during his transition from immigrant to citizen. 5. Counteraction: Giving all would-be patients first-aid treatment of psychology and self-control. Democratizing the highest types of medical service so that the best shall be available for all. Professional Education and Practice 683 Dentistry in Cleveland By Haven Emerson, M. D. ASIDE from or rather in addition to the persistent forces which tend to drive any profession onward and upward in public esteem, the dental profession in this country has been advanced in its own cone ?pt ion of service and in its scientific application of prevention and treatment of dis- ease by two movements of much importance. The demonstration of the benefits of oral hygiene and periodic cleansing of the teeth of children by Dr. Fones, of Bridgeport, Conn., and the proof of casual relationship between focal infection in root canals and other dental lesions and a multitude of secondary joint, cardiac and general constitutional symptoms may be said to have dominated much of the modern crusade for better dentistry, for preventive dentistry and for the close professional cooperation between dentistry and medicine in private, hospital and public health work. In all of this Cleveland dentists have taken an active and leading part and the city is fortunate in having within its limits those who direct the for- tunes of the Dental College, the Research Laboratory, the Cleveland Dental Society and the Cleveland Mouth Hygiene Association. According to the best information there are about 550 registered dentists in Cleveland, of whom 290 are members of the Cleveland Dental Society, which is the local professional body, a constituent of the state and national dental societies. If the Ohio Dental Practice Act required an annual registration of all dentists, as is the case in several other states, an accurate statement of the number of dentists legally practising dentistry in Cleveland could be made. The better control of illegal practice which such law permits has proved to be of great value to the profession and to the public, in New York State among others. The private practice of dentistry in Cleveland presents no abuses or inadequacies except such as arise from the selfishness and ignorance of an occasional practitioner who fails to measure up to the present day standards of his profession. The well-to-do and those of moderate means can obtain adequate dental care without excessive expense and of a high grade whether for preventive or reparative purposes. From the reports of the highest type of supervising dental officers in the army during the war, it was found that well over 75% of the crown and bridge and root canal filling was done so poorly as to develop or permit the development of pus pockets with all the dangers of secondary low grade sepsis and its numerous sequelae. Mechanical dentistry, done for a price instead of aseptic technic used in the spirit of modern surgical science, seems to be at least as much of a cause of disease as the neglect of oral and dental hygiene by the poor and ignorant. There are quacks and commercial low grade practitioners in this as in the medical profession, because there is often more money in such methods 684 Hospital and Health Survey for the illegitimate and irresponsible than in a professionally conducted office. The Jews of the Woodland Avenue region suffer particularly from the services of dental quacks. Free dental work in Cleveland is supplied at six public schools, at three health centers and at one hospital (City Hospital). There are ten chairs in use and 156 clinic hours a week, or a totalof 6,900 hours a year of service offered. The work is mostly for children and for hospital out-patients. A dental dispensary used for teaching purposes, operating 80 chairs, is main- tained on a more than self-supporting basis by the Dental College. The fees charged are similar to those charged by beginning dental practitioners. In Boston five institutions offer either free or at-cost. dental services with a total of 247 chairs used for 5,956 hours a week and 309,712 hours a year. In the city of Rochester, N. Y., there are 38 chairs almost exclusively for children's work. The six school dental dispensaries are supported by the taxpayer's money through the Board of Education. Each unit includes a dentist and an assistant and is open five days a week for three hours at each session and for 40 weeks a year. Children are referred from among school children by the school medical inspectors and nurses. The extent to which the work has grown and the range of service given is seen in the following table: Patients Visits... Emergency — Prophylaxis. -. Amalgam.... ... Deciduous extraction... Permanent extraction.... — Surgery referred. ~ Oxyphosphate of copper. Oxyphosphate of zinc Arsenic Roots filled Abscess treatment.. The three mouth hygiene dispensaries operated by the Cleveland Mouth Hygiene Association at three of the health centers are operated for fifty weeks of the year, five days a week and three hours at each session. The outfit and personnel of each is the same as that provided for the school dental clinics. The cost of these is met from 'the Community Fund as a part of the budget presented by the Welfare Federation. A dental surgery open a half day (of three hours) a week for out-patients needing operative relief and extractions, and six half days (of three hours 17 Total 1918 Total 1919 Total 1,969 3,473 4,421 4,454 ' 6,411 6 , 976 651 1,267 1,621 383 661 1,196 839 1,654 3,165 1,608 1,927 3,911 142 56 18 192 15 183 127 670 1,399 112 115 61 126 61 5 188 87 5 109 136 67 Professional Education and Practice 685 each) a week for the hospital patients is provided by the city at City Hos- pital.* At the College of Dentistry of Western Reserve University" a public den- tal clinic is operated for all kinds of dental work. This is more than sup- ported by the charges made, which are not very different from charges of beginning practitioners with a clientele of mechanics, clerks and small trades people. The lack of adequate bookkeeping prevents any statement of the margin of profit earned by this dental dispensary. The profit of $24,000 indicated in the last annual report of the University is obviously erroneous as nothing is charged for building or upkeep, depreciation, light, heat and so forth or for the overhead cost of teachers and supervisors. Self-supporting public pay clinics, operated under strict professional con- trol as to services and prices, are needed and would meet a real demand for those of moderate means. Dental care for the poor is limited largely to extraction and remedy of gross pathological conditions causing obvious inconvenience or pain. Lack of knowledge of the needs and possibilities of oral hygiene is responsible for the neglected teeth of most dispensary patients. Dental clinics where a small fee is charged are badly needed in the congested districts. It is admitted that if all who needed dental care applied to existing den- tists for treatment, there would not be enough dentists to do the work on a basis and with the facilities of private practice. The three Mouth Hygiene dispensaries, operated five half days per week, are the only available and acceptable service (except the private dental practitioner) for thirty to thirty-five thousand parochial school children. Fifteen Mouth Hygiene units, each composed of a dentist, a dental hygienist and an assistant, operated eleven half days per week, would serve this group of children quite well; i. e., would provide the prophylactic service neces- sary for eighty-five or ninety per cent of these children and would provide for from one-third to one-half of the repair service necessary. The public schools of Cleveland should increase their present equipment from six dispensaries operated five half days per week to thirty-five Mouth Hygiene units operated eleven half days per week, which would care quite well for seventy or seventy-five thousand children. The amount of surgical service under anaesthesia required would be in- creased by the fifteen Mouth Hygiene units above referred to, to the extent that probably five half-day clinics will be required every week at the City Hospital. Should the Board of Education undertake to solve their problem as above suggested fully double the amount of surgical service will be required in addition. Attention should be called to the fact that after a very few years the surgical service will undoubtedly decrease, for if the Mouth Hygiene movement is of real value there should be little demand for the surgical service for school children after the first seven years. It would be desirable to have three hospitals suitably located provide for the surgical dental service. *A full-time resident dental surgeon has been placed on duty now, and the clinic is open all day, s even days a week. 686 Hospital axd Health Survey We suggest that this service could well be united with the nose and throat service as the equipment in many respects is similar. All the groups with whom the Survey staff have come in contact, such as visiting nurses, charity and social agencies, settlement houses and the foreign- born have emphasized the inadequacy of dental service in Cleveland. When it is seen, that almost as much public dental dispensary service is provided in Boston in a week as in Cleveland in a year, the reason for complaint is plain. It would be wholly superjluous to offer arguments for the need of mouth hygiene among the children in the public or parochial schools. The matter is amply argued by records of the incidence of dental defects in the office of the bureau of School Medical Inspection and by the record of ac- complishment a few years ago at the Marion School. Dispensary dental work in every case has fallen short of its possibilities where there has been either no supervision, or supervision by unpaid or underpaid men. The service in Rochester would never have been a success without Dr. Burkhart, or his like, as a leader; nor would the service in Bos- ton have been a success without Dr. Cross, or one of his kind, at the head. In the same way the work in Cleveland will not be a success if we expect to secure as a leader in this work a man at $3,303.00 a year, nor can the work be carried on much longer without paid supervision. DENTAL SERVICE IX HOSPITALS It is accepted in many hospitals of many cities that the professional staff is incomplete without dental surgery represented and sharing in staff respon- sibilities. A dentist should be appointed on the attending staff of every one of the larger general hospitals of Cleveland, with a definite service in wards and dispensary. The hospitals and other institutions in Cleveland now providing some dental surgery for patients are as follows: Mount Sinai Hospital There are on the staff of Mount Sinai Hospital two dental consultants. Dental and Oral Surgery is the only service provided. Such cases as seri- ously need prophylaxis are sent to the Dental College. The Dental and Oral Surgery dispensary is open from 8:30 to 10:00 A. m. on each Monday and Thursday. The Dental and Oral Surgeons, being members of the staff, enjoy the privilege of operating upon private patients at the hospital, for which they may receive fees as in all departments of the hospital; however, no compensation is received by the, dentists from dispensary or open ward patients. The present dispensary facilities are one dental chair with the necessary equipment, located in the annex where, with the present staff and time (two mornings per week), about eight hundred cases per annum may be cared for. Cases are admitted for dental surgery only. The hospital Professional Education and Practice 687 plans the enlarging of this service in the near future, together with the addition of prophylactic service. There is no opportunity to develop a purely dental oral surgery service for out-patients at the present time. Cleveland City Hospital The City Hospital maintains a dental surgery department, the operating- room being situated in an amphitheater in the female division on the ground floor of the main building. The outfit consists of one operating chair, vari- ous nitrous oxide machines and a fair equipment of instruments for dental oral surgery, together with instruments for other forms of dental service that are likely to be necessary in the care of the regular hospital patients. The staff of the City Hospital consists of a Visiting Dental Surgeon, a Visiting Dental Anaesthetist, a Resident Dental Surgeon, temporarily spending half time; and one or two nurses assigned to the service as needed. Out-patient service for dental oral surgery is rendered on each Friday from 1 to 4 p. M. An average of fifteen extraction cases are cared for each afternoon. During the past two years [some fifteen hundred anaesthesias have been ad- ministered. This service is inadequate in volume and should be increased at the earliest possible time. The most reasonable and economic manner of increasing the service in the present building will be by providing two or more separate operating rooms (adjacent but entirely separate) and each having its own equipment. A waiting room should be provided for the dental cases. The corridor is now used. The entire service should be upon the level of the main floor and as near as possible to an entrance to the building. With the suggested arrangement the volume of cases could be largely increased with a minimum outlay of expense and a minimum increase in staff personnel. Children's Fresh Air Camp A dentist spends two half days per week at the Fresh Air Camp. He cares for the children of the institution only. Simple extractions are made under novocain. More serious work requiring general anaesthesia is referred to the City Hospital. Jewish Orphan Asylum Two dentists each spend a full day per week at the Asylum. General service is rendered the children. Simple extractions are made with the use of novocain. More serious cases requiring a general anaesthetic are taken on occasions to the dentist's private office. Service is for the children of the institution only. St. Luke's Hospital There is no official dental appointment on the staff of St. Luke's Hospital. However, a dentist administers anaesthetics almost constantly and is recog- nized by the staff, but has no appointment. On rare occasions this dentist removes teeth, but no dental service is provided. 088 Hospital and Health Survey Lakeside Hospital At present there is no official dental service at Lakeside Hospital; how- ever, we are informed that such. is under consideration and will probably be inaugurated at an early date. •j Cleveland State Hospital for the Insane The State Hospital has not at the present time a dentist on its staff and has not had for a year or two past. We are informed that they have no appropriation for that purpose, therefore do not anticipate such an appoint- ment in the near future. The State Hospital for several years furnished dental service to the inmates. St. Vincent's Charity Hospital At the present time there is no dental service at St. Vincent's Charity Hospital. In many respects Charity Hospital would be an ideal location for a Dental and Oral Surgery. Mention of dental service in industry will be found in the Industrial Hygiene Survey, Part VII. A limited service of high quality is provided in five establishments approximately at cost. There is urgent need for more dentists in industry and the need would seem to justify inclusion of some of the special dental hazards in industry in the dental curriculum. COLLEGE OF DENTISTRY This professional school has passed through many financial, educational and administrative vicissitudes and at present is within reach of standards and support which will entitle it to rank with the best. Its present needs are more teaching room, a moderate increase in its equip- ment, a small outlay for a simple teaching, reference and periodical library, improvement in the teaching of anatomy and pathology in conformity with the high conceptions and standards of these departments in the medical school and a considerable increase (10) in the teaching staff, especially of full-time men in the laboratory and clinical courses. More students are now accepted than can properly be accommodated and taught. An increase of 50% in the space is needed, if an entering class of 75 is accepted. It is estimated that $200,000 will be needed for additional space in the next five years. Probably $10,000 would meet the lack of equipment now. The absolutely indispensable in the way of books and periodicals for teachers and students would cost about $4,000. To pick teachers of dentistry simply from among successful practitioners will continue here the same misfortunes and inadequacies which have been a plague to medical education. The men selected must expect to make teaching a career and be fit to employ permanently as such. Professional Education and Practice 689 As soon as the obligations assumed by the University when it took over the school from its commercial supporters are paid off an endowment should be raised for the support of dental teaching. Within the next five years this school needs a million and a quarter of dollars to provide the grade of education for which applicants are clamoring, in numbers the University cannot accept. The College of Dentistry would profit greatly from organized interest, criticism and support by the Cleveland Dental Society. The school and the profession cannot get along without each other and for the credit of both they should have mutual support, which does not exist at present. There are no facilities for graduate education of dentists. They should be developed and offered by the college. THE DENTAL HYGIEXIST In the interest of public service, to provide trained aids to the prac- tising dentist, to keep pace with the practice in leading states of the country, it seems evident that the College of Dentistry should undertake the training of dental hygienists and should support the efforts of the organized profes- sion to obtain the amendments in the State Civil Code necessary to legal- ize this profession in Ohio. Dental repair work among children has been reduced by 50% by the em- ployment of dental hygienists. The modifications in the State Civil Code proposed by the Cleveland Mouth Hvgiene Association (affecting bv slight changes in the wording- sections 1320A, 1321A, 1320B, 1321B, 1321C, 1321D, 1321E, 1323A, 1324A, 1324B, 1324C) are strongly approved, and it is our opinion that the changes might well go further and permit the practice of dental hygienists in private offices of dentists as well as in institutions. Such modifications have been made and have met with uniform satisfaction in eleven other states, includ- ing Connecticut, Massachusetts, New York and Maine. There are two important professionally supported activities in the field of dentistry of considerable importance in Cleveland. One, the Dental Research Laboratory of the National Dental Society, has been a center of important studies in the interest of exact scientific practice. The other, a distinctly local organization, the Cleveland Mouth Hygiene Association, must be credited with most if not all that has been done in the field of public education in preventive dentistry and oral hygiene in the city. From modest beginnings in 1897, when its influence was first felt in the better teaching of school children, this Association developed increasing puplic support and resources. In 1905 it maintained the dental dispensary at City Hospital. In 1914 money was raised sufficient to pay expenses of operating six school dental dispensaries. Since then the Board of Education has paid for them. The work of the Association has continued to be effective and their budget of $11,533 for 1920 to defray the expenses of the five dispensaries at Health Centers was approved by the Welfare Federation. 690 Hospital and Health Survey The Survey is indebted to officers of each of the professional groups above considered for information and advice. RECOMMENDA T/ONS It is recommended that: 1 . Measures be taken to obtain such amendments to the State Civil Code as will permit the licensing of dental hygienists and their employment in private practice and in public institutions, under the direction of licensed dentists. 2. The State Civil Code be amended to require the annual registration of licensed dentists. 3. The training of dental hygienists be undertaken by the College of Dentistry. 4. Sufficient financial support be obtained for the College of Dentistry to provide ade- quate increase of space, teachers and equipment, a library, and freedom from debt on account of obligations to commercial interests. 5. The Board of Education aim to provide a gradually increasing service which within the next five years will put all school children under adequate periodical dental inspection, cleansing and repair. Prophylactic cleansing of children's teeth twice a year is adequate. Tooth brush drill should be a part of school education. 6. Those responsible for the children attending the parochial schools institute dental' service similar or equivalent to that advised for the children of the public schools. 7. Administration of all public dental school and dispensary services supported by the tax payers be put under the direction of one competent full-time paid dentist, within the Division of Health or under the Board of Education. 8. The dental surgical service at City Hospital be increased fourfold. 9. The dental surgical service for out-patients at Mt. Sinai be increased as soon as funds can be obtained. 10. The Hospital Council prevail upon at least two other of the privately endowed hos- pitals to establish out-patient dental service. 11. A dental surgeon be appointed on the visiting staff of each of the larger general hos- pitals and a dental interne be provided to carry out such prophylactic and reparative work on' patients as their condition permits or requires. 12. A dentist be provided at Warrensville Infirmary. 13. Both medical students and nurses receive in their preparation to practice, instruction in the principles of the cause and prevention of dental disease and that nurses receive practical training in the technic of cleansing patients' teeth. Professional Education and Practice 691 Pharmacy in Cleveland By Haven Emerson, M. D. AS the knife is to the surgeon, so the drug or chemical is to the physician, and there must be keenness and strength and appropriateness in each. Whether we look upon the pharmacist as the dispenser of package goods over the counter, the compounder of special remedies or physicians' prescriptions, as an analytical chemist or as a wholesale manufacturer of standard drugs and biological products, he is as indispensable an auxiliary to the physician in the medical service of the community as are the dentist and the nurse. His education, the conditions of his employment, his protec- tion against illegal practitioners, his standards and his aspirations are all matters of importance to the public health and to the welfare of the sick. In the absence of any authoritative or official registry of licensed or gradu- ate pharmacists in Cleveland, and using the figures available from the roster of the Northern Ohio Druggists' Association and the lists in the hands of local wholesale drug supply houses, we can estimate that there are at the present time about 400 drug stores and probably 500 or more registered pharmacists and registered assistant pharmacists in Greater Cleveland. Probably ten per cent of the above number have had no college training and it is safe to say that seventy-five per cent have had it. What number have had some college training but did not graduate in pharmacy it is im- possible to estimate. The length of courses taken by those who graduated was either two or three years. The major portion of the pharmacists here who have had college training- received it at the Cleveland School of Pharmacy prior to the time when it became an integral part of Western Reserve University. Some few gradu- ated from Ohio State University, Ohio Northern University, the University of Michigan, The Cincinnati College of Pharmacy and the Philadelphia College of Pharmacy. PHARMACY LAWS Prior to August, 191.5, anyone could take the state examination offered by the State Board of Pharmacy for registered pharmacist or registered assistant pharmacist if he had served an apprenticeship of four years in a retail drug store. If the applicant had attended a school of pharmacy he usually received credit on his "experience requirement" for the time he spent in school. Schools of pharmacy made no requirement of high school education for entrance until a few years ago when they began to require one year of high *We are indebted to Mr. Edward Spease, Dean of the School of Pharmacy of Western Reserve University for valuable aid in preparing this chapter and for information dealing with drug supplies for hospitals and in the question of proprietary medicinal preparations. 692 Hospital and Health Survey school training. Some few university schools have of course for some years past demanded high school graduation as a requisite for entrance. In 1915 the Ohio Legislature passed a law requiring two years of high school study for entrance into recognized pharmacy schools and that the applicant be a graduate of one of these recognized schools. The matriculant must also obtain an entrance certificate from the State Board of Pharmacy and this certificate is issued by an entrance examiner who may evaluate credits or give examinations to obtain them. This entrance ex- aminer himself must be a college graduate with the degree of A. B. or B. S. and must not be connected directly or indirectly with any pharmacy school. This examiner besides his experience as a high school teacher is to- day an employe of the State Department of Public Instruction. The legislature in 1919 passed an amendment to the Pharmacy Law requiring four years of high school for entrance into a pharmacy school. This must be upon diploma after four years of study in a high school, normal school or academy, or be by examination given by the state board entrance examiner. The course of study given to a student in a recognized school must con- form to the Pharmaceutical Syllabus of 1913, which was prepared by the American Pharmaceutical Association, the American Conference of Phar- maceutical Faculties and the National Association of Boards of Pharmacy. The least course given must be of two years' duration, consisting of certain didactic and laboratory hours totaling not less than 1,200 in all. The course must be given entirely in the day time and two months must elapse between the two school years. Not less than three full-time professors must be employed. Some of the Ohio schools and notably the Western Reserve University school exceed this minimum. Here the school years and hours per week are of university length and the work is of university grade. A total of more than 1,700 hours is given for this two years' course. Four full-time instructors and nine part-time instructors are employed. Among the laws governing the practice of pharmacy are to be found all the Pure Food and Drug laws, Narcotic laws, Prohibition laws, Poison laws and special regulations governing the sale of drugs in drug stores. ADEQUACY AND ENFORCEMENT OF LAWS The laws now governing pharmacy would be entirely adequate if there were not so many exceptions to them. As they now stand they are quite rigorous enough concerning what is to be sold and how it is to be sold in drug stores, but the exceptions to the laws permit anyone to compound patent medicines and sell simples, such as Epsom salts and the like, in stores other than drug stores or from wagons or by house-to-house canvass. Many poisonous substances may also be sold if put up in packages bearing proper labels. Professional Education and Practice 693 One of the tendencies of the present time is for druggists to cease manu- facturing preparations for their store use and to buy these preparations ready made. This has been brought about partly by the fact that manu- facturers have secured laws through which they may purchase tax free alco- hol for the manufacture of such preparations as tincture of iodine and cer- tain other preparations where there is absolutely no question of the alcohol being completely denatured. The objection to this lies solely in the fact that the Government denies this privilege of economical purchase of alcohol to the retailer, by requiring this alcohol to be secured in large quantities and to be denatured with the iodine or other substance at the distillery. This enables the manufacturer to make and sell many standard drugs much cheaper than can the retailers. The same privilege should be extended to the retailer or to groups of retailers. Anything that limits the retail drug- gist's professional practices tends to discourage and suppress his ability. In like manner the prescribing of proprietary preparations by the physician lessens the druggist's practice and hence his ability to compound. Few physicians think out and write their prescriptions with a definite-purpose for the use of each ingredient. The habit of "counter prescribing" is not as prevalent as is supposed but is always augmented in a neighborhood where a dispensing physician resides. Two things will overcome this practice entirely, one is strict enforce- ment of law relative to this practice and the other is education both of the physician and of the pharmacist. It is rare to see a druggist who is a thor- oughly educated and cultured man do very much counter prescribing or do more along this line than to sell medicines of the customer's own selection. It is not rare to find this druggist often advising the customer to go to a physician. A much better type of drug store service would be available if the law requiring a registered pharmacist to be actually in a retail drug store, hos- pital or industrial plant pharmacy, and other places where drugs are com- pounded and dispensed, were rigidly enforced. That these exceptions are tolerated is due to the lack of knowledge on the part of the public as to the danger of indiscriminate sale of drugs and poisons and to the apathy of physicians in supporting measures to remedy these conditions. About the only thing that may not be done outside of a drug store is prescription filling. The State Board of Pharmacy is permitted to hire only one inspector to see that drug stores have a registered pharmacist in them at all times and to see that proper registration of bulk poisons is made. This inspector may not receive much over $1,400 per annum and of course he must be responsible for the entire state. This means that not even the drug stores are forced to obey the laws, to say nothing of the dispensing of drugs indiscriminately by unqualified persons in hospitals, industrial plants and stores other than drug stores. 694 Hospital and Health Survey The clause of the Ohio Statutes requiring a registered pharmacist to be in actual and personal charge of a drug store at all times is not rigidly en- forced, due largely to lack of inspectors to secure evidence, and indeed it seems scarcely necessary to attempt its enforcement when drugs may be indiscriminately compounded and sold by anyone if only the vendor does not call his place of business a drug store. The city of Cleveland has no rules, laws or regulations governing drug, stores, with the exception of the narcotic ordinance and the general sanitary ordinances. COOPERATION WITH THE HEALTH DEPARTMENT The druggists of Cleveland, through their organization, The Northern Ohio Druggists' Association, an incorporated body, have been able to aid the Health Department greatly in correcting many abuses in sales of drugs and medicines. They have appointed an advisory board who meet with the City Chemist, at his request, upon matters in which they are interested. When mistakes have been made in prescription filling, in drug stores, these mistakes have been brought to the attention of all the stores and aid has been given the department in the rectifying of these mistakes. The most important feature of the work is in the review of patent medi- cines. The druggists have agreed not to stock patent medicines unless they have been submitted to the City Chemist for approval of label and claims, and whenever the City Chemist issues an order for the removal of a patent or proprietary medicine from the Cleveland market the druggists have refused to sell this preparation until the order has been rescinded. The force of this is that the City Chemist need not bring suit against the druggist or druggists in question to restrain a sale, but that the burden of proof is upon the manufac- turer and he must either convince the City Chemist of the merit of his claims or must bring suit against him. No suits have been brought by such manu- facturers, nor is it at all likely that such suits will be brought, as long as there is judgment and honesty used in issuance of the orders by the City Chemist; for the bringing of a suit would require the disclosure of the ingredients of the proprietary medicine and at once the value of the nostrum would be dissipated since secrecy and the claims of a therapeutic value based on worth- less or inert ingredients is the basis of this whole colossal fraud. The inge- nuity and effectiveness of this method of repression of valueless or fraudu- lent patent medicines is worthy of imitation in other cities and states. This and the appreciation by the press of the value of honest drug advertisements would soon stop a national disgrace, save the public millions of loss annu- ally and spare the ignorant and the ailing the disappointment of useless medication. THE SCHOOL OF PHARMACY The School of Pharmacy of Western Reserve University was founded in 1883 by the local druggists. At that time only a series of lectures were given to apprentices. From this small beginning it grew until two courses were Professional Education and Practice 695 given, one of two years' duration and one of three years' duration. Until the fall of 1917 these courses were arranged so that the student could go to school three days a week and work on alternate days in a retail drug store. Since the fall of 1917 the student has been required to put in full university hours in school, both per week and per year. The two-year course is now perfected upon the basis of giving the student two years of college work of university length and quality. The school is located in a building in the heart of the business district, which today, due to traffic and business condi- tions, does not permit the use of delicate instruments for instructional pur- poses. The surroundings detract greatly from the educational value of the school. The faculty consists of four full-time instructors, three of whom have the university degree of B. S. and two of whom have an additional degree of M. S. One of those with a degree of B. S. has no pharmaceutical degree, but two of them have the degree of Pharmaceutical Chemist. The fourth in- structor mentioned above has the degree of Graduate in Pharmacy and the degree of Pharmaceutical Chemist. Part-time instruction is given by nine other men, one with the degrees of A.B., A. M. and M. D., another with the degrees of A. M. and LL. B., another with the degrees of A. B. and A. M., another with the degree of A. B. The others are laboratory assistants, one of them a senior in the college of liberal arts during the past year. As the School of Pharmacy grows the laboratory assistants will, as op- portunity offers, be chosen from among the graduate students. The School of Pharmacy has been financed during all these years from tuition fees and by gifts from the local druggists. This method of financing does not permit of very much development toward better things and indeed at present almost forbids growth. The School of Pharmacy needs: (a) Location on the University campus, a move which is planned for the immediate future. (b) Endowment of approximately one million dollars, or pledges for annual support amounting to the interest on that amount at five per cent. (c) Greenhouses and a medicinal plant garden, to serve the double purpose of providing live material for demonstration and research (instead of relying at present upon the dried "cadaver" material of the commercial market) and of furnishing fresh drugs of standard tested quality to the hospitals of the city. The value of fresh herbs, as in the measurement and study of the effects of belladonna and digitalis, for instance, is obvi- ous. The effect of soil, temperature and other cultural conditions on the quality of drugs could be studied with great advantage. (d) Expansion of the courses to permit of granting a degree of B. S. after four years of study, to properly qualified students, men and women. This expansion should permit of a four-year study of chemistry and should 696 Hospital and Health Survey include physics, mathematics and certain academic or cultural studies and languages to permit the pharmacist to be an educated as well as a trained graduate. This plan is now in existence in all the large universi- ties of the Middle West and West. The pharmacy schools east of Ohio are nearly all on the every-other-day plan, as mentioned above. New York and Pennsylvania schools will not go upon the basis of requiring high school graduation for entrance for another couple of years. (e) Additional instructors. The school is now doing no research and it can neither maintain its present standing nor progress unless its teachers be productive. The research problems confronting the student of phar- mecy are many and it is indeed discouraging to scholars to be so bur- dened with teaching that they can give no thought to research. Valu- able cooperative research facilities should be made available through joint studies with the Department of Pharmacology of the Medical School, which has already made so many notable contributions to scientific therapeutics. (f) A Manufacturing and Professional Service for Hospitals. The School should equip a manufacturing laboratory where preparations, liquid, solid and tablet form, should be produced for the hospitals. This would not only create an incentive for good work on the part of the students but would show them during their formative period that habits of exact- ness are necessary and that their work is directly related to public health. The elimination of high overhead charges and the manufacture on a cost basis in such quantities as the hospitals -now use cannot help but materially lessen cost of all such materials to the hospitals. It is inferred in the above writing that each hospital maintains a pharmacy and complies with the Ohio Statutes in employing a registered pharmacist. The Survey recognizes that this is not a true statement of existing conditions. It may be, however, that small hospitals could have their ward requisitions or prescriptions filled at certain hours by a traveling pharmacist and his corps of student assistants, or could send them to a larger hospital at certain intervals and have them taken care of properly in that way. The School of Pharmacy of Western Reserve University can offer a serv- ice to the hospitals of Cleveland that may be said to have two direct objects. The first is to enable the hospitals to render a much higher type of medical service to the public, and the second is to lower the cost of medicines to the hospitals. Under the first heading, which is one entirely in keeping with the ideals of good hospital service, the Pharmacy School should be asked to serve in an advisory capacity. 1. It should supervise the organization and arrangement of the hospital pharmacies. 2. It should aid in the purchasing of pharmacy supplies, inasmuch as it is impossible to buy drugs and chemicals intelligently without a direct knowledge of the items themselves and of the firms from which they are bought. The tendency of modern times is to view drugs and medicines Professional Education and Practice 697 as commodities only. This has been brought about by the rapid growth of "patent" and package medicines and for this reason price is sometimes the only deciding factor. 3. It can advise in regard to the proprietary medicines now in use in the hos- pitals to avoid the duplication of preparations and to show when many of these preparations, if needed, can be manufactured by the hospital phar- macy or by the school organization as discussed later. 4. It can analyze and otherwise test the drugs, preparations and chemicals that are purchased after competitive bidding, in order that sick room sup- plies may meet standard specifications. This will insure to the physicians a knowledge that the substance supplied is exactly what it should be. If the above suggestions be carried out it will result in systematizing the pharmaceutical work of the hospitals which, unfortunately, is often lightly passed over in perfecting the other seemingly much more important services of the hospital. It will also result in directing all purchasing through one office, such as is maintained by the Hospital Council, and thus the supply of any one item for a given period for all hospitals will be purchased at one time, entirely upon specification and with the result of a better price for the quantity purchased. Under this last, or the second heading, the School of Pharmacy should likewise carry out two things : Furnish its senior students to the hospitals for internships. This would accomplish two purposes. It would provide cheap but efficient help to the hospital pharmacist, enabling him to render a service in the hospital that he is unable to give under the present arrangement. This is especially true where free or part-pay clinics are conducted and medicines dispensed. Besides demonstrating the value of an educated and not "rule- of -thumb" pharmacist to the hospitals themselves, it will send out to the public men better equipped to serve it by reason of this high type of practical training. It need scarcely be added that it will further the pharmacist's own knowledge of his responsibility to the public whom he serves. A school of pharmacy to be efficient should have the same academic standard as a school of medicine. Unless the school of pharmacy is sup- ported as are hospitals and medical schools the same menace will result as occurred in the era of proprietary medical schools and commercial hospitals, and the public health will suffer instead of gain at the hands of its graduates. RECOMMEND A TIONS It is recommended that: 1. The interest of the Academy of Medicine and of the Hospital Council be united with that of the Northern Ohio Druggists' Association and of the Division of Health, to bring action through the State Legislature for adequate personnel and appropriation for the enforcement of existing laws dealing with the presence of the registered pharmacists in drug stores and hospitals. 698 Hospital and Health Survey 2. Amendments in the laws of the state be obtained which will bring to an end the pernicious practice of house-to-house, street vendor and other irresponsible kinds of drug selling and will restrict the sale of drugs to such stores as have a registered phar- macist on the premises during business hours. 3. Amendment in the state law be obtained which will permit retail druggists, through controlled cooperative action, to obtain the benefit of the same economies in the pur- chase of tax free alcohol as are now the exclusive privilege of the large manufacturers. 4. The policy of the Division of Health in suppressing the sale of fraudulent proprietary medicines be vigorously supported by the Chamber of Commerce, the press and by the advertising interests of the city. 5. The trustees of the University move as rapidly as practicable to meet the needs as indicated above, particularly in the matters of providing (a) greenhouses and a plant garden, (b) teaching staff adequate to permit of research as part of the duties and privileges of the instructors, (c) space and equipment to permit the school to offer the services of its instructors and students in the process of education, to the hospitals of Cleveland and for the testing, standardizing and manufacture of drugs and chemicals. 6. The Cleveland Hospital Council invite the School of Pharmacy to survey the condi- tions and costs of hospital purchase and compounding of drugs and chemicals, with the object ultimately of obtaining from the staff and students of the school in return fbr certain privileges offered by the hospitals for the training of students in practical phar- macy, the consultation service and economies in purchase and manufacture which may be expected from such a professional and educational group. 7. Each hospital not now purchasing drugs and chemicals through the Central Purchasing Bureau furnish the Bureau with a list of drugs and chemicals purchased by them for the past five years, or failing such record, for the ensuing year, in order that the bulk of the trade may be estimated and action taken by the Hospital Council and the School of Pharmacy in the interest of economy. THE CLEVELAND HOSPITAL AND HEALTH SURVEY REPORT j List of Parts and Titles I. Introduction. General Environment. Sanitation. II. Public Health Services. Private Health Agencies. III. A Program for Child Health. IV. Tuberculosis. V. Venereal Disease. VI. Mental Diseases and Mental Deficiency VII. Industrial Medical Service. Women and Industry. Children and Industry. VIII. Education and Practice in Medicine, Dentistry, Pharmacy. IX. Nursing. . X Hospitals and Dispensaries. XL Method of Survey. Bibliography of Surveys. Index. The complete set may be obtained at a cost of $5.50 plus the postage and single parts at 50 cents each plus the postage, from THE CLEVELAND HOSPITAL COUNCIL, 308 Anisfield Building, Cleveland, Ohio Printed by The Premier Press Cleveland, O. Nursmgf Part Nine Cle velajnd] Ho spi tal and Health S ur ve y .'" Copyright, 1920", by The Cleveland Hospital Council Cleveland, Ohio Published by The Cleveland Hospital Council , 308 Anisfield Bldg. Cleveland - Ohio Preface The Hospital and Health Survey of Cleveland was made at the request of the Cleveland Hospital Council. The Survey Committee appointed to be~|directly responsible for the work and through whose hands this report has been received for publica- tion consisted of the following: Malcolm L. McBride, Chairman; Mrs. Alfred A. Brewster, Thomas Coughlin, Richard F. Grant, Samuel H. Halle, Otto Miller, Dr. H. L. Rockwood, Howell Wright, Secretary The staff responsible for the work were : Haven Emerson, M. D., Director, and the following collaborators : Gertrude E. Sturges, M. D., Assistant Director; Michael M. Davis, Jr., Ph. D., Director 'of the Hospitarand Dispensary Survey; Josephine Goldmark, B. A., Director of the [Nursing Survey; Wade Wright, M. D., Director of the' Industrial Hygiene Survey; Donald B. Armstrong, M. D., Director of Tuberculosis Survey; S. Josephine Baker, M. D., D. P. H., Director of the Infant and Maternity Survey; T. W. Salmon, M. D., Director of the\MentallHygiene % Survey ; W. F. Snow, M. D., Director of the Venereal Disease Survey; Louis I. Dublin, Ph. D., Director of the^Vital Statistics Survey. The expenses of the Survey and of the publication of the report have been met by appropriations received from the Community Chest, through the Welfare Federation, of which the Hospital Council is a member. The report as a whole, or by sections, can be obtained from the Cleveland Hospital Council. A list of the parts will be found in the back of this volume, together with prices. TABLE OF CONTENTS Page Introductory Note 707 I. Nurses' Training in Cleveland. Hospital Training Schools Standards of Comparison _ 709 A University Training School 710 Results of Field Study _ 712 Organization of the Training School _ 713 Entrance Requirements 715 Capacity of Hospitals and Service Offered... _ 716 Instruction Teaching of Nursing Procedures _ 724 Teaching of Fundamental Sciences. _ 728 Instruction in Other Subjects _ 732 Conditions of Work ' Ratio of Nurses to Patients _ _ 735 Hours of Duty... _ __ 736 Vacation _ 738 Provision of Ward Helpers __ 738 Living Conditions 740 Recommendations _ _ _ 741 Postgraduate Courses University Course in Public Health Nursing Origin 745 Organization _ 745 Finances 746 Staff....... 746 Students... 747 Instruction.... 748 Field Work 748 Recommendations 751 Institute of School Hygiene 752 II. Public Health Nursing Introductory Scope of Survey 753 Some Elements of Success 754 Value of the Generalized System 754 Some Causes of Failure 755 TABLE OF CONTENTS— Continued Page Central Nursing Committee Organization 756 Activities A • : 757 Recommendations 757 Division of Health Scppe of Work ,. 758 Present Staff „...' 759 Analysis of Activities 759 Analysis of Administration. 764 Recommendations 769 Visiting Nurse Association Scope of Work 773 Present Equipment 774 Analysis of Activities •_ 774 Analysis of Administration..., : 778 Recommendations 781 Board of Education Scope of Work 782 Staff. 783 Analysis of Activities 783 Analysis of Staff and Administrative Methods 786 Recommendations 788 University District Analysis of Administration 790 Analysis of Activities 790 Supervision 795 General Summary... 795 Recommendations 796 Prenatal and Maternity Service Present Service 797 Types of Patients to be provided for.. 797 Types of Nursing Care Needed.... 798 Appropriate Agencies for a City-wide Service.. 798 Recommendations — 803 Industrial Nursing Function of the Industrial Nurse 803 Types of Service Rendered 804 Some Causes of Failure... 806 III. Some Notes on Private Duty Nursing. Unnecessary Employment of Full-time Graduate Nurses 808 Employment of Trained Attendants 809 T INTRODUCTORY NOTE HE Nursing Survey and Report has been in charge of Josephine Gold- mark, Secretary of the Committee for the Study of Nursing Education, and Anne H. Strong, R. N., Assistant Secretary of the Committee. The field work for the study of hospital training schools was done by Mrs. A. F. Piggott, Maryland State inspector of training schools. A brief study of the teaching in the larger training schools was made by Miss A. H. Turner, professor of physiology at Mt. Holyoke College. In writing the report on the hospital training schools, assistance was rendered by Miss Pauline Angell. The investigation of public health nursing agencies in Cleveland was made jointly by Miss Elizabeth G. Fox, Director of the Bureau of Public Health Nursing of the American Red Cross, and Miss Janet M. Geister, Western Secretary of the National Organization for Public Health Nursing. To Miss Fox credit is due for outlining the plan for a Prenatal and Maternity Nursing Service and for the detailed recommendations to the various pub- lic health nursing agencies. Both these investigators, Miss Fox in particu- lar, assisted in the writing of these reports. The field work for the study of industrial nurses was done by Mrs. Anna M. Staebler, Secretary of the Massachusetts Committee on Health in Industry, and some supplementary studies in this field were contributed by Miss Wilma I. Ball, Secretary of the Consumers' League of Ohio. To all the cooperating societies, who released their workers for the Nurs- ing Survey for varying periods of time, acknowledgment and thanks are due. Nurses Training in Cleveland Hospital Training Schools THE study of hospital training schools in Cleveland has covered the thirteen schools recognized under the State Law. Of these, four were studied in much detail (City Hospital, Lakeside. Mt. Sinai and St. John's) ; the remaining nine were more briefly inspected (Cleveland Maternity, Fair- view, GlenviUe, Huron Road, Lakewood, St. Ann's Maternity, St. Alexis, St. Luke's and St. Vincent's.) The investigation centered upon all those factors in the hospital and the training school which are related to the nature and adequacy of the training; the adequacy of service to patients in the hos- pital was considered only in so far as it bears upon the work of the students. The hospital training schools in Cleveland exhibit, in greater or less degree, the general characteristics which are found in similar institutions elsewhere. The excellence and the weaknesses inherent in the established system of instruction, both theoretical and practical, are amply illustrated in the various schools of the city. They share that spirit of devotion and ser- vice which has for a half century been the distinction and the legitimate pride of the training schools for nurses; they share also in varying degree the lack of standards and of independent organization, the inadequacy of teaching and equipment, and the exploitation of students, which has been too often accepted in lieu of education.* STANDARDS OF COMPARISON The objects of study and standards of comparison taken in the study of Cleveland training schools have in the main been those set forth as "reason- able and desirable" in 1919 by the Committee on Education of the National League of Nursing Education. Without subscribing to the details of the curriculum there set forth, we have measured the training schools by these recognized standards together with certain additions of our own. The standing of each hospital with relation to the desirable standards is discussed in this report; a separate detailed account of each hospital has been submitted to the authorities of the institution. This record brings out the strong and the weak points of nursing educa- tion in Cleveland, and shows concretely how much remains to be done to bring the training schools up to the level which they should reach to meet the clinical opportunities and the clinical needs of the city. To introduce radical innovations into any established human institution is obviously a slow and delicate task. In their business of nursing the sick, the hospitals cannot at once, or even within a short period of time, be deprived of their present labor supply. Any changes must of necessity be gradual, and in the following report the standards followed and the recommendations * The investigation upon which the report is based was made in the winter of 1919-1920. Notable improve -nents have already been made in a number of the hospital training schools since that time and many others are under consideration. 710 Hospital and Health Survey made for immediate adoption only approximate the conditions under which students should ultimately be trained. Within the required limits, undoubtedly many desirable changes in indi- vidual hospitals can be indicated, which will improve the training now given. But these changes should be recognized as merely ameliorative. They rep- resent temporary improvements, not the fundamental reorganization of the training school under university auspices, which is needed for the future development of nursing education. A UNIVERSITY TRAINING SCHOOL In the possibility of a central training school under university auspices, Cleveland has the opportunity of making an important contribution to the ultimate solution of the problem, the independence of hospital and training- school, the recognition of the nurse-in-training as a university student throughout. A preliminary university affiliation has already been tempo- rarily and partially tried in Cleveland. The successful wartime expedient of providing college instruction in the fundamental sciences for 88 student nurses during the summer of 1918 set the precedent for an extension of such a university connection. Moreover, the university has already given proof of its broadminded interest in permanently providing training of college grade for young women who desire to enter this increasingly important branch of public service, the profession of nursing. A preliminary plan has been proposed by the uni- versity for a future school or department of nursing, subject to obtaining financial support for such an undertaking. The plan proposed, while still tentative, is highly commendable in in- cluding various features essential for the success of such a central university school. Briefly stated, it proposes to give a definite period of college training, chiefly in the introductory sciences but with some cultural studies, an equal length of time for hospital training and a final academic period for additional courses in the nursing specialties. For the graduates of these courses both the nursing diploma and the university degree are to be granted. In this proposal for a School of Nursing a distinctive contribution is made. In the few other cities in which such a five-year college and hospital course is offered, the courses are in combination with but one or two hospitals; the Cleveland plan would be offered in cooperation with several hospitals to start with and with as many additional ones as "can maintain standards of training high enough to warrant their recognition. " Some Benefits of the University Training School Better Students and Better Instruction One of the main benefits of a university connection such as the one pro- posed would be to attract to the profession of nursing young women who are now repelled by the inferior teaching provided, and the subordination of their education to the needs of the hospitals. In the pre-nursing period Nursing 711 of instruction, it will be possible to give science teaching of far higher grade and with laboratory equipment far better than provided in the ordinary hospital course. Improving Instruction on the Wards A second benefit, upon which general stress should be laid, is the oppor- tunity afforded to the university to exert its influence in raising the edu- cational standards of the hospitals which desire affiliation. It is clear that one essential element of this plan must be the cooperation of the hospital in offering instruction in the wards of such a quality as to deserve the uni- versity degree. In our subsequent discussion of the Cleveland hospitals the success or failure of teaching in the wards is indicated. In the possi- bility of refusing affiliation to hospitals whose instruction in nursing pro- cedures, either in the class room or in the wards, is below standard or educa- tionally wasteful, the university school can be a potent force for good. It should use its power of approval or disapproval freely, for in no other way than by scrutiny and criticism of the grade of teaching provided by the hospital can the educational side of the training school be sustained against the exigencies of hospital needs. Training for Advanced Work in Administration, Teaching, and Public Health The special function of the university course will be to prepare the leaders in the different fields of nursing. Impartial investigation finds crying need for more adequately trained teachers and administrators in the hospitals. Such a course would supply administrative heads with better fundamental training and a wider background than are now general. The limited edu- cation of many who are in positions of responsibility in the training schools has been one cause of their difficulty in grappling with the perplexing prob- lems of the schools. Similarly, such a course would help to provide more adequately trained nursing instructors. The lesser educational qualifications of instructors in schools of nursing as compared with instructors in colleges and other pro- fessional schools is very marked. In the schools of nursing the instructors are frequently required to teach many subjects, often more than teachers in country high schools; yet for this great task, they have themselves had only their own nurse's training, of perhaps some years past, sometimes supple- mented by courses at Teachers' College, New York. Even after years of experience and the most painstaking work, the instruction often reflects the limited background of the teachers. A university training school would be of high value in providing teachers with more actual information as well as some knowledge of methods of teaching. Thirdly, the university training school will fill a much needed place in providing the training essential to meet the demands of public health nurs- ing. Here, the final period of academic study would include case work and 712 Hospital and Health Survey the many phases of social service, without a knowledge of which the nurse's training alone cannot fit a woman for acceptable work in this rapidly develop- ing field. A Shorter Basic Training for All Nurses In addition to training for advanced work the university should assist in providing better science teaching for the rank and file; that is, for students who have either no wish or no ability for specializing in the higher branches of nursing, but who would take advantage of a good basic nursing training, especially if it were shorter than the present three-year course. Such stu- dents would obtain in the university the training in the preliminary sciences; they would, under a plan to be subsequently worked out in detail, be gradu- ated after a basic training of about two years and four months, with the diploma of nurse but without a university degree. Such nurses would be available primarily for bedside care. They would not have the added training and experience which is needed to fit for the exacting needs of public health nursing and for teaching and administrative positions; but by a reduction of the present three-years' course, the bedside nurses would be available in larger numbers and help to meet the present shortage. Such a shortening of the course would be possible both through the better teaching in the college and also through the elimination of non-educational housekeeping duties and of the present indefensible repetition of services. It will be noted that in the foregoing discussion no definite length of time has been proposed either for the full university-hospital course oj" for the briefer basic training. At present the 3-year course is the rule and a 5- year course has been suggested for the central university school. How far these courses may safely be reached by elimination of the non-educational features noted above, still remains to be determined. Studies of hospital training schools in other cities, of which the Cleveland Survey has been one, are now ia progress by the Committee on Nursing Education. From detailed observation of the work and instruction of first, second and third year students in different types of hospitals a composite picture will be obtained of the total careers of students and the training afforded at each hospital. This study will aid materially in determining how the present course may be reduced without sacrificing any of the essen- tial services. Sufficient time has not yet been afforded to complete these intensive studies on which will be based our ultimate recommendations for a detailed curriculum for both types of university students. RESULTS OF FIELD STUDY It is obvious that no general statements can cover the Cleveland training- schools as a whole. Their procedures naturally differ with their size, their age, financial resources, religious affiliations, etc. The results of our field study are here summarized so far as possible. The standing of the hospitals is shown with relation to the standards regarded as desirable under present conditions, that is, while students are still used to staff the wards. The dis- Nursing 713 cussion falls under the following heads: organization of the training school, minimum entrance requirements, capacity of hospitals and services offered, instruction, conditions of work and living conditions. ORGANIZATION OF THE TRAINING SCHOOL The relationship between schools of nursing and hospitals should be essentially the same as that created between medical schools and hospitals. The school of nursing, like the medical school, exists primarily to give tech- nical education to students who are to obtain part of their training in the wards of the hospital. It follows necessarily that many important factors in the training school for nurses fall wholly outside the administrative scheme of a hospital. (a). The best organization of a school of nursing is clearly the university organization, in which ward training is given in such hospitals as come up to the conditions of teaching and of living required by the university for edu- cation of its students. (6). Until the university organization is formed a similar arrangement might be effected by an independent board, capable of directing the educa- tional policies of the training school, which could contract with the hospital to give the necessary ward training supplementing the laboratory and di- dactic teaching supplied. Among the Catholic hospitals or in hospitals administered under religious organizations which have no Boards of Trustees or which are subject to the Bishop of the Diocese, an advisory committee might be established at once to direct the educational policies of the train- ing schools. (c). In such hospitals as may still continue to keep the training school as part of the hospital organization, there should be appointed by the Board of Trustees a training school committee, composed of both men and women, to direct educational policies. This committee should be composed of rep- resentatives of the Board of Trustees and other persons known to have had experience in education and also members of the alumnae of the school. The superintendent of the hospital and the director of the training school in the hospital and representatives of the medical staff selected by the medical executive committee, though not members of the training school committee, should sit with the committee. The superintendent of nursing in the hospital should be appointed by the Board of Trustees of the hospital, on nomination of the superintendent of the hospital, with the concurrence of the training school committee. It is considered desirable that the superintendent of the hospital should delegate to the superintendent of the training school the appointment and dismissal of nursing personnel. The offices of principal of the training school and superintendent of nurses, that is an educational and administrative office, may or may not be combined in the same individual. When they are combined the head of the training school should be designated "Superintendent of Nurses and Prin- cipal of the Training School." 714 Hospital and Health Survey So far as concerns the make-up of the coniniittee, in Cleveland only one of the 11 general hospitals studied had a training school committee approxi- mating the desirable form.* This hospital is St. Luke's. It is worthy of note that the committee has on it an alumna of the school and that it has taken a special interest in providing, so far as is possible with unsuitable buildings, unusually homelike conditions of living for the nurses. Some variations from the above form of the training school committee are the following: At Lakeside eight of the twelve members are women. At Huron Road the committee consists of only three members, all of whom are attending physicians. One is also a member of the Board of Trustees, and one is an instructor at Western Reserve University. None of the ten remaining hospitals has a training school committee. At Mt. Sinai this lack may in part account for the fact that the living conditions for the students and the equipment in class rooms and labora- tories fail to come up to the high standards of the other departments of this hospital. An advisory board at the City Hospital has recently disbanded and the appointment of the chairman of a new committee was at the time of the investigation under consideration by the Director of Public Welfare. None of the Catholic hospitals has a training school committee; nor has Fairview. Glenville, or Lakewood. A former training school committee at Fairview has recently been abandoned. Cost Accounting An adequate system of cost accounting is practically unknown in train- ing schools. Cleveland is no exception to the rule. For none of the hos- pitals is it possible to state the per capita cost of student nurses, including maintenance as well as instruction. Xor on the other hand, is it possible to state the financial value of work done by the students and staff and the saving to hospitals from the utilization of their services. Money Allowance to Students The once prevalent custom of paying students a small yearly sum during training is gradually beins; abandoned. To attract students of good calibre, it is clearly more desirable to devote such funds to improving the course of training. Better teaching, equipment and living conditions are a greater attraction for desirable students than a small financial inducement. In- deed, some hospitals instead of paying their students are charging a small fee for instruction. In Cleveland the old custom of paying students exists in all but two hospitals, Lakeside and St. Luke's. Even in these, the system still prevails in the custom of providing uniforms and textbooks. "The two spec'al hospitals, Cleveland Maternity and St. Ann's, are omitted in this section. Xtksixc 71 5 MINIMUM ENTRANCE REQUIREMENTS The Ohio state law requires that students be at least 18 years of age when they enter the training school. Most of the Cleveland training schools do not go beyond this requirement, but four, Huron Road, Lakeside, ; Lake- wood and St. Luke's, make 19 the minimum age for entrance. In four schools a few students under 18 had at the time of our investigation, been accepted; at the City Hospital, there were 2 who entered under age, at Fairview 3, at St. Alexis 2, and at St. Vincent's 3. The age at entrance of 459 students in 9 hospitals was obtained and showed that in all but 3 of these hospitals, the median age at entrance was "20 or over. Age at Entrance* Huron Road Lakeside St. Vincent's .......... Glenville Mt Sinai ■.'.'. St. John's... Cleveland City Fairview .. St. Alexis * Data on this point were not obtained from Lakewood and St. Luke's. f That is, ranging all the ages from highest to lowest, the median is the age of the student in the middle . Minimum Educational Requirement According to the Ohio law, the minimum educational requirement for entrance into the training school is completion of one year of high school. Of the 11 hospitals considered in this connection, 4 (Huron Road, Lake- side, Mt. Sinai and St. Luke's) require graduation from high school for en- trance. At St. Luke's this requirement has just been put into effect, and the first class entering under the new regulation is made up entirely of high school graduates. In the other three schools, the requirement is of longer standing, and all three make exceptions to the rule, as is shown in the fol- lowing table. The personal histories of 528 students in 11 hospitals were obtained and showed that 347, or 65%, had completed four years of high school, as follows : Age Required Median Agef 19 22 19 22 18 21 18 20 18 20 18 20 18 19 18 19 18 18 716 Hospital and Health Survey Education at Entrance Total No. No. with 4 years of of Students* High School or more Percent Lakeside 133 125 93 Mt. Sinai 64 60 93 St. Luke's 59 50 84 Huron Road 33 26 78 Cleveland City 63 33 52 Fairview 24 12 50 St John's 30 11 36 St. Alexis 9 3 33 St. Vincent's 78 20 25 Glenville 22 5 22 Lakewood 13 2 15 Total 528 347 65 Exclusive of the three Catholic training schools, St. John's, St. Alexis and St. Vincent's, and the 3 smallest training schools remaining, Fairview, Glenville and Lakewood (which, as is later suggested, might well combine in giving theoretical instruction to their students), the percentage of students qualified for college entrance is 83%. * In a few hospitals data is not available for one or two students. CAPACITY OF HOSPITALS AND SERVICES OFFERED Desirable Standards To qualify as fitted to give an adequate training of nurses, a hospital should provide the requisite number of patients and variety of suitable services. According to the standard, a general hospital under municipal or private endowment, neither too large nor too small, is best fitted for this need. As a teaching field the general hospital of 400 to 500 beds is held to rank first, if it gives not only the four main branches— medical, surgical, children's and obstetrics — but certain special branches, such as communi- cable diseases, mental and nervous disorders, etc. If all of these branches are not included in the clinical resources of the hospital, they should be made available for the students through affiliation with other hospitals. Hospitals of more than 500 beds, while they frequently offer a richer variety and number of services, labor under greater difficulties in the way of securing adequate supervision and instruction of the students. Hospitals having less than 400 but more than 150 beds also offer excellent teaching facilities. Those of less than about 50 beds cannot maintain schools of accepted standards. N'UBSIH G 717 Findings 1. Hospitals of More than 400 Beds The City Hospital In Cleveland the only hospital of more than 400 beds is the City Hos- pital with 781, of which 481 beds are utilized for training. The difficulties of securing adequate supervision for so large an institution have here been increased by the insufficiency of the nursing staff for actual care of the sick. The shortage of students and of proper ward help has led to the diversion of graduate nurses to routine care of patients from their primary duty of supervision and instruction of students. Thus, for example, the graduate nurse responsible for the supervision of students having training in the children's wards of 40 beds, had only 2 stu- dents and 1 attendant for the care of these patients. In addition she was also head nurse in the adjoining temporary influenza ward of 23 beds, where she had only 1 student and an attendant to assist her. In this emergency, the Superintendent of Nurses was trying to secure another graduate for the influenza ward, which had just been opened. Supervision and instruction were clearly impossible; the first object was necessarily to care for the patients as well as difficult conditions permitted. Faulty technic on the part of the students was observed and under the circumstances could hardly have failed to occur. (a). Clinical Opportunities In its clinical opportunities, this hospital offers an unusually wide range of experience. In contrast to all the other Cleveland hospitals, it offers an extensive and acute medical service with definite segregation of chronics and a particularly adequate field for training in pediatrics and communi- cable diseases, including venereal disease. The training school, however, is not able to make the most of these clinical opportunities. The medical, surgical, obstetrical and children's ser- vices are inadequately staffed, poorly equipped, badly housed in the gloomy old main building,- and have been allowed to become run-down and below standard. The contagious and venereal disease services, on the other hand, might well be further developed to afford opportunities for affiliation for students from other hospitals. The contagious disease service is in a new building with modern pro- visions for the efficient care of patients and consequent good training of students. Moreover, supervision is good and theoretical instruction is given at the same time with the practical experience on the wards, so that the two can be properly correlated. Commendable precautions are taken to protect the students from infection and to prevent them from carrying it to others. For this purpose the hospital is exceptionally well equipped. 718 Hospital and Health Survey This department is necessarily more fully staffed than other depart- ments, even at their expense. The pupil nurse service is supplemented by affiliating students from two other hospitals. That the exceptional oppor- tunities for training are appreciated by the students is evident from a comment from the superintendent of Glenville Hospital, one of the affiliating schools afterward visited. "This service is an elective one for senior students. So fa/ all senior students have asked for it, and on return here comment most enthusiastically on their experience. " Other Cleveland schools of nursing might well take advantage of affilia- tion with this contagious hospital, thus securing a much needed experience for their students. Such affiliations would also release a certain number of City Hospital students for the other services there, as the four to six months of contagious disease experience required of them at present could be shortened if an adequate nursing service in this department were otherwise provided. In the specific (venereal disease) wards, also, more favorable conditions for training are noted, and valuable experience for the student is found here, especially in the Women's Department, which includes 12 beds for obstetrics complicated by venereal disease. The capacity of the venereal disease wards is 50 men, 42 women and 8 children, and the building has recently been renovated to meet the demands of the service. The training possibili- ties are good and affiliation could well be arranged for students from other schools wishing to include this experience in their preparation for the public- health field, or even in their general training. Such an arrangement would help to remedy the insufficiency of the nursing staff at present, which makes it impossible for the nursing duties to be properly organized. The buildings for the tuberculosis service and the chronic patient ser- vice in which the nervous and mental cases are housed, although they might afford valuable clinical oportunities, cannot offer adequate training until radical changes have been made. 2. Hospitals of Between 290 and 140 Beds The second group of hospitals considered have the following number of beds. St. Vincent's : 290 Lakeside 289 Mt. Sinai 255 St. Alexis 250 St. John's 158 St. Luke's 140 While these hospitals offer a sufficient number of beds to comply with the recommendations for a good teaching field for nurses, a consideration of the variety of services provided is also needed in order to gauge their ade- quacy for the purposes of training. Nursing 719 (a). Predominance of the Surgical Services In the main, the outstanding fact is the inadequacy of the medical ser- vices and the specialties, broadly speaking, on the one hand, and on the other the predominating claims of the surgical services, at the expense of the for- mer. The predominance of surgical services is the natural result of the in- sufficient number of hospital beds, the emergencies of surgical need taking precedence of medical needs, and the added fact that a higher proportion of surgical cases than of medical require hospital care. The predominance of surgical services obviously makes for a badly balanced scheme of instruc- tion. It is plainly impossible to give a well-rounded nursing education when so large a proportion of the student nurses' time is absorbed in purely surgical or predominatingly surgical work. This lack of proportion is amply illustrated in the records of practical experience of individual students at various hospitals. Number of Beds and Percentage of Admissions The most obvious evidence of the extent to which surgical training dominates other services lies in the proportion of beds assigned to each and in the percentage of admissions. At Lakeside there are 85 surgical beds to 61 medical; St. Alexis has 124 surgical to 50 medical; St. John's 89 surgical to 29 medical; St. Luke's 56 surgical to 36 medical; St. Vincent's 123 surgical to 42 medical. At St. Alexis, on the day this hospital was visited, of the 25 beds in the women's medical department, 17 or over two-thirds, were occupied by surgical cases. At Mt. Sinai an even proportion is maintained, namely 47 surgical beds to 46 medical. Analysis of the available figures showing the admissions for two hospitals indicates still more clearly the extent to which Cleveland hospitals are given over to surgical cases. At Lakeside in the year 1918 surgical admissions were 3,388 as contrasted with 1,819 medical, and in 1916 (that is, when the entire surgical staff was available), there were 4,160 surgical admissions as against 1,498 medical. The latter figure included admissions in pediatrics. At St. Luke's the record of admissions for 1919 shows that 25% of the cases were medical as against 55% surgical. Number of Days Spent in Surgical Services The bearing of these facts on the nurses' training is shown by the record of their actual days spent in surgical services. Thus, from a study of the records at Lakeside it was found that of 17 seniors who had been in the hospital 2 years and 9 months, 12 had already had from 7 to 10 months' training in the surgical wards and operating room, though the time planned for these services is 6 months. Of the remaining five, 3 had had 6 months, 1 had had 5 months, and 1 had had 4 months in these services. When gynecological and gauze room experience is added, as well as 75% of the time spent in private service, which may legitimately be reckoned as surgical, these 17 seniors had spent from 14 to 19 months in the various surgical services. 720 Hospital and Health Survey In contrast to the time spent in the surgical wards and operating room (ranging from 5 to 10 months) is the time spent by these 17 seniors on med- ical wards, ranging from a little less than 2 months to 6 months. The median * is about three months and three weeks as against a median of seven months in general surgical experience. At St. Luke's, 6 seniors, who had been in training from 2^2 to 2% years, had spent from 6 to 13 months in surgical services. This does not include the months spent' in the private service, a large proportion of which is sur- gical. These same students had spent from 4 to 8 months in the medical wards, the median being between 5 and 6 months as against a median between 9 and 10 months in surgical experience. The actual experience of 12 seniors at St. Vincent's shows a similar dis- proportion. With two exceptions, these students had not yet completed ~3^ years of their training, and yet already 3 had had 9 months, 1 had had 10 months, 4 had had 12 months, 3 had had 13 months and 1 had had 14 months in the various surgical services. The medical experience of these same students ranged from 4^ to 834 months, the median being a little less than 6 months (174-177 days) as against a median of 12 months in surgical service. That it is not impossible to approximate more nearly the program of services planned is proved by the example of Mt. Sinai. This hospital is more successful than any other in this group, in keeping the surgical experience to the specified time, even though the time planned is somewhat long. Six months each are allowed to medical nursing and surgical nursing, including nursing of private patients. The records of 7 seniors, who had been in training 34 months or over, showed that in surgical service in the wards, the students spent from 3 months to a little more than 5 (160 days); the median is 4^2 months. In medical ward service, the 7 students spent from 23^ to 7 months, the median being nearly 6 months (171 days). On private duty, the students had spent from a month and 3 weeks to 5 months, the median being a little more than 33/2 months (107 days). As private duty is for the most part largely surgical, it is reasonable to conclude that at this hospital surgical service, which on the wards was slightly below the time planned, is supplemented by the private surgical duty, and the medical service, which in the wards approximates the 6 months planned, i* not unduly prolonged by the private duty. In the operating room all seven seniors under discussion exceeded the 2 months planned for this service. Two of these students, however, were specializing, and their time was purposely prolonged. Only one of the remaining five overstayed the time planned by as much as one month; the other four exceeded the time by one to two weeks. * That is, ranging all the months from highest to lowest, the median is the figure showing the middle number of months. Nursing 721 From this summary, it appears that with the exception of Mt. Sinai the tendency is to devote at least twice as much time to surgical training as to medical* (6). General Inadequacy of the Medical Service for Training This inadequacy is due to two causes, the predominance of the surgical services, and the large proportion of chronics. The predominance of the surgical services and the consequent curtailment of training in the medical service, has been dealt with above. The proportion of chronics in the medical wards visited ranged from 40% to 58% in the three hospitals in which this condition was observed. At Lakeside, on the day when the medical wards were visited, 8 of the 19 patients on the men's ward, and 4 of the 11 patients on the women's ward were chronics. In order to make the most of the inadequate medical service for teaching, the students at Lakeside are, by an excellent practice, required to hand in written case reports while on duty in the medical wards. At St. John's, on the floor assigned to medical cases, 24 were under treat- ment on the day of the inspection. Of these 14 were chronics and 2 were surgical cases. At St. Vincent's there w r ere 14 patients in the women's medical ward, of whom 6 were chronics, two of them in reality boarders of several years' standing. At Mt. Sinai and St. Luke's no data on this point were obtained. At St. Alexis chronics are segregated on a special floor. But in this hospital, owing to the lack of graduate nurses, training is given in the women's wards only, so that students receive no experience either medical or surgical, in the nursing of men patients. (c). Communicable Diseases At the time of the investigation, none of the hospitals in this group pro- vided any experience whatsoever in communicable disease, except for occa- sional cases which develop in the hospital and cannot be transferred. This failure is all the more striking, owing to the rare opportunities for training in communicable disease offered at the City Hospital, of which the small hospital of Glenville, for instance, has taken advantage. id). Pediatrics Only two hospitals of this group, Lakeside and Mt. Sinai, have an ade- quate number of beds for training in this branch. The other four hospitals either provide no beds for this service, or provide a very small number, which are almost all used for surgical cases and thus afford no training in pediatrics proper. (e). Obstetrics Of the six hospitals under discussion, three offer obstetrical training within their own wards. These are Mt. Sinai, St. John's and St. Luke's. Except at St. Luke's, no provision is made for out-patient obstetrical training, the student nurses thus failing to obtain experience in outside prenatal work, or * Records of actual experience were not available for students at St. A'exis and St. John's. From the assign -nent of beds, it is evident that in these hospitals, as in St. Vincent's, at least two-thirds of the entire hospital service is surgical. T^ Hospital and Health Survey in caring for patients id their homes. At Mt. Sinai there is a large out-patient prenatal clinic, but students are not assigned to work in the district. The follow-up work there is done by the social service department. A few stu- dents, who elect public health work, may have prenatal experience in the University District. At St. Luke's, student nurses have training in all. three branches of obstetrical work, prenatal, partum, and post-partum. Lakeside and St. Vincent's provide obstetrical training through affilia- tion, the former at the Cleveland Maternity, and the latter at St. Ann's. The Cleveland Maternity affords training both on the wards and in the dis- trict, but Lakeside did not, at the time of the investigation, avail itself of the outside prenatal and partum experience for its students. Moreover, the type of supervision for student nurses given by the Cleveland Maternity .is inadequate and scarcely up to the standards of modern public health work. Students from St. Vincent's have no opportunity for out-patient work. The sixth hospital in the group under discussion, St. Alexis, has at present no obstetrical training either within its own wards or by affiliation. (f). Xenons and Mental Diseases Except for occasional cases, these hospitals offer no experience in the care of patients suffering from nervous and mental diseases, nor is there indeed any opportunity for offering such training to students. At the City Hospital there is a large group of mental cases, which should afford a desirable field for training. But the absence of any modern methods of treatment makes this impossible at present. In contrast to the now accepted methods of treatment in enlightened institutions, patients are under close confinement and practically in custodial care in gloomy cell-like rooms. (q). Private Service • The public wards are the best training ground for student nurses, and by far the greater proportion of their time should be spent there. It has been suggested that the ratio of private to free beds should not exceed one to four in hospitals which train nurses. Two of the hos- pitals in this group, Lakeside and St. Vincent's, have a ratio nearly twice as high as is considered desirable, the ratio in each case being 1 :2.7. The ratio at Mt. Sinai is 1:5.5; at St. Luke's 1:4; at St. Alexis 1:3.9 (exclusive of feeds on the floor used for chronics); at St. John's 1:3.7. Mt. Sinai follows the excellent practice of relying mainly on graduate nurses for the staffing of the private rooms. The days spent in private service by students at Lakeside range from 87 to 306, the median being 195 days, or slightly over six months. The time planned for the service at Lakeside is four months. At St. Luke's the range is from 131 to 210, and the median between 140 arid 155 days. At Mt. Sinai, the range is from 53 to 149 days, with the median 107 days, about three months less than the median at Lakeside, and a month less than at St. Luke's. Information as to the time actually spent by students in private service whs not obtained from St. Alexis, St. John's and St. Vincent's Charity. St. N Vs ft sing. ■ 723 Vincent's Charity plans that each student shall devote six months to private duty nursing. It is apparent that undue emphasis on the private service constitutes a distinct weakness in the training at Lakeside and St. Vincent's Charity and the same tendency is noticeable at St. Luke's. 3. Hospitals of Between 140 and 50 Beds :Exclusive of Cleveland Maternity (61 beds) and St. Ann's Maternity (55 beds), to which, as special hospitals, these standaids do not apply, there remain four smaller general hospitals. These can provide the necessary variety of services only by affiliation with larger institutions. These are: Fairview ': 100 beds Huron Road 87 " Glenville 70 " Lakewood :.' 53> " The medical service in all four hospitals is limited and affords but meagre training for nurses. In fact, it appears that the only services adequate for nurses' training are surgery and obstetrics. Even in the surgical service, little or no experience is afforded in such important branches as orthopedics and diseases of the eye and ear. In obstetrics also, training is limited. With the exception of the Huron Road students, who affiliate at Cleveland Maternity, the service is entirely lacking in partum and post-partum care in the homes. Students at Glenville and Huron Road receive prenatal train- ing in the University Health District. Lakewood and Fairview students do not get this experience. In all four hospitals too large a proportion of the training is in the private service. For, medical, communicable, nervous and mental diseases, as well as for pediatrics, all of the hospitals of this group need affiliation, to give adequate training. Glenville makes an excellent beginning by requiring four months' affiliation in pediatrics and providing elective courses in communicable diseases, both of these at the City Hospital. Glenville was at the time of the investigation the only hospital in Cleveland to recognize and take ad- vantage of the unusual clinical facilities offered there. The other three hospitals in this group do not make good then" own deficiencies by any such affiliations, thus failing to recognize the primary importance of these services in the nurses' training. 4 Out-Patient Departments . ''Of- the 11 general hospitals, 5 have no out-patient department. Of the 6 remaining institutions, Mt. Sinai offers the most complete opportunity for training, as almost all the services are represented in active clinics. Lake- side, records show a higher daily average of, patient attendance than Mt. Sinai, but Lakeside lacks prenatal and dental service. St. Vincent's Charity lacks pediatric, orthopedic, prenatal and dental services. The work at St. Lyke's is reported to be "that of a specialized industrial clinic with chiefly surgical interests. " The medical clinic is small and an eye, ear, nose and throat clinic has just been started. There are, however, active prenatal 5524 Hospital and Health Survey and gynecological clinics where students may receive valuable training. The Huron Road dispensary is given over almost entirely to surgical cases; medical cases are only occasional. The City Hospital has a weekly dental clinic, which is very active, but there is no other dispensary service. Since a detailed report has been made on the organization and work of the Cleveland dispensaries, they are not further treated in this report. None of them are fully utilized as teaching fields for student nurses. Likewise social service departments are not treated here, since a special study has been made of the work of these departments. 5. Public Health Nursing At present a very small number of students take advantage of the ex- ceptional training for public health work offered in the University Teaching District. In this District, Cleveland has made a distinct contribution of the highest grade to the development of generalized city nursing. In no city is a better opportunity afforded for training and supervision in such work, if sufficient time is given to take advantage of it Two months of this training are now allowed by five hospitals. The course is elective at City, Lakeside and St. Luke's. It is required at Glen- ville and Huron Road. Mt. Sinai allows four months of training in the Uni- versity Teaching District, but the course is available for only three or four students each year. At City also it is possible to elect a four months' train- ing in the District. INSTRUCTION Teaching of Nursing Procedures Demonstration Room A special room for the teaching of nursing procedures is provided at seven of the eleven hospitals considered in this section.* At St. Vincent's, how- ever, the room was not in use at the time of the investigation. At Glenville, Huron Road, St. Ann's and St. Luke's the same class room is used for nurs- ing procedures that is used for other subjects. At Lakeside and City the class room is large; at Mt. Sinai it is adequate; at Glenville it is small. At the others the room is fair as to size. The room at St. Ann's is crowded with material used in connection with the lecture courses. At only three hospitals is the demonstration room equipped with running water and gas or electric stoves. These three are Glenville, Lakewood, and Mt. Sinai. At the City there is a stove but no running water; at Fairview and St. Luke's there is running water but no stove. . The other hospitals rely on facilities in adjacent rooms. All the rooms are supplied with material sufficient for demonstration, though there are special difficulties in hospitals which have no special room. At Huron Road a bed is brought in when needed. At St. Ann's material for demonstration is said to be brought from the wards when needed. At St. Luke's the material is brought over from the hospital by the instructor. * Information on most of these points was not obtained from St. Alexis and Cleveland Maternity Hospitals. Nursing 725 At only two hospitals is the demonstration room supplied with material sufficient for practice by individual students. These hospitals are Fairview and Mt. Sinai. Methods of Teaching With the exception of St. Vincent's, where students were being taught entirely on the wards at the tims of the inspection, there is class room in- struction in the theory and practice of nursing in all eleven training schools. All are supplied with a Chase doll for demonstration. In addition, students are used for demonstration except at St. Ann's, St. John's, and St. Luke's. * At Lakeside, patients are brought over from the wards as sub- jects for the demonstration of some procedures, especially for such proced- ures as bathing and hair-washing. Patients serve as subjects at Glenville occasionally, and at Fairview also patients are occasionally used, but only in the wards. Practice in the Class Room Special periods for practice in the demonstration room are assigned at Huron Road and St. John's. At Huron Road, a practice hour of 1 hour daily is allowed, except on Saturday. At St. John's, 3 hours of practice a week is required of probationers and 1 hour a week of juniors and seniors, by way of review. At Fairview, City, and Lakeside, no special period is assigned, but part of the demonstration period is used for practice by individual students. At Mt. Sinai the study hour is frequently used for practice. At St. Luke's there is no opportunity for practice between classes, as the room is in use for other subjects and all material removed. Glenville and St. Ann's like- wise make no provision for practice in the class room. Class room practice is supervised by the instructor in the six hospitals which make any provision for such practice of procedures.! Hours The hours devoted to class room instruction in the theory and practice of nursing by Cleveland training schools are as follows :i St. Luke's 170 hours Mt. Sinai ..: 151 Lakeside 120 Lake wood 120 Huron Road , 100 St. John's - 65 City - 60 St. Vincent's 60 Fairview 50 Glenville 48 * At Huron Road no information was obtained as to the use of students and patients as subjects for demonstration. At Lakewood the course was in process of organization, and the use of students as sub- jects was planned. t Supervised practice is planned at Lakewood. Course at St. Vincent's not given at time of inspection. 726 Hospital and Health Survey St. Ann's Maternity Hospital gives 10 hours to affiliating students. At Cleveland Maternity 24 procedures are demonstrated to affiliating students. Correlation of Theoretical Work with Practical Work in the Wards Obviously, the test of theoretical instruction in nursing is its application in the wards-. The teaching of practical procedures, to be fruitful, must be associated not only with demonstrations and practice in class, but with close supervision of the student's work in the wards as soon as possible after the class work. Without such close correlation of theory and practice, nursing technic tends to be lax and unintelligent. Example of Good Correlation Of the thirteen hospitals in Cleveland a high standard of correlation was found only at one hospital, Mt. Sinai. Here the teaching of nursing pro- cedures is not only excellent in the class room, but is followed up by careful assignment of students for practice in the wards in the same procedures which they have just learned in the class room, with thorough supervision by. the instructor. The provision of standardized equipment, both in the class room and in the wards, has been a very considerable factor in making possible uniformity of nursing procedures, and has contributed to the accu- rate technic of the students observed in the wards. The fact that students are not hurried when on duty in the wardsj.but, owing to the provision of ward attendants, labor-saving devices and adequate equipment, have time to carry out the procedures exactly as taught, also contributes to the uniform excellence of technic observed. The graduate nurses in charge of wards have been appointed on account of. special qualifications. The head nurse of the children's ward is a graduate of the Boston Children's Hospital; the head nurse of the obstetrical ward has had postgraduate training at the Chicago Lying-in Hospital; and the nurse in charge of the operating room is a graduate of St. Mary's, Rochester, Minnesota. Thus student nurses have the advantage of instruction. given by specialists in their own departments. . . , ; St. Luke's was in the midst of reorganizing its instruction at the time of the investigation, but already had developed methods which should result in excellent correlation. For example, all procedures are demonstrated to the head nurses in the class room, in order to enlist their interest and co- operation in the teaching of students and to insure uniformity of method. Failure to Correlate Theory and Practice The varying lack of success in correlating theory and practice in nursing procedures at the other Cleveland hospitals is due to different causes. Lack of Equipment At the City Hospital, where exceptionally good provision is made for class room teaching, the entire lack of many essentials in ward equipment would Nursing 727 make it impossible to exact good nursing technic, as taught in the elass room, even if there were adequate supervision of ward practice. Lack of Organization At Lakeside, owing to other required duties, the instructor of prac- tical nursing has not sufficient time to supervise adequately even the proba- tioners on the wards. Moreover, no provision is made for the immediate application of class room teaching. For some students there may be an interval of some weeks before they have opportunity to put their class room teaching into practice. Conflict of Teaching with Administrative Duties At four other hospitals, Fairview, Glenville, St. Alexis and Lakewood, the teaching of practical nursing is carried by the superintendent of nurses in addition to her administrative duties. This arrangement obviously does not allow enough time for either teaching or organized supervision of nursing technic. The pressing demands of purely administrative interests continually thrust into the background the apparently less immediate needs of teaching. At two other hospitals, Huron Road and St. Vincent's, a somewhat similar interference with proper practical teaching is found. At Huron Road a head nurse is expected to give the class room and practical instruction in nursing procedure while her primary duty is management of a ward or floor. At St. Vincent's, the supervisor of the gynecological and women's medical wards was the instructor. Obviously, the successful combination of. ..two such functions is impossible. No opportunity was presented to see the instruction in nursing procedures at St. John's, owing to the illness of the instructor at the time of the investi- gation. Instruction at the Maternity Hospitals . The remaining hospitals, Cleveland Maternity and St. Ann's Maternity are soecial hospitals, giving obstetrical training to second and third year students, and to students of advanced standing. In the case of these stu- dents, acquaintance with nursing procedures is presupposed, except, in the special field of obstetrics. In addition, both hospitals offer courses of 15 months in obstetrics to women who have had no previous training in. nurs- ing. ' At Cleveland Maternity, demonstrations, supervision and instruction on. the wards are given by graduate nurses. At St. Ann's, the teaching and supervision are below standard, since they are in large part carried out by graduates of the fifteen months' course in obstetrics only. While far-reaching recommendations have been presented in the 'section on Prenatal and Maternity Nursing Service, which may by some be con- sidered as implying unjust criticism upon the quality of nursing service now given by the Maternity Hospital, it is particularly to be noted that it is not the quality of professional care either by physicians or nurses which is criticised. It is not conceived by the staff of the Survey that among the functions of a university teaching hospital is the administering of a city- 728 Hospital and Health Survey wide prenatal service. Lack of good administrative organization, inadequacy of supervision, lack of continuity of the present nursing service for maternity cases, are the main reasons for the recommendations that the Visiting Nurse Association and not the Maternity Hospital assume the broader functions proposed. Without the initiative, the standards, the demonstrations in this field made by the Maternity Hospital medical and nursing staff, Cleve- land could not now even consider such a thorough-going program of maternity care as is proposed. Cleveland's mothers owe much to the Cleveland Ma- ternity Hospital. Opportunities for Case Study Case study is required of student nurses only at Lakeside and Mt. Sinai. At Lakeside this good feature is found only in the medical wards. Teaching of the Fundamental Sciences* In most schools of nursing instruction in the fundamental sciences is weak, owing to the lack of good teachers and of equipment, and the lack of preparation on the part of the students. Yet the employment of teachers is in itself an advance over former methods of instruction. Most hospitals are equipped with one or more rooms in which it is pos- sible for students to gather around a table, view specimens, and otherwise witness a demonstration by the instructor, of the principles to be taught. But this is not real laboratory instruction, which should provide for individual experiment and observation. None of the eleven general hospitals studied in Cleveland is prepared to give individual laboratory instruction in all four of the fundamental science courses. Details of the equipment provided are given under each science course. None of the hospitals makes any separate allowance for laboratory supplies, demonstration material, or reference library. Instructors are often overtasked with administrative duties. The teach- ing staff at Lakeside is materially hampered by the necessity of attending to many details in the administering of the school. In five of the ten hospitals considered in this section, the same person who administers the training school is expected to carry all or at least the heaviest part of the teaching. At the City Hospital, the acting superinten- dent of the training school teaches 7 subjects, spending 19 hours weekly in class work in addition to the nursing administration of a hospital with nearly 800 beds. An emergency at Fairview makes the instructor also the acting- superintendent of nurses, though even in normal times she shares many of the responsibilities of administering the school. At Glenville and Lake- wood, the administration of the training school and the instruction of nurses is carried on by the same person. At St. John's, the superintendent of nurses carries in addition to 18 teaching hours, the administrative duties of her position in which she seems to have no assistance even for the clerical work. * In this section St. Alexis is emitted throughout, owing to the absence of systematized instruction and of records concerning the course given during the year since this training school was started. Nursing 729 It needs no argument to prove that such duties cannot successfully be combined. The more pressing demands of administration take precedence: the teaching must inevitably suffer. If a higher standard of instruction is to be established, the appointment of full-time instructors is an urgent neces- sity. The only alternative is a central school of nursing, to which students may be sent for instruction. (a) Chemistry Six hospitals give instruction in this subject, City, Fairview, Glenville, Mt. Sinai, St. John's and St. Vincent's. Four others, Huron Road, Lake- side, Lakewood and St. Luke's, avail themselves of chemistry courses in the nearest high schools. Lakewood pays a fee of $80.00 for the course; the in- struction for the students of the other hospitals is furnished gratis by the city, through arrangement with the Board of Education. Method Of the six hospitals in which chemistry is taught, three have some indi- vidual laboratory work; City, where half the time allowed is given to the laboratory, Mt. Sinai, and St. Vincent's, where only a few hours of labora- tory instruction are provided. In the others, the instruction is almost wholly by lecture with occasional demonstration. Mt. Sinai gives a preliminary course to students who have not had chemistry in high school. A more advanced course is given to all students. The teaching of chemistry in the high schools appears to be of high grade though limited in scope. Equipment Of the six hospitals which provide their own course in chemistry, only one, the City Hospital, has adequate equipment for both laboratory work and demonstration. At Mt. Sinai and St. Vincent's, the supplies appear to be adequate for demonstration purposes. At St. John's, Fairview and Glenville, the equipment is inadequate for either method of instruction. Hours The hours devoted to this subject in Cleveland training schools are as follows : Lakewood 40 hours (High School affiliation) Mt. Sinai 33 Lakeside 30 " (High School affiliation) Huron Road 30 " " . " " St. Luke's 24 " " " " City : 20 " St. Vincent's 20 " St. John's 18 " Glenville 12 " Fairview. 10 " 730 Hospital and Health Survey (6) Anatomy and Physiology All of the ten hospitals give some instruction in this subject. Method and Equipment In one hospital, Huron Road, instruction is almost wholly by formal lectures and quizzes, with demonstrations at intervals; in the others, mainly by recitations on assigned texts with some demonstrations. In only two hospitals, Lakeside and Mt. Sinai, is there in addition some individual laboratory work, though the equipment is very meagre. Hours The hours given to this subject in Cleveland training schools are as fol- lows : Lakeside .... ...70 hours Mt. Sinai _ ...62 St. Vincent's..... _ ._ 60 St. Luke's... _ .56 Huron Road 51 City , " 50 St. John's :. .....50 Glenville _..._"_ .....40 Lakewood:.. 36 Fairview _-_ 30 The time allotted to anatomy and physiology in 4 schools outside of Cleve- land is as follows: University of Cincinnati.. 150 hours University of Minnesota . '. 144 " Johns Hopkins 110 " Children's (Boston) .100 " (c) Dietetics Of the ten general hospitals eight give some instruction in this subject; i. e., City, Fairview, Glenville, Huron Road, Lakeside, Lakewood, Mt Sinai and St. Luke's. Two other hospitals, St. John's and St. Vincent's, send their students to the Y. W. C. A. for instruction in this subject. With the exception of Lakeside and St. Luke's, all these courses strongly empha- size cookery, and give a minimum amount of instruction in the basic principles of nutrition. This failure is all the more serious owing to the growing recognition of the primary importance of nutrition, especially in relation to children and the movement for Child Welfare in which nurses bear increasing responsi- bility. Equipment Lakeside and City have good laboratories fitted for teaching dietetics although at the City it is not adequately supplied with individual utensils Nursing 731 At Huron Road the laboratory is fairly adequate. The remaining five hos- pitals provide decidedly inferior equipment for teaching this subject. In some instances the room provided is unsuitable (such as the main kitchen at St. Luke's), and in others there is a lack of utensils for individual work. Hours The time allotted to this subject in Cleveland training schools is as fol- lows : Mt. Sinai -60 hours Lakeside.. -52 " St. Vincent's .45 " St. John's :... 45 " St. Luke's , -. 44 " City ... __l _ 40 " Huron Road 40 " Fairview. 32 " Lakewood 25 " Glenville..' 24 " In four schools outside of Cleveland the hours given in dietetics and cookery are as follows : University of Minnesota 70 hours Philadelphia General 66 " Children's (Boston) ...„ 56 " Boston City 56 " / (d) Bacteriology x\ll of the hospitals give some instruction in bacteriology, but in none is there adequate equipment for the individual laboratory work essential for this subject. Equipment Material for demonstration in bacteriology is good at Mt. Sinai, and fairly good at Lakeside and St. Vincent's. At all the other hospitals this equipment is very meagre. Hours The time devoted to this course in Cleveland training schools is as fol- lows: St. Luke's 36 hours Huron Road _. : , 24 " Mt. Sinai 21 " City 20 " Lakeside .20 " St. Vincent's ..: .20 " Fairview 12 " Glenville... J 12 " Lakewood 11 " 732 Hospital and Health Survey At St. John's, this course is combined with hygiene. In four schools outside of Cleveland, the hours given in bacteriology are as follows: University of Minnesota 99 hours Children's (Boston) 76 University of Cincinnati... ; ..75 " Presbyterian (Chicago) 70 " Method In only one of these, Mt. Sinai, is individual laboratory work given, and even there with inadequate space and too meagre equipment to make this form of instruction effective. The course is divided into half laboratory and half recitations on assigned texts. Lakeside, which has no laboratory work, could probably arrange for it by utilizing more extensively the possib'lities of the pathological department of the hospital. Half of the course at Lakeside is devoted to demonstration by the instructor and half to lecture and recitation. At the other eight hospitals, the method of instruction varies, being mostly demonstration at St. Luke's and St. Vincent's, and mostly lectures at Fair- view and Glenville. The others combine these methods. At St. John's the work in bacteriology is not given as a separate course, but in combination with the course in hygiene. Instruction in Other Subjects The length of the course is only one factor, and by no means the most important factor, in determining the value of the instruction. Yet the pro- portion of time devoted to various groups of subjects is highly indicative. Comparisons of the time devoted to instruction in the more advanced subjects are difficult to make, since the classification and arrangement of subjects show wide variation. Thus, in one school the lectures on gynecology are included in the course in surgical diseases, in another in the course in obstetrics, and in others, as a separate series. In the same way the lectures in operating room technics orthopedics, and eye, ear, nose and throat dis- eases are sometimes given as separate courses, and at other times included in the general surgical lectures. In the same way, it is difficult to make comparisons of instruction in the different branches of medicine. Thus, communicable diseases, nervous and mental diseases, occupational diseases, venereal and skin diseases, and pediatrics, are given as separate courses in some schools, and in others two or more are combined into a single course. In one, all these subjects are given as one course, under the title of medical diseases. Notwithstanding these differences in classification, comparisons can fairly be made between groups of allied subjects. Thus, we may combine in one group under the general title of surgical subjects the following: eye, Nursing 733 ear, nose and throat diseases, gynecology, operating room technic, orthope- dics and surgical diseases. The number of hours of instruction given to these surgical subjects in 9 Cleveland training schools, ranges from 34 to 73. One school cannot be included, since in that school gynecology is included in obstetrics. Again, comparisons may fairly be made by grouping under the single head of medical, the following subjects: communicable diseases, medical diseases, nervous and mental diseases, pediatrics, and venereal and skin diseases. In this group of medical subjects, Cleveland schools give fronr|52 to 109 hours of instruction. Hours of Instruction in Three Groups of Subjects Preliminary TOTAL Medical Surgical Sciences All Subjects City 90 43 Fairview 61 34 Glenville 56 48 Huron Road 82 65 Lakeside 92 70 Lakewood- 54 59 Mt. Sinai 52 * St John's. 109 73 St. Luke's 62 44 St. Vincent's _ 88 60 In obstetrics the hours given range from 12 at St. Luke's to 31 at Huron Road. Except for Lakewood, which gives 18 hours, the time devoted to this subject in the other hospitals is from 20 to 30 hours. The total number of subjects listed in the curricula of the Cleveland training schools ranges from 17 to 29, in addition to the four fundamental sciences already considered. These four sciences, viz. anatomy and physi- ology, bacteriology, chemistry, and dietetics and cookery, may be considered the preliminary subjects, or those introductory to the specifically technical and professional work to follow. In nursing schools already affiliated with colleges and universities, the tendency is to consider these subjects pre- requisite to the strictly professional training. It is significant that the Cleveland hospitals devote to these four sub- jects from 20% to 28% of the total time devoted to class instruction, leaving only from 72% to 80% to the subjects that constitute the main body of pro- fessional instruction. It is instructive to compare, for example, the time devoted to the group of medical subjects, which ranges from 8% to 19% of the total time allowed for class room instruction, or to the group of surgical subjects, which ranges from 7% to 13%, with the time devoted to the pre- liminary group which ranges from 20% to 28%. When it is recalled that the time allowed for the preliminary subjects, though large in proportion to * Figures not comparable, since gynecology is included in course in obstetrics. t Includes a course in hygiene which is combined with bacteriology. 130 472 76 365 88 365 122 596 162 672 112 469 176 655 148 f 598 140 572 145 505 734 Hospital and Health Survey the total hours of instruction, is in reality meagre, the disproportionate time allotted to purely professional subjects is a still more serious indication of the inadequacy of the curriculum. This fault, common to nursing schools in general and not peculiar to Cleveland schools, illustrates the emphasis that has universally been placed on the manual side of the nurses' training, to the exclusion of sufficient class room instruction. Proportion of Total Class Hours Devoted to Medical and Surgical Groups Compared with Proportion Devoted to Preliminary Sciences*. Medical City 19 % Fairview 16 Glenville.-- .*...... 1 5 Huron Road 13 Lakeside 13 Lakewood.. 1 1 Mt. Sinai 8 St. John's 18 St. Luke's 10 St. Vincent's... 17 gical Preliminary Sciences 9% 27% 9 20 13 24 10 20 10 24 12 23 t 26 12 24 7 24 12 28 Method of Instruction ~* In the presentation of most of the purely professional subjects three of the hospitals, Fairview, Glenville and St. Luke's, rely mainly on the lecture method. In the other hospitals there are recitation periods in connection with most of the. lecture courses. At two hospitals, Lakeside and St. Vin- cent's, periods are, in many subjects, set aside for demonstration. * The courses in psychology and venereal and skin diseases, however, are purely lecture courses except at St. Vincent's where recitations and demon- strations are given. Likewise, the course in mental and nervous diseases is taught entirely by lecture except at Lakeside, Mt. Sinai and St. Vincent's. The correlation between class and ward instruction in Cleveland training schools seems on the whole to be as carefully planned as in other schools of comparable standing. As long as students staff the wards at need, com- plete correlation of theory and practice is probably impossible. Yet in many instances in Cleveland there was evident failure to come as near as possible to the best practice. Thus, with the exception of St. Vincent's, the classes in surgical diseases and medical diseases are given in the student's second year in the school, after she has presumably for many months had the care of both medical and surgical patients. The difficulty encountered by small schools in giving proper instruction to their students is illustrated by Lakewood which is unable to give all * Other subjects not specified in the composition of these groups are omitted in this section. t Figures not comparable since gynecology is included in course in obstetrics. Nursing 735 courses each year, since the number of students in each class is small. For example, the course in anatomy and physiology is given in alternate years. Thus instruction in this fundamental subject is not given to some students until their second year. In the same class, therefore, are students iri the second year, first year, and preliminary period. These last are the only students who receive this instruction at the time when it should properly be given. The advantages that would result from combining with other schools are obvious. Iri all of the Cleveland schools* important courses are given in the even- ing, a highly undesirable practice. Evening classes not only deprive students of time for recreation, but also require mental activity when students are fatigued from the day's work in the wards. St. Vincent's makes extreme demands upon its students in this respect. In this hospital 94 hours of class instruction are given after six o'clock in the evening. In this evening work is included all or part of the following courses : bandaging, massage, medical diseases, surgical diseases, obstetrics, eye, ear, nose and throat diseases, venereal diseases, psychology and ethics. Three other hospitals, Fairview, Glenville and Lakeside, give 50 hours of instruc- tion or more in the evening. CONDITIONS OF WORK Ratio of Nurses to Patients The ratio of student nurses to patients which is desirable for teaching as well as for efficiency of service, is influenced by differing conditions in different services and even in different wards. The best general opinion places the desirable ratio in an active ward service at about 1 nurse to 5 patients on day duty; 1 nurse to 10 patients on night duty. In Cleveland, of the 8 hospitals for which information is available, 5 hospitals meet this desirable ratio for day duty. These hospitals are: HurOn Road, Lakeside, Mt. Sinai, St. John's f and St. Luke's. Of the remaining three hospitals, Fairview and St. Vincent's fall short, having a ratio of 1 nurse to 8 patients, while the City Hospital provides only half the requisite number of student nurses. This lack is in part supplemented by helpers in some wards. "^ For night duty, only 1 hospital, St. John's, comes up to the desired figure. The others range from 1 nurse to 12 patients at Mt. Sinai, to 1 nurse to 27 patients at St. Vincent's. At the City Hospital, the ratio was given as 1 to 25, but examination of the hospital's own records showed on the night of January 22nd that it had been possible to provide only one nurse to 40 patients. * Information on this point was not obtained from Huron Road. f On the day of inspection a lower ratio was found, i. e. 1:9.7 on medical floor; 1:8 in women's surgical ward. 736 Hospital and Health Survey The ratio of students to patients in private service must necessarily be higher because this is a room service. According to the standard, 1 nurse to 3 patients is correct for day duty; 1 nurse to 5 patients at night. In almost all the hospitals the ratio either just meets or falls slightly below the desired figure for day duty. Night duty shows a wider deviation from the standard, St. Vincent's providing only 1 to 16 patients. HOURS OF DUTY 1. Day Duty In the past, the failure of the trainng schools as educational institutions has been due largely to the excessive hours of labor required. To state the case is to prove it. To expect study or intelligent application from students is manifestly impossible in addition to the " nine-to-ten -hour working day, the twelve-hour night and the seven-day week," which, according to the standard curriculum, is "still required in most hospitals." During the past year the introduction of the eight-hour day has made marked advances. Eight Hours In Cleveland three of the thirteen training schools have nominally an' eight-hour day. These are Huron Road (where there is, however, a nine- hour day in private service), Lakeside and Mt. Sinai. This good showing is, however, lessened by the fact that in all three hospitals class work and study and meal times fall, as is customary, in the students' so-called "free off-duty time." At Mt. Sinai class work exceeding one hour per day is counted as time on duty, at Huron Road extra time is allowed off "when possible." At all three hospitals one half -day off is given on Sundays. In some services there are additional hours off on Sunday. All three hospitals give one half-day off weekly. Eight and One-half to Nine Hours At the City Hospital the hours of duty range from 83^ to 9, and are reduced to 4^ on Sunday. Class time is occasionally counted as time on duty. A half-day weekly is allowed. Nine Hours The remaining nine hospitals have a nine-hour day on five days of the week. All give one-half day off per week and vary in their hours on Sunday, St. John's and St. Vincent's having nine hours*, and the others ranging downward to four and a half. It should be noted that at Fairview and Lakewood, class time is cpunted as time on duty, and at Glenville this is occasionally done. In consequence, the work on the wards at these 3 hospitals is often less than nine hours, par- ticularly in the junior year. At St. John's juniors have only 8 hours on the wards. * On every third Sunday hours of duty reduced to 2 and 1 1-2 hours respectively, at these two hospitals. Nursing 737 2. Night Duty The educational value of night duty lies in part in the added responsi- bility and initiative which it entails for the students. Obviously, however, the benefit of this service is obtained at the cost of added physical and nervous exertion. The assignment to night duty should, therefore, be neither too long in duration nor too frequent; and careful provision should be made to furnish to the students on night duty quiet and privacy for sleep in the day time. These primary precautions in the interest of health and education appear often to be ignored. Moreover, the study of individual students shows frequent examples of exceeding the period of time planned for night service. Night duty should be assigned with special reference to the nursing ex- perience to be obtained which may obviously be great in medical and obstet- rical services, but is negligible in a surgical service. Length and Frequency of Night Duty Eight Hours Lakeside, Mt. Sinai and Fairview have eight-hour duty. At all three hospitals the term of the service is nominally two months. Mt. Sinai suc- ceeds in keeping night duty substantially within the limits set for it, but at Lakeside continuous periods of night duty though not intended to exceed 8 weeks, have in fact, according to the hospital records for the present senior class, run as long as 16 weeks. No data on this point were obtained from Fairview. Lakeside and Fairview plan three periods of night duty, Mt. Sinai four, totalling respectively six and eight months. Over Eight Hours and Less than Twelve Four hospitals fall in this group. Cleveland City requires nine and a hah hours night service, with one hour off for a night lunch. The term of duty here is only two weeks at a time. Cleveland Maternity and Glenville have 10 hours, Glenville having six terms of six weeks each, totalling nine months. Huron Road has 11 hours in periods of one and two months, totalling five months. This hospital gives one night off duty per week. Twelve Hours Five hospitals have a twelve-hour night, with a half hour off for a night lunch. These hospitals are Lakewood, St. Alexis, St. John's, St. Luke's, St. Vincent's. Of these, two have a half-night off at regular intervals, Lake- wood monthly, and St. John's fortnightly. The term of duty ranges from six periods of eight weeks each (or nearly a year) at Lakewood, to three or possibly more periods of one month each at St. Alexis.* * At the 13th hospital, St. Ann's, affiliating students are not assigned to night duty. 738 Hospital and Health Survey Classes During Night Duty Lack of consideration for the students' health and study is apparent in the custom of holding classes in the early morning or at early afternoon hours, before the nurses have satisfied the primary need of sleep. In six of eleven hospitals in Cleveland, there are early morning classes for students on night duty. These six hospitals are: City, Glenville, Huron Road, Mt. Sinai, St. Luke's, and St. Vincent's. One hospital, Fairview, has classes in the early afternoon at two o'clock. The four remaining hospitals, Lakeside, Lakewood, St. Alexis and St. John's, have classes at a more rea- sonable hour, that is, after three o'clock. Time Off After Night Duty The strain of night duty is often recognized by allowing a brief vacation, after each term of service. With the single exception of Lakeside, this cus- tom is followed by the Cleveland training schools. The time off varies from one to two and a half days. At St. Vincent's three days off are given. Sleeping Quarters for Night Nurses To afford quiet and privacy for rest during the day to the students on night duty, special rooms or dormitories should be provided for them. Four hospitals, St. John's, St. Vincent's, City and Cleveland Maternity, have such an arrangement. In the other hospitals little effort is made in this direction. As most rooms are double, it may frequently happen that a day and a night nurse share a room. An attempt is made to put room-mates on night duty at the same time, but this is difficult and often impossible to arrange. Vacation With four exceptions, Cleveland training schools give a 3-weeks' vacation each year. The schools which allow only 2 weeks for vacation are the City, St. Alexis, St. Vincent's and St. Luke's. Provision of Ward Helpers One of the most obvious wastes of the student's time and energy in the present organization of training schools is the excessive amount of house- work required, and the failure to supply ward helpers. The hospitals in Cleveland differ greatly in this respect. In most of them it is taken for granted that the student nurse performs a large part of such duties. From actual observation in the wards it appears that with the exception of one hospital, from two to eight hours daily are spent by student nurses as occasion arises in non-educational duties such as: Making surgical supplies. Running sterilizer. Cleaning and mending gloves. Nursing 739 Dusting and cleaning wards and service rooms and rooms of private patients. Folding and putting away linen. Setting and carrying trays, washing dishes. Washing soiled linen, tending switchboard and front door. At Lakeside 3 probationers and 3 advanced students are regularly assigned to the gauze room where three-quarters of the time is spent in the routine preparation of surgical supplies. It is planned that each student shall spend a month and a half in this service which can scarcely have any educational value after the first two weeks, and comes appropriately in the probationary period. The only considerable attempts to relieve the nurse by providing ward helpers are at Huron Road and, to a greater extent, at Mt. Sinai, where the students devote more time to strictly nursing duties than in other Cleveland hospitals. At Mt. Sinai the installation of thoroughly modern equipment has simplified the problems of housekeeping in general. The labor involved in caring for patients is reduced to a minimum by the liberal provision of portable equipment and by the introduction of labor-saving devices. Moreover, the students' time is saved at this hospital, by employing at- tendants to perform a multitude of routine duties, which have been learned by students during the preliminary period and are educationally valueless to them at a later stage. The failure of other hospitals to supply such service makes the example of Mt. Sinai and Huron Road all the more noteworthy. It is worth while to describe the arrangement for ward helpers at Mt. Sinai in some detail. On private floors attendants are employed to do all dusting, caring for flowers, answering the telephones. Half an hour before meals, they set trays in the diet kitchen, the nurse serving only the hot food. The attendant carries trays to and from the patients' rooms. In the afternoon she is employed in making surgical supplies. The attendant works 8 hours per day, and re- ceives $40.00 per month and one meal a day. In the public wards lay helpers are employed only during vacation period. In the surgical supply room two full-time women are employed at $50.00 per month with three meals a day, and two part-time women three hours each day. These women were employed as diet kitchen maids at $25.00 per month, and asked to be employed in the surgical room at their hours off in the afternoon. In the operating room one full-time woman is employed at $50.00 per month and three meals a day. She cleans instruments and the room, and makes surgical supplies. In the obstetrical department ward helpers do the same general duty as on the other wards. In addition, the attendant has charge* of all clean linen, sweeps and dusts the nursery, and holds the babies during supplement- ary feeding. Thus, the housekeeping duties of the students are reduced to a minimum, such as scrubbing babies' individual basins, and sterilizing them. While students are supposed to make surgical supplies in spare time, it was noted that in fact, their time was fully occupied with strictly nursing duties. 740 Hospital and Health Survey Undoubtedly the elimination of routine housekeeping duties and other non-educational tasks has done much to foster the study by student nurses of cases on the wards, and their unusual intelligence in discussing these cases. But even at Mt. Sinai it is estimated that the student may spend daily one and a half hours folding and putting away linen and about an hour cleaning wards and service rooms, and the unique opportunities of the dis- pensary as ja training field are only partly utilized because students' time there is more than half filled with routine cleaning and arranging supplies. LIVING CONDITIONS The Nurses' Residence* To counterbalance the strain of abnormal conditions met in the hospital wards, the student nurse needs the relief of outside interests and a wholesome home life. These needs are too often left unprovided for when the nurses are lodged in ordinary houses improvised as homes for a large student body without proper bedrooms or lavatory equipment, and without any special rooms for study or recreation. If the nurses live in the hospital building, they do not have sufficient opportunity to shake off the ward atmosphere. Even mild social recreations are often made impossible by the close proximity of the patients. The nurses' residence should, therefore, be a separate building in the near vicinity of the hospital. It should be constructed to meet the needs of a nurses' home, with reception and recreation room, library, class room, study room and single bed rooms, with proper lavatory equipment and such accessory rooms as kitchenette, laundry and sewing room, exclusively for the use of the students. In Cleveland all of the hospitals but two, house their nurses in separate buildings. These two are Lakeside and Huron Road, which set aside a separate wing with the entrance through the hospital. At St. Vincent's and St. John's, although there is a separate building, it is reached only through the hospital, and is undesirably located in the rear. The nurses' residence at the City Hospital is the only nurses' residence in Cleveland which is satisfactory. The other nurses' homes were originally built for other purposes. Four of these, Huron Road, Mt. Sinai, St. Alexis, and St. Vincent's, provide no nurses' reception room. Four, Glenville, Lake- wood, St. Alexis and St. John's, provide no separate recreation room. None have a room set aside for study. The general and reference libraries are inadequate at City, Lakewood, St. Alexis and St. John's, either on account of lack of books and magazines, or owing to their inaccessibility. Two Cleveland hospitals, Lakeside and St. Luke's, have a social director for the students. In the nurses' homes in Cleveland, the double room is the rule, the single room the exception. Even more undesirable than the double room is the * Cleveland Maternity and St. Ann's omitted in this section. Nursing 741 dormitory. Six of the eleven nurses' homes visited, lodge some of their students in dormitories. At St. Vincent's sixty-five, of a possible eighty- nine students, are housed in dormitories having from three to ten beds each. Obviously, the nurses' residence should have adequate hygienic surround- ings for the nurse and provision for personal hygiene and immaculate clean- liness. Ample lavatory facilities are a necessity, the provision of one bath- room to six students being regarded as the minimum requirement. The nurses' residence at the City Hospital is excellent in this respect, and, in addition, stationary basins are provided in each room. There is also a large lavatory adjacent to the dining room, though by a curious omission there are no toilets in this lavatory. The other institutions make fairly adequate provisions with respect to general lavatories, excepting St. Luke's and one floor at St. John's. Dietary Since student nurses are engaged in arduous physical and mental work, careful selection of their food is a matter of prime importance. This appears to receive reasonable consideration in the Cleveland hospitals. The nutritional value of attractive service should not be overlooked. A cafeteria service, three meals a day for three years, is not satisfactory, es- pecially in the case of persons who must be on their feet long hours every day. In Cleveland three of the hospitals, Lakeside, Lakewood and Mt. Sinai, rely on cafeteria service, good of its kind. Under existing labor con- ditions, it is justifiable, but it should clearly not be a permanent feature of the nurses' dining room. RECOMMEND A TIONS 1. A UNIVERSITY SCHOOL OF NURSING It is strongly urged that a University School of Nursing be established at the earliest possible date. This school should be on the same academic basis as are other under- graduate schools of the University. The instructors should be members of the University staff. All students should fully meet the usual requirements for admission, and the com- bined university and hospital course should lead to the Bachelor of Science degree. The didactic instruction, both in class-room and laboratory, should be given by the school. In order to obtain the necessary ward practice, the training school should make con- tracts with the several hospitals whereby the latter should agree to receive students for training in specified branches of nursing. Affiliating hospitals should be required to meet the standards of instruction and conditions of work established by the University, in order that the training shall be of grade equal to that furnished in practice fields of other schools of the University. Time must necessarily elapse before a University School of Nursing can be success- fully planned and launched. In the interval the Cleveland Training Schools should take immediate steps to improve the present course of training. 742 Hospital and Health Survey The recommendations which follow embody some of the obvious changes needed to improve working and living conditions for the student nurses and to strengthen the in- struction now given. The recommendations as to the content of the curriculum and the relative length of courses are not here given. On these points it has not yet been possible to formulate conclusions, as noted earlier in this report (see page 712). Studies of hospital training schools in other cities, of which the Cleveland Survey has been one, are now in progress, by the Committee on Nursing Education. From detailed observation of the ward experi- ence and instruction of students in different types of hospitals, material is being gathered on which the Committee will base its ultimate recommendations for a detailed curriculum. The recommendations which follow will, it is believed, not only improve the train- ing but will help to attract students of higher calibre, who have been repelled by the un- necessary physical hardships and inferior instruction of the present training schools. 2. ORGANIZATION OF THE TRAINING SCHOOL Various proposals as to the organization of training schools are presented in detail on page 713 of this chapter and need not be repeated here. Cost Accounting A separate and detailed budget for the training school should be prepared, and a system of cost accounting should be adopted to show the total cost of the training school, including instruction, maintenance, etc., and covering the value of services rendered by the students and staff of the school. Money Allowance to Students Cleveland training schools should abandon the practice of paying students, and should use funds thus released to build up their educational work. Payment to Lecturers The growing practice of paying the members of the medical staff who teach in the school of nursing should be generally adopted. 3. MINIMUM ENTRANCE REQUIREMENT The minimum educational requirement for admission to a school of nursing should be not less than completion of high school. 4. SERVICES OFFERED Hospitals which cannot offer adequate clinical facilities for instruction in the four main branches (medical, surgical, children's diseases and obstetrics), as well as in the im- portant special branches of communicable diseases and mental and nervous disorders, should provide such opportunities for their students by affiliation with institutions capable of offering them. It is urged that all students who expect to enter public health work should be allowed to elect the eight months' course, but at the least they should be allowed the four months' period of training in the University District. Nursing 743 Dispensaries and social service departments should be utilized for training students as soon as adequate teaching and supervision are assured. 5. INSTRUCTION Instruction in the fundamental sciences and in the other necessary branches can best be afforded by a central training school, under University auspices, such as is recom- mended above. If such University affiliation should not prove feasible, or if there is delay in joining it, it is recommended that several training schools of similar grade in Cleveland combine in furnishing theoretical instruction to their students. No lower educational requirement for admission should be accepted than that required for University entrance. Teaching of Nursing Procedures Whatever combination with other schools may be made in the future, whether under University or other control, it is clear that a demonstration room and equipment for teach- ing nursing procedures will continue to be needed in every hospital that admits students for training. It is therefore urged that every school not now so supplied for demonstra- tion and individual practice, should provide these needed facilities without delay. The technical work of probationers and also of more advanced students should be supervised by the instructor. Every student should be carefully taught each nursing procedure in the class room before she is allowed to carry it out on the wards. Moreover each student should be supervised by the instructor when she carries out any procedure for the first time, and she should not be assigned to any duty regularly until the instructor has made sure that she is proficient, and has notified the head nurse to that effect. Pro- cedures should be demonstrated to head nurses by the instructor. Similarly, the teaching of diet in disease must always be given at least in part within the hospital in order to correlate class instruction with the actual feeding of patients on the wards. It is therefore urged that every hospital not now possessing adequate class- room and laboratory facilities for the teaching of diet in disease should provide these facilities immediately. Equipment similar to that needed for teaching dietetics is needed. Teaching of Fundamental and Technical Subjects Prior to the establishment of a central school of nursing various immediate improve- ments in teaching and equipment should be made in the fundamental sciences and the technical subjects. These improvements have been indicated in separate reports to the different hospitals. 6. CONDITIONS OF WORK Neither day nor night duty should exceed eight hours out of the twenty-four. Class hours should be included in this time. Students on night duty should in no case have classes until after a period of at least eight hours has been allowed for sleep. Night work should be limited to short terms of not more than one month each. To compensate for the strain of night work a brief vacation should be given at the completion of each term. 744 Hospital and Health Survey 7. LIVING CONDITIONS The provision of suitable living conditions and opportunities for recreation are urged as matters of first importance. The nurses' residence should be separate from the hospital, but in close proximity to it. It should contain reception and recreation rooms, library, class and study rooms, and accessory rooms for the exclusive use of the students, such as kitchenette, laundry and sewing rooms. Students should have single bedrooms, and there should be generous provision of bathrooms and lavatories. For students on night duty special sleeping rooms should be provided, which should be situated so that quiet and freedom from disturbance are assured. Special attention should be given to providing recreation, both indoors and out. Facilities for indoor recreation might well include a gymnasium and swimming pool, and should, at the least, include good facilities for dancing. If space permits, tennis courts should be provided for the exclusive use of the nurses. It is recommended that social directors should be appointed, who should be charged with directing the recreation and social life of the students. 8. REDUCTION OF PRESENT THREE-YEAR COURSE With the practical development of the recommendations given above it should prove possible to reduce the present three-year course for all nurses. At this time, for the reason given above (see page 712), it is not possible to make specific recommendations as to the amount of time by which the regular nurses' training may safely be reduced. The higher standard of admission, the elimination of uneducational house work, better instruction, practical and theoretical, a better balanced provision of services, will enable the course to be reduced by at least eight months. « The principles underlying such reduction of the present three-year course are two: 1. That all nurses-in-training should have the same basic education, after which they may be graduated with the certificate or diploma of nurse; 2. That in addition, courses should be provided leading to special diploma for public health nurses, for teaching and administrative positions in hospitals, and for specialties in private duty. This plan is proposed in the belief that nurses graduating from the shorter basic training will be available primarily for bedside care. The more advanced courses will attract students of higher calibre who are needed for the nursing specialties, especially for teaching and administration in hospitals and for public health work. It is the conviction of the Nursing Survey that without a thorough clinical training the responsible duties in these rapidly developing fields cannot be successfully met. 9. TRAINING OF COLORED STUDENTS The question has recently been raised as to providing opportunities for colored stu- dents to obtain the nurses' training in Cleveland. At one hospital — the City Hospital — this is a question of practical moment. There can be no doubt that at the City Hospital, where the training school is maintained by the city, all citizens have equal rights. The Nursing ^> education afforded by the city should therefore be available for all students, irrespective of color. So far as concerns living arrangements at the hospital, the possibility of friction may readily be removed by following the custom of allowing colored students to live at home during their training. Post Graduate Courses WESTERN RESERVE UNIVERSITY COURSE IN PUBLIC HEALTH NURSING Origin THE impulse that led to the founding and development of this course came from a group of lay women interested in the Visiting Nurse Associa- tion. To them it became apparent, as visiting nursing broadened from primarily remedial work into constructive efforts for family health, that the preparation afforded to nurses by hospital training schools was insufficient to prepare them for the social and preventive work required m this rapidly developing branch of nursing. Additional instruction both, in the classroom and in the field was clearly needed. With the same vision and energy from which Cleveland has richly profited in other forms of nursing and health work, plans for a course of training were made and put into effect. For 5 years the course thus established was offered by the Visiting Nurse Association, with the assistance of the De- partment of Sociology of Western Reserve University, the Associated Charities, the Anti-Tuberculosis League, the Babies' Dispensary and Hos- pital, and the Department of Medical Inspection of the Board of Education. The Visiting Nurse Association took the financial and administrative re- sponsibility, secured a director, and set aside as a practice field the area now covered by the University Public Health Nursing District. As the work of training developed, it became clear that direction might more appropriately be exercised by an educational institution than by an executive organization. After 5 years, therefore, the Visiting Nurse Asso- ciation transferred the management of the course to the University, and in 1916 it became a constituent part of the Division of Health Administration in the School of Applied Social Sciences. Organization The organization effected was excellent. By becoming an integral part of the University, the stability and educational purpose and standards of the course were assured. At the same time, through the appointment of an advisory committee and the establishment of the University Public Health Nursing District, the course has maintained its close connection with public health nursing activities, and has secured a unique field for the instruction of students in practical work. The Advisory Committee is composed of 13 members, of whom a lay woman is chairman. The superintendents of nurses of the following organi- zation are members: the Division of Health, the Board of Education, the 746 Hospital and Health Survey Visiting Nurse Association, and the Babies' Hospital and Dispensary. The Dean of the School of Applied Social Sciences is also a member, and the others are lay women respresentative of the group to whom Cleveland owes much of its progress in various branches of health work. The Director of the course is secretary of the Committee. So long as such a group forms its policies and directs its activities, the maintenance of proper balance between theoretical and practical work seems assured. The University Public Health Nursing District is perhaps the most potent single factor in rendering the course one of the best in the country. This crowded district was selected as a practice field on account of the varied experience it affords for public health nursing. The course is planned on the principle that the students for effective training must not only observe the work of others, but must themselves carry responsibility, under expert supervision, for actual practical work. The plan presupposes that field work corresponds to laboratory work in other departments of the University, and that it should, therefore, be controlled by the School in order that it may be carried on according to sound educational methods. With the exception of school nursing, the work in the University District is almost entirely generalized. This arrangement is of great value to the student, since it eliminates the waste of time inevitably resulting from assignments of work distributed among several different agencies. But still more important, it teaches the student methods of dealing with every type of health problem encountered in the families she visits, and thus forms an excellent preparation for community work. In post-partum work, however, the opportunities are meagre, since much of this service at the present time is carried by the nurses of the Cleveland Maternity Hospital. The organization of the University District, and the character of the field work are described in a special report. Finances . The budget is prepared by the Advisory Committee. Expenditures must be approved by the Committee. The expenses of the course, above receipts from tuition fees, are met by the University and contributions from the Visiting Nurse Association and the Anti-Tuberculosis League. The Board of Health gives the supplies used for its own especial activities in the district, but is not empowered to appro- priate funds for the work of a private organization. Staff The teaching staff consists of the director, 5 nurse instructors in the University District, the instructors in the several courses given by the School of Applied Social Sciences and a number of lecturers. The director of the course holds the appointment of Assistant Professor in the University, and teaches one course. She is directly responsible to the Dean of the School and to the chairman of the Advisory Committee. In addition to administering the work of the course, she is responsible for de- Nursing 747 tailed supervision of the work of the University District. She also lectures in training schools, serves on the Central Committee on Public Health Nursing, and in her official as well as personal capacity she is called upon to advise and assist in many nursing activities in the community. It is clear that the responsibilities of- her office are many and heavy. The work of students in the University District is directly supervised by the five instructors. These nurses, all of whom are graduates of the course, have been selected for their ability to teach and to supervise. That their work is of a high order is shown in the report on the University District. One of the instructors acts as assistant director in addition to her other duties. Her responsibility for administration is however limited except dur- ing the absence of the director. Students For admission to the course, applicants must be graduates of approved training schools for nurses, and must be eligible for membership in the Na- tional Organization for Public Health Nursing. They must also be graduates of high schools, or have received an equivalent preliminary education. To the latter requirement, however, a number of exceptions have been made. Application for admission to the course is made on the regular blank of the School of Applied Social Sciences. Since this blank calls for no details of the nurse's training, it is not especially well adapted for this group of applicants. Letters are sent to the high school and nurse's training school attended by the applicant requesting a general statement in regard to her work and her personal qualifications. Three personal references are also required, and to each of the persons whose names are given, a letter of inquiry is sent. Credentials of applicants are evaluated by the Advisory Committee in conference with the Director of the Course and the Dean of the School. The final decision in regard to admission is made by the Dean. Students who complete the course satisfactorily receive certificates. Students not registered for the entire course are admitted for four months of training in field work. No certificates are granted for this work, but those who complete the work satisfactorily receive 15 points of University credit. These students must have the same professional and educational qualifica- tions as those taking the full course. Pupil nurses from any training school meeting the standards set by the Ohio State Association of Graduate Nurses may be received for two months' experience in the University District. These pupils must have completed two years of training, and must have had their training in surgery, and in ob- stetrics, if possible. 748 Hospital and Health Survey During the year ending June 1, 1920, the following number of students was enrolled: One- Year Course, Graduate Nurses.. 19 Four Months' Field Work: Graduate Nurses 31 Pupil Nurses 11 Total 61 Sixty-four pupil nurses were received for two months' training. These pupils were admitted monthly, the number varying from 5 a month during the summer months to 10 a month during the winter. The total number of nurses, not including those who graduated in 1920, who have received certificates, is 45. Instruction One regular course is offered, which leads to a certificate. It extends over one academic year, and is divided into two parts, one devoted largely^to didactic work, the other to field work. The didactic work is given during the first semester, and consists /)f jthe following courses: Public Health Nursing..... 30 hours Hygiene and Preventive Medicine. .24 " Bacteriology - 96 Household Problems 29 Practical Sociology 60 Problems in American Society.. -30 Case Work with Families.... 72 Mental Hygiene... —.10 " During the first semester the students spend two afternoons (6 hours) weekly in work with the Associated Charities. Additional courses may be taken by students exempted on the basis of previous work from one or more of these courses. During the year 3 students so exempted took courses in psychology, government and social legislation. The character of the didactic work of the course could not be judged, since the investigation was carried on in the second semester, after the lec- tures had been concluded. It was, therefore, impossible to evaluate the class room teaching. The subjects selected, however, are those specially needed by nurses preparing for public health work. Field Work One semester, or approximately 4 months, is spent in field work. Ordi- narily, this work follows directly after the semester devoted to theoretical work. The field work is, however, given three times during the year. In Nursing 749 some cases the students take field work in the summer months, and begin the theoretical work subsequently. The usual division of field work is the following : University District 11 weeks School Nursing 3 weeks Hospital Social Service or Humane Society, or other Special Agency (observation) — 1 week Industrial Nursing (observation) 1 or 2 weeks as elected Rural Nursing (observation) 1 or 2 weeks as elected During the first week a number of excursions are made in order to ac- quaint the students with Cleveland social agencies and social workers. In the University District students carry on the usual activities of the Visiting Nurse Association, and the nursing work of the Department of Health, in which anti-tuberculosis work and infant welfare work are in- cluded. Supervision in the University District To each instructor is assigned a number of students, including both graduate and pupil nurses. Seven is the maximum number of students assigned to one instructor. Each student is assigned by her instructor to a subdivision of the district, and as her knowledge and skill develop, she is increasingly held responsible for the work in her particular section. When students begin their field work, they are taken out one at a time (very occasionally two at a time) by the instructor, who gives the instruction in the home and does the work required, while the student observes. A thorough discussion of the visit follows. On a subsequent visit the roles are reversed, the instructor observing while the student conducts the visit. This procedure is repeated with different types of visits, such as to prenatal cases, communicable disease cases, and so on, until the student has been gradually introduced to the various types of work usually encountered in the district. Three times daily the students report at the station, to receive assign- ments, to plan their work, and to carry out the necessary office detail. An opportunity is afforded at these times for conference with the instructors. In this way the instructor is enabled to keep constant oversight of the stu- dents' work, and the students have an opportunity for immediate consulta- tion and advice upon problems arising in the families they visit. Every morning a conference is held by the Director, which is attended by all the instructors and students. These conferences, in which the students take an active part, constitute an invaluable part of the training. The program may consist of demonstrations of nursing technique, instruction in new procedures, consideration of social or other problems in individual families, or discussion of subjects of general professional interest. Students thus have the benefit of demonstrations given by the instructors in the homes, of direct supervision of their own work in the homes, of in- 750 Hospital and Health Survey dividual conference three times daily with the instructor in the office, and of group discussion in the morning conferences. By this careful teaching they are enabled to derive the full benefit from their experience in field work. The nursing technic of the students who were observed gave evidence not only of good supervision, but even more important, it showed that the students had a knowledge of the principles of hygiene and sanitation. Some- times nursing work is done in which the technic is mechanical, — where the nurse observes the details as they were taught her but does not use intelli- gence in adapting the underlying principles to the special circumstances she encounters. In the University District, however, the reverse was found. In their scrupulous attention to detail in the home, in the beautiful care given the patients even in the most difficult surroundings, in their careful disposal of soiled linen and dressings, in their regard for the patients' modesty and comfort, the students in the University District showed that their work was not merely a routine, but was based on an application of the underlying principles of public health and of good nursing. School Nursing For experience in school nursing students are assigned to the Nursing Division of the Board of Education. During the 3 weeks spent in school nursing they are expected not only to observe, but also to assume responsi- bility under direction for a part of the work. Industrial Nursing The experience in industrial nursing consists mainly of observation in 3 or 4 factories. Altogether 12 industrial concerns in Cleveland are cooperat- ing with the University District in offering the students opportunities for observation and experience. It has been possible for a number of students to spend a week each in observing the work in the Goodrich Tire Co. in Akron. Clinics Unusually ample facilities for observation and training in clinics are available for the students. All students, except the pupils admitted for 2 months only, attend the following: Clinic for Well Babies, Prenatal Clinic, Tuberculosis Clinic, and the Babies' Dispensary (sick babies). In the University District Health Center prenatal clinics are held twice a week, and prophylactic baby clinics three times. These clinics are con- ducted by the instructors and attended by the students, who thereby obtain valuable experience in clinic management. Students usually spend 12 hours in all at the Clinic for Well Babies, and 4 to 6 afternoons at the Prenatal Clinic. Six hours for 3 weeks are spent by students at the Tuberculosis Clinic of another Health District (Health Center No. 8). The hours of observation are followed by lectures and discussions. Nursing 751 Babies' Dispensary An important part of the clinic experience is the training at the Babies' Dispensary, where the students spend afternoons for a period of two to three weeks. During this time 16 hours are devoted to lectures and discussion, of which 8 are lectures on sick babies by physicians, and 3 are classes in prac- tical work given by the Superintendent of Nurses. One hour each afternoon is spent in reading the literature of diseases of children. The practical work consists of attending examinations during which the cases are explained by the doctors, and of some supervised work in the clinics; of instruction in the Social Service Department; and of work in the Milk Laboratory, where modifications are taught. The excellent standards of infant welfare work established by the Babies' Dispensary are reflected in the child hygiene work in the University District. The effectiveness of the teaching is shown by the readiness of mothers to cooperate in preventive work, their ability to follow the nurses' directions in milk modification, and their willingness to bring their children to clinics for observation as well as for treatment in illness. It is clear that the work at the Dispensary constitutes a valuable part of the students' practical training. Conclusion The tests of public health nursing are many and various, — as many, per- haps, as the types of people and of needs that are met. But underlying all the differences of race or creed, of age or individuality, is the common ques- tion: How does the public health nurse meet her problems? Not merely how well does she nurse this or that patient, or how well did she cheer this or that person, but what total impression does she make on her families, how far does she succeed in solving the total family health problem? Has she taught her families anything of hygienic living, has she gotten their confi- dence, has she observed and taken measures to deal with evidences of illness or failures in habits of health in other members of the family beside her im- mediate patient? Judged by such standards, the course in public health nursing has clearly achieved a large measure of success. Various factors already described have operated to bring about this result. Special recognition should, however, be given to the devotion of the professional staff, and to the public spirit and appreciation of the modern public health nursing movement which has been shown by the University authorities and the lay committee who are jointly responsible for this notable contribution to nursing education. In general, then, the Course in Public Health Nursing is admirably organized and highly effective. Its usefulness could be even further increased by an expansion of its staff, better office facilities, and ampler provision for post-partum service, in accord with the following recommendations. RECOMMEND A TIONS 1. A full-time assistant director sTiould be appointed, who should share the teaching and relieve the Director of part of her routine duties. Hospital and Health Survey The Director should thus be enabled to devote more time to developing the work, to increasing facilities, and to extending the training. 2. Another instructor should be appointed. 3. A private office should be secured for the Director, and additional office space for the instructors and students. 4. The number of post-partum cases nursed by each student should be increased as soon as possible. 5. In view of the need throughout the country for trained public health nurses and the exceptional opportunities for training afforded in Cleveland, efforts should be made to secure the greatest possible number of students, and the staff and teaching facilities should be sufficient so that all qualified applicants may be admitted. The greatest possible number of pupil nurses should be enabled to take the four months' training in field work. INSTITUTE OF SCHOOL HYGIENE p * 1 The Institute of School Hygiene, organized by the Cleveland Board of Education with the cooperation of Western Reserve University, gives a six weeks' summer course to graduate nurses who have had practical experience in public health nursing. This Institute includes eminent experts from various parts of the country upon its instructing staff and attracts several hundred students who are enthusiastic about the benefits derived therefrom. The course offered is a real contribution to graduate nursing education, and deserves to be generously supported so that it may be continued and ex- tended in future years. Nursing 753 Public Health Nursmgf in Cleveland INTRODUCTORY IN the development of public health nursing in the United States, Cleve- land has played a leading part, various features of which stand out con- spicuously for their high degree of excellence, as standards set for the whole country. Among these successful elements, the most conspicuous are the existence of the Central Nursing Committee for the city, the concentration of activi- ties in a small number of agencies, the development of generalized nursing and the existence of the Univeristy Public Health Teaching District. Underlying all these activities and essential to their success has been the unusual degree of interest and responsibility on the part of the various authorities and boards in charge, both professional and lay members. With- out this sustained backing, the different organizations at work could not have achieved the success of which, in spite of various shortcomings and misdirected efforts, the Nursing Survey found proof in its detailed appraisal of the field. The recent opening of the beautiful Nurses' Club with its exceptional opportunities as a professional and social center, illustrates concretely the appreciation of nursing work in Cleveland and the generous participation of lay workers in the best interests of the profession. Scope of the Survey The organizations carrying on public health nursing which were studied by the Nursing Survey were the following: the Division of Health, the Visiting Nurse Association, the University District, the School Nurses, and some Out-Patient Departments of Hospitals. Nursing at the Babies' Dis- pensary and Industrial Nursing were also studied. Findings and recom- mendations as to the work of each agency are given later in this report. Our study covered the details of organization and administration, the personnel and plans of work. In addition our investigators accompanied nurses into the field, in the clinic and health center, the school, factory and home and observed their personal contacts with individuals and families. For by this test obviously such work stands or falls. No matter how well planned and administered in theory, or how lofty the aims and ambitions of organizations, they can ultimately be judged by nothing more or less than by the performance of their agents in the field, by the success of their efforts in preventive as well as curative work. The statistics of attendance at clinics or health centers, or the number of visits made per nurse or district does not tell the story completely without observation of the quality of service; the success or failure in teaching the elements of hygienic living as well as giving nursing care, or protecting the community from disease. 754 Hospital and Health Survey Some Elements of Success Common to all the organizations studied is the unusually fine spirit of the staffs, whose members almost without exception were found conscien- tious and alert. The existence of the Central Nursing Committee and the concentration of work in a few organizations obviously makes for greater uniformity of method and treatment than when diverse agencies are at work, and lessens £he chances of duplication or misunderstanding. The most notable contribution, however, made by Cleveland in the public health field is the success of the generalized nursing system, demon- strated most completely in the small University District, with its high ratio of nurses to population, by the Visiting Nurse Association less completely in a larger area and by the municipal staff so far as it has been adopted for the city as a whole. No other city of its size or larger has ventured to adopt a generalized municipal system. Few smaller cities have done as much. Cleveland is thus leading the way in one of the most hopeful developments of the modern public health work. Value of the Generalized System By generalized nursing is meant in this report the system by which a com- munity is divided into small districts, one nurse being assigned to each dis- trict to do all the necessary varieties of nursing and of instruction inhabits of health in that district. In successful generalized nursing, the resources of the separate nursing specialties are pooled. Overlapping of visits for special purposes is elimi- nated; overhead charges for maintaining separate services are reduced. The generalized nurse, doing either instructive or bedside work, is enabled to cover the ground, to find new cases and grapple with family problems as the specialized nurse in many instances cannot. The assertion is often made that under the generalized plan, the special needs of public health work, such as child hygiene or the care of tuberculosis, is neglected or less successfully carried on than when the nurse is trained along one such line, and devotes herself exclusively to her one specialty. This is a controversy of long standing; it is undoubtedly true that demon- strations of the value of one special service such as the work of the Ma- ternity Centre Association in New York, or of many tuberculosis societies, are of great value in setting standards of performance or in developing a more perfect technic than is often possible in the excessively large districts and with the excessive number of patients carried by many general visiting nurse associations. Yet where generalized nursing has had the fairest trial in Cleveland, that is in the University Public Health District, where the number of nurses to copulation and the supervision of the work is most adequate, no branch of nursing appears to have suffered from being merged into the general service, but has on the contrary gained. Where the nursing has been partly generalized, that is under the over burdened nursing service of the Division of Health, the bedside care of the sick has, as we shall see, been neglected; under the Visiting Nurse Association, the instruction of the family in hygienic habits has not received sufficient emphasis. Nursing 755 Obviously, for the success of generalized nursing, highly skilled super- vision is a prime requisite. Direction by specialists must keep the balance between the various needs of the different nursing specialties. In our recommendations for the organizations studied special emphasis has therefore been laid on methods of administration and supervision. Some Causes of Failure 1. Inadequate Numbers of Nurses Where failures were found in the work they were due, in Cleveland as elsewhere, to two main causes: insufficient number of nurses and inadequate or faulty supervision. The volume of work undertaken is far too great for the size of the different staffs, and too great for their combined numbers. According to the best opinion for a generalized service the ratio of nurses to population should be about in proportion of one to 2,000. In Cleveland, counting all but industrial nurses, the proportion is about one to 5,228 pop- ulation. The distribution of nurses is as follows: Division of Health (66 at work at time of investigation) 80 Visiting Nurse Association _ _ 32 Board of Education : 3 1 University District 10 Total...... 153 Populat'on, 796,836. Ratio, approximately 1 to 5,228. To reach the recommended figure of 1 to 2,000 population the total number should be 400 nurses. To reach even the ratio of 1 to 3,000 popula- tion, the total number should be 266, an increase of 113 nurses over the present figures. With the present shortage, it is manifestly impossible to do justice to all phases of the work. The second main cause of failure which disclosed itself in various of the organizations studied is the lack of adequate or correctly conceived super- vision. Indeed, supervision of the right order proves itself to be the crux of public health nursing. It is essential not only for planning the work of the staff and coordinating their activities but as a stimulus and guide for the individual nurse in her function of teaching the principles of health as well as giving bedside care. Supervision of the right order means the actual accompaniment of nurses in their home visiting. It brings to their help, especially in the non-acute cases, where little change is seen from visit to visit, a fresh point of view,, greater experience, an ability to see new angles of old cases. 756 Hospital and Health Survey Again and again, as the following reports show, the presence or lack of intensive supervision in the different organizations studied discloses itself in the quality of the work. It is for lack of stimulating direction that the work of the school nurses tends to become routine; that the nursing service of the Division of Health tends to become an extension of a clinical service, centered on the clinics, rather than a true public health nursing function, going out into the homes. The Central Committee on Public Health Nursing ONE of the most valuable assets for public health nursing in Cleveland is the existence of the Central Committee on Public Health Nursing. This committee is probably unique among agencies for the directing of public health nursing, in its composition, and in its influence in matters of public health. It is not too much to say that the high rank of Cleveland as a'center for various branches of public health nursing is due in large part to the existence of this committee and the interest in public health nursing which it reflects. To the work of the committee is to be ascribed the un- usually high standards of the nurses in the municipal nursing services as well as in the private organizations. Organization Several years ago this Central Committee was created, representing each of the organizations doing public health nursing in the city, composed of two representatives from each, one of whom was the superintendent of nurses and one a trustee, board member, or executive officer, "for the maintenance of 4 uniform standards of training and of public health nursing throughout the^city. " The following organizations were included : Division of Health of the City Department of Welfare, Board of Education, Babies' Dispensary and Hospital, Visiting Nurse Association, Anti-Tuberculoois League, Western Reserve University Teaching District. Each organization selected its own representatives and the whole group chose a chairman and vice-chairman who might not be from among its members, but were added to the committee, and engaged a secretary on part time. The committee does not meet at regular times, but whenever there is a problem to be studied and acted upon, perhaps not oftener than four or five times a year at present. Its decisions are not binding, but are presented in the form of recommendations to the organizations represented, and have almost invariably been voluntarily approved and acted upon. Nursing 757 Activities The matters that have been considered by the Central Committee, and standards determined are: 1. The receiving of all nurse applicants and securing credentials. 2. The passing on all credentials, accepting or rejecting the applicant. 3. The assignment of applicants to the various public health nursing organizations, and exchange of applicants from one organization to another. 4 Discussion and recommendation of uniforms. 5. Recommending salary schedules. 6. Study of bags and equipment. The chairman of the Central Committee (always a layman) and the superintendents of nurses form an eligibility sub-committee which performs the duties under numbers 2 and 3. All professional standards are determined by this sub-committee. The assignment of applicants to the various staffs is determined by this sub-committee on the basis of first, expressed prefer- ence of applicant; second, urgency or emergency need; third, the date on which the request for additional nurses was filed by the superintendent. There has been no dissension among the superintendents over the assignments. Nurses are told of the work of all agencies and allowed to express preference if they have any. They are assigned to the agency of their choice if there is a vacancy. RECOMMEND A TIONS The Central Committee has already performed a notable service in har- monizing the problems of personnel, professional standards and salary schedules, and it is thoroughly representative in its composition. But additional factors must be continuously considered for the effective growth of public health nursing in any city : Coordination of the activities of the various public health nursing agencies. A well balanced development of different types of work in accordance with a coherent program for the city. Continuous study of the expanding needs of the city, and of new de- velopments in public health nursing. Maintenance of uniformly high standards. The Central Committee appears to be the body logically to be charged with the responsibility for the additional factors enumerated. Therefore, it is recommended that the Central Committee assume the following func- tions in addition to those it already has, its decisions, however, as hereto- fore, not to be binding upon the organization represented. 758 Hospital and Health Survey New Functions 1. Coordinating all nursing agencies of the city and obtaining agree- ment among them as to the functions to be performed. 2. Review of all plans for new projects or for modification of current programs of participating agencies, based on data from the Welfare Federa- tion. 3- Creation of several sub-committees for research and consideration of special professional problems. Some of these might be for the present: Prenatal and maternity service, Industrial nursing, Generalized nursing. 4. A campaign to recruit students for training schools and graduate nurses for public health nursing. 5. Adding to personnel representatives from the Chamber of Com- merce and industrial nurses, and placing them with others on a sub-committee on industrial nursing. 6. Adding to personnel representatives from the proposed Obstetrical Council and placing them with others on the sub-committee on prenatal and maternity service. 7. Appointment of a sub-committee to advise with the Division of Health, and with its permission to supervise the proposed extension district. Division of Health Nursing Service Scope of the Work THE nursing service of the Division of Health covers a wide range of activities including nearly every form of public health nursing coming within the range of any municipal health department's functions and many more than are usually undertaken by municipalities. Starting with the prevention of communicable diseases in 1909, the service has been. ex- tended year by year until it now includes eight branches of public health nursing, as follows: Undertaken in Prevention of communicable diseases _ 1909 Tuberculosis work ., 1910 Infant Hygiene 1911 Prevention of Blindness _ 1912 Regulation of Midwifery „ 1912 Supervision of Boarding Homes for Babies _ _. ,, ,. 1913 School Nursing in the Parochial Schools 1917 Prenatal Nursing _— ~ 1918 Nursing 759 These services" were maintained as separate units, each with its own staff of nurses, until early in 1917 when the separate staffs were combined into one, the field divided into smaller districts, and each nurse assigned a district and held responsible for all kinds of work within that district. Cleveland is to be congratulated on its advanced stand in thus adopting a generalized muni- cipal nursing system. The Present Staff The present staff (March, 1920) consists of an assistant director, three special supervisors, seven field supervisors and seven assistant field super- visors, in addition to a field staff of 66 nurses. There are two stenographers at each of the seven Health Centers and the Nursing Service shares the use of several at the main office in the City Hall. Analysis of Activities Communicable Diseases In seven districts sanitary officers place and remove placards on houses in which there is a contagious disease. In these seven districts the nurses visit patients having scarlet fever and diphtheria. In the remaining district' (District number 1) the nurses do the placing and removing of placards and lyisit| patients having contagious diseases which are placarded as^follows: Cerebro spinal meningitis, Infantile paralysis Diphtheria, Scar'et fever, Whooping cough, Measles, Chickenpox, Typhus fever, Cholera, Plague, Leprosy. Diseases rarely occurring in Cleveland. In none of the districts do the nurses visit smallpox patients or families from which a smallpox case has been removed. The nurse's duties include explanation of the sanitary code; the establish- ment of isolation of the patient and instruction of the family concerning the maintenance of isolation; the establishment of quarantine. The nurse also determines what persons are to have permits to leave the house and she issues the permits; she takes release cultures unless the doctor on the case prefers to do so himself; arranges for hospital care for the patient and the giving of nursing care. 760 Hospital and Health Survey Conversation with the nurses and supervisors and study of the records leads to the strong impression that attention is largely focussed on the issu- ing of permits and the time-consuming taking of cultures, rather than on the care of the patient, the instruction of the family in caring for him, or on measures for their own protection. "Nursing care is rarely given," is the unanimous opinion of both nurses and supervisors because in their estima- tion, "it isn't needed." Typhoid patients have been visited only since the fall of 1919 and then only for the purpose of filling out a questionnaire in the attempt to trace the source of infection. No attempt is made to care for the patient, to teach the members of the family how to care for him, nor how to protect them- selves. Neither is any effort made to see that the patient has such care; only 5 cases out of 165 came to the attention of .the Visiting Nurse Associa- tion last year. Pneumonia cases are not visited or reported to the Visiting Nurse Asso- ciation to be visited. Outside of Districts I. and VIII., no attention is paid to measles or whooping cough. While from the point of view of checking the spread of a contagious disease it may be futile to do more than to placard these dis- eases, from the point of view of the future health of the patients, instruction in nursing care and supervision are badly needed to prevent the frequent, serious and often fatal sequelae. Such oversight and care could be given by the staff of the Visiting Nurse Association. Tuberculosis Scope: The tuberculosis work includes the maintenance of 35 tuberculosis clinics a week, and the follow-up work in the home. Every patient who comes to a clinic is visited in his home and if his case is positive or cannot be satis- factorily diagnosed he is "carried on the books" and visited occasionally, if the doctors are willing. All cases reported as positive by doctors and all patients whose sputum has been sent in for analysis are visited. Likewise, all patients referred to the Hospital Admission Bureau to be sent to the City Hospital, the State Hospital or Warrensville, and all suspicious or positive cases referred by other nursing or social agencies are visited. Plan: Unless they attend the clinic regularly, an effort is made to visit all these patients once a month to give detailed instruction in treatment of the pa- tient and prophylaxis. Nursing care is supposed to be given to all those in need of it who are unable to pay seventy-five cents a visit. Those able to pay this amount are supposed to be referred to the Visiting Nurse Asso- ciation, but only 51 cases were cared for by the Visiting Nurse Association between October, 1918, and October, 1919. The statement is made that there is little need of nursing care. It is intended to have the whole family and other persons who have been exposed, especially the children, examined at the Health Center or by a private doctor. If a very suspicious or posi- Nursing 761 tive case fails to return to the clinic, a form letter is sent. If there is no response a second is sent containing a threat to send an officer after the patient. This is often efficacious, but if it brings no response, the officer is sent. Apparently this method is used with some frequency. Performance: While diagnosis and instruction at the clinic and the effort to secure clinic attendance are emphasized, study of the home conditions, the arrange- ment for prophylactic mode of living at home, careful instruction and nurs- ing care are inadequate and home visits are far too infrequent. Nursing care is rarely given. The nurses do not have time to hunt up incipient or ad- vanced unreported or undiagnosed cases. The records show that there is an average of about 100 tuberculous patients to each nurse. The reports show that in one month the average number of visits made by the nurses to patients tuberculous, suspicious and non-positive was .47 per patient. In a second month it was .64 per patient. The supervisors stated that it was not possible to visit even the positive cases once a month, and the suspicious and contact patients were visited at intervals varying from two to six months. The records verify these statements. It is, therefore, evi- dent that the patients are not seen frequently enough for effective curative or preventive work, and that little attention can be given to securing exami- nation of the family and others exposed. There is no easily applied check in the records to show the frequency of clinic attendance and home visits. Nor is there any study of the sources from which the cases come to reveal areas of the city which should be brought under surveillance. In accompanying nurses in their districts much time was lost in attempt- ing to locate some tuberculous patients who had moved away a month before. If the nurses were able to call on their patients more frequently it would be easier to keep in touch with them when they moved. Child Hygiene Scope: This service included the maintenance of well baby clinics at 13 prophy- lactic stations; follow-up visiting of these babies in the homes; visiting all babies attending the Babies' Dispensary and Hospital; visiting all babies whose births are reported, and visiting babies discovered in the course of routine work in the districts or reported by doctors and neighbors. Performance: From the records it appears that each nurse has under supervision an average of about 200 babies. Study of the records shows that an average of .4 visits is paid each baby each month; that is, each baby is visited about once in every 2 to 2^ months. One in every 9 babies comes to the clinic once during the month. 762 Hospital and Health Survey Attention is largely concentrated on feeding of babies; instruction in infant hygiene both at the clinic and in the home is somewhat neglected. Home visits are too infrequent and irregular. From the records it appears that nursing care is rarely given and then very inadequately. These condi- tions are due to the fact that the nurses have too large a number of patients per nurse to care for. Yet individual instances of good home visiting were found. Thus, in accompanying one nurse in a visit to the mother of twin babies, the investi- gator was impressed with the nurse's sympathy and good teaching. With three older children and a husband to take care of, the mother, herself half sick, had prepared the babies' milk modification excellently, and showed the results of thorough instruction. She brightened at the nurse's entrance. Prevention of Blindness Baby eye work was done by the Babies' Dispensary and Hospital until January, 1917. At that time it was turned over to the Division of Health. It was done at first by a special group of nurses until August, 1919, and was then put into the general service. Nurses are sent to care for ophthalmia neonatorum cases the same day they are reported, and they try to return as often as necessary. Where the case is acute and home care inadequate it is sent with its mother to the hos- pital. There are no figures to show the number of such cases or the care given. The opinion of the director of the staff is that it is well done. Trachoma is a reportable disease and all cases reported by doctors or by the Board of Education are visited by the nurses. Midwife Supervision This work is entirely under the control of a special supervisor. There are 160 licensed midwives and 110 practising without licenses. The licensed midwives are visited in their homes at irregular intervals for the purpose of giving them instruction in prenatal and infant hygiene, technic, and exami- nation of their bags and stubs. Some are visited frequently; some not oftener than once a year. They are not supervised during delivery, nor do they receive demonstrations. There is little time or opportunity for the discovery of illegal practitioners. Much more frequent visits are necessary. (For further discussion of the midwife situation see report on child health work, Part III.) Supervision of Boarding Homes The nurses are supposed to visit each home in which babies are boarded out under license from the State Board of Charities and to send a report to the Humane Society. There are no records to show the frequency of these visits or the thoroughness of the work done. All these babies get special milk free from the Health Center, and the matron is expected though not compelled to bring the babies to the Health Center regularly. Nursing 763 A visit to a boarding home with one of the nurses in the course of our investigation, gave evidence of good home teaching. The baby was anaemic, with an acute vaginitis, had broken places on lips and irritation of mucous membrane in mouth, the latter indicating a probable digestive disturbance. Instructions in regard to vaginal care evidently had been very good, for the trouble was clearing up rapidly. Parochial School Nursing In March, 1917, the Division of Health Nurses undertook some work in 17 Parochial Schools, increasing to 21 schools for the school year 1918-1919. 9323 pupils in these schools received one physical inspection (by a nurse alone). In addition to sending a note to the parents, an effort was made to follow up all children found to have defects. No tabulation has been made to show what percentage of defects the nurses succeeded in having cor- rected. Incomplete as this service was, it consumed a good deal of time and effort, and no doubt certain appreciable results were obtained. For the school year 1919-1920 all the remaining parochial schools were added to the list making a total of 68 with a school population of approxi- mately 35,000. To have carried on the work at all for so many schools would have consumed the full time of at least twelve nurses and twice that number would be needed to get real results. As the entire field staff of the Nursing Service averaged only about 50, it was obviously impossible to de- vote the necessary time to school nursing in addition to the many other heavy duties. No attempt was made, consequently, to carry out the pro- gram of the previous year. A single observation was made of each school room full of pupils to discover any evidences of contagious disease. A visit was undertaken once a week to each school to get a list of absentees and to give the sisters an opportunity to consult the nurse about any special cases. The nurses undertook to visit as many as possible of the children who were seldom absent or whose absence was not explained. Such work cannot be called school nursing. Until the staff can be in- creased to devote the equivalent of the full time of twelve nurses to this service, it would seem better to concentrate all the work in a few schools (those in one district) where it can be done intensively and adequately. Prenatal Nursing The extension of advice and supervision to all prenatal patients except those under care of a private physician was undertaken in 1918. Those unable to have a private doctor were carried until visited by the out-patient nurse from St. Luke's or from the Cleveland Maternity Hospital. No definite routine has been established and no attempt is made to do urinalysis or take blood pressure. Little effort has been made to work up this service, the nurses frankly admitting that they have too much to do to undertake this additional bur- den. Less than one visit per month is paid each prenatal patient. Tho- rough work (according to the standard of the New York Maternity Center) 764 Hospital and Health Survey is not undertaken. Again until the staff can be augmented in sufficient numbers to make thorough work possible, it would seem advisable to dis- continue this service except for one district and in that district to make it a part of the city-wide service elsewhere described. Analysis of Administration Organization The chart of organization of the Division of Health places the Nursing directly under the Commissioner's office, serving all bureaus as needed and directly under his control. For budget purposes the nurses are distributed among the bureaus of Child Hygiene, Communicable Disease, and Tuber- culosis. As a matter of fact there is a single staff of nurses doing general- ized work under one director, who is responsible to the Commissioner. Headquarters Staff At present the staff at Headquarters consists of: Director of Nurses, Assistant Director and three Special Supervisors, one having supervision of parochial schools, one of eye work and midwifery. The third is responsible for various duties, compiling the monthly statistical reports, such as bi- weekly Health Center staff meetings, visiting nurses who are sick, and per- forming several other odd duties. The work is so arranged at headquarters that none of the staff are charged with responsibility for analyzing the character and results of the work, for studying the needs and personalities of the staff and developing them for promoting true leadership in supervision and for extracting the maximum value of generalized work through building up family health work. The headquarters staff instead are engaged in more or less routine duties which give them no time or opportunity for these broader, fundamental duties. The absence of a special office for the director tends to immerse her constantly in unimportant details that should be carried by others. Staff at Health Centers Spirit of Staff The present staff at each Health Center consists of a nurse supervisor and an assistant supervisor and from 6 to 12 field nurses. Each center has a fine spirit of team work and loyalty The helpful, generous cooperation of nurses and supervisors calls for commendation. The cooperation between the Health Centers and other social agencies is close and productive of good results. In discussing their cases, the nurses have their information well in hand, and are not easily confused. The spirit of the work cannot be criticized; on the contrary, the spirit of service that dominates the work is admirable. All of the supervisors and nurses who were seen are evidently working very hard and against the odds of having too much to do, and of trying to do it without carefully organized plans. Nursing 765 Organization of work The large burden of administrative detail put on the supervisors when they were given charge of the Health Centers has developed a faulty system of supervision. The supervisors and their assistants spend practically all their time within the Centers, and have virtually become Health Center Managers. The assistant supervisors were appointed with a view to re- lieving the supervisor, to enable her to devote more time to the instruction of the nurses. The assistants, however, have also been absorbed in the administrative detail of the Center, without noticeably relieving the super- visor. This means neglect of one of the primary needs, the supervision and teaching of nurses in the homes, without which generalized service is not successful. Thus, for instance, sufficient care is not given to fitting nurses into their districts. One nurse accompanied by our investigator in her home visits proved to be totally out of sympathy with the Polish people in her district and their apparent stolidity. She is enthusiastic over the Italians. With better supervision she might be transferred to another district; her approach to her people might be improved. Again, in another visit the need of instructing the nurses in their home visits was well illustrated. Here the last culture of a little girl who had been ill with diphtheria had proved negative. She was of no further interest to the nurse, though looking pale and sick. "There is no use trying, the mother is ignorant, " was her response to a suggestion about the little girl's health. Various times in the investigator's presence, a nurse consulted the super- visor at the Health Center concerning difficult tuberculosis cases, usually concerning refusal of patients to go to the sanatorium. Each time, the case seemed to the investigator sufficiently serious to warrant a visit to the home by the supervisor in order to confirm the nurse's findings. The super- visor, however, had either no time or no inclination to do more than advise the nurse at the Center. In Center routine, each supervisor has a different method. Yet this work can be systematized without in any way destroying the initiative of the supervisor. The supervisors appear tired and worried by their respon- sibility. Two of them have recently had extended leaves of absence owing to illness. This is probably due as much to lack of system as to too much work. The burden of administrative detail could be lightened without giv- ing up any supervisory functions. Much of the management of the Center could be better done by an experienced office manager. The nurses' time in the Center, which should be devoted to consultation with the supervisor, telephoning doctors and other agencies, and record work, is very much interrupted by affairs of the Health Center. . Clinics are, for instance, often held in the same room. Lack of Supervision of Nurses in the field The nurse is well supervised in clinic procedure, and she is free to confer with the supervisor on her troublesome cases. The routine method of dis- missing cases only after careful consideration by the supervisor and on her 766 Hospital and Health- Survey approval, is excellent. In the field, however, the nurse works alone; it is only when a definite problem has developed that the supervisor accompanies her. In but one of the Centers is there any effort on the part of the supervisor to go over a nurse's cases with her regularly, to remove the closed cases, and to check upon the frequency of visits. The supervisor checks up the nurse's work by reading her dictation, or by laboriously going over her charts in the general file. There appears to be a tendency to shift the emphasis in health work from the home to the Health Center, and to make the visits to the Center, on the part of the patients, the end and object of all the work. While the majority of the supervisors expressed the wish that more home visiting with nurses were possible, apparently few of them realized what this should mean. Indeed, several stated that little home visiting was neces- sary since they trusted their nurses. Several others felt that only where definite home problems existed, supervision of home work was necessary. There appears to be little realization of the need of supervision of non- acute cases, where no obvious problems exist, but where adequate direction is essential for constructive public health nursing. Many health problems are obscure. The nurse in a continual rush of work is apt to get into a rut, and., unsupervised, to follow the path of least resistance. The experienced eyes of a supervisor are essential for a fresh point of view. This is especially true of the subtle or non-acute cases that constitute a majority of the Di- vision of Health calls. These patients, where little change is seen from visit to visit, call for greater skill, quicker perceptions, more alertness, than do those requiring only bedside care. Such skill and perception and alert- ness are stimulated by personal visits of the supervisor, which, when done in the proper spirit, are welcomed by the nurse. The number of supervisors and clerical assistants is not too small. One director of nurses, ten supervisors, seven assistant supervisors, at least four- teen full-time stenographers, are now available, yet both supervisors and nurses seem to be submerged in the mechanical details of the work. The average number of nurses per supervisor is unusually low for such a large group. With the addition of an office manager and a possible curtailment of the administrative work in the Centers, it would be possible for the supervisor to spend at least half of every day in the districts. If a careful analysis were made of the activities of the supervisor and her assistant, recording every detail of their work for a definite length of time, many duties, now con- sidered essential, could be eliminated or shifted to others, thereby allowing the supervisor time to make home visits with the nurses. It should be pos- sible to divide the clinic work between three persons, — the supervisor, the clinic nurse, and the office manager. Well trained volunteers might also be helpful in clinics. N UBSING 767 Record* In spite of the fact that in every Center but one, the supervisor, her assistant, and two full-time stenographers spend practically all their time in clerical and administrative work, the nurses find it necessary to spend an average of two hours daily, out of their seven-hour day, in work in the Center. Observation might possibly show the time so spent to be even greater, especially in the Centers where the nurses return at noon or at four o'clock for new calls. There is only one Center of which this statement does not hold true. Much of this time is taken up in clerical work. A simplified and coordinated system of records would eliminate a large amount of this routine work. The compilation of the monthly statistical reports is a very difficult task because of the cumbersome and confused method of reporting. The record system, having been developed piecemeal and service by service, is far from coherent. Many figures are gathered which serve no useful purpose, and figures necessary for a proper appraisal of the work and an accurate measure- ment of results are not obtainable. An altogether unjustifiable amount of the nurses' time, both at the City Hall and in the Health Centers, is con- sumed in keeping up this complex and voluminous system of bookkeeping. Reorganization is needed, but it is doubtful whether anyone in the Division of Health is qualified to evolve a properly simplified method of record keep- ing. An expert should be engaged to reorganize the system, both in the City Hall and the Health Center, and thus save valuable time now being- was ced in unnecessary clerical work. The proper person to provide forms, to organize records and to analyze the tabulated information received through the nurses' reports, would be the statistician of the Division of Health, as proposed in the chapter on Vital Statistics. After such a system had been installed it should, so far as possible, be turned over to an office manager. It is highly desirable that such an office manager be appointed in the office at the City Hall and one at each Health Center, to whom the greater part of the detail work could be shifted in order that the supervisors may have an opportunity to attend to their more im- portant duties of direction. The laborious work now spent in keeping the milk book — to mention only one instance — could be turned over at once to the office manager. The Staff of Field Xerses Abundant evidence is available to show that the nurses are heavily over- loaded with work and are carrying far too many patients per nurse, and covering too large a territory to do effective work. They average 260 fam- ilies each. The number is considerably higher when estimated by indi- viduals. They are overburdened with the intricacies of the complicated record system and the large amount of time spent in the clinics leaves in- sufficient time to develop home visiting. As a result, the nurses are often discouraged. The average number of home visits is. over 300 per nurse per month. The patients scarcely receive an average of one visit per month. 768 Hospital and Health Survey The nurses are doing their best under this accumulation of overwork, but cannot be expected to obtain substantial results when they are able to give so little attention to constructive teaching to patients in their homes. New Nurses New nurses do not receive proper introduction to their work. They are sent out with another nurse" for a day or two and receive only such instruc- tion as a very busy Supervisor can find time for in the Health Center. No other instruction is given. The character of the nurse's work is not studied, her weaknesses found and methods of correction pointed out, nor is there any way of developing the abilities of a nurse. No efficiency records are kept. Such a record should not only analyze the nurse's ability and work, but it also should demonstrate the supervisor's ability to know the nurses, to fit them into districts, to develop strong points and to direct enthusiasm and energy into proper channels. The record of the nurse should be dis- cussed by the Center supervisor and the director of nurses, and the nurse put into the district she can best serve. At present the supervisors have no regular method of trying to fit the nurse to the district. If it is apparent that she is not getting cooperation, she is transferred, but this happens in- frequently. Uniforms The nurses wear any kind of street clothes they choose. They go in and out of district homes giving nursing care in suits and woolen dresses. This is not only exceedingly bad practice but detracts from the usefulness of the nurse, since she is not readily recognizable as a nurse while at work in the district, and her costume is not suitable for giving nursing care. Probably one reason that so little actual nursing occurs is the fact that the nurses do not wear uniforms. Even though they are protected by a gown, they are over cautious in approaching the bedside of a contagious or infectious case. If effective work is to be done in home visiting, teaching by actual example must take place, and this cannot in wisdom occur unless the nurse is in a washable uniform. Moreover, the smart uniform adds to the dignity and impressiveness of the nurse. GENERAL CONCLUSIONS The principles and plans of the Nursing Service of the Division of Health are, in general, excellent. Its performance, however, does not equal its ideals, mainly because it has not increased its staff sufficiently to carry the ever increasing volume of work. The majority of its shortcomings can be laid at the door of the insufficiency of numbers. The rest are due to a top- heavy plan of management and insufficient supervision. At present emphasis centers around attendance at Health Centers, diag- nosis and prescription for treatment. The nursing service is in reality an extension of a clinical service rather than a true public health nursing serv- ice. Home visiting is an adjunct rather than the prime activity of the nurse. What is needed is greater frequency of visits in the home, and also longer Nursing 769 visits so as to enable the nurses to pay more careful attention to the health of the family, to the teaching of hygienic habits, and the giving of nursing care. A Proposed Extension District In order to afford an opportunity for the city to extend its nursing serv- ice further in the direction of a generalized system, without at present im- posing further duties upon the staff as a whole, it is desirable that such ex- tensions be undertaken in one district only, which might be designated the Extension District. One of the present Health Center Districts might be devoted to this purpose. In this district two experiments making for a completely generalized service might be tried. In addition to the present activities of the nursing staff, the following services might be undertaken: 1 . Prenatal nursing as a part of the city -wide plan. 2. School nursing in the parochial schools. If these experiments prove successful there might later be added; 1. General medical and surgical nursing service. 2. Obstetrical and post-partum nursing. In order to provide every opportunity to make such an extension dis- trict successful, it should have the following favorable factors: 1. A district of approximately 50,000 people. 2. The direction of a well trained public health nurse who has had experience with generalized work, including visiting nursing. 3. A supervisory staff of four supervisors. 4. A nursing staff of 18 nurses (1 to 3,000 population). A sub-committee on'generalized nursing of the Central Committee might be requested by the Health Commissioner to act as an advisory committee for the Extension District and expected to exercise close oversight of its con- duct and results. RECOMMENDA TWNS It is therefore recommended as follows: ACTIVITIES /. Communicable Disease Prevention: That more attention be given to protection of members of the family other than the patient, to arranging for adequate nursing of the patient, and to instruction regaiding prevention of sequelae. That pneumonia, measles, whooping cough and typhoid cases be reported to the Visiting Nurse Association, which will seek permission of the private doctor to give nuning. 770 Hospital and Health Survey 2. Tuberculosis Work: That this service be continued and greatly increased, especially in the field of home visiting for instruction and nursing purposes, and in an effort to discover new cases. All tuberculosis patients should te visited at least once a month and those in need of care much more frequently. Much more effort must be given to having the family and those exposed examined. 3. Child Hygiene: That this service be continued and amplified. Much more home visiting is impera- tive for careful instruction in infant and child care and for nursing care. That a standard routine be adopted and mechanical methods devised to check it up. All babies should be visited at least once a month and sick babies daily. 4. Supervision of Midwives: That this work be increased; visits be made more frequently; time be provided for hunting illegal practitioners, for demonstration and for inspection of technique and de- livery. 5. Prevention of Blindness: That the present routine be continued, but it should be made certain that the care given is adequate in frequency and quality. 6. Supervision of Boarding Homes for Babies: That a definite routine of visits and procedures be established, extending to these babies constant oversight in all matters of health and general care, as well as feeding. 7. Parochial School Nursing: That the present entirely inadequate and nearly futile effort of providing service for all parochial schools be discontinued. That all parochial school nursing be concentrated in the proposed Extension District, whc;re an intensive piece of work may be done. 8. Prenatal Nursing: That this service be restricted to the proposed Extension District, as a part of the city -wide maternity system. 9. Extension District: That one of the present Health Center districts be set apart as an Extension District for the purpose of initiating new projects or methods before undertaking them on a city- wide basis, in accordance with the detailed suggestions made above. ADMINISTRATION 1. Organization: (a) That all nursing service now carried on or to be carried on by the Division of Health be under the direction of a Director of Nurses, who should be immediately respon- sible to the Commissioner of Health. N-U:E[£'ING 771 (b) That the nursing service for the Bureaus, whose work requires the services of nursing (such as the Bureau of Communicable Disease, the Bureau of Child Hygiene, and the Bureau of Tuberculosis) be performed by the general staff of nurses, and that the proper relations shall be maintained through consultation by the Director of Nursing, and the Directors of the three mentioned bureaus, all policies and decisions being subject to the approval of the Commissioner of Health. 2. Headquarters Staff: (a) That the positions of Director and Assistant Director be continued as at present. (b) That the present plan of special supervision be discontinued and reorganized as follows : That four assistant supervisors be appointed, each to have charge of the general oversight of certain activities, as follows: 1. Baby and child hygiene. 2. Communicable disease. 3. Tuberculosis. 4. Midwifery, boarding homes, eye work. The fourth assistant supervisor to have an assistant. (c) That these supervisors should have two functions, acting as special consultants in their own field, and as instructors in their special services. These supervisors should work out and conduct a scheme of continuous education for the staff. They should be responsible for the instruction of new nurses in the routine policies and procedures of the work and in the special technique and practices of each special service. They should also be responsible for classes, consultations and conferences for the whole staff. In their capacity as special consultants they should be responsible for the study and analysis of the nursing work accomplished, both as to quality and quantity, and the de- velopment of this work in their own special services. They should make studies in> co- operation with the directors of the various bureaus of the Division of Health, and should act as liaison officers between these bureaus and the nursing service. They should act as a connecting link between the Nursing Service and the special outside institutions related to their work. (d) That there should be an office manager responsible for all the business details of the office, and for all the records. This position should be sufficiently well paid to make possible the employment of a thoroughly competent woman. (e) That the Director of Nursing should have a private office. 3. Records: That the record system be simplified; that a record expert or the statistician of the Division of Health be employed to set up a simple, practical and effective record system and that the statistical work be done by the office of the statistician of the Division of Health rather than by the nurses. The record system for the Health Centers and Headquarters should be uniform, and the office manager should be held responsible for it. In order to secure continuity and 772 Hospital and Health Survey high grade service there should be assurance o e promotion and increase in salary for all the clerical staff, based on merit. 4. Health Centers: (a) That there should be a district supervisoi, who should be responsible for the administration of the Health Center, but whose principal duty should be the supervision of the staff nurses and their work in the homes. Fully two-thirds of her time should be given to field supervision. She should not be subordinate to but chief over the clinic nurse and the office manager, suggested below. (b) That there should be a clinic or dispensary nurse whose full time should be de- voted to the Health Center, for the purpose of running the clinics and talking with patients who come out of clinic hours. She should have no responsibility for home case work or for field work. (c) That there should be an office manager (not a nurse but a competent business woman), who should have charge of the business management of the center and of all the mechanical and record work, and receiving calls and relaying such of them as are emergent, to the nurses in the field. There should be a uniform system for office management and record work in all the centers. Salaries should be paid in these positions high enough to .nsure a thoroughly reliable, intelligent and businesslike personnel. (d) That the practice of having two or three nurses in attendance at clinics be dis- continued; that the clinics be conducted by the dispensary nurse with the possible assist- ance of one staff nurse; that if more assistance is required, it be provided by a clerical worker and not by a nurse. (e) That a routine of field supervision be established, and that the field supervisors render to the Director a weekly record of their work. (f) That a separate room be provided in the Health Centers for the field superviso and her field nurses. (g) That districts be greatly reduced in size, possibly cut in half. 5. Field Staff: (a) That the staff should be increased until no nurse carries more than 125 patients, preferably 100. This will mean largely increasing the present staff. (b) That the staff nurses consult with the field supervisor daily concerning their case work and that she in turn take up any special case problems with the special supervisors at Headquarters. (c) That an efficiency report be prepared by the field supervisors monthly for each nurse, to be submitted to the Director and kept on file. (d) That each staff nurse prepare a monthly statirtical report of her work. (e) That new nurses spend the first two or three days of their service in the main office to receive instructions from the special supervisors in the routine, the records and the general practices of the work. Nursing 773 (f) That new nurses be taken out by the field supervisor for at least two or three days before they are allowed to go alone, and that they be then visited at frequent intervals by the field supervisor (once a week for a month) while at work in their district. (g) That new nurses attend weekly classes at the City Hall, to be conducted by the special supervisors, to be trained in the technique and methods of work in the special fields. (h) That the weekly conference now being held for the whole staff at the City Hall be continued, and be included in the scheme of education worked out by the special super- visors. 6. Salaries: That the salaries of the staff nurses, the field supervisors and the special super- visors, be increased to meet the schedule recently recommended by the Central Nursing Committee. 7. Uniform: That a wash uniform be adopted and worn by all members of the staff (except the Headquarters Staff, if so desired). Tne Visiting Nurse Association of Cleveland Scope of the Work THE Visiting Nurse Association of Cleveland undertakes to extend home nursing care, except in communicable disease, to anyone in the city not cared for by any other public health nursing agency. This service is given free to those unable to pay for it; part pay is charged to those unable to pay the regular fee; all others pay the full fee. The pay sjrv'cs is not restricted, but may be used by anyone except that it cannot be obtained at a regular fixed hour, nor extending over one-half day, nor for cases in which only attendance is wanted and no nursing care for illness is needed. Visit- ing nursing is also provided for policy holders of the Metropolitan Life In- surance Company, for which the company pays the Association at the rate of sixty cents (60 cents*) per visit. Nursing care in tuberculosis is given only to those patients able to pay 75 cents or more per visit; care is given in diseases of babies under three years, attended by private doctors, but not to babies attending the clinics of the Division of Health; and care is not given in illness among industrial workers who are provided with home nursing service by their employers. With these exceptions the Association undertakes to care for patients of all ages and patients with all types of disease, acute and chronic, medical, surgical and obstetrical, including also the making and teaching of milk modifications for infants under the care of private doctors. Like all visiting nurse associations of equal grade, the Cleveland Associa- tion has placed chief emphasis upon the primary need of caring for the poor * Charge has now been changed to $1.00 as recommended by the Survey. 774 Hospital and Health Survey who cannot pay for nursing service. Second, is felt the need of caring for persons of small means who may be able to pay a very small fee. For persons of moderate income a pay service at cost has been recently introduced and should be widely extended. The extension of pay service is not alien to the policies and purposes of any well organized visiting nurse association, but is a natural and logical development of its work. Such a well organ iaed hourly service, at a moderate price, under centralized management is not unlikely in the future to solve the problem of the de- creasing number and increasing cost of private duty nurses. One of the striking developments in paid service, which the Cleveland Association, like a few other leading nursing organizations, has recently taken up, is a paid day and night service during delivery. This work fills a need than which none is more important, but with which for lack of the necessary personnel and funds, visiting nurse associations have in the past not attempted to grapple. The value of teaching family hygiene and giving attention to the health and hygienic habits of the whole family is recognized by the Association, but is not sufficiently emphasized as a definite function of the nurse. The Present Equipment In order to perform this work a staff is maintained consisting of a super- intendent of nurses, an assistant superintendent, three supervisors, and at present 21 regular staff nurses and six substitutes, and a clerical staff con- sisting of one office secretary and one clerk at central office and one stenog- rapher at each sub-station. There are a central office and three district offices, all of which are ample in size and equipment for their functions. Analysis of Activities Study of the work performed by the Visiting Nurse Association proves it to be of highest grade so far as it goes, but that it does not go far enough. The spirit manifested by the whole organization is lofty, and the work is thorough, painstaking and kindly. This Association has been of great value in demonstrating many activi- ties to the municipality, such as the care of tuberculosis, industrial nursing, and, together with the Babies' Dispensary, work for babies both sick and well, etc. By turning over these successive activities to municipal and private agencies, the present scoDe of the work appears to be narrowing and to lack extension into the new fields of services waiting to be developed. The Board of Trustees of the Visiting Nurse Association has never lacked vision for new opportunities of service. It will doubtless continue its policy of extending into new fields as occasion offers. Care of the Sick The care of medical and surgical patients occupies the greatest part of the nurses' time. Approximately four-fifths of the patients are medical or Nursing 775 surgical cases, only a very small percentage (less than 1%) of whom are chronics. The kinds of illness cared for are many, but include very few cases of tuberculosis or other communicable diseases or intestinal diseases of infancy. Between October, 1918, and October, 1919, 51 tuberculosis patients and 16 intestinal cases among babies were treated. Yet the records of the Division of Health show that the second highest cause of death in the city of Cleveland in 1917 was tuberculosis, and the third, diarrhoea and enteritis among children under two years of age. While it is true that the Division of Health provides for the care of all contagious diseases and for tuberculosis patients not able to pay 75 cents a visit, and of sick babies whose parents are unable to pay 75 cents, it never- theless is surprising that so few tuberculous patients over the 75 cent limit were found in need of nursing care, and so few sick babies outside the scope of the municipal staff. While the city record shows only 165 cases of typhoid during the year, a negligible number of these, only five, are on the visiting- nurse list. Moreover, few post-operative cases discharged from hospitals before com- plete recovery are under visiting nurse care. Many hospitals dismiss sur- gical patients as soon as they have recovered from the operation itself, who still require dressings of the wound for weeks and possibly for months. For patients of little or no income these dressings should be done without cost. Visiting nurse service would seem to be the solution. Frequently, also, private doctors are glad to turn over such dressings to the visiting nurse, doing the dressings themselves only often enough to keep track of the prog- ress of healing. Apparently, little such service is rendered by the Cleveland Association, although there is presumably considerable need for it. Indeed the Association should be called on for a wider service of the kind. It is desirable that the hospitals should send the regular clinic agents to call on patients merely to secure their return, or where there are special medi- cal or social conditions which the hospital has studied and with which it is in touch. But all patients leaving the hospital who need medical or surgical care are appropriate patients for the Visiting Nurse Association and an effort should be made to have the hospitals refer them to the Association. Observation of a limited number of home visits showed the quality and character of nursing care to be excellent, being careful and thorough, and done with much gentleness, where the work of the nurses in their districts was observed by the investigator. Marked kindness, sympathy and interest was shown by the nurses in most cases. It was apparent, however, that the actual nursing care given was of first importance in the eyes of the nurses; and that they failed to consider the health of the whole family as part of their responsibilities and did not take sufficient advantage of opportunities to teach prevention of illness, or home and family hygiene. The records of the Association, however, show that a substantial amount of attention was devoted to social diagnosis and treatment, since practically 25 per cent of the patients cared for between October, 1918, and October, 1919, were referred to hospitals, dispensaries, or other health or social agen- cies. 776 Hospital and Health Survey While undoubtedly the giving of nursing care is the prime function of a visiting nurse association, it seems clear that more teaching could be done by the Cleveland staff without lessening the quality or quantity of nursing care. Many opportunities also present themselves to secure or advise treat- ment — medical, surgical, dental, optical or hygienic — for members of the family not coming within the range of the school, municipal or industrial nurses. While the statistics in Cleveland do not show the amount of such work done, none of the visiting nurses who were accompanied in the districts seemed to be taking advantage of these opportunities as vigorously as they might. In the opinion of the Superintendent of the Association the sick among the poor are receiving adequate care and are being brought to the attention of the Association, through its cordial relations with other social remedial agencies and their frequent calls. There are, however, no statistics to show the number of patients so referred. The Superintendent thought that the pay service had not reached its maximum usefulness, and that a decided ex- tension of this service was needed, and would be of benefit to and well re- ceived by those of small and moderate income. Prenatal Nursing It was found that prenatal care was being extended to patients under the care of private physicians and to patients expecting to go to the hospital for confinement or to have a midwife. It was not given to patients under the care of an out-patient maternity service. It was stated that, although they engaged the doctor some time ahead, very few of the pregnant patients carried by the visiting nurses had medical oversight until the time of con- finement.^ Hence the prenatal instructions given to those patients by the nurses, with the doctors' consent, are of special value as safeguards. With the wide possibilities of benefit inherent in prenatal nursing both for the individual mother and for the community, this nursing service should go further than it now does. Visits are a month or more apart, instead of every ten days or two weeks as they should be for the best results; no urin- alysis is made or blood pressure taken, and instruction might be somewhat more thorough. The reason given was that the nurses did not have time to make frequent calls of sufficient length upon these patients. They would be glad to enlarge this service and could do so with great advantage if the staff were increased sufficiently. Maternity Service The post-natal care given by the regular staff nurses was excellent. The work of the special obstetrical nurses was not observed, but judging from the high quality of the work of the rest of the staff, it is presumed that this was well done also. This service is provided at any time to any home patient under the care of a private physician and able to pay the fee of $5.00* It is not provided to patients unable to pay this fee, since such patients are not • This fee has been changed to $7.00 since the investigation was made. Nursing 777 usually under the care of a private physician, but have hospital or out-patient maternity care, which provides nursing service. The maternity service of the Visiting Nurse Association, though still on a small scale (234 confinements in 1919), is steadily growing. It should be increased as rapidly as the staff can be increased to care for it. Factory Service Two factories are in affiliation with the Visiting Nurse Association through contract, one being supplied with two nurses and the other with one through the Visiting Nurse Association. These nurses were former members of the visiting nurse staff and are still supervised by its superintendent and her assistant. They send to the Association a monthly statistical report and attend the staff meetings. During the factory nurses' illness or vacation, the Association supplies a substitute. The factories pay the Association for this service, including salary, equipment and carfare, and the Association pays the nurses, who wear its uniform. In the past such an arrangement was maintained with six factories, but four have discontinued it. It is highly desirable that the Central Nursing Committee work out a plan for some agency to assume this activity. Supervision of the 104 industrial nurses in Cleveland is urgently needed. (For further details of nurses in industry see Part VII.) Out-Patient Maternity Affiliation Up to January, 1920, both the out-patient maternity service of Western Reserve and of St. Luke's were in affiliation with the Visiting Nurse Asso- ciation. Formerly this meant that the Visiting Nurse Association selected the nurse, but recently the hospitals have selected the nurses, and they have had their selection "regularized" by passing their credentials through the Central Committee and the Visiting Nurse Association. This affiliation has come to be only a form since the Association does not select or supervise the nurses or have any authority over their work. All that remains is that the nurses' salaries are paid through the Association. There appear to be no advantages in this arrangement, and it is clearly a disadvantage to the Visit- ing Nurse Association to be responsible for a piece of work over which it has no authority. January 1st this affiliation was discontinued with St. Luke's, but continued with Western Reserve. The Medical College had a gift some years ago for a memorial nurse, the "Powell Nurse," for its out-patient maternity service. The College believes there was a stipulation that the nurse should come through the Visiting Nurse Association, and is therefore unwilling to discontinue this perfunctory affiliation for fear of losing the right to this gift. It would seem that such arrangements should be abandoned in favor of a city-wide single prenatal service, recommendations for which are given elsewhere. Pilgrim Church Service Pilgrim Church pays $500.00 a year towards the salary of one nurse to care for the people in the neighborhood of the church. The church endeavors to serve a non-sectarian group. The nurse has her office in the churchjmild- 778 . Hospital and Health Survey ing, at the request of the church, in order to make a place where the neigh- bors can be cared for. She does many dressings in her office, and also in- spects and watches over the church kindergarten. The church has marked out- the area in the city which it wants her to serve. This area is not an appropriate one in relation to the rest of the West Side district. Nurses going into one district must frequently cross this district. The western sec- tion of it is more accessible to one of the other districts. The nurse does not report to the West Side office or keep her records there, the latter being kept in the church office.* The supervisor of the West Side district, therefore, must come to the nurse's office in order to see her or to go over her records. The result of this arrangement is that the nurse works almost alone and receives very little supervision and assistance. This arrangement appears to be inadvisable, both from the point of view of policy and of administration. As a matter of policy, it would be awkward, if contributions were to be received from other churches, to permit them to determine the location of the nurse's district, and to have her office in the church. This would result in confusion and disorganization of the present well planned system of the Visiting Nurse Association. The precedent, therefore, seems to be a bad one. From an administrative point of view, the result is the undesirable isolation of one of the members of the staff, cutting her off from intercourse with other members and from the assistance and over- sight of her supervisor; also the necessity of maintaining district boundaries which are exceedingly disadvantageous to the management of the work in the West Side district. Service Outside of the City . Lakewood has its own Visiting Nurse Association, which is affiliated with the Association in Cleveland. It has a separate Board of Trustees, who raise funds, determine policies and administer the work. The nurses, however, are supplied by the Cleveland Association, which also supplies substitutes when needed. Salaries are paid through the Cleveland Association. These Lakewood nurses attend the staff meetings of the Cleveland Association, and are supervised by the superintendent of the Association or her assistant. They wear the Cleveland uniform and send a monthly report to the Cleveland Association. ; Bratenahl Village, a well-to-do residential section, pays the Association $250.00 a year to have a nurse call twice a week at the school to inspect the children.' There is also a school doctor, who attends occasionally. The nurse does little home visiting. Analysis of Administration The administration of the activities of the Visiting Nurse Association seems to be well planned, systematized and carried out. The main office and sub-stations are managed in a smooth, businesslike way and for the most * Since the recommendations of the Survey were received the records have been removed from the Pilgrim Church and the Pilgrim nurse reports three times a week to the West Side Station. N fj r s i x G 779 part the: record systems seem to be adequate, fairly simple and kept up-to- date. The amount of clerical work required of the nurses has been reduced to a minimum. No record is kept of the source of calls, making it impossible to analyse the frequency and amount of the use made of the Association by other agen- cies. An annual analysis of the sources from which calls come would be illumi- nating. It frequently shows that certain agencies are not calling upon the Association at all, or not as frequently as they might, or that agencies with whom close relations were supposed to exist have in reality made few calls upon the Association. It gives definite evidence of the number of dismissed patients turned over to the Visiting Nurses by the hospitals. It shows to what extent the doctors are making use of the nurses. All the members of the Visiting Nurse staff interviewed indicated that the doctors were giving the Association excellent cooperation, but there were no statistics to prove this fact. A tabulation of the sources of calls would give all this information, and afford a definite basis on which to determine where the service could be built up. There is a cheerful, dignified spirit among the members of the staff, both in the stations and in the districts. Devotion to the work seems to be genuine and whole hearted, and it is quite evident that the officers and staff of the Association are working constantly to insure a dependable quality of service. The harmony that exists among the supervisors and their constant oversight of the work in the field tend to stabilize the service and to insure to the patients skilled and carefully planned services. The supervisors make every effort to insure the best of care to the patients without overworking the nurses While only four nurses were accompanied in the districts, one of whom did not come up to standards, the work observed bore the marks of consistency, honesty and well grounded preparation. Two or three factors, however, tend to diminish initiative and ability to plan and manage on the part of the staff nurses. These factors are the fol- lowing:* (a) In two districts the supervisors allow the nurses too little planning of the day's work. The nurses make out a list of their calls, and the super- visor then changes the arrangement of them as she sees fit, or decides which patients are to be seen and which are not. This takes away from the staff nurse the necessity of planning her own work and of managing and perform- ing it in a way to bring about the best results. It lessens her sense of respon- sibility and makes her very dependent upon her supervisors. (b) The unit of the organization so far as records are concerned is the supervisor's district and not the staff nurse's district. The districts occupied by the staff have no name, letter, or distinguishing mark and no identity. The list of patients and the statistical report of the work is made out for the whole district covered by the supervisor and not for the smaller districts in which the nurses themselves are working. This means that there is no * Since the Survey recommendations were received the following changes have been made. Every nurse now has her own district, keeps her own day-book, makes out her own monthly statistical report. 780 Hospital and Health Survey way of picturing the work in each nurse's district as a single piece of work; no method of measuring the work performed by individual nurses, conse- quently no basis of comparison and no basis for pride in accomplishment. This does not tend to build up individual initiative, or the spirit of competi- tion with the work of other members of the staff. No use is made of the census tracts of the city in outlying districts, either for the individual nurse or fcr the supervisor's district. These fundamental districts as arranged for useTsy the census should be used as units or by multiples for the Visiting Nurse Association administration as for the district subdivisions of every other private and public health agency. (c) In two districts many of the nurses make a practice of returning to the station three times a day.* This is a waste of time, and again weakens the nurse's sense of responsibility for her work. The tendency is for her to go to her supervisor constantly for advice rather than to think out her prob- lems herself. While there is thus no lack of supervision and in some cases too much supervision in the administration of the work, there might to advantage be even more supervision than there is in the home visiting. A study of the supervisors' record for two months showed that during one month super- visors went into the districts with the staff nurses 33 times, and the second month 34 times, visiting in the first month 64 families, and in the second 114; yet in one month four nurses were not ever accompanied by the supervisor, and in the other month six nurses were unaccompanied. According to this record the supervisors spent an average of about one- third of their time in the field, but not more than half of this was spent in accompanying the staff nurses. The supervisors appear to make visits alone in the district. This is not desirable practice, as it means that the nurses are deprived of the supervisors' guidance in such cases and that the super- visors are handling alone the most difficult situations, instead of using them as teaching opportunities. A good feature of the work is that the supervisors regularly attend the case conferences held by the Associated Charities. It is desirable that the staff nurses who occasionally attend these conferences, should also do so regularly. The nurses average seven and a half calls a day. If the nurses did not return to the office so often more work might be accomplished without inter- fering with its finish. With an enlarged staff and a saving of the nurses' time in going back and forth, especially in the outlying districts, the activi- ties of the Association might be doubled and many more persons get the bene- fit of the fine services offered. Experience in many communities has proved that until the city is able to take over these nursing services in full, private organizations must perform this function of helping save life and restore health. The overwhelming majority of sick persons must be cared for in their homes; a very small pro- * The nurses now are required to go to the station but once a day. Nursing 781 portion are cared for in hospitals. The visiting nurses must be supported., since to them the community must look for this home nursing care. RECOMMENDA TIONS It is recommended: ACTIVITIES (a) That care of the sick be extended to a larger proportion of the population, espe - cially to persons of small and moderate income, through vigorous advertising and other campaign methods. The work may well be extended district by district as the staff is increased, rather than to undertake it at once for the whole city with inadequate staff. The full fee for the pay service should be increased to $1.00 to cover the cost of a visit. It is believed that this service will never be attractive to persons above the poverty line, unless they are able to pay its full cost. (b) That the affiliation now existing with the Maternity Hospital be discontinued. 1 That responsibility be assumed for a city-wide prenatal and ma- ternity nursing service, elsewhere recommended in detail. 2 That the present paid day and night maternity service be expanded. (c) That greater efforts be made to reach sick babies and tuberculous patients through the pay service. (d) 1 That arrangements be made with the several hospitals to refer to the Association all patients leaving the hospital who are in need of nursing care either surgical or medical, and also all dispensary cases needing nursing care and unable to return to the clinic. 2 That the doctors who seem to have the majority of such cases be offered the services of the visiting nurse. (e) That if the Division of Health is willing, the Association be notified of all typhoid, pneumonia, measles, whooping cough, scarlet fever and diphtheria cases re- ported, and such patients be visited wherever the doctor in charge is willing. (f) That arrangement be made with the Division of Health to have district phy- sicians, as a routine practice, notify the Association of all patients visited, excepting only cases referred at once to hospitals, and those discharged on the first visit. (g) That more attention be paid to the health of the family and the teaching of hy- giene in the homes. ADMINISTRATION (a) That the staff be enlarged to meet the needs of the extended activities recommended above. This will probably mean doubling the staff now, and as these activities grow, doubling it again. (b) That as the staff is increased the number of supervisors be increased to keep the ratio at approximately one supervisor for every ten nurses. 78£ Hospital and Health Survey ' (c) 1 That one automobile be provided for each sub-station for use especially in the outlying districts; thus also making possible more frequent visits of the super- visors, especially to the outlying districts. 2 That as an alternative, the nurses in the outlying districts be provided with a sub-station, and come in to the district station only two or three times a week. To these outlying districts the older and more experienced nurses should be assigned. (d) That the Pilgrim nurse report to the West Side station and that the boundaries of the Pilgrim District and the neighboring districts be changed to bring about a more advan- tageous arrangement. The nurse could still maintain a dispensary service at the church if desired. (e) That the individual nurses' districts be made the unit of work, giving them a fixed number or letter, and requiring a statistical report for each of these units monthly, and that the unit of district work be the official census tracts, singly or in multiples. (f) That the individual nurse report to the district office only once a day. (g) That the amount of supervision of the nurses in the field be increased and be lessened in the station. (h) That the nurses attend Associated Charities' case conferences more frequently. (i) That methods be devised of developing the individual initiative and resources of the nurses (a weekly round table is suggested for the discussion by the staff, of district problems, case work, and allied subjects.) The nurses themselves might well plan and conduct these round tables. (j) That a record of the source of calls be kept. Nursing Service of tne Board of Education IN school nursing, as in the other branches of public health nursing, Cleve- land is fortunate in having, through the agency of the Central Nursing Committee, a high professional standard. In school nursing, as in the other branches, a valuable demonstration of work has been made. A fine spirit and diligent application have been found throughout the department. The failures which have disclosed themselves in the course of this investi- gation are in the main due to the same causes as those in various other organ- izations studied: that is inadequacy in numbers and faulty supervision. Yet there is every reason to think that with adequate enlargement of the staff, with proper supervision, and with a change of emphasis in the work to reduce some of the less important activities and strengthen the more essen- tial features, a school nursing system second to none can be built up. Scope of the Work 1. Assisting medical inspector with physical examination of children. Every school child receives one examination a year; some of those found to be defective are examined more than once. Nursing 783 %. Inspection of pupils by class rooms. After the summer, Christmas and Easter vacations, the children are inspected, a room at a time, by the doctor and nurse, for signs of communicable disease, skin disease, running ears, or pediculosis. Once a month the nurse makes a similar inspection, devoting about 7 to 10 minutes to an entire roomful of children. 3. Securing correction of defects found through the examinations by means of: Notes and messages sent to parents, Consultations with parents at the school house, Visits to the home. 4. Maintenance of "dispensary hour" in each school for: Treatments, Dressings, Emergencies, Inspection of excluded children. 5. Health talks to individual pupils. 6. Health talks to classes in class rooms. The Staff The staff of the nursing bureau consists of: 1 supervisor of nurses, 2 field nurses, 30 staff nurses, 6 junior health workers, 1 stenographers (part time only). There is a central office in the administrative building, but there are no branch offices. Analysis of Activities Examination of Children Since these examinations are made by the medical inspectors they need no comment in a study of nursing work. They are made rather rapidly, usually without the taking of medical histories, and except in a few instances, they are not complete examinations. Moreover, most of the corrections recommended are routine recommendations, such as removal of tonsils and adenoids, and treatment for dental and visual defects. It would seem. 784 Hospital and Health Survey therefore, that the school nurses might be released from attending the doc- tor during these examinations, and be replaced by junior health workers, thus saving much of the nurses' time for more productive work. Where less obvious and simple conditions are found, and treatment is more tech- nical and personal, the nurse should consult with the doctor, in order to receive more detailed instruction than is written on the record. Inspection of Pupils by Rooms The nurse spends an hour or more each school day in making room in- spections, for the purpose of detecting skin lesions, running ears, pediculosis, and symptoms of communicable diseases. These examinations of an entire roomful of children are completed in 7 to 10 minutes. On account of the preoccupation of the nurse with other duties, even these necessarily super- ficial inspections can be repeated only at intervals of about 4 weeks. Be- tween examinations the teacher must be relied upon to notice symptoms and to refer children to the nurse during the "dispensary hour." Since previous training and experience in such work cannot be expected of teachers, the nurse should not only determine the physical condition of the children at the time of her visit, but should also confer with the teacher and instruct her, so that she may render this service to the best of her ability during the long intervals between the nurse's visits. Teachers who are cooperative and become fairly proficient will need less frequent visits from the nurse, and more attention can be given to school rooms of those who are new or less interested. This cooperation between the nurse and the teacher should result in more effective supervision of the health of the children day by day, than is now possible. Correction of Defects — Lack of Home Visiting The most important activities of school nurses are arranging for the correction of defects, the improvement of conditions personal or environ- mental causing defects, and the establishment of better health habits. In the case of many children, a real remedy for an abnormal condition cannot be prescribed until the child's environment has been studied. Change in the mode of living is often essential not only to the correction of physical defects, but also to the complete restoration and maintenance of health. These changes in living can be accomplished in most cases only by thought- ful persuasive visits during which the nurse may talk over the child's condi- tion at length with the parent, may discover what influences in his home life are harmful, or what may be wrong in his hygienic habits, and may advise the mother thoroughly and carefully concerning any changes needed. Such visits are the very heart of school nursing. Thus, for instance, a boy in one of the Cleveland schools, who had had skin trouble since babyhood, had been to many doctors and dispensaries without relief. It was discovered by the nurse in a home visit that his diet consisted chiefly of tea, coffee and sweets. "We've plastered him with the things the doctors were experimenting with," said his family, "but nothing helped until you got after his food." Nursing 785 In Cleveland, at present, much time is given to finding defects and to recommending treatment; little time is given to seeing that those defects are remedied and that the child's mode of life and surroundings are improved. Reliance is placed largely on sending notifications to the parents, and on consultation with parents in the schools. It is apparent that the results of this practice are not wholly satisfactory. The school records for the war year 1917-1918 show that 32,918 children were found to have defects, of which 12,544 or 38.1% were corrected. 6,397 consultations with parents were held, and many of these consultations may have been return visits of the same parents. During that year the nurses made only 9,010 visits to the homes. This small number should be in part ascribed to the fact that the nurses assisted in a very large number of vaccinations during the year, over 45,000 as against approximately 16,000 in the next year. During 1918-1919, only 2,789 consultations with parents were held, but the nurses made 13,544 visits to homes. The defects corrected num- bered 43.6% of the total number. So many factors enter into the correcting of defects that it would be unjust to draw final conclusions from the numbers given; nevertheless the increase in the number of corrections is striking when compared with the increased number of home visits, even though the number of consultations with parents at the schools showed a decrease. Various duties within the school buildings engage the nurses until the middle of the afternoon. They are consequently unable to spend more than one hour and a half a day, and one half -day, in visiting the homes of the children, a total of perhaps ten hours a week out of thirty-eight and a half. Furthermore, constructive case work appears to be almost unknown. The follow-up in the homes appears to consist chiefly of brief visits, or, as the nurses describe them, "flying visits" made to obtain the parents' consent to an operation or other correctional treatment, instead of careful repeated health teaching without which a high degree of success is im- possible. The need for more and better home visiting is clearly indicated. Dispensary Service Nearly half of the nurses' time is spent in the dispensaries, where much of the work consists in giving treatments and doing dressings. Just how necessary it is for the nurses to spend so large a share of their time in dispf n- sary work can only be determined by further observation. A careful analysis should be made to determine whether the time could not be re- duced without detriment to the work. Individual Health Talks The dispensary work observed was too hurried to permit individual health talks to the pupils. In some of the smaller schools it is possible that more time may be given. To be effective such talks should be simple, slow, painstaking, and repeated more than once. A single, rather hasty health talk to a child needing correction is of doubtful value. Even a satisfactory talk would be far more efficacious if repeated to him at home, after talking with his mother and studying his home life. 786 Hospital and Health Survey Health Talks to Classes These talks on health habits could be very valuable if given according to a definite graded schedule and system, in a regular orderly fashion. There is a great difference in the subject matter and manner of presenting it to first grade pupils and eighth grade pupils. The present unstandardized, ungraded, and unsystematic method renders these talks of little value. They should be made a definite part of the curriculum of every grade, and should be given by the teachers whenever the nurses do not have time to give them in this way. The present staff would not have time to give such systematic instruction. Analysis of Staff and Administrative Methods Supervisor The supervision of this nursingservice is lodged in the hands of one super- visor and two field nurses. While the spirit arid intentions of the supervisor are excellent, there are certain marked shortcomings in the conduct ofjj the work. Not only are there too few supervisors for the size of the staff, but the purpose and aims of supervision are apparently misconceived. It would assist the supervisor to carry the responsibilities of her position if she were advanced in rank. She should have the title and salary of director or superintendent of nurses. Field Nurses One field nurse has eight nurses assigned to her, and in addition is respon- sible for staff nurse duties in one school and one eye clinic. She therefore gives only half her time to supervisory duties. The other field nurse has 22 nurses under her. The field nurses in their supervisory capacity are expected to visit only those staff nurses who have been newly appointed, or who are* thought to need special supervision. Last year several of the staff nurses received no supervisory visits from a field nurse. Both of these nurses spend much of their time in substituting for sick nurses and the rest in training new nurses and laboring with poor ones. The good nurses have, therefore, none of the benefits of supervision. Radical change is needed here. These nurses should have the rank, title, position, and salary of supervisors. None of them should have any staff work to do as is now the case on the West Side. As a matter of routine they should spend two half-days a month with each of their staff nurses, one half -day with her in the field, and the other half in the school. To make proper supervision possible, it will be necessary to increase the number of supervisors. There should be one supervisor for every ten nurses at most. Each supervisor should have an office in her district. She should be responsible for the management of her district, and the work of the nurses in it. She should hold definite office hours, when any of her staff can find her for consultation. The staff should be encouraged and expected to consult her frequently about case work. When the value of case work is Nursing 787 taught and practised, the staff will have many problems to consult her about. At present they have few. It is important to have monthly statistical reports made by each staff nurse, studied and corrected by each supervisor and then referred to the superintendent or director. At present daily reports are made by the nurses, and these are summarized monthly in the main office. A personal record of efficiency and personality of each of her staff should be prepared by the supervisor, after careful observation of the nurse and study of her work, and transmitted every three months to the director, for permanent record. Such records should be prepared monthly for new nurses for the first three months. In some measure the deficiencies apparent in the work are due to the fact that the number of nurses and supervisors is inadequate. But from the analysis of administration it is clear that the most serious weaknesses in the system arise from the failure to appreciate that the supervisor is to be a leader and consultant, whose duty it is to develop her staff, to help them see and meet their problems, to train their faculties and correct their mistakes, to analyze their work and its results. The absence of such supervision is evi- dent in the nurses' work, which is often routine in character, lacking in origi- nality and in grasp of opportunity. Nurses The staff nurses seem to be faithful, honest workers, performing their duties conscientiously, but it is quite obvious that they lack sufficient super- vision. They clearly show a lack of leadership and development. They have too many children (approximately 3,000 per nurse) and too many school duties to accomplish the very necessary home visiting. The staff should be increased to give a ratio of 1 nurse to every 2,000 children, if a junior health worker is provided for each nurse. Otherwise the ratio should be one nurse to every 1,500 children. There might be provided with much benefit to the service one "floating nurse" under each supervisor to fill the place of sick nurses. Junior Health Workers These workers seem to be of a unique type, originated and developed in Cleveland, on the whole with very good results, which are largely due to their being well educated. All of them are college graduates. They have relieved the nurses of much routine work in attending the doctor during examinations, have been responsible for getting dental defects corrected, and have taken many children to dispensaries. There seems to be no reason why all of this work could not be given to them. Placing one health worker with each nurse would result in freeing the nurse for more important duties. On the other hand, to allow home visits to be made by these workers, to secure information about children to whom Binet tests have been given, and those referred to dispensaries, appears to be a mistake. Such visits, especially the first named, give much opportunity for constructive health work, and require a trained discrimination in observation of health as well as social conditions. They should, therefore, be transferred to the nurses. 788 Hospital and Health Survey Conferences In order to promote the enthusiasm and inspiration which comes from the rivalry, competition and spirited discussion of new and live topics, weekly meetings of the nurses are held each Saturday morning, of the whole group or of sections of the nurses according to the size of assembly rooms available at the headquarters or elsewhere. Unless interest in these meet- ings is well maintained, perhaps in part by bringing in outside speakers as occasion offers, but chiefly by prepared discussions by members of the staff, the object of the meetings, that is, the building up of esprit de corps and unity in the staff, will be missed. From time to time these should be turned into carefully prepared case conferences, at which certain cases presenting difficulties, solved or unsolved, should be presented. Such conferences will do much to arouse in the nurse a sense of the importance of good case work and a knowledge of the way to go about it. For the same reason the nurses should be encouraged to attend the case conferences of the Associated Charities. Records At present there is little coordination in the records. The child's indi- vidual record is kept in the school room. This record is very brief and tells little of what is done for the child. The doctor's orders are on this card. The work done by the nurse is usually, though not always, entered on the correction slip in her file. Home visits are kept on still another card. An effort to check the nurse's accomplishment against the doctor's recommenda- tion is almost hopeless. The individual health record of the child is keut on the teacher's desk, supposedly to keep the teacher informed of the child's physical condition. These records follow the child from room to room together with his school record. The teachers, however, are uninterested because nothing appears on this record that would give them a clear idea of the child's physical con- dition. Therefore, it would seem much more intelligent to have this record kept in the dispensary with the other records, and have them so arranged that it would be possible to know the entire performance of health work in regard to each child, unless, as proposed on page 312 of the child health report, the records in the school room include all items of the child's health history as they should.* The method of using the correction slips for notations of home visits and corrections accomplished i& exceedingly bad. It does not make for per- manency, and there is no way of using them as a basis for statistical study. The absence of a monthly report from the nurse is also a factor in making it difficult to know what the nurse has actually accomplished. A simple, accurate, and comprehensive report should be made by the nurse every month as a part of the whole statistical report. In no other way can she keep a check on her own activities, know what she has accomplished, and measure her progress. RECOMMEND A TIONS The following recommendations are directed toward concentrating the work of the nurses on the more essential activities, which they alone can conduct. * A new cumulative record card has already been developed. Nursing 789 ACTIVITIES (a) Staff nurses should be released from assisting doctors with examination of the children, and replaced by junior health workers. (b) Room inspection should be made by nurse and teacher in cooperation. (c) In correction of defects, efforts should be concentrated on home visits, thus chang- ing the present emphasis. (d) The work done during the "dispensary hour" should be further analyzed, and the time reduced, if possible. (e) Individual health talks should be given to children at home, with explanations to the mother. (f) Class room talks, graded and standardized, should be given as a regular part of the curriculum. (g) An elementary course of instruction in the principles of teaching should be ar- ranged for the nursing staff. ADMINISTRATION (a) The present rank of supervisor should be advanced to that of superintendent or director. (b) The two field nurses should be advanced to rank, title and salary of supervisors, "and the number of supervisors increased in the ratio of 1 to every 10 staff nurses. • (c) Each supervisor should be held responsible for the management of her district and the work of her nurses. - (d) Each supervisor should have an office in her district. She should keep office hours for consultation with her staff. (e) The staff should be increased by 30 nurses. The number of schools under each nurse should be decreased. (f) The number of health workers should be increased in proportion to the increase in the nursing staff, but only in case well educated women can be obtained for these positions. (g) Weekly staff conferences should be continued. (h) The staff should attend Associated Charities' conferences frequently. (i) The record system should be reorganized to provide coordination of the individual child's records. A monthly statistical report should be made by each nurse. Every four months an efficiency record for each nurse should be made by the supervisor. The University Public Health Nursing District AS described in the report on Nurses' Education in Cleveland, a course in public health nursing is given by Western Reserve University under the School of Applied Social Science. The details of the organization, management, finances, etc., of the University District, are described in that record and need not be repeated here. The unique character and opportunity of the University District as a practice field have been commented on. It remains to describe the Uni- versity District as a community service of the first order; that is, as a demon- stration of nursing almost entirely generalized and carried out with a marked degree of success. The University District is an area set aside for the practical training of public health nurse students in which the activities elsewhere carried on by the Nursing Service of the Division of Health and the Visiting Nurse Asso- ciation, are performed by the students under the direction of an independent 790 Hospital and Health Survey teaching staff. The area coincides with Health District No. 8, estimated at 60,000 to 70,000 population. It is one of the most congested and poorest parts of the city. Analysis of Administration Staff The director of the course and of the field work is a public health nurse on the University payroll as an assistant professor. She teaches one course at the University and is in general charge of the district, teaching and super- vising the students and performing all the administrative duties. The direc- tor's duties are many and difficult, and are indeed beyond the capacity of one person. A full-time assistant director is needed to take over many routine matters, so that the head may have free time for the more important duties of her position. Assisting her are five nurse instructors, one of whom is designated assist- ant director, with limited administrative duties. Each instructor is a pub- lic health nurse in charge of a part of the district and responsible for the students assigned to her area. The district is thus divided among these five supervisors, as is also the management of the clinics held in the district. Each instructor is in addition responsible for the teaching of certain practical subjects, particularly those in which she has had special experience. There is no other permanent staff. With the exception of school nursing and out-patient maternity work, nursing in the district is done by the stu- dents of the course as a part of their training. The number of students actu- ally at work in the district at any one time varies. There are graduate students who are taking the full course, and others who are taking only the four months' practical work. There are also ten undergraduate students sent from nurses' training schools for two months' experience. The highest number in the field during the past year has been 33 and the lowest 10. There are also an office secretary, a business woman, who is responsible for many business details, and three typists. . Plan The district is divided into five sections, each in charge of an instructor. These sections are again divided into sub-sections, one for each student nurse. The number of nurses in each section ranges from two to six or seven. Each student nurse has full responsibility for her sub-section in which she carries on a generalized service, under the direction of her instructor. Analysis of Activities Visiting Nursing General visiting for free, part-pay and full-pay patients and for Metro- politan Life Insurance policy holders is carried on in this district exactly as done elsewhere by the Visiting Nurse Association, with the exception of attendance at confinements and minor operations. The student staff is also Nursing 791 entrusted with the nursing care which in other parts of the city is given by the nurses of the Division of Health. Owing to the character of the popula- tion there is little call for hourly nursing. Because of the difference in the size of their respective districts, it is diffi- cult to compare the amount of nursing done by the University District Staff with that of the Visiting Nurse Association. Apparently there is little difference either in volume or quality, except that, because of the generalized character of their nursing, the University students are able to give more attention to the family as a whole. Certainly visiting nursing has not suf- fered by being made a part of this generalized service. Owing to the higher ratio of nurses to population in this district, the at- tention given to sick babies and tuberculosis patients can be more regular and thorough than that given elsewhere by the nurses of the Division of Health. As much emphasis is put on nursing care as on any other aspect of the work, and full provision is made for it. In fact, as high a standard of care is given to these patients as to other bed patients at home. Child Hygiene This service in the University District is similar in scope to that of the Nursing Service of the Division of Health. One or two exceptions are noted; all babies whose births are reported are visited and cases under the care of a private doctor are not dismissed. In January, 1920, there were 510 well babies attending the Prophylactic Clinic, 1,885 well babies not attending the clinic, 843 sick and convalescent babies attending the Babies' Dispensary and Hospital, and 21 babies under private doctors; a total of 3,259 babies under three years of age, or about 100 babies to each student nurse. Two or three children are often in the same home. The babies attending the clinic regularly are visited two or three times every six months. Sick cases are seen daily, or as often as necessary. Well babies not attending clinic are seen when possible, sometimes two to six moiths elapsing between visits. The director and instructors think it is worth while to carry these well babies even though they are not seen fre- quently. The records show that the average is five visits a month per baby. The record also shows that a large proportion of the new babies taken on each month are discovered by the nurses themselves as they go about on other errands among their families. The best of nursing care, as has been stated above, is given to sick babies. It would be desirable to have well babies likewise visited more frequently. Tuberculosis The scope of tuberculosis work done by the University District corre- sponds with that done by the Nursing Service of the Division of Health. There is no tuberculosis clinic in this district, patients being referred to Health Center No. 2, unless able to have a private doctor. It was evident that the patients were being well cared for and kept under watchful supervision. But although the nurses are willing and able to give 79-2 Hospital axd Health Survey all the bedside care necessary, they find that little is needed. Most of their cases are ambulatory, many of them working, and very few bedridden. Advanced cases are persuaded to go to the hospital. It is believed that if there were many bedridden cases in the district not under the care of the nurses, the fact would be known. The nurses are eager to find all such pa- tients. Just as in the case of children, the nursing is far more adequate and of a higher standard throughout than that given by the nurses of the Division of Health, i The nurses believe that they are in touch with the majority of cases showing marked symptoms, but that there are probably a number of other cases missed for the following reasons: 1. Because the men are away at work all day when the nurse is about, and no one in the family thinks that they are sick enough to report to her. 2. Because early cases conceal the fact that they are losing weight or showing symptoms, and unless a nurse happms to see them she is not told of them by the patients or family. 3. Because patients, both incipient and advanced, have more money than before the war and go to private doctors who often fail either to diag- nose the case, or to report it. Patients, moreover, change doctors frequently and are often not under observation long enough to give them a chance to diagnose or report the case, or else the doctor does not tell the patient what is the matter, for fear he will go to another practitioner. Many such cases used to go to the dispensary. 4. Because the district includes many people of limited education and opportunity, the last to appreciate a subtle or hidden danger. For the same reasons the nurses believe that they are getting only fair results in their efforts to persuade positive and suspicious cases and those who have been exposed to infection to go to the tuberculosis clinic. Similarly the nurses find it difficult to persuade members of the family to be examined; they refuse to see the necessity of going to a clinic if they feel well. Patients soon grow restless in the hospitals. They complain of poor food or of being lonesome, and come home as soon as they are a little better, long before their malady is arrested. Many go back to work soon after returning home. A report of January, 1920, shows that out of 209 positive cases on the books, 159 were attending a clinic; and out of 1,060 suspicious, non-tuber- culous and exposed cases, 881 were attending a clinic. The records further show that the average number of visits per month per patient for the whole group is only .3. If the visits were restricted to the positive cases only, the average would be 1 visit per month per patient. From this it is plain that the visits should be more frequent. At present each nurse averages 30 patients, under observation. Nursing 793 Communicable Disease Control The Division of Health reports all communicable diseases, except small- pox, promptly to the University District. The nurses visit all of them, reportable and not reportable, for the following purposes: To place and remove placards. To instruct in care, isolation and prophylaxis. To issue work permits. To give nursing care. To take cultures. To maintain quarantine. The nurses find that through this work they have an excellent chance to give care, to teach, and to be helpful to the family when most needed. The nurses perhaps lose some of their popularity because of restrictions which they must place on freedom of movement, but on the whole the family does not harbor resentment against them. No great amount of nursing care is needed because both private and city doctors send most of the very sick cases to the hospital. The District serv- ice is willing and prepared to give as much nursing care as is needed. Teach- ing the family and caring for the patient are considered of as much impor- tance as maintaining quarantine, issuing permits, or taking cultures. Nurs- ing care has been given to the few cases of typhoid which have been reported. Pneumonia has not been reported to the University District by the Divi- sion of Health. It would seem well to have these cases reported also. This work occupies about one-sixth of the nurses' time. Prevention of Blindness The University District provides care for trachoma cases, but has not undertaken to be responsible for opthalmia neonatorum. Midwife Supervision This service has not been taken over for the Division of Health. Supervision of Boarding Homes for Babies There are only four of these homes in the District, and they receive the same oversight and supervision as other homes in the District in which there are babies. There is no doubt that more care and supervision should be given to this group of infants. Prenatal Nursing The nurses find most of the pregnant cases while they are out in the Dis- trict and in the homes. Doctors do not report very many, and midwives 794 Hospital and Health Survey only a few. Births reported from this district to the Division of Health in 1918 were 1,618; for 1919 the figures were not obtainable. In 1919 the Uni- versity District had 479 pregnant women attending clinic and almost as many more under supervision at home. In the opinion of the director, one in every two pregnancies in the district is carried. About one-third of the births in the district are delivered by the Out-Patient Maternity Service, one-third by midwives and one-third by private doctors. Private doctors send many of their cases 1 to hospitals. The nurses urge women who are not consulting a doctor to go to the prenatal clinic. They also send to the clinic private physicians' cases with the physicians' consent, and patients who expect to have midwives. A pre- natal clinic is conducted twice a week at Health Center No. 8. The nurses try to visit prenatal cases at least once a month, and when possible once in three weeks. The cases reported to the Maternity Hospital Out-Patient Service still attend the clinic and are cared for by the University District nurses. If they develop abnormal symptoms they are turned over to the nurses of the Out-Patient Service. There has been some duplication of work by the nurses of these two organizations. Patients are referred to private physicians for maternity care, if able to pay the fee of $50.00. If not, they are referred to one of the two Out-Patient Maternity Services. Post-natal care is given by the Out-Patient nurses. As this service is popular there is not much maternity service left for the nurse of the University District. This is a disadvantage, as the students need adequate practice in this field. On the other hand, the University District alone has as many pregnant patients under supervision as there are under prenatal care in all the other districts of the Division of Health combined. School Nursing No school nursing is done by the University District. It does not seem possible for the present staff of the University District to undertake as inten- sive work in the parochial schools as is now given in the public schools by the Board of Education. The students get their education in this branch of work under the Board of Education. It is deemed a wise decision that the University District should not undertake school nursing, unless the number of student nurses is increased. Clinics No tuberculosis clinics are held in the University District. It is hoped that it will soon be possible to hold such clinics. Prophylactic baby clinics are held three times and prenatal clinics twice a week. These clinics are con- ducted for all purposes except medical services, by the instructors of the Uni- versity District for the purpose of giving the public health nurse students experience in managing clinics and familiarity with clinical resources. This experience is indeed valuable for the students, but it puts a great deal of responsibility upon the nurses who are already carrying a heavy burden as Nursing 795 instructors and supervisors of the districts. One instructor spends on an average eight hours per week in her clinic, and another spends an average of fifteen hours, in addition to the full day given every month to balancing the milk book and compiling the milk report. These instructors must pre- pare for the clinic, do a large share of the clerical work (volunteer help has not been satisfactory and paid clerical help has been irregular), teach nurses who are on duty in the clinic and assume the entire responsibility of its man- agement and success. A physician is in attendance at each clinic session. In order not to have the burden too continuous, rotation has been arranged among the instructors, but this does not lighten the volume of work. It merely changes the personnel. If the high standard of work in the teaching district, for which the instructors are largely responsible is to be kept up they should not be required to give thL time to the dispensaries. In order to keep this service under the University District, however, a special instruc- tor for the dispensary should be appointed. This will in any case be neces- sary if a tuberculosis clinic is opened. Such an instructor would very mate- rially relieve the pressure on the other supervisors and make possible the development of newer principles and procedures in this important activity. Supervision The object of supervision in public health nursing is to detect weaknesses and develop strength in the nurses; to protect the patients; to prevent exploitation of the nurses; to coordinate and utilize to the best advantage the energies of the staff. The criticism has been brought against the University District that it employs too many instructors or supervisors. This question received earnest consideration, but evidences of over supervision though carefully sought, were not found. The director of the District, in accepting the responsibility of furnishing nursing care to everyone who needs it within this District, must first consider how, with a constantly changing staff of nurses, the standard of nursing can be kept consistently high and uniform. She must also consider how the heavy demands for nursing can best be met without exploitation of the nurses, who in this District are all to be regarded as students in training. Ample proof was given that the character of the supervision is excellent. This excellence was shown by the way in which the possibilities of nurses necessarily of different calibre were developed. Even the less well trained or those of less native ability showed in their work clear evidences of good teaching. It is probably due to the intensive work of the staff of instructors that the nursing standards of the University District have been high, that the patient's interests are most carefully guarded and that the nurses have been fully protected from too much work in the field. General Summary The character and volume of the work in the University District prove that a nursing program which is almost completely generalized except for 796 Hospital and Health Survey school nursing can be carried out with excellent results. No branch of nurs- ing undertaken has suffered from its merging into this general service. An excellent quality of service is given in all types of disease. Prenatal nursing- is more vigorously developed than in any other district. Care of tuberculous patients and sick babies is as thorough and constant as for other patients. It should, however, be said that visits for instruction and prevention should be more frequent. A larger number of students would make this possible. All communk-able diseases, except smallpox, are attended and preventive measures are emphasized. In fact, the work throughout is painstaking, conscientious, intelligent and of high quality. The University District has proved also that it is possible to care for a district satisfactorily without a permanent staff other than the instructors. It has been shown that continuity of service can be maintained through the instructors and that the students are capable of carrying responsibility for a part of a district and receiving the best training and development by so doing. The supervision, training and leadership given by the director and instructors is of the highest quality. It is evident, however, that the director and instructors in their efforts to be fair to patients and nurses alike are carrying very heavy responsi- bility. The method of remedying this has not revealed itself in so short a study, but requires careful consideration. In spite of the constant burden of work there is a cheerful devotion to duty that reflects itself in the work of the nurses in the field. An assistant director and instructor in charge of the clinics would relieve the tension appreciably. The University District has been looked upon as an independent labora- tory for experimentation in policies and methods. In so far as this adds to the teaching advantages, it is sound and advisable. Experiments which might jeopardize or injure the success of the students' experience and educa- tion should be tried elsewhere. The fact that the district is a teaching district and that the work must have educational value has always been recognized and kept clearly in mind. For this reason the responsibility for the field work has, with success, been placed directly upon the students. On the other hand, the needs and prerogatives of the patients have never been minimized or lost sight of. The educational character of the work has proved to be to the patient's benefit rather than detriment, just as it is true that medical attention in hospitals attached to medical schools is usually better than in other hospitals. The students are, in fact, receiving thorough practice in public health nursing; the patients are receiving a very excellent quality of nursing service. Close study failed to disclose any indication of the exploitation of either group. RECOMMENDA TIONS 1. That the director be provided with an assistant on full time. 2. That an additional instructor be secured to take charge of the clinics. 3. That the number of students who can be accepted be increased. Nursing 797 4. That the University District continue its prenatal nursing and undertake post- natal nursing as a part of the city-wide maternity service. 5. That instructive and preventive work among sick babies and tuberculous patients be developed more thoroughly. Prenatal and Maternity Nursing Service FROM the foregoing accounts of public health nursing in Cleveland, it is evident that one of its most important phases is the least coordinated, that is, the nursing provided for maternity care, including prenatal, partum and postpartum services. Five separate agencies are at present carrying on these services, in whole or in part in Cleveland. These are: Maternity Hospital, St. Luke's Hospital, Mt. Sinai Hospital, University District, and the Visiting Nurse Association. In addition, since 1918, the nursing division of the Division of Health has been charged with the duty of prenatal care, but, as shown in the report of that Division, little work as yet has been done along this line. In the report of the Cleveland Survey on Dispensaries and Hospitals, details of the organization and of the medical work of these agencies are given, Part X. Here we are concerned only with the character of the nurs- ing services needed and provided. As we have seen, a consistent effort has for some years, with a large measure of success, been made in Cleveland to develop the system of general ized nursing, concentrated under as few agencies as possible. It is, there- fore, high time to plan for a maternity nursing service on a city-wide plan, to consider how it may best be organized and administered. Types of Patients In any comprehensive plan, various types of patients must be provided for. Figures are available to show the total number of births registered by type of delivery, and the proportion which each type forms of the total number of births registered for the year 1919, viz: 19,123. Grouped by their arrangements for confinement, the following types of patients need nursing care : 1 . All patients who are to be confined in hospital beds ; accounting in 1919 for 4,980 registered births, or 25.5% of the total. 2. All patients who are to be confined by out-patient service; account- ing in 1919 for 1,257 registered births or 6.5% of the total. 798 Hospital and Health Survey 3. All patients who are to be confined by midwives; accounting in 1919 for 5,903 registered births, or 30.8% of the total. 4. Some patients who are to be confined by private doctors who are not giving prenatal care and consent to have the clinic extend such care. 5. Some patients to be confined by private doctors for whom consulta- tion is desired. The cases delivered by private physicians, both in institutions and in patients' homes of whom groups 4 and 5 form a large part, acccount for 13,- 196 births registered, or 69 per cent of the total registered births for the year 1919. Types of Nursing Care Needed For the first group, to be confined in the hospital, prenatal care in the home is needed. . ■ For the second group, who avail themselves of out-patient departments, nursing care is necessary in addition, during the confinement and post- partum period. For the third group, who are delivered by midwives, prenatal care is needed. For the fourth and fifth groups, comprising patients of private doctors, the three types of care are needed. Moreover, experience proves that besides adequate . clinical equipment, vigorous continuous propaganda work in the home is needed. Without it, few take advantage of the clinic, unless in need of free services, or until late in pregnancy; many improvident women, relying on hospital care at the last moment, never go to the clinic or have any prenatal care; midwife cases, which comprise a third of the total registered births in Cleveland in 1919, have no prenatal care at all; many patients engaging a private doctor during the last month or two have no prenatal care or medical supervision. A study of about one thousand records from the three main agencies giving prenatal care and with available statistics (Western Reserve Univer- sity District and St. Luke's) showed that only about 12 per cent of all these cases had prenatal care before the fifth month, while 62 per cent of the cases had prenatal care during the last three months of pregnancy. Appropriate Agencies for a City Service In proposing a city-wide plan for a complete prenatal maternity service, the question at once arises, to what agent or agencies it should be entrusted. Obviously, no one of the five agencies now in the field could, with its present equipment, take over so large an added responsibility. Is it, then, de- sirable to create a new agency for the purpose, or to propose the expansion of one of those already taking part in this work? And if so, which of the present agencies is best fitted for such an expansion on the basis of its present methods and equipment? Nursing 799 The municipal nursing staff, is, as we have seen, greatly overburdened, and in need of reorganization in the assignment of work and supervision. The Division of Nursing is at present grappling with the problem of absorb- ing the duties with which it has been newly charged each year. It would, therefore, be inadvisable at this time to propose to add to it another and still larger undertaking. The city has neither funds nor facilities at this time to undertake responsibility for obstetrical and postpartum nursing care. More- over, the city might not succeed in reaching patients under the care of pri- vate doctors, large numbers of whom have only moderate incomes, so that they cannot afford private nurses and must depend upon visiting nursing care. In 1919, as we have seen, the total number of births delivered by private doctors numbered 69 per cent of all births registered. Only two other agencies have been seriously considered for city-wide maternity nursing service. These two are the Maternity Hospital and the Visiting Nurse Association. Maternity Hospital The proposal to extend the nursing service of Maternity Hospital so as to offer a general prenatal and maternity service, does not commend itself for various strong reasons. It would indeed appear to be a fundamental mis- take. The Maternity Hospital has in the past performed a valuable service, such as is the function of a University hospital, in teaching the possibilities in this field and demonstrating the actual saving of life which goes with a prenatal, partum and post-partum service. This hospital should continue to be, fundamentally and increasingly, a training field for nurses as well as for medical students, i n the obstetrical • field. To attempt to extend its community work and to establish a city service, instead of developing and extending its valuable function of train- ing, would be to miss its proper office. Moreover, the nursing service of a hospital by its nature does not cover the great majority of registered births, that is, those occurring neither in the wards nor under the out-patient department, but attended in their homes by private physicians or midwives. In 1919, of the total confinement cases reported in Cleveland, 37.2 per cent were delivered by physicians in the homes of private patients, and 30.8 per cent by midwives in the patients' homes, or an estimated total of babies delivered by these two groups, of 13,000 or 68 per cent. But even if these points were not conclusive, certain weaknesses in the methods of work as at present carried on, would in a larger area be a serious drawback to good service. The nursing care of this hospital is character- ized by a lack of continuity in the nursing personnel and by a lack of the best conceived type of supervision as described in other sections of this report. Lack of Continuity The lack of continuity is shown by the division of the work. Details of the organization of the Maternity Hospital clinics are given in the Dis- 800 Hospital and Health Survey pensary Report, Part X. Here the chief points of the nursing service are described. The prenatal nurse, with headquarters in her prenatal station calls on the patient and makes observations until the time of delivery. The patient is then turned over to the delivery nurse of the hospital, who is taking a special course in obstetrics. She may be a pupil nurse, or she may be a graduate. She accompanies the medical student for delivery in the case of each primipara, in all other cases the delivery nurse goes, if any one of them is available. Thus all the advantages gained by the prenatal nurse from knowing the patient and having won her confidence are lost. The post-partum nurse must begin the acquaintance over again. The record system is not such as to give the help which might be given in keeping up the connection. The prenatal records appear to be inadequate in scope and poorly kept. Lack of Supervision Prenatal Care: For prenatal care, four full-time graduate nurses are employed. They give service at the six prenatal clinics now operated, and spend the rest of the time on home visits. They average about ten calls daily, rising in some cases to fifteen calls. Where districts are densely settled and the cases happen to be so grouped that transportation does not require much waste of time, fifteen instructive visits may not prove to be impracticable, but in general more than ten prenatal visits a day will be found to result in sacri- fice of thoroughness. Moreover, though all patients are supposed to be visited every two weeks, and acute cases daily, it was stated in the course of the investigation that these visits are not regular. A normal case, attending the clinic regu- larly, may be seen at home only two or three times during pregnancy. The nurses carry in their bags blood pressure apparatus and equipment to make urinalysis. But these are not used for every patient visited, as the best practice requires. Abnormal cases are seen daily or every other day as indi- cated. The Director of Nurses makes an effort to see every case which is re- ported to the clinic, but not necessarily with the nurses. Of supervision in the field, as developed for graduate nurse staffs in the best public health work, and essential as a stimulus as well as a guide, there is here none. Any abnormal cases are discussed with the Director of Nurses. Abnormalities found in home visits are reported verbally to the Director, who enters this information on the prenatal index card, made out when each new case is admitted; but there is no detailed weekly or monthly report kept by the nurse as a record of her own performance. There is no system by by which the frequency of the patient's visit to the dispensary or the nurse's visit to the home is automatically checked up. Delivery and Post-Partum Care: This care is given by the student nurses under supervision of the assist- ant director. Each new nurse is taken into her district by the assistant Nursing 801 director, but for only half a day. Thereafter, the assistant director drops in on her daily during a period of about a week. There are four nurses doing post-partum work, each averaging about eight cases daily. This number is, again, too large for adequate care and instruction in the home. If labor occurs during the day, either the director or the assistant director makes an effort to get into the home before the baby is delivered. Each newly delivered case is seen by the assistant di- rector the day after the confinement. Oversight of the patient's condition is thus assured; but regular supervision of the nurses who, it must be remem- bered, are here students-in-training, is not accomplished. From observation of five post-partum~ cases, it was evident that while the essentials, such as care of the breasts, external irrigation,' care of the baby, etc., received careful attention, the work was not up to the nursing standards observed by the Visiting Nurse Association or in the University District. Doubtless the unusually large number of cases carried by the Western Reserve students accounted for this fact. The rooms were not left in as good order as desirable, no uniform is required, one nurse being observed at work in a chiffon waist. Prenatal and Postnatal Work in a Generalized Service In contrast to the specialized work of the Maternity Hospital, there is available in Cleveland the example of an agency which includes prenatal work in a generalized nursing service. This is the University District, which in 1919 had 442 dispensary cases, which may be compared with 485 dispensary records studied at the Maternity out-patient department. The home visits of the University District nurses upon 442 dispensary cases numbered 1 391 or 3.1 per cent per patient as against 271 visits upon 483 dispensary cases or .6 per cent per patient by the Maternity nurses. In the generalized service, therefore, the home visits recorded were 5 times greater in number than in the specialized service. The average number of dispen- sary visits per patient recorded in the generalized service were much more numerous than in the specialized (2.4 in the University District as against 1.5 at Maternity). In comparing the percentage of cases reached early in pregnancy, the University District is again far in advance according to the records studied, having brought almost half (46%) of its total cases under care by the sixth month, while Maternity had only 19.2 per cent under care at that period of pregnancy. It seems apparent that the Maternity hospital records studied do not truly represent the quality of the service rendered by this institution, but as the permanent records of any service should be available as a basis for evalu- ation of that service, the results of this study of records are given. 802 Hospital and Health Survey Records of No. Dis- Dispensary pensary Aver- No. Home Aver- . Cases Studied Visits age Visits age Maternity _ 483 708 1.5 271 .6 University District 442 1084 2.4 1391 3.1 St. Luke's _ 141 No record of home or dispensary visits. Mt. Sinai _ No record of home or dispensary visits. The University District thus in a small district and with a high ratio of nurses to population illustrates the possibility of including prenatal and postnatal care in a general nursing service for the sick which gives family care and instruction. While it is true that fruitful demonstrations of special maternity services have been made in other cities, nevertheless an extension of the generalized nursing service for the sick is especially appropriate, since Cleveland has proved its ability to conduct generalized public health nursing with a con- siderable measure of success, as well as a true generalized nursing service in the fields of sick nursing and public health nursing in the University Dis- trict. The Visiting Nurse Association In the Visiting Xurse Association there is available an agency, doing generalized sick nursing in homes on a city-wide plan, with adequate and skilled supervision, which already makes a specialty of medical, surgical and maternity nursing,— excellently done and capable of further expansion. This Association now serves all groups of patients, the poor and those of moderate income, midwife and private doctor's patients, as well as those intending to have hospital care. For an extended program to provide general maternity care, this Asso- ciation could provide service by a graduate nurse trained in visiting nursing, and could also provide supervision for student nurses if necessary. It would afford uniformity and continuity of service, the same nurses being available for all three types of care. Because of its large staff, small districts, and other nursing contacts, it could greatly increase the usefulness and adequacy of the clinics through the early discovery of pregnant patients, who would be urged to seek medical oversight at once, at the clinics. Such patients would also receive careful prenatal nursing at home if they could not be persuaded at once to attend a clinic. For these reasons, the Visiting Xurse Association appears to be the logical agency in Cleveland to which the extended prenatal and maternity services for the city should be entrusted. It would mean a large expansion for this Association entailing large expenditures, and responsibilities with which the Association is well fitted to cope. Xo greater opportunity to serve the community, and indeed to demonstrate such a service to the whole country, could be offered. After the demonstration had been made, it would be desirable and in line with past policy in Cleveland gradually to turn over this service to the Nursing 803 municipal staff. If the proposed Extension District of the Division of Health is established as is suggested elsewhere (page 769) for the extension of the municipal nursing work, it would be desirable to substitute for the Visiting Nurse Association the municipal nurses in that district, except for attend- ance at delivery. As the assumption of this service in the Extension District of^the Di- vision of Health proves practical and successful, and as the whole nursing service of the Division of Health is built up to meet its present activities, and becomes able to assume new functions, the service might be turned over district by district to the Division of Health, or the prenatal service might first be turned over, the transfer of care during confinement and post- partum care being postponed. RECOMMENDA TIONS It is therefore recommended: 1. That the Visiting Nurse Association give prenatal instruction and nursing care in the homes, reporting findings to and receiving instruction from the clinics daily. This service could be provided by the Visiting Nurse Association as a uniform service to all clinics. 2. That clinics be maintained under the proposed Obstetrical Council to serve the entire city by zones or districts according to agreement among the various hospitals, nurses for service within the clinics to be provided by the hospital wherever possible, by the Visiting Nurse Association where impossible. 3. That nursing care during confinement be provided by the Visiting Nurse Associa- tion (a continuous graduate staff for deliveries to be provided by the Visiting Nurse Asso- ciation for this purpose), or by students of the hospitals under the supervision of the Visiting Nurse Association. 4. That post-partum nursing be provided by the Visiting Nurse Association for all clinics, or by student nurses under the Visiting Nurse Association. 5. That in the University District, for the Visiting Nurse Association, the university staff be substituted, except for attendance at delivery. That in the proposed Exten- sion District of the Division of Health the Visiting Nurse Association be replaced by the municipal nurses, except for attendance at delivery. 6. That a uniform procedure be established for all districts and observed by all staffs. 7. That if the proposed Obstetrical Council is formed, a sub-committee on prenatal and maternity nursing from the Central Committee act as the sub-committee on nursing of the Obstetrical Council, and that the Central Committee be represented on the Ob- stetrical Council and vice versa. Industrial Nursing THE Survey of Industrial Hygiene in Cleveland has shown that there were, at the time of the investigation, seven full-time industrial phy- sicians and 104 industrial and mercantile nurses. In 36 plants, 66 nurses were working with part-time physicians. These figures indicate clearly enough the responsibilities of the nurse in industry, and the possibilities which lie before her in her contact with the 804 Hospital and Health Survey large bodies of men and women who are congregated in industrial establish- ments. Obviously, no hard and fast rules can apply to all types of industrial nursing; it must vary with conditions, with the size of plants, the type of management and of employe, etc. But under all these differences and with all the varied duties which the industrial nurse may legitimately perform, there should be one essential aim, common to all good public health nursing, that is, the maintenance of health and the teaching of hygienic habits. With so wide a field before her and in a branch of public health work so new and unstandardized, it is not surprising that the industrial nurse has as yet, broadly speaking, scarcely found herself. She stands too often between the industrial physician, who for the most part regards her as a mere adjunct to the surgical dispensary, and the employer or his representative, in whose mind she is vaguely to function in creating better industrial relations in his plant. The danger, therefore, is that industrial nursing will be diverted on the one hand into pure dispensary assistance, or on the other, into pure welfare work. In neither of these, though both may be part of her duties, lies the sole function of the industrial nurse. On her training and personality it will in many instances depend whether she develops a constructive type of work, enlisting the management's and workers' cooperation, or is submerged in the routine of first aid or of factory housekeeping or recreational activities. The Nursing Survey made a detailed study of twelve representative in- dustrial nurses in Cleveland to observe their work, the types of duties per- formed by them and the emphasis on prevention of illness and of accidents as well as on treatment. The establishments visited included metal working plants, food and clothing factories, public utilities, and department stores. Three of these plants had full-time physicians, the others had either a part- time or no physician. Work Confined to First Aid Several of the nurses observed were confined in their activities wholly to the first aid room; they were strictly dispensary nurses with no thought of responsibility beyond dressing injuries and no encouragement on the part of the management to expand their interests. The limitations of this type of work were well illustrated by one of these nurses whose business-like dis- patch enabled her to handle quickly and efficiently the large number of cases passing through the dispensary, but whose lack of interest and coldness re- pelled any further advances on the part of the girl employes in illness or trouble. In contrast to this nurse was an older woman, also of the dispensary type and less well equipped technically, but of warm human sympathies who had gained the confidence of a large body of workmen in another plant through the contacts made in the first aid room. An extreme instance of failure to connect first aid work with prevention of injuries was observed in another plant where a man was treated three times in one day by a nurse for cutting his hand at the same machine. Here Nursing 805 the nurse was not allowed to leave the dispensary. She was regarded by the management, and had learned to regard herself, as a permanent fixture of the first aid room, a mere mechanical agent for binding up cuts or wounds. Work Outside the Dispensary Ranging upward from this most limited performance, there were ob- served in Ceveland many varieties of work and of responsibility carried by the industrial nurse. In some plants the nurse had in charge, under the standing orders of the attending doctor, the entire first aid and emergency treatment, and was responsible for all records, follow-up, re-dressings, etc. In one such establishment the nurse made a rule of having the doctor, in his daily visit, see all new cases and all infections. Procedures naturally differ as to the nurse's responsibility for such mat- ters as plant sanitation and the safety of employes. While supervision of these matters is, in large plants, in the hands of specialists, in smaller fac- tories such supervision was found to be a valuable part of the nurse's work, especially when combined with instruction of the employes in matters of sanitary equipment and safety. Sharing in Prevention of Accidents In contrast to the dispensary nurse and the repetition of cuts cited above, other nurses in Cleveland were taking part in the prevention as well as cure of accidents. One nurse regularly inspected the scene of accidents. While this might lead her beyond her field, when technical knowledge of machinery was needed, yet she had been able to point out obvious, overlooked causes of accidents such as bad lighting or the presence of an obstruction in the way of the employes. The industrial nurse should have sufficient knowledge of the technical processes used in her plant to know and advise on the safeguards provided. Yet she is often totally uninstructed in such matters. On one occasion in Cleveland the nurse was found wholly ignorant of certain types of respirators provided for a certain process and hence incapable of advising the workers with regard to using them. Sharing in Prevention of Disease Constructive health work and ability to gain the workers' confidence so that they will consult her in matters of ill-health, incipient as well as acute, should clearly be the center of the industrial nurse's business. The other aspects of her work-first aid, safety, sanitation and welfare work — should all be directed to this general end. The aim of maintaining health and educating the workers — men and women alike — in matters of health should, indeed, distinguish the industrial nurse from other types of welfare workers. Individual instances of good work along these lines were observed in Cleve- land, but as elsewhere, it was on the whole slighted and too often ignored in the multiplicity of other duties. In many plants the nurse spends far too much time on recreational and welfare activities. Absorption in these is as alien to constructive health 806 Hospital, and Health Survey work as absorption in surgical routine. In one establishment the nurse devoted two evenings a week to social meetings, while failing to note obvious health hazards in certain rooms and making no effort to educate the girls by talks on health either individually or in groups. The transfer of workers from jobs for which they are physically unfit to other positions better suited to their physiques is a genuine health measure which nurses may well recommend to the management. Such transfers had been successfully recommended by nurses in Cleveland for various cases of flat-foot and varicose veins. Some girls affected by a necessarily cold work- room and others who were suffering from dermatitis had been benefited by a change. These isolated examples show how great an influence the nurse may have in prevention of the illness before it becomes acute, if she is per- sonally familiar with the workers and on terms of confidence with them. Education in hygienic habits is also clearly one of the nurse's first duties, as yet little developed. One nurse had recently regained a valuable girl worker and had lessened her susceptibility to constant colds, by persuading her to give up chiffon waists in winter-time and to dress more warmly. Another nurse encouraged hygienic habits in a good factory by making daily inspections, providing clean caps and aprons and urging personal cleanliness. In one room unaffected by the artificial ventilation, she had arranged to have the windows opened ten minutes, morning and afternoon. Another example of good preventive work, along a somewhat different line, was the nurse's successful insistence upon installation of a sterilizer in the lunch-room of a plant in which employes known to be suffering from tuberculosis and venereal disease were in contact with the other workers. Some Causes of Failure Too often, however, instead of trying to teach hygienic habits the nurse relies merely upon giving drugs. Contrary to all good medical and nursing practice, nurses were found habitually giving sedatives and medication for many minor ailments. This widespread practice should be abandoned at once. Another serious fault in industrial nursing in Cleveland, which it shares with industrial medical practice, is the lack of records and statistics. In many cases neither the management nor the industrial physician encourages or indeed takes any interest in the nurse's reports. Yet without reports and records, the nurse cannot gauge her own progress or be in a position to prove her points to her superiors. A simple and effective system of records, adapted as necessary to the conditions of individual plants, and showing so far as possible the relation of nursing care to such matters as compensation claims, statistics of accidents, illness and absence of employes, is one of the most urgent needs of industrial nursing in Cleveland. Provision of lay assistants in record keeping as well as in the dispensary is greatly needed and would release the nurse for her more important duties. Lay assistants are desirable also for all routine following up of absentees. In all cases of illness, too little emphasis' on home visiting was found in Cleve- land. This lack is unfortunate since a knowledge of home conditions and Nursing 807 good contacts in the home are of first importance in obtaining the genuine confidence of the workers. The services of the Visiting Nurse Association of Cleveland should be called on for bedside care if necessary, after perhaps one or two visits by the industrial nurse. The isolation of the industrial nurse keeps her from contact with the rapid developments of public health nursing and of industrial hygiene, with which she should be acquainted and in which she should share. Few indus- trial nurses have had adequate training for their special field, most have at best learned through their own experiences and their native abilities. In cities in which industrial nurses are a part of some agency, such as the Visiting Nurse Association, they, like the rest of the staff, benefit from belonging to such an organization and sharing its general standards and practices. The Nursing Survey has recommended the inclusion on the Central Nursing Committee of a representative of industrial nursing. The Industrial Nurses' Club might be of much more technical professional value to nurses than it has been in the past, and either it, or some similar organization, should be actively organized. It should be a real center for developing this most recent, and one of the most important, branches of public health nurs- ing as it is capable of being developed in industry. A discussion of Industrial Nursing also appears in the chapter on Indus- trial Medical Service, Part VII. 808 Hospital and Health Survey Some Notes on Private Duty Nursing Unnecessary Employment of Full-Time Graduate Nurses IT is often asserted both by physicians and by trained nurses that in many cases of minor illness or of convalescence, the services of a graduate nurse are unnecessary and that such cases can be adequately cared for by less highly trained persons, or indeed by members of the family. With the object of obtaining some more concrete information as to such possible substitution, a brief inquiry was addressed to a small group of private duty nurses in Cleveland. The number of cases reported on is too small to be at all conclusive, but the replies received are suggestive and in- dicate that a wider investigation might yield valuable conclusions. Inquiries were addressed to 25 nurses. They were asked whether, dur- ing the past year, any of their patients could have dispensed with the care of a full-time graduate nurse, either altogether or for part of the time. Replies were received from 15 nurses. They were also asked which if any of the fol- lowing substitutes could have replaced the graduate nurses, viz: a so-called "practical" nurse, members of the patient's family or an "hourly" nurse, that is, a graduate nurse engaged for an hour or two per day. Use of Hourly Nurse Recommended Of 275 cases nursed during the period reported on, 68 or a quarter (24.7%) might, in the opinion of the nurses, have done without their services for all or part of the illness. The outstanding fact which emerges from this brief inquiry is the agree- ment among the nurses that of the 46 patients who could have dispensed with their services for part of the time, 34 or almost three-quarters (73.9%) could have been cared for by hourly nurses. This estimate is no doubt in part due to the large number of acute surgical cases represented in the total group. For in such cases expert continuous nursing may obviously be needed for only a short time, after which an hour or two per day might readily suffice for the necessary daily nursing care. Nature of Cases Of the total number of cases reported, about three out of five were hos- pital cases, and of these almost all were surgical. The remaining two- fifths, mainly medical cases, were nursed at their homes. Only about one in nine of the home patients was surgical. Acute cases reported upon far outnumbered chronic cases, both at home and at the hospitals. The proportion of acute to chronic cases at home was 95 to 9, and in hospitals it was 159 to 12. Two of the nurses stated that they did not take any except acute cases. The inclusion of the reports of these nurses makes the proportion of cases which could have been cared for without graduate nursing care less than it would ordinarily be. Number of Nurses Reporting Unnecessary Employment Thirteen out of the fifteen nurses reported that they had been unneces- sarily employed at some time during the period reported on. (For various Nursing 809 personal reasons the period reported on varied from four to seventeen months, the average being somewhat over ten) . The two nurses not having had such cases were among the four reporting on a very short period, viz : from four to six months only. Amount of Unnecessary Employment As has been stated, in 68 of the 275 cases reported on, the graduate full- time nurse might have been otherwise replaced. Omitting one nurse whose service consisted of an exceptionally rapid succession of acute cases, the total number of cases of unnecessary employment amounted to 67 out of 226, or 29.6%, which is more nearly representative of the group. In individual reports the percentage of cases of unnecessary employment varies greatly, ranging from 72.7% of all cases cared for by a nurse in the period in ques- tion, down to 2% of all cases, the median being 44.4%. In other words, one nurse had 11 such cases out of 20 cases in all; another had 8 out of 11; the lowest proportion being 1 out of 49. Similarly, the length of time spent in unnecessary employment by the 15 nurses varied greatly. No definite statement can be made on this point, as information was sometimes lacking and sometimes uncertain. One nurse reported as much as three months' unnecessary nursing in a year's experience, or 25% of her total time; another 4 months out of 11M> months or 34.8%. The average length of time so spent for 10 nurses who were able to give an estimate, amounted to something over Vy^ months per nurse per annum. Possible Substitutes for Full-Time Graduate Nurse Of the sixty-eight cases on which these graduate nurses reported un- necessary employment, about one-third could have been cared for by some other arrangement during their entire illness. In fourteen of these cases a practical nurse, in seven cases a member of the family, and in one case an hourly nurse, would have sufficed. The remaining two-thirds (46) could have dispensed with the full-time graduate nurse's services during a part of their illness only. As has already been stated, in thirty-four cases, she could have been replaced by hourly nursing. In seven, it is believed that a practical nurse would have sufficed, and a member of the family in the remaining five cases. Thus, in the opinion of the 15 nurses consulted, the cases cared for dur- ing the given period were divided as follows: (a) A large proportion of cases in which hourly nurses could have relieved the full- time nurses after the most serious stage was passed, and one case which could have been entirely cared for in this way. (b) A considerable proportion of cases which could have used a practical nurse dur- ing the entire sickness, and a few in which such nursing could have been utilized for part of the duration of the case only. (c) A few patients who could have been nursed during their entire illness and a few during part of their illness by members of their own families. EMPLOYMENT OF TRAINED ATTENDANTS In Cleveland as elsewhere the employment of trained attendants has been a subject of controversy. On the one hand there is undoubted need 810 Hospital and Health Survey of persons capable of rendering personal service and some small degree of nursing care to those who are ill but who do not need the services of a grad- uate nurse. The present shortage of nurses for bedside care emphasizes the desirability of making available the services of such a class of workers, in order to release the graduate nurses for duties which they alone can compass. Our brief inquiry into possible substitutes for the full-time graduate nurse shows jthat in the opinion of these private duty nurses themselves, a part of their cases might have been carried by attendants or "practical" nurses as well as by "hourly" nurses. The Nursing Survey recognizes the value and need of the trained at- tendant. It has been urged to formulate an educational plan and short courses for the training of such workers. But to this plan there appear to be at present several valid objections. For it must be recognized that the employment of the trained attendant brings with it unmistakable dangers, especially when, unequipped, she assumes the part of the fully trained nurse. Against this danger the patient must in some way be protected. The experience of the Visiting Nurse Association of Cleveland, in dis- continuing its attendant service after almost three years' trial, appears so far as it went, to have been conclusive. The failure was due to causes oper- ative elsewhere as well as in Cleveland, that, is to the difficulties of retaining control of the work and the charges of the attendants, while responsible for their employment. That the pay of trained attendants can be very much lower than that of the graduate nurses, it is probably unreasonable to expect, since their cost of living is not materially less than that of the graduate nurses. That there is a genuine demand for the trained attendant in her own sphere, the experi- ence of the Visiting Nurse Association has amply demonstrated anew. The question at once arises whether safeguards cannot be devised to re- tain the benefits and minimize the dangers of such a service. From experi- ence in other lines of work it would appear that no better safeguard has been devised than through legislation defining the status of, and licensing, both graduate nurses and those trained to give services of a different but no less necessary order. A precedent for such legislation already exists in many states but not yet in Ohio, in the laws licensing the practice of dental hygienists (Connecti- cut, New York; Massachusetts) that is, of persons authorized to practise dental cleansing without use of instruments and only under the supervision of a licensed dentist. Here there has been established successfully the licensing of two different grades of workers, for different grades of service in the same profession. Penalties for fraud, or for practising under any but the appropriate name, should obviously be provided for in such legislation. At the present time, and until the necessary regulation by city or state ordinance, has been enacted, it does not appear desirable to recommend the establishment of courses for further training of attendants in Cleveland. The framing and enactment of suitable legislation should take first place, in plans for action in this matter. THE CLEVELAND HOSPITAL AND HEALTHgSURVEY REPORT List of Parts and Titles I. Introduction. General Environment. Sanitation. II. Public Health Services. Private Health Agencies. III. A Program for Child Health. TV. Tuberculosis. V. Venereal Disease. VI. Mental Diseases and Mental Deficiency. VII. Industrial Medical Service. Women and Industry. Children and Industry. VIII. Education and Practice in Medicine, Dentistry, Pharmacy. IX. Nursing X. Hospitals and Dispensaries. XL Method of Survey. Bibliography of Surveys. Index. The complete set may be obtained at a cost of $5.50 plus the postage and single parts at 50 cents each plus the postage, from THE CLEVELAND HOSPITAL COUNCIL, 308 Anisfield Building, Cleveland, Ohio Printed by The Premier Press Cleveland, O. Hospitals and Dispensaries Part Ten Cleveland Hospital and Health Survey Copyright, 1920 by The Cleveland Hospital Council Cleveland, Ohio Published by The Cleveland Hospital Council 308 Anis field Bldg. Cleveland • Ohio Preface The Hospital and Health Survey of Cleveland was made at the request of the Cleveland Hospital Council. The Survey Committee appointed to be directly responsible for the work and through whose hands this report has been received for publica- tion consisted of the following: Malcolm L. McBride, Chairman; Mrs. Alfred A. Brewster, Thomas Coughlin, Richard F. Grant, Samuel H. Halle, Otto Miller, Dr. H. L. Rockwood, Howell Wright, Secretary The staff responsible for the work were: Haven Emerson, M. D., Director, and the following collaborators : Gertrude E. Sturges, M. D., Assistant Director; Michael M. Davis, Jr., Ph. D., Director of the Hospital and Dispensary Survey; Josephine Goldmark, B. A., Director of the Nursing Survey; Wade Wright, M. D., Director of the Industrial Hygiene Survey; Donald B. Armstrong, M. D., Director of Tuberculosis Survey; S. Josephine Baker, M. D., D. P. H., Director of the Infant and Maternity Survey; T. W. Salmon, M. D., Director of the Mental Hygiene Survey; W. F. Snow, M. D., Director of the Venereal Disease Survey; Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey. The expenses of the Survey and of the publication of the report have been met by appropriations received from the Community Chest, through the Welfare Federation, of which the Hospital Council is a member. The report as a whole, or by sections, can be obtained from the Cleveland Hospital Council. A list of the parts will be found in the back of this volume, together with prices. - - :■ vi ■ - '• . /-'■■ TABLE OF CONTENTS I. The Care of the Sick — p aQe Resources for Care gjg Some Definitions §22 II. Hospitals — Hospital Provisions and Community Needs 828 Organization for Service 838 The Human Problem of the Hospital Patient 849 The Medical Profession and the Hospitals 858 Finances and Administration 868 Some Practical Matters of Administration 877 III. Dispensaries — Dispensaries in Cleveland 890 The Public Health Dispensaries 901 Policies and Needs g^2 The Down-town Dispensary , 922 IV. Special Problems — The Convalescent and the Hospital 926 Community Program for Convalescent Care._ 938 Chronic Illness and Its Care 944 Social Service in Hospitals and Dispensaries 952 The Ambulance Service of Cleveland 961 V. Hospital and Dispensary Planning — Community Planning qqq Individual Hospital Planning 973 Organization to Carry Out Plans 979 Appendix — Tables... 984 Hospitals and Dispensaries By Michael M. Davis, Jr., Ph. D. I. Tne Care 01 the Sick RESOURCES FOR CARE NO thorough understanding of the work and problems of the hospitals and dispensaries of Cleveland can be had without seeing these institu- tions in a broad perspective. The primary purpose which leads to the establishment of hospitals and dispensaries is to provide care in illness. We need to understand not only what hospitals and dispensaries do for their patients, but also their relations to the community, and the part which they should play in the life of the average family. ■ The volumes of the Cleveland Hospital and Health Survey which precede this, in the Survey's series of publications, have been devoted to general com- munity problems and to public health programs. As Dr. Haven Emerson, Director of the Survey, says: "First comes the description of the environ- ment of the community; then its efforts at self -protection against disease. Then we must logically put education before practice; and, as the climax of the whole, the most elaborate, the most intricate, the most difficult of all medical social undertakings, the Hospital and the Dispensary, to show how a community does or can take care of those whom it has failed to protect." The great emergencies which strike the life of the average family are sick- ness, accident, and unemployment. Sickness and accident both affect the physical welfare of the body, varying from the most trivial illness to the gravest emergency. The resources for dealing with sickness and accident vary accordingly, from the application of the simplest home remedies to the tense dramas of the operating table. Studies of sickness made by the Metropolitan Life Insurance Company among its industrial policy holders, and by other agencies, indicate that from two to three per cent, of the population of a city like Cleveland are usually sick at any one time. This excludes minor illness and diseases not causing incapacity. In greater Cleveland this means that 20,000 to 30,000 persons are usually to be found ill on any given day, the number of course showing a wide variation according to season and to other conditions like the wide- spread presence of epidemic disease. We know that the hospital popula- tion of Cleveland ranges from 2,000 to 3,000, being generally near 2,500. Thus about ten per cent, of the sickness in Cleveland, excluding "minor" ailments, is generally cared for in hospitals. These figures should help to put the hospital problem in its due perspective. * The section of this report entitled "Some Practical Matters of Administration," is by Warren L. Babcock, M. D., Consultant in Hospital Administration for the Survey. Other contributions by Dr. Babcock are indicated in their places, and his helpful cooperation throughout is gratefully acknowledged. Mrs. Mary Strong Burns, R. N., is the author of the section on "The Convalescent and the Hospital," and Frederic Brush, M. £>., of an important part of "Community Program for Convalescent Care." For the collection of much information utilized in the report the author is indebted to many of his col- leagues in other branches of the Survey. Especial acknowledgment should be made of the studies con- tributed by Anna M. Richardson, M. D., and by Miss Harriet L. Leete, R. N.; and of the devoted, pains- taking work of Miss Josephine Colegrove in the collation of data and the preparation of the manuscript for the printer. 82t) Hospital and Health Survey We need to approach the study of the hospitals and dispensaries of a great city from the standpoint of the community rather than of the institu- tion; to see them as the average citizen and the average family sees them, rather than as the physician or the specialist in hospital administration. Laying aside for the moment the demands which the average family may make on hospitals and dispensaries for the promotion of health, a real though slowly growing part of their function, the primary reason for the utilization of hospitals a*nd dispensaries is the occurrence of sickness or accident. When- ever illness or accident comes, the individual or the family must reach a decision as to what is to be done. Choice must be made among possible resources. It is well to list these resources so that all of the elements of the picture shall be in mind. A list of ten resources for the care of illness might be included: 1. The home remedy, 2. The advice of friend, grandmother, or neighbor of reputed wisdom, 3. The private physician, 4. The drug store, 5. The physician of an organization of which the patient or family is a member (for instance, lodge doctor, industrial physician, city physician), 6. The quack doctor or medical institute, . . 7. The midwife (for obstetrical care), 8. The nurse, 9. The hospital, 10. The dispensary. The attitude of a community towards its hospitals and dispensaries is made up of the points of view of its individual citizens. These points of view are practically expressed in determining what choice is made among the resources for the care of sickness. Such choice or decisions are influenced by considerations of finances, but also by custom, personal connections, prejudices and information or misinformation regarding the availability, powers and prestige of the various resources for the care of a given case of illness or accident. It is obvious that the ten resources for the care of illness vary in their grade of efficiency. It is obvious that the various elements in the popula- tion select resources differently. Thus the use of the midwife is largely con- fined to foreigners; the quack reaps his richest harvest from among the less educated; the service of the dispensary at the present time is chiefly for those of limited means. One man with a pain in his back goes to a dispen- sary. Another equally unblessed with this world's goods hies himself to a drug store and purchases and applies a widely advertised "Rheumatic's Ready Relief." One woman goes to a hospital for an operation; her neigh- bor two blocks away refuses to go to an institution even on the advice of .her.. Hospitals and Dispensaries 821 family physician, because she is "afraid of hospitals." A member of a lodge utilizes the services of the official doctor of the organization during a minor illness, but when he thinks something serious is the matter with him, he calls' a "real doctor," meaning one whom he pays. Quacks' offices are thronged with thousands of credulous victims, and the mails are filled with money directed toward the coffers of patent medicine vendors. Choices among the resources available for the care of sickness are as varied as the circumstances surrounding each case, and as manifold as human nature itself. A health survey of Cleveland might theoretically arrange the ten resources for the care of illness in the order of their relative efficiency, and then study, for different sections of the population, their usual order of utilization for different kinds of sickness or accident. Such a study cannot practically be made, but supposing for the sake of argument that it could be made, let us ask this question: would the order of utilization by the people' of the ten resources for the care of illness correspond to their order of relative efficiency? In so far as it does not, the well-being of the community suffers. Reputable physicians and the hospitals and dispensaries in which these physicians ren- der service, obviously constitute the primary and fundamental medical re- sources for the care of illness and the promotion of health.. Are they used' with the degree of fullness and of discrimination with which they should be? If not, why not? The answer would not be the same for all groups of the population. A study of the hospitals and dispensaries of Cleveland cannot rightly be limited to the amount and the nature of the work done, the internal adminis- tration, and other technical problems, important as these are. It needs also to include a study of the attitude of different sections of the people' — the medical profession, the well-to-do, the poor, the foreign-born, etc., toward these institutions. It is on the basis of these attitudes, understandings or misunderstandings, that the choice among medical resources is made in time of sickness or accident, and upon which the utilization of hospital and dis- pensary for the benefit of the public ultimately rests. Financial support of hospitals and dispensaries by the community depends precisely on the same considerations. In this section of the report of the Cleveland Hospital and Health Survey, therefore, an endeavor will be made to review the details of the work of the hospitals and dispensaries of the city, in their medical, administrative and financial aspects, and to consider also the relation of these institutions to the various sections of the public which use them or need to use them. Hospitals and dispensaries represent or ought to represent the organization of medical services upon a scientific basis, bringing to bear upon the needs of the individual patient the maximum resources in equip- ment and skill that twentieth century medical science can muster. To pro- mote a better understanding of hospitals and dispensaries by the community is to promote at the same time their better and more discriminating utilization, and their more effective and generous support. 822 Hospital and Health Survey SOME DEFINITIONS The hospital and the dispensary, taken together, comprise what may be called the organized or institutional practice of medicine. In the private prac- tice of a physician, some patients are seen in his office, others in bed in their own homes or in a private room of an institution. In the institutional practice of medicine the dispensary patients correspond to those who are seen in the physician's office, and the hospital patients to those whom he sees in bed. During the winter of 1919 and spring of 1920, when the Survey was made, there were 47 institutions known as hospitals, and 26 dispensaries and health centers in Cleveland and Lakewood. Under a law of Ohio which became effective in 1919, all hospitals and dispensaries must be registered with the State Department of Health and render to it an annual report. Eight of the above 47 "hospitals" had not registered with the State Department of Health at the time the field work of the Survey was completed (June, 1920). Their names were found in the telephone directory. They are not further referred to in this report, except in relation to the public supervision of hos- pitals, in the section on "Organization to Carry Out Plans." The definition of dispensary as thus far interpreted by the State Department of Health does not appear to include the Health Centers or clinics doing primarily preventive work. The medical institutions of Cleveland may be further divided according as they are members of the Cleveland Hospital Council or not. Table I. in the Appendix gives the hospitals and dispensaries of Cleveland, stating after each the approximate number of beds in the hospital, and the approxi- mate number of annual visits by patients to the dispensary. On the accompanying map these institutions are shown in their proper location. It is important to state certain definitions and distinctions which will be of service in understanding the problems and relations of the hospitals and dispensaries of Cleveland. Hospitals may be broadly classified in two ways: first, according to the character of diseases treated, and, second, according to the relation of the institution to the community. With regard to the character of diseases treated, the distinction is between general hospitals, such as City or Lakeside Hospitals, and special hospitals, such as Cleveland Maternity or St. Ann's Maternity Hospital. The latter receive only patients of a designated medical type. It will be observed at once that Cleveland has few of the second group. On the other basis of classifying hospitals in their relation to the com- munity, two divisions may be made: (a) Public-service hospitals. (b) Proprietary hospitals. » ? c 1 * 823 824 Hospital and Health Survey The first class receive patients as a public service, whether pay, part-pay or free patients. The second class are conducted as corporations for the profit of their owners. It is important to notice that the term "private hospital," which is not infrequently used, is decidedly ambiguous. The word ''private" is sometimes employed to indicate a hospital supported by private funds as distinguished from a state or a municipal hospital. In another sense, a private hospital is taken to mean one which receives only private ratients of certain physicians and no ward or "staff" patients. In still a third sense, the word "private" is applied to a hospital which is conducted as a private business for profit. To use the same word "private" for a hosrital which is performing a great amount of public service rendered alike to those who pay and those who do not pay, as for an institution which is run as a business enterprise, involves dangerous confusion. The term "proprietary" makes the proper distinction. This term, however, is not necessarily one of reproach. It is perfectly legitimate and proper for an individual or a corporation to maintain a hos- pital for profit, as a business enterprise. Such an institution corresponds to a "private school" or "academy," and may be as well conducted and as useful to a limited circle of patients as are many well known private schools to their clientele. As will appear later, a number of institutions in the above list fall within the proprietary class. There are some of these hospitals which were 'ncorpo- rated as business organizations to be run for profit, but which in practice are conducted as oublic service institutions, and have been so recognized by the Cleveland Hospital Council. According to the principles which will be laid down in this report, the extent 'to which the public should assist financially in the maintenance of a hospital should vary in orecise degree with the amount and proportion of public service rendered by the institution. To be able tc measure this accurately and to make the results of this measurement known to the public or to the agency representing the public, such as the Community Fund, is one of the important aims which those interested in hospitals must have in view. The degree of public service rendered by a hospital does not correspond with the number of its free patients. Some persons have the notion that doing charity means giving something for nothing. The twentieth century idea of charity is a service, not a dole. The public service rendered by a hospital should be measured from a financial standpoint by the amount of rare given at a rate lower than the cost of the service. This in practice means measured by the number of days of care rendered during the course of a year. If a patient is treated for a day and pays only half the cost of the service, the hospital may be credited with one-half of a day's free care. Such is a simple method of estimating the financial aspect of the public service of a hospital. From the professional standpoint, public service must be estimated in terms of kind and standard of care, a more technical and difficult matter to evaluate. Classification of hospitals according to the quality of service, an invidious task, fan be undertaken here only with reference to one distinc- Hospitals and Dispensaries 825 lion. The public ought to understand the difference between the "medical boarding house" and the hospital. In every large city are found institutions, usually of the proprietary class, which have an operating room, a nursing service, and which receive the patients of private physicians, put them to bed, nurse and feed them, and provide for nursing attendance at operation if the case is surgical. The pri- vate physician carries the same individual responsibility that he would if the patient were in bed at home. The difference is merely that there are facilities for a major operation close by, and that the patient's household is spared the difficulties of adjustment to illness, the introduction of a trained nurse, provision for a special diet, etc. These are to all intents and purposes medical boarding houses. The modern hospital is as different from a medical boarding house as a passenger liner is from a tramp steamer. Both float and both will take one somewhere. But one is just a boat, while the other is a boat plus an organ- ization. The modern hospital provides the physician with certain facilities which are unavailable in the patient's home. Medical practice today requires more than the physician's individual trained senses. Laboratories for many te^ts and an X-Ray department are necessary adjuncts to modern medical practice. The patient cared for at home can secure these benefits only through expensive and somewhat slow recourse to private laboratories. In the hospital, this equipment and a vast variety of other instruments and apparatus are brought together under a single roof, and organized under a single control, so as to be most economically and effectively used. Modern me r cine also is highly specialized. No one physician can master all the science. Many cases require examination and study by physicians each representing a different branch of medicine, in order that all the necessary facts be obtained, and through consultation an accurate diagnosis of the disease be established. The staff of a modern hospital provides a group of specialists working with joint equipment, and under a mutually acceptable plan of team work, which should render the service of each of maximum value to the others as well as to himself and to the patient. Similarly the modern hospital provides assistants to the physician of special skill; the medical assistant, the interne; the laboratory assistant, the technician; the nurse, and the social worker. Through the aid of these assistants the highly special skill of the physician is kept for just that kind of work which requires it, and his time is not spent on routine or details. Consequently with a given expenditure of time and energy he can render service to a much larger number of patients, and more effective service at that. A modern hospital may be defined as an institution in which there is joir t use of medical equipment and cooperative organization of medical skill for the diagnosis, treatment and prevention of disease. A critical study of hospitals makes it clear that 'some institutions main- tain the principles of the medical boarding house with respect to their private 826 Hospital and Health Survey I atients, while having a well organized system for modern hospital work \\*ith respect to their ward cases. Is privacy a substitute for service? The distinction between the two types of services will be illustrated in numerous ooints during the course of this report, and will be of importance in connection with certain final conclusions. Each hospital trustee and every hospital patient will do well to see how these principles work out with re- gard to the hospital which he knows best. The dispensaries may be classified as are the hospitals. As a matter of fact, the list of dispensaries on pages 984-986 contains none of the pro- prietary class. There are indeed some clinics maintained in Cleveland by individual physicians, whether on their own account or in connection with industrial establishments. Some of these are reputable enterprises; some of them are merely quack medical institutes. The latter class will be referred to only in connection with some general recommendations of the Survey in the section on "Organization to Carry Out Plans," as are the hospitals not registered with the State Department of Health. Cleveland has only one dispensary treating the sick of the class confined to special diseases — the Babies' Dispensary. Its clientele is limited to chil- dren not over three years. A highly important group of special dispensaries, however, are the public health dispensaries, which aim to prevent rathei than treat disease, to educate rather than to cure — the Health Centers, Baby Prophylactic Stations, and Prenatal Clinics. Broadly speaking, a line for the support of dispensary work is drawn by the municipal authorities on the border line between preventive and curative medicine; private support of dispensary work being largely though not wholly confined to the dispen- saries treating the sick, and public support being almost entirely confined to the dispensaries whose work is primarily preventive and educational. The term "dispensary" originally meant a place where medicine was given out or dispensed to the poor on the prescription of a physician, and the word has persisted, although at the present day the giving out of medicine is a minor function of a dispensary. Medical diagnosis, advice, and treat- ment other than medicine are the services of primary significance. The term "out-patient department" is frequently used as synonymous with dis- pensary when applied to a dispensary which is part of the organization of a hospital — the bed cases being the in-patient department and the dispensary the out-patient department. In this report, the term dispensary will be generally used except when it is desired to draw a special distinction between the "in" and the "out" patients. The unit for measurement of the services rendered by hospitals and dis- pensaries is important to define. Hospital service is measured in days of care. A patient who has been in the hospital for two weeks has in this sense received fourteen units of service. The unit for measuring dispensary serv- ice is the visit paid by the patient to the clinic. It will be observed that the visits paid by patients to a dispensary in the course of a month or of a year is much more than the number of individuals treated, just as the number of days' care given patients in a hospital is much larger than the number of Hospitals and Dispensaries 827 different patients. In actually studying the work of a given institution or of the city as a whole, we are of course interested in the number of individuals cared for as well as in the bulk of service rendered. Days of hospital care and visits to dispensary clinics represent the latter element — bulk of work done. The number of individuals treated is in practice a more difficult figure to obtain, because of the likelihood of the same individual, in case of readmission to dispensary or hospital, being counted as a different patient. One of the fundamental problems of every professional institution today is how to make a specialized and technical piece of work clear to the average person. The problem is to interpret hospitals and dispensaries to the com- munity. This means stating facts showing the kind, amount and quality of service rendered, and stating them in such a way that they are easily understood by the average person. It is of relatively little importance what facts a temporary survey gathers and reports — such facts are at most only a cross-section, a momentary picture. It is of very great importance what facts the hospitals and dispensaries gather and present regularly to the public, and how they present them to the unprofessional mind — whether in a vivid and convincing fashion or in dry and technical form. What a board of trustees needs to know about their own hospital or dispensary; what the contributors to the Community Fund need to know about all hospitals and dispensaries; what the general public needs to know about the hospitals as a whole or about its municipal institution in particular — these are of fundamental importance for the Survey to suggest. The cost of maintaining medical institutions has been increasing with great rapidity, not only because of the general rise in prices, but because of advance in medical science, the more elaborate equipment that is necessary, the higher specialization in many branches — in a word, higher standards of service, yielding better results for the cure and prevention of disease. Public comprehension of these new and higher standards has lagged behind their establishment in the strongest institutions. Such comprehension forms the basis on which taxes for municipal institutions must be levied and cam- paigns for community chests or for building funds successfully accomplished. Adequate moral and financial support of hospitals and dispensaries depends upon making these standards and needs clear in terms of human interest and popular understanding. The defining of units, the assembling of sta- tistics and the compilation of professional reports are fundamental prerequi- sites. The statement and interpretation of these data to the community are a necessary sequence. 828 Hospital and Health Survey II. Hospitals HOSPITAL PROVISIONS AND COMMUNITY NEEDS Reserving the study of dispensaries for Chapter III., we may now com- pare the hospital facilities of Cleveland with those of other communities and with the probable needs of the city. During the winter of 1920, while the Survey was in progress, the number of hospital beds in the cities of Cleveland and Lakewood was 3,378, including all the institutions registered with the State Department of Health. Of these, 3,088 beds were in the 20 hospitals of the Cleveland Hospital Council, as follows: Beds Cleveland City Hospital :... 785 Cleveland Maternity Hospital , 60 Fairview Park Hospital 85 Glenville Hospital 74 Grace Hospital 35 Huron Road Hospital..... 84 Lakeside Hospital. 289 Lakewood Hospital 53 Lutheran Hospital , 50 Mount Sinai Hospital 225 Provident Hospital 29 Rainbow Hospital 85 St. Alexis Hospital 250 St. Ann's Maternity Hospital 55 St. Clair Hospital 43 St. John's Hospital 150 St. Luke's Hospital 139 St. Vincent's Charity Hospital 290 Warrensville Tuberculosis Sanatorium 270 Woman's Hospital — 37 Total - 3,088 Hospitals and Dispensaries 829 The 11 non-council hospitals included 290 beds, as follows: Beds Cleveland Emergency Hospital = 22 Cleveland Home Hospital - 10 East Cleveland Hospital '. 31 East Fifty-fifth Street Hospital - 60 East Seventy-ninth Street Hospital 22 Florence Crittenden Home - 12 Joanna Private Hospital 9 Mrs. Hitchcock's Private Hospital - 15 St. Mark's Hospital..! 45 Salvation Army Rescue Home 54 Wright's Hospital .' 10 i Total..... 290 In this classification it is to be noted that in conformity with the usual practice, beds (1) for the insane and feeble-minded, (2) for the infirm and aged, (3) in orphanages, and (4) under the control of the United States Government, have not been included. The list includes hospitals for general and special cases of an acute or chronic nature, and convalescents, but not the four classes mentioned above. This point is important in making com- parisons with other communities. If these beds are compared with the population of the cities of Cleveland and Lakewood, taken together, we should find that there are 3,378 beds to a population of approximately 840,000 in these two cities. However, these beds are serving more than the population of Cleveland and Lakewood. They are used by what may be called the metropolitan district, and even more distant areas depend upon them. We may form a definite estimate from data collected by the Survey on the two days, December 3, 1919, and January 15, 1920, on each of which was taken a census of the patients in the Council hospitals and in three others. A tabulation of the patients in these hospitals on these two days by location of residence(the average of the two days) showed that of the 2,651 patients 14.7 per cent., or practically one- seventh, came from outside the city of Cleveland. This number includes of course those coming from Lakewood, but it is certain that at least one-eighth of the patients who were in the hospitals on these two days came from out- side Ceveland or Lakewood. At least one-eighth therefore should be added to the population served by the hospitals on our list, which would make a total of about 945,000. Dividing this by the number of beds, 3,378, we find that there is provision to the extent of about 2.8 beds to one thousand of popu'ation. This is a fundamental figure, because it is an index of the de- gree of provision of hospital service for community needs. Its significance will require elucidation. 830 Hospital and Health Survey Comparisons must needs be made with other communities. In the 1919 report of the United Hospital Fund of New York City, a classified list is given of the hospitals in that metropolis. There is shown a total of 28,2C8 beds, which does not include the four classes of institutions mentioned above, or many small private institutions such as appear in the Cleveland list among the non-council hospitals. The proportion of patients coming from outside the limits of Greater Xew York is not known, but most of the suburbs of Xew York are better provided with hospitals than the outlying- districts of Cleveland. It is assumed that the omissions from the list of hospitals in Xew York given by the United Hospital Fund would probably balance in number the beds required to serve non-residents. On this basis, provision of hospital beds in the metropolis in proportion to population is five per thousand. Boston provides another basis of comparison. The legal city of Boston is a little smaller than Cleveland, according to the 1920 census, 727,000 against 796,836, but Boston is one of some 38 towns and cities within the metro- politan district, with a total population of approximately 1,500,00D. A list of hospitals in this "Greater Boston" showed, from figures in the Medical Directory of 1918, 140 hospitals, general and special (excluding those types above named) with a total of 7,247 beds. This is 4.83 beds to 1,000 of popu- lation. Taking the city of Boston alone, with a census population in 1920 of 727,000, it was found that there were 108 hospitals, with 6,062 beds. This is an average of 8.3 beds to 1,000 population, but this figure should not be used for comparative purposes, since so large a proportion of the Boston beds are used by the metropolitan district, with double the population of Boston proper. For purposes of comparison with Cleveland, the figure for the metropolitan area should be taken. It will be observed that the figures for Xew York and for "Greater Boston" are almost exactly the same. It is apparent that Cleveland falls far below either Boston or Xew York in providing hospital service in proportion to its population. On the basis of five beds per thousand Greater Cleveland needs fully 4,725 beds, or at least 1,350 more than now exist. In view of the fact that even when new beds are planned for, time is required to build and equip the hospitals to contain them and that population needs continue to grow, it may be conservatively esti- mated that Cleveland needs to add 1,500 beds to its hospital capacity as quickly as possible. Even at the present moment (June, 1920) it must be recalled that while the 1920 census showed a smaller population for Cleve- land than had been anticipated, yet the growth of the suburbs, which must depend largely upon the main city for their hospital service, has been pro- reeding at such a rapid rate that it is fair to estimate that not less than 1,500 rather than 1,300 beds should be stated as the shortage in the year 1920. Were this merely a conclusion derived from statistics, it would be indeed questionable. The statistics, however, are worked out merely to give an index to well-established facts showing the shortage of hospital beds in Cleveland and the unfortunate results of this shortage. To depict these Hospitals and Dispensaries 831 will require a closer analysis of the service offered by the hospitals of the city. The hospitals of Cleveland are predominantly devoted to surgery. On the two Survey census days, if the hospitals of the city were taken together (omitting City Hospital, Warrensville Tuberculosis Sanatorium, andRainbow Hospital), it was found that 48 per cent, of the patients were surgical, and that in the majority of the hospitals the ratio was much higher. The reason that City Hospital is excluded is because in its 785 beds are included large groups of cases such as tuberculous, alcoholic, venereal disease and contagious. disease patients, which do not appear in any other hospital. On the census days, only 21.5 per cent, of the patients represented general medi- cine, and only 9.4 per cent, special services. 18.7 per cent, were obstetrical, and 2.4 per cent, not stated. The figures themselves are given in a footnote.* Cleveland is seriously deficient in provision for special classes of cases, f Obstetrical cases are found in the majority of the hospitals. The average for the two census days was 313, or about one patient in ten, 9.3 per cent, of the total patients in the Cleveland hospitals on those days. Provision for obstetrical cases in special hospitals is made only at Cleveland Maternity Hospital and at St. Ann's Maternity Hospital, a total of 115 beds. Recent years have seen a great increase in the demand for care in hospitals at the time of confinement, particularly by middle-class families, but these cases have had in the main to be provided for in the general hospitals, without the de- velopment of special hospitals, special services, or special wards to meet the particular need. Regarding cases of eye disease, it was found that only one hospital, Lakeside, makes any special reservation of beds, four beds being held in the male surgical ward of Lakeside for this service. There is no special ward in the city for ear, nose and throat cases. In Xew York 608 beds are provided in special institutions for eye, ear, nose, and throat cases, aside from such provision as is made in the general hospitals. In Boston, 219 beds are pro- vided; in Baltimore, 153; in Philadelphia, 58; in Chicago, 32. In special provision for children, Cleveland is similarly lacking. Pediatric services exist at Lakeside, City and Mount Sinai, and beds are set aside for children in the following additional hospitals: Children's Fresh Air Camp, Fairview Park Hospital, Huron Road Hospital, Lakewood Hospital, Rainbow Hospital, St. Alexis Hospital, St. Ann's Hospital, St. John's Hos- pital, and St. Luke's Hospital, making a total of 302 beds designated as chil- dren 's beds, for other than contagious or convalescent cases. * Classification of Patients, Census Days (averaged i Type of Service Medical Surgical Obstetrical Special . Not stated tin 1918 Boston had beds in special institutions to the number of 2698, as follows: Tuberculosis 792 Children 240 Eye and ear 225 Women (maternity) 436 Contagious.. 340 Women and children together 542 -Cancer 25 Convalescent 98 umber Percentage 361.0 21.5 805.5 48.0 312.5 18.7 157.5 9.4 40.0 2.4 832 Hospital and Health Survey It will be observed that these are all parts of general hospitals. As com- pared with this, New York has 1,298 beds for children in special hosritals, and in addition, at least as many more beds specially set aside for children in a number of general hospitals; Boston has about 240 beds for children in special hospitals and more than that in pediatric divisions of a number of general hospitals. On the two census days, there were 496 children found in the Cleveland hospitals, of whom 57 were in the contagious disease service of City Hos- pital. The vast majority of the remaining 439 were scattered through the wards and rooms of general hospitals, the greater number being surgical cases. In the matter of provision for contagious cases, Cleveland has 100 beds at City Hosoital. Boston has 340 beds in its City Hosoital. In connection with contagious diseases, these figures are comparable, since both institutions rarely take cases except from within the limits of the legal city. It is stated by such a national authority as Dr. Charles V. Chapin that for the common contagious diseases (excluding tuberculosis, venereal diseases, etc.), a com- munity should provide at least one bed for every 2,000 of pooulation. This in Cleveland would mean almost 400 beds. Boston it will be observed has measured up to Doctor Chapin's estimate; New York, with 2,100 beds for contagious cases, almost meets it. A special report of the Survey dealing with tuberculosis (Part IV.) has shown that Cleveland has not enough beds for this disease. The estimates of the specialists in venereal disease are to the effect that at least 200 beds should be provided in the City Hospital, and that a certain amount of provision should be made in general hospitals. (See Part V.) In the orthopedic service, a branch of medicine of rapidly increasing im- portance, Cleveland has an insignificant provision. The number of reported orthopedic cases in hospital beds, at the time of the Survey, was not known, except at Rainbow Hospital, which is chiefly designed for convalescent orthopedic cases of children. Boston has about three times the provision for orthopedic cases as has Cleveland, and New York has over 360 beds in special hospitals alone for acute cases of this type. These facts go to show where the deficiencies in provision of hospital beds in Cleveland lie. The reason for the shortage of beds is obviously that the population has grown more rapidly than has recognition of needs for more hospital service. We find in the Cleveland hospitals the more urgent sur- gical and some medical cases being treated, but very little development of services for special cases. In general it may be said that the urgent diseases or emergent cases, particularly surgical, which force themselves on the com- munity's attention and upon the attention of the individual hospitals, and which cannot be denied admission, have left little room for other types of work. The effect of this shortage of 1,500 beds cannot be measured. We can only estimate the number of sick persons who have had to be cared for in their homes with inadequate facilities for diagnosis, for nursing, for diet, and for Hospitals and Dispensaries 833 care of all kinds. The number of cas^s of disease needing the services of a specialist, the complete and thorough observation necessary to make a diagnosis, such as is only possible under hospital conditions, we can only infer. We can only in imagination picture the suffering that has resulted, the development of slight illness into serious, the diminution of productive power, the loss of opportunity to prevent as well as to cure disease. Such shortage of hospital beds can only mean a waste of the vital resources of the popula- tion. Against these figures ought to be set others which suggest an almost contradictory picture. If there were a shortage of beds, it might seem at first sight that the 3,400 beds now available should be constantly filled to their capacity. Such, however, is not the case. On the first census day, Decem- ber 3, 1919. 2,581 hospital patients were reported as in hospitals with a theoretical capacity at the time of 2,831 beds. On the second census day, January 15, 1920, 2,663 patients were reported in hospitals having 3,001 beds. The percentage of beds filled on the census days for this group of hospitals, was 95.7 and 88.7, respectively. A similar comparison can be made on the basis of an entire year, by tak- ing the number of beds in the hospital and multiplying this number by 365, thus securing the maximum days of care that might be given during the year, Comparison of the actual number of days' care, as reported, with this figure gives the proportion of utilization of hospital facilities for the year. For the group of seventeen hospitals for which figures were obtained for the year 1918, a total of 929,825 days of care was possible but only 686,967 days of care were given, or 73.9 per cent. During the year 1919, for a group of six- teen hospitals, a total of 930,465 days of care was possible, but only 645,280 days of care were given or 69.3 per cent. It should be stated at once that we cannot expect a hospital or group of hospitals to have all beds filled all the time. There are periods of epidemics, and in normal times there are occasional days when a hospital may have every bed taken, but such conditions are exceptional. A hospital may re- fuse cases when it has vacant beds, because there must be classification of patients to a greater or less degree, and the ward for which the patient is suited on account of his sex or disease may be full, while there may be vacancies elsewhere. Inability to receive a given patient is thus compatible with some vacancies in the same hospital. Over any considerable period of time during the year, there are many reasons why a certain number of beds cannot be completely utilized. Rooms and wards must be renovated and occasionally repairs are necessary. In many hospitals a certain number of beds are set aside for the temporary detention of patients, particularly chil- dren, during a period of observation so as to eliminate risk of contagious disease. Such are some of the reasons why hospitals never show the use of their beds during the year up to anything like 100 per cent, of capacity. An annual average of 75 per cent, is a very fair showing. During the winter and spring months there is generally greater demand for hospital service 834 Hospital and Health Survey than during the summer and the autumn, and consequently a higher ratio of use of beds is usually found for the six months beginning with January, if compared with the other six months of the year. Hospital administrators may take advantage of this condition by doing repairs and renovations, so far as possible, during the less active months. A tabulation of individual hospitals presents some interesting points, as shown by Table II in the Appendix. It should of course be one of the prime aims of hospital administration to utilize the facilities of the plant to their fullest capacity. Good hospital administration should show a higher average use of beds than 70 per cent, for a year. Conditions will vary among general hospitals. Conditions in special institutions, such as hospitals for maternity cases, children, chronic cases, etc., must be considered on their own merits. Thus, in the Cleveland City Hospital, certain large units are set aside for tuberculosis,, neurology (includ- ing many alcoholic cases), venereal diseases and contagious cases, and the demand for these beds is affected by many conditions different from those which affect the general medical and surgical services. It should, how- ever, be the aim of hospital administration to make its internal arrangements as flexible as possible.* While contagious and acute surgical cases are not safely to be mixed in the same wards, there should be a constant effort toward the utmost flexibility of classification so that pressure on one division of the service can be relieved by rearrangements which utilize beds vacant in other divisions. A comparison of Cleveland figures with those of a number of leading New York hospitals shows the majority of Cleveland institutions in a somewhat unfavorable light. Nineteen hospitals in the United Hospital Fund of New York showed in 1919 an average of 79 per cent, of their bed capacity filled. The lowest hospital showed 63 per cent, and four showed 90 per cent, or over. On the whole it may be said that a general hospital should be so adminis- tered as to run to an average of at least 75 per cent, of its capacity during *Figures provided by the City Hospital just before this report goes to press show, for the year 1919 and the fi st nine months of 1920, the details of the use of the different divisions of the hospital. These are as follows: (The figures in the parentheses are for the first nine months of 1920, and the others for the year 1919.) Department Tuberculosis Contagious Specific Observation Main and Convalescent. Beds 100 (100) Total Days Treatment Possible 36,500 (27,400) Total Days Treatment Given 27,447 (16,430) Percentage Occupied 75.7 (59.9) 100 (100) 36,500 (27,400) 14,806 (13,859) 40.5 (50.5i 75 (125) 22,500 (35,250 13,575 (13,264) 60.3 (38.7) 50 (50) 18,250 (13,700) 12,077 ( 8,938) 66.2 (65.0) 400 (380) 146,000 (104,120) 105,001 ( 74.614) 72.0 (71.7) The very wide variations between the degree of use of the different services of the hospital are ap- parent. It will be noted that the small percentage of use, particularly of certain divisions, has continued t hroughout a long period of time. Hospitals and Dispensaries 835 the year as a whole, and that an average of over 80 per cent, should be expected during the busier portion of the year. A figure as high as 90 per cent, ought to be the goal. In estimating the hospital needs of a large community, however, it would not be safe to expect a percentage of utilization of hospital beds as a whole throughout the year to be more than 75 per cent, at the present time, even in the face of a general shortage of beds with consequent increase of pressure. The Survey has sought to point out the necessary inflexibilities of hospital arrangements and the irregularity of demand throughout the year to account for this seeming inconsistency. On the map on page 823 are shown the eight "Health Districts" used by the Cleveland Division of Health for administration purposes. The hos- pital population of the city on the two census days was tabulated with refer- ence to location of residence of the patients according to these health dis- tricts. Comparison with the map will assist in interpreting Table III in the Appendix which gives this tabulation. A glance at this table and at- the map shows that the hospitals of the city have not been located according to any general plan, nor to any great extent with reference to the needs of any particular locality. Thus District II and District VIII show the largest proportion of cases in the hospitals, and this is what one might expect considering the congested residential character of District VIII, and also the enormous business and industrial population of District II, during the working hours. A large amount of need for hospital attention invariably arises under such conditions, yet the only hospital in District II is Huron Road, and the district has less than one-third the number of beds per thousand of population that are provided in Health District III, which, with three t : mes the proportion of beds ac- cording to population, shows less than one-third the number of hospital cases per thousand. Comparison with District VII is also instructive. A number of hospitals are found located near the boundaries of districts, and belong to the one as much as to the other, but the more fundamental fact is that the range of service of many hospitals has very little relation to the district in which it is located. Table IV in the Appendix shows the proportion of cases on the first census day registered in each hospital from its own health district. Further study of the individual hospitals on the second census day and in some cases for other periods, showed quite clearly that hospitals can be divided into two groups, with respect to their range. One type, such as Huron Road, Lakeside, City, Mount Sinai, St. Luke's, and St. Vincent's, have what may be practically called a city -wide range. The proportion of cases drawn from their own vicinity is no larger, or is less than one would expect in proportion to distribution of population. In the other group are hospitals such as Fairview Park, St. John's, Glenville, Lutheran, Provident, Grace, St. A n's, and St. Alexis, which show a large proportion of patients drawn from the'r own vicinity. The difference between the two classes is often more striking when the figures for the individual hospitals in the latter 83<> Hospital and Health Survey class ai : e examined in detail. In some instances from two-thirds to three- fourths of the patients are found to be drawn from the hospital's own dis- trict or a neighboring district, so that the great bulk of the hospital clientele is local. Generally speaking, the range of the larger hospitals is wider than the range of the smaller ones. The facts shown in these tables are of importance in connection with the location of future hospital units, and will be referred to later in that connec- tion in the section on Community Planning. It is important that each board of trustees understand the range of its own hospital. Adaptation to the special needs of its clientele is a very different matter in a hospital which serves primarily its neighborhood from the case of one which draws from all over the city and from the environs. The most important summary conclusion to which the data in this sec- tion lead is the shortage of 1,500 hospital beds in Cleveland in 1920. The work of the existing hospitals has been unduly limited, because of this short- age, to urgent surgical and to maternity cases. Medical and special work, particularly for children, has not been provided for in any adequate degree. Study of the Cleveland hospitals reveals these conditions quite clearly, and they are thrown into relief by comparisons made with Xew York and Boston. It is apparent that while the best administered hospitals of Cleveland have used their beds to as full capacity as the best institutions elsewhere with which comparisons have been made, the hospitals in Cleveland as a whole have fallen below a desirable percentage of utilization of their theoretical capacity, even in the face of the community's need for beds. Some of the reasons for this have been indicated, and the need for flexibility and efficient administration has been pointed out as a remedy. ,«fl NlORl__8£O.S «ow Fig. II. Provision and Need for Ilosjnta Rens Hospitals and Dispensaries 837 Distribution of hospitals according to sections of the city shows lack in the past of any general planning and the need for the formulation of prin- ciples by which the locations and functions of future hospitals can be de- termined. It is apparent that there is special need and large demand for hospital service coming from the central section of the city, and inasmuch as a considerable part of the need from this section is known to be of an urgent character, future plans for the location of hospitals must take into con- sideration local provision for this central section. It has been sought in this section to point out not only general matters of interest to the city as a whole, but to indicate some of the kinds of facts which hospitals need to know about themselves; which the trustees and their representatives should have periodically reported to them. In how many hospitals do the monthly reports to the trustees show, for instance, the percentage of beds used in each of the main divisions of the hospital in pro- portion to the theoretical capacity of each division? Shrewd business men know just what facts to demand in regular reports from their own enter- prises so that they shall be able to determine whether or not the business is well run. Trustees should be as discriminating in the selection of the facts which they ask to have set up as the guideposts for the business and policy of their hospitals. 83S Hospital and Health Survey ORGANIZATION FOR SERVICE A hospital is much more complex than most business organizations of equivalent size. Its peculiarity is the inclusion of a number of different pro- fessions, each highly specialized, which must work together and which must be kept in effective working relations. The basis of a hospital is its medical staff, but in addition to this medical element, is the business administration, represented by the business men of the trustees, by the superintendent^ and by his administrative assistants; the nurses, another highly specialized and well organized group; social service, representing still another and different type of work in the hospital; and finally, the housekeeping, mechanical, and clerical groups, who maintain the essential daily routine of the plant. It should be added that while the emphasis of the work of most superinten- dents is on the business side, the superintendent ought to interpret, develop and represent all phases of a hospital's activity. Hospital personnel thus includes such widely varying elements and draws them into such intimate relationship that the successful organization and administration of a modern hospital is a difficult matter requiring special training and skill. There are stated at the end of this chanter a series of recommendations regarding hospital organization to which the discussion of this chapter aims to lead, and which it endeavors to interpret. The basis of hospital organization may be one of three types. The first, which is found only in the proprietary hospital, is a group of stock- holders or owners of the hospital corporation, who may or may not have an interest in the professional and welfare activities of the institution. The second type, as represented by City Hospital, is under the direction of a single man, the Director of Pub ic Welfare, who appoints the executive officer and staff of the hospital. The third type, the usual form of organiza- tion of privately supported hospitals, is that of a board of trustees. Cer- tain hospitals which are under the control of religious organizations fall somewhere midway between types two and three. It is proper enough that there exist proprietary hospitals as a form of business enterprise meeting an apparent public demand, but no hospital which aims to be in the public service class can expect to receive public con- fidence and support unless it has as its governing authority an individual or group possessing the point of view of public service, without financial interest in the operations of the institution. The conditions found in the City Hospital of Cleveland indicate very clearly the need for more general public interest in an institution of major importance, such as this. The most serious administrative deficiency found at the City Hospital by the Survey was in the nursing service. So great a shortage of nursing service was found that the conditions amount to a serious neglect by the. city of its solemn responsibility for the humane care of sick and helpless citizens. It is recognized that the ultimate responsibility rests with the fitizens of Cleveland, who should have approoriated more money for the maintenance of City Hospital. More immediately, the responsibility rests Hospitals and Dispensaries 830 with the appropriating authorities of the • Cleveland municipal administra- tion.* The executive officers of the Department of Public Welfare and the City Hospital should be held responsible for voicing the need in a clear, effective, and persistent way, both to the appropriating authorities and to the public. There is not evidence that sufficient attention has been called to the conditions by the administrative officials who have been aware of them. In the nursing service of City Hospital a decided shortage of students exists, and in some instances, of the supervising staff also. It is a conserva- tive estimate that there are only about one-third as many students as are needed for the number of patients, as 63 students are assigned the 481 beds used for training — a ratio of one student to 7 or 8 beds. The ratio of students to beds was in actual practice lower than this — one student to 10 beds in the general services during the day, and one student to 40 beds at night. Due to the shortage of student nurses, ward attendants have had nursing duties assigned to them for which they were entirely unqualified. The presence of a board of trustees or cf a visiting committee who were actively interested in the hospital might probably have been of great service to the administrative officers of the hospital and to the Director of Public- Welfare in making apparent to the municipal administration and to the general public the neecis of the City Hospital and the gravity of the present deficiency. As the Survey has recommended, an appropriation of $150,000 a year for nursing service is necessary for at least the next year or two in order to secure a sufficient number of graduate nurses to provide a minimum of satisfactory care for the patients. If, as the Survey has also recommended, a sufficiently capable head of the training school can be secured with an ade- quate corps of trained assistants, it is probable that the training school can be so built up that the amount just mentioned can be diminished in future years, as an increased number of student nurses is received, up to the maximum for which the hospital can provide suitable training. At Warrens ville Infirmary the lack of medical and attendant service is also grave, and here again the institution has been lost si^ht of, even by sections of the public which, if they knew the fact's, would be interested to arouse public opinion to better conditions. The need is not only for more medical staff and attendants at Warrensville, but also for recreational facili- ties for old people and others who are patients and who need some element in their lives beyond the barest minimum of physical care; also for the em- ployed help of the institution, who, particularly under present economic- conditions, are obtained with difficulty in a place which is relatively isolated in comparison with other places in which as good, if not better, wages, can be secured. Much in this direction would gladly be done by volunteer assistance if the right people knew the facts and were interested to be active in the matter. It has been recommended by the Survey that the Cleveland City Hos- pital be governed by a board of trustees, which would require a change in the *It is recogrrzed that legal restrictions upon municipal taxing power have placed considerable imitations upon Cleveland's expenditures for public services, as in many other cities. 840 Hospital and Health Survey city charter. It may be pointed out that from the standpoint of efficiency, government by a director need in no way suffer in comparison with government by a board of trustees. The effectiveness of either form of government depends upon personnel, the recommendation in favor of a board of trustees being chiefly that of greater stability through changing municipal administrations. This again may work for good or ill, depending upon per- sonnel. At some periods it would serve to retard progress, and in others to prevent disruption following a political overturn. On the whole, however, a board of trustees is desirable. Even under the most ideal conditions of municipal administration, a city hospital needs to be brought in contact with its community, and this can best be secured by attaching to the institution in some way a group of dis- interested citizens, men and women, who will visit it, be in touch with its work, help its governing and executive officers by friendly advice, and above all else, interpret the institution, its work, and its needs to the financial appropriating authorities and to the public as a whole. The formation of a strong board of trustees best accomplishes these purposes, but if this pro- posal proves unacceptable, some progress toward the same result may be accomplished by a properly selected visiting or auxiliary committee, appointed by the Director of Public Welfare; such a committee of course having only advisory powers. The degree to which such a board will be of practical service will depend almost entirely upon the Director. He has it in his power to stimulate the board to activities which will not interfere with the hospital's activities but be of benefit, or, on the other hand, he may reduce the group to one on which few capable individuals will find interest in serving. In the absence of a board of trustees, however, the presence of some such advisory body is highly advisable. A hospital which is managed by a religious sisterhood will do well, as four such hospitals in Cleveland have recently done, to appoint a lay advis- ory committee which will exercise much the same functions as a board of trustees though without the legal authority usually vested in them in other hospitals. For the typical hospital, privately incorporated, there should unques- tionably be a board of trustees. Such bodies are usually either self-perpet- uating or elected by a hospital membership or by church or other organiza- tions which constitute the hospital corporation. Members of boards should have definite terms, and the personnel should change slowly, a few terms expiring each year. Many of the chief deficiencies in hospital administration in Cleveland and elsewhere have arisen because of defects in the make-up of the board of trustees or in its relationship to other groups in the hospital organization. The composition of boards of trustees has too frequently been determined by an historical accident which threw together a group of doctors and lay business men who together made up the original body, or on the other hand the board is composed entirely of business men, who are usually immersed in affairs, and leave to the medical staff or to one or two of their own number, practically the whole responsibility for administration of the institution. Hospitals and Dispensaries 841 Perhaps the most frequent cause of difficulty in Cleveland has been the existence of a number of different boards or groups within the same hospital, without clear definition of their respective powers and duties. Thus there may be found a board of trustees, a board of managers, and an auxiliary board in the same institution. The personnel of one of these groups may be entire 1 y women; of another, entirely men; the third may be also of women, or of both men and women. The original reason for the formation of these different bodies was obviously the desire to interest as many persons as pos- sible in the hospital for the sake of moral and financial support. Principles of organization applicable to hospitals as well as to business establishments require that there shall be one governing authority. The existence of other boards or committees is not inconsistent with this principle, but the pro- visions of the by-laws and the actual practice of the hospital should make it quite clear that a single body which should be known in general as the "Board of Trustees" has complete authority*, and that all other commit- tees or groups have advisory powers or delegated powers only; nor should powers be delegated by the board save to committees which include some of its own membership. Delegation of power to other committees almost invariably leads to division of authority and confusion in administration. In a few hospitals where numbers of different boards and committees exist, a simple remedy is practical — consolidation. There are usually found a certain number of active members within each committee, just about enough altogether to make a single effective governing body. A board of trustees of a hospital ought to include within itself all the chief elements with which the hospital is concerned. Boards frequently suffer from being composed entirely of business men. Boards of trustees should include other elements which enter deeply into the work of a hospital. Education is one of a hospital's interests, in relation to nurses, to medical study, and to the community in general along health lines. Every hospital, particularly those connected with medical schools or maintaining training- schools for nurses, should include in their boards one or more persons inter- ested in or connected with educational activities. Men and women concerned in the philanthropic and social service relations of a hospital likewise repre- sent an element which ought to be on every hospital board. Selection of personnel from the business, educational, philanthropic, and other elements which ought together to make up the circle of interests of a hospital is no easy task, for the group as a whole must not be too large, it must be har- monious, and must be capable of prompt and effective action. Such mingling of interests in the personnel of a board is a goal to be sought for. Men experienced in the management of business affairs constitute a necessary and valuable element, but men and women interested and concerned with other activities need to be sought for and included. It is perhaps not quite clear to the average person why the physicians who do the medical work of a hospital should not be members of its board of trustees. The accumulated experience of hospitals throughout the country * It is well to restrict the use of the word "Board" to this one body, and to use the term "com- mittee" for all other groups, medical and lay. 842 Hospital and Health Survey is against such membership. The physician who is on a hospital staff or who is in active practice will have, if a member of the board of trustees, a double position and a double interest. The word double is not to be inter- preted as meaning selfish. As a member of the board, the physician is in a position of authority over the hospital policies. As a member of the staff, he is connected with the conduct of a definite piece of work — carrying out these policies within the hospital. So long as hospital staffs are made up of practising physicians, each of whom gives a portion of his time to the hos- pital service, the selection of a few of these men for membership on the board of trustees is certain to create difficulties. The medical knowledge and in- terest of the physician is the professional guide to which the board of trus- tees must give attention, but this guidance from the medical staff can best be furnished through the medical staff's own organization, acting as a pro- fessional body and related to the board through a suitable committee and through the superintendent. The nursing work of a hospital is another element of great importance in the daily administration of the hospital, and one which at the present time presents especial difficulties. A special section of the report of the Cleveland Hospital and Health Survey is devoted entirely to nursing (Part IX.) Here it may be mentioned merely that the relation between the nurse and the hos- pital administration in the past has been largely through the nurses' train- ing school. As the nursing report shows, hospitals have been too ready to utilize their training school for nurses as a means of securing cheap labor. Part of the young woman's payment for receiving education in nursing has been rendered by giving manual service. Nurses are too much in demand to permit these conditions to continue. While part of the education of a nurse lies necessarily in the hospital and dispensary, where practical ex- perience must be gained, the education of the future nurse and the daily conduct of the hospital routine cannot be identified so closely in the future as they have been in the past. The education of nurses must stand in a greater measure on its own feet, as an educational enterprise, affiliated with the hospital more along the lines of the affiliation between medical school and hospital. The routine work in caring for patients must be conducted in a larger measure by women who have already had their educational train- ing for the work, and who do not receive an educational course as part of their compensation. The varied activities which have been carried out in the past by the graduate nurse and the pupil nurse must in the future be conducted by an apportionment of tasks among graduate nurses, attendants, maids, and orderlies. In its relation to hospital organization, this may mean physical separa- tion between the training school and hospital in many instances, as out- lined in the nursing report. The conduct of training schools by hospitals as part of their own organization requires special knowledge and usually a special committee, in order that educational policies may be developed, and educational standards maintained. For these reasons, the special training school committee recommended in the plan of organization is deemed de- sirable. The relationship proposed between the trustees, the training school committee, the superintendent of the hospital, and the head of the nursing service, should be considered carefully. Hospitals and Dispensaries 843 The social service department represents the newest element to enter the hospital, and its position as yet has not received universal recognition. In a number of the best institutions, however, in Cleveland and elsewhere, the social service department is developed and its place is fairly well defined. Few boards of trustees and few superintendents have at the present time sufficient knowledge concerning the policies and the methods that should prevail in a social service department to be able to guide it properly. A special social service committee is therefore thought desirable, to serve with advisory powers only, and to help in developing the social service of the hospital so as to be of the maximum assistance to its medical work. A failure on the part of the board of trustees to give sufficient authority to their executive officer, the superintendent, is another source of weakness in not a few hospitals in Cleveland as elsewhere. More than one executive head in an organization is an obvious weakness and danger. To manage a modern hospital with all of its varied interests and all the widely differing groups within its personnel, requires a man or woman of unusual ability and tact, and with special training. Everywhere in the country the number of such qualified persons is at present far below the demand. The board and its advisory committees need to supplement the superintendent in advisory as well as in directing ways. It will be observed that according to the plan for hospital organization outlined in the following, the superintendent stands in a central position, meeting with the board on the side of hospital adminis- tration', and with the medical executive committee on the side of the hos- pital's professional activities. A third aspect, which is not mentioned in the plan of organization, but which may be taken for granted, is the superintendent's relation to his administrative departments; the steward, the dietitian, the engineer, as well as the head of the nursing and of the social service departments. Periodical conferences between the superintendent and the administrative group are desirable. Medical, nursing, social, and administrative interests within the hospital render it desirable that from time to time representatives of all the different groups be brought together for their better mutual understanding. Recommendation number 6 points in this direction. It is particularly im- portant that members of the board of trustees shall understand personally the hospital inter-relationships and the different parts of its work, and that they shall come into contact at first-hand with sources of information. Through such conferences held from time to time for the discussion of selected problems, this can be achieved. There is no stimulus to members of a managing board like direct contact with facts and with the people who are doing the work over which they have authority. ''What is the whole duty of a Trustee?" is perhaps the fundamental question concerning hospital organization. How is a man or woman living in a great city and with business or other definite vocation, to give sufficient time to a hospital really to understand its work and to be able to meet to the full the responsibilities of trusteeship? The question cannot be answered in general terms, for the activities of a modern hospital are so varied and so technical that few members can come into sufficient touch with all of them to have sound judgment upon all questions that may arise regarding any 844 Hospital and Health Survey one of them. Yet, by division of labor among the members of a board, and above all, by a really active sense of responsibility made effective through the leadership of the president or other officers, a reasonable degree of knowl- edge of the work of the hospital can be gathered by each member, and the sum total, when the board gathers together, will be sufficient to render the trustees a truly responsible governing body. •j It is of particular importance that the trustees understand what facts they should know of periodically, so that these may be presented in the monthly and annual reports of the superintendent. The percentage of beds used in each division of the hospital has already been mentioned as one of these important facts. The length of stay of cases in the different divisions of the hospital is another. At the time of the Survey census, it was found that taking the general hospitals of Cleveland as a whole, 44.6 per cent, of the patients had at that time been in the hospital from three to fourteen days, 13.2 per cent, had been in the hospital less than three days, 19.2 per cent, between fourteen and thirty days, 9.2 per cent, between one month and two months, and 12.9 per cent, more than two months (9% not stated). The proportion of cases staying for these longer periods is higher than it should be in hospitals designed primarily for acute stages of disease. The reason lies largely in the lack of dispensaries and of facilities for convalescent and chronic patients in Cleveland, to which attention will be devoted later in this report. A study of individual hospitals showed wide variations in this figure, ranging from no patients staying over sixty days to as high as 29.9 per cent. A report showing the length of time that patients have been in the hospital, and the number in the various divisions of the hospital who had been there more than a normal period, should be of distinct value to the trustees as well as to the medical staff and the superintendent. Statistical record of patients who have been refused admission is another item of significance. Monthly reports should show the number of refused cases, classified by the main type of case, i. e., medical, surgical, children's, etc., and classified also according to whether the applicant was for a pay, part-pay, or free bed, and with classification according to reasons for re- jection. Not a few hospitals fail to keep any memorandum of cases refused admission because of lack of room or other reasons. Data as to whether or not a waiting list is maintained, or whether refused cases are placed on the waiting list, are also of value, although the maintenance of a waiting list is not always practicable. Statistics regarding the results of care have been developed somewhat through the American College of Surgeons, but their further development and the regular reporting of the condition of patients at discharge and at specified periods thereafter should be part of the regular reports of hospitals in the future. Similarly in dispensaries, the trustees should know what proportion of patients pay one visit and never come back to continue needed treatment. Those items are mentioned here merely as illustrations and of course are in addition to the ordinary statistics of the number of patients admitted, the number of units of work done in each of the chief divisions, and the financial Hospitals and Dispensaries 845 figures showing income and expenditures for the various departments of the institution. In the section on individual hospital planning we shall return to this subject and summarize the more essential facts which a hospital or dispensary should gather and present regularly for the information of its governing body, its supporters and the public. To substitute guidance by facts for guidance by impressions and by hearsay is the goal of the best ad- ministration. Summary of Principles of Hospital Organization* 1. The final governing authority of the hospital should be a Board of Trustees. No member of the Board should be a member of the active or consultant medical staff of the hospital. Hospitals which are under a re- ligious or public city or federal organization and which therefore cannot have Trustees, should appoint an Advisory Committee similarly constituted. In addition to the men members of the Board of Trustees who represent chiefly financial, administrative and broad public interests and experience it is of much importance that there be included on the Board of Trustees a representative of some institution of higher education, viz: University, Nor- mal College and women members whose experience and interest can be relied upon to contribute constructive ideas and opinions. 2. The appointment of the medical staff should be vested in the Board of Trustees. All members of the staff, chiefs of services, or assistants should be appointed by the Board for terms of one year renewable by the Board. The nomination should be made on the initiative of the Board of Trustees or of the Medical Staff or of an executive committee of the medical staff. The Board of Trustees should consult with the Superintendent, or Chief Executive Officer, before confirming the nomination of a Medical Staff, or of i ndividual members thereof. 3. The Superintendent of the hospital should be appointed by the Board He should have entire administrative authority over all departments of the hospital. Under the rules and regulations adopted by the Board of Trus- tees, the Superintendent of the hospital should have authority to nominate or appoint all heads of departments and employes. This implies the au- thority for discharge or dismissal of any employe for cause. The superin- tendent should be the representative of the trustees in relation to the staff or outside interests. 4. The medical staff should be definitely organized for the promotion of team work, common policies and satisfactory relations with the administra- tion of the hospital. Regular meetings of the medical staff or sections thereof should take place for the discussion of professional work. For guidance in organizing such professional conferences the recommendations of the American College of Surgeons are called to the attention of the medical staffs of hospitals. The staff should be organized into divisions or services, medical, surgical, etc. It is desirable that there be a recognized chief for each division. * Prepared in collaboration with Haven Emerson, M. D., Director of the Survey, and W. L. Bab- cock, M. D., consultant on Hospital Administration. 846 Hospital and Health Survey (a) Provision should be made in the By-laws of the Hospital for the recognition of physicians, not members of the staff, whose practice in the hospital complies with definite hospital standards. It is recommended that these physicians organize into an auxiliary staff, without service or voting power, and that a delegate or delegates from this staff be recognized by the Trusteesj and Attending Staff as their representative. 5. There should be a Medical Executive Committee composed of mem- bers of the medical staff, selected by the medical staff or by the Board of Trustees on the nomination of the medical staff. The Superintendent of the Hospital should be a member of this Committee. The total member- ship of the Committee should not be so large as to be unwieldy. Seven members is generally the maximum desirable. 6. It is recommended that the Board of Trustees of hospitals arrange for periodica] conferences of designated members of the trustees, of the medical executive committee, the superintendent and administrative officers such as the heads of the training school or nurses' service, and of the social service department. This joint group should meet periodically for the discussion of hospital policies or administrative matters. 7. The staff of the dispensary or out-patient department should be ap- pointed according to the principles above laid down and the physicians serving in the dispensary should receive definite recognition as members of the hospital organization and staff. For each department of the dispensary there should be designated a chief of clinic who should be under the general authority of the chief of the corresponding department of the hospital, but who should be directly consulted by the superintendent or the assistant superintendent who is in charge of the dispensary on all matters affecting the dispensary. The chiefs of the dispensary service should constitute a Dispensary Medical Committee which with the superintendent, the assistant executive in charge and such others as may be designated should meet from time to time on dispensary matters. It is suggested that a representative of the dispensary staff be a member of the Medical Executive Committee. 8. The medical staff of the hospital acting thru the Medical Executive Committee and the Superintendent should formulate a definite set of stand- ards, subject to ratification by the Trustees, for all professional work of phy- sicians in the hospital touching such matters as attendance, the making and supervision of records, diagnosis, use of laboratories, X-Ray and other diagnostic aids, the duties of residents and internes, the inter-relation of staff physicians and outside physicians, the matter of fee-splitting, etc. 9. Physicians not members of the hospital staff should be entitled to send to the hospital and to treat therein private cases in rooms or wards, subject, however, to such limitation as to number of beds to be allotted to outside physicians as may be formally made by the Trustees, and provided that the physicians treating such cases conform to all standards made by the Medical Staff. " Hospitals and Dispensaries 847 10. No physician should receive a fee from patients other than such fees as may be permitted to staff physicians nor should any physician receive a fee from a patient unless the charges for the hospital care have been met according to the rate established for various rooms or wards for members of the staff and outside physicians alike. 11. In such hospitals as may still continue to keep a training school as part of the hospital organization there should be appointed by the Board of Trustees a training school committee composed of both men and women, to direct educational policies. This committee should include representa- tives of the Board of Trustees, with other persons known to have had experi- ence in education, and also members of the alumnae of the nurses' training school. The superintendent of the hospital and the director of the train- ing school in the hospital and representatives of the medical staff selected by the medical executive committee, though not members of the training school committee should sit with the committee. r Among the Catholic hospitals or in hospitals administered under a re- ligious organization which have no boards of trustees and are subject to the direction]: off the Bishop of the diocese, a committee on the training school, advisory; to! the Bishop, might with advantage be established at once to direct the]educational policies of the training school. The relationship between schools of nursing and hospitals should be essentially the same as that created between medical schools and hospitals. The School of Nursing, like the medical school, should exist primarily to give technical education to students who are to obtain part of their training in the hospitals. An ideal organization for a school of nursing which should be realized in Cleveland as soon as circumstances permit is clearly the University organiza- tion in which ward training would be given in such hospitals as come up to the conditions required by the University for educational purposes for its students. 12. The superintendent of nurses in the hospital should be appointed by the Board of Trustees of the hospital, on nomination of the superintendent of the hospital with the concurrence of the training school committee. She should have administrative authority, subject to the superintendent of the hospital, over the entire nursing service and she should be responsible for the educational standards and policies as laid down by the training school com- mittee. It is considered desirable that the superintendent of the hospital should delegate to the superintendent of the training school the appointment and dismissal of nursing personnel. The offices of principal of the training school and superintendent of nurses, are educational and administrative offices, respectively, and may or may not be combined in the same individual. When they are combined the head of the training school should be designated "Superintendent of Nurses and Principal of the Training School." 848 Hospital and Health Survey 13. The Social Service department of the hospital should be under the direction of a head worker who should be responsible to the superintendent. It is recommended that there be a Social Service Committee, which among other members, should include one or more of the trustees, of the medical staff and the superintendent of the hospital. Hospitals and Dispensaries 849 THE HUMAN PROBLEM OF THE HOSPITAL PATIENT ''Treat not only the disease, treat also the man." These words of Ru- dolph Virchow set the standard for the highest form of hospital service. The two or three thousand patients who are in the hospitals of Cleveland daily, present the hospitals not only with a variety of bodily ills, but with problems of personality and environment which are as varied as human nature, and which influence vitally the ultimate success of the hospital's mission to maintain as well as to restore health. Virchow's words set not only a standard but express a warning, for the hospital's great danger is overspecialization — attending to pathology and overlooking personality. Successful work in the operating room may be independent of what the patient is or thinks or feels, but successful restora- tion of the patient to health and living efficiency depends not only on the surgery but on the patient's state of mind after he goes from the operating room to his bed in the hospital and from his bed in the hospital to his home. In a survey it is necessary to consider persons as well as patients, in order that a true picture be given of the hospital's services, of their relation- ships to the community, and of their values and deficiencies, as judged by the final results in making people well and humanly efficient. The Survey has therefore endeavored to study the people and their reaction to the hos- pitals of Cleveland as well as the hospitals of Cleveland in their relations to the people. Several hundred interviews and conferences were held with physicians, including both members and non-members of hospital staffs; with nurses in hospitals and in public health fields; with social workers; with organizations of the foreign-born; with church workers; and with people met more or less at random in their homes or elsewhere. Those who are accustomed to hospitals too often fail to recognize how new and strange an experience, to the average patient, is his first contact with a hospital. The admission procedure, the unfamiliar antiseptic odors, the sight of many sick people, the precise business-like efficiency of hurry- ing nurses and doctors, fill many a patient with vague and uncertain ideas of what may be going on behind the many closed doors, and what may soon be happening to himself. Courage is easily lost in the strange insti- tutional atmosphere. The educated man who is familiar with hospitals, having previously been a patient or a visitor, and who is self-confident and at ease even during sickness, is in quite a different position from the un- informed immigrant who has never had contact with doctors or hospitals in his life, or the timid woman, or the sensitive child. It is not that hospitals or their personnel lack kindness in the treatment of the patients. It is their business to be helpful, and hospitals and their doctors, nurses, and other personnel generally are, but it is rather that hos- pitals are helpful in a professional and technical way, while the patient is generally full of worrying questions he would like to have answered, of fore- bodings which it would be desirable to dispel, of states of mind which depress him, and which, if maintained, will hinder his recovery. These forebodings 850 Hospital and Health Survey and these states of mind require not merely a general attitude of kindness, but sympathetic insight, clear analysis, and definite action to dispel. The human problem of the hospital patient can be perhaps best illustrated by the foreign-born. On the two Survey census days, 63.1 per cent, of the adult patients were American-born, and 36.9 per cent, were foreign-born. According tq the estimates in 1917, of the Cleveland Americanization Com- mittee, there were 744,728 total population in the city, of whom 231,939 were of foreign birth, 466,142 native born of native parents and 281,586 native born of foreign or mixed parentage. Those of the third group are largely children. Taking these figures, we find that the 231,939 foreign- born are 49.7 per cent, of the 466,142 native born of native parentage. This figure may be roughly compared with the percentage of foreign-born adults in the hospitals of Cleveland, which was just stated as 36.9 per cent. This illus- trates an important point which studies in other communities have verified — that the foreign-born adult generally uses the hospitals less than the American-born adult. This is largely because of lack of familiarity with an institution with which many immigrants had little experience, previous to coming to this country. It must be remembered that a large number of recent immigrants have come from small towns and many of them think, "Hospitals are places where you go to die." A considerable proportion of the foreign-born patients, moreover, speak little or no English. The attitude of the foreign-born toward the hospital reflects all the lights and shades of the hospital's own attitude toward its patients of foreign birth. Frequently the very human and impressionable surface which the foreign-born presents ready for the hospital's sign and seal, is masked be- hind an -enforced silence because of unintelligible speech. Too often the phrase "those ignorant foreigners" shows merely lack of understanding by the x\merican-born. A common language is the searchlight most useful in discovering physical, racial, or temperamental needs, and means of adjust- ing the hospital regime to treat these. When the hospital has given time and thought to its task, it has been able through sympathetic interpretation to convince the patient of its friendly interest, its ability in diagnosis, its skill in treatment, and when this conviction is made doubly sure by intelligent follow-up work in the home, there is every evidence that the hospital's work is worth while, that the patient is grateful and appreciative, and that the experience has been of permanent educational value to him in the matter of personal and public health and in the growth of a sense of social and civic participation. The result is different when the hospital has had no specific machinery for getting at the back of the foreign patient's mind, and making the some- what inflexible and mysterious hospital routine less a puzzle to him. The patient's mild skepticism as to whether American hospitals are good places for the foreign-born, increases to a large doubt. This is further enlarged by his friends, who have trouble in being understood at the inquiry desk; who may be unable to talk with the doctor or to get the diagnosis. If a medical case, the patient worries through a retarded convalescence and goes home glad to be free — and wondering! If a surgical case, often his climax of Hospitals and Dispensaries 851 protest against the vast unknown of Hospital machinery is a refusal to per- mit operation. He leaves against advice, grateful for the somewhat peremp- tory- discharge of the hospital, which in turn, feels inwardly affronted that its effort to help should be powerless before his unreasoning "stupidity." In seven hospitals the proportion of foreign-born adult patients was over 30 per cent., the maximum being as high as 47 per cent. No hospital in Cleveland has made any definite provision for interpreters, either as a matter of promoting the ease and comfort of the patient, or of increasing hospital efficiency. As a rule the hospital is concerned with "making the patient understand" — "We manage to make them understand somehow." Some other patient of the same mother tongue who has learned English is pressed into service, or an employe or a visitor is called upon. The prob- lem, however, is not merely "making the patient understand, " but is to render the patient "understood. " The following table, based on the average of the two Survey census days, showed an interesting phase, the contrast between the proportion of pay, part-pay, and free patients among the adult foreign-born and the American- born patients in the hospitals of Cleveland. Hospital Patients on Two Survey Census Days, Averaged American-born Number Percentage Pay 989 39.2 Part-pay 735 29.1 Free 733 29.1 Information not furnished 66 2.6 Total 2,523 1,474 The table indicates what one would expect, that the foreign-born show a much larger proportionate use of the free beds. The generally higher eco- nomic status of the American-born is doubtless sufficient explanation. One important relation of the hospital to the community is the furnishing of information about the condition of patients. Patients themselves want to know how they are getting on, and their relatives and friends likewise wish this information. Hospital staffs and administrators must use their dis- cretion in what they tell the patients or relatives, just as private physicians do, yet the hospitals often fail to give elementary and necessary information or to give it in a way which will be helpful or even useful. Many inquiries come by the telephone. A story has been reported of an immigrant family, very anxious to secure information as to the condition of the father who had been taken to a hospital after an accident. Unable to Foreign-born Number Percentage 351 23.8 444 30.1 631 42.8 48 3.3 852 Hospital and Health Survey speak English, the mother and her children had recourse to the neighbor- hood druggist. He called up the hospital ihree times, and was unable to learn anything that would either satisfy himself or relieve the "family's acute anxiety. The error was not inhumanity on the part of the hospital, for the information was later furnished readily, but was due to the fact that the telephone operator had not been taught to appreciate the importance of interpreting the hospital to the public. This incident would not be men- tioned were it not an illustration of many. i The importance of this duty is often not sufficiently clear to the hospital administration to make them provide adequate instruction to the person or persons who are responsible for answering such inquiries, either in person or over the telephone, or to cause the selection of a sufficiently trained and tactful person to perform this function. Sometimes a mother is eager to see her child frequently. There are often perfectly good reasons why she should not see the child at all or during certain periods, but not infrequently there is failure to explain to an anxious family why the privilege is denied. Interpretation of the hospital's work, rules and results to the public is part of the hospital's job. The public includes its own patients, their rela- tives and friends, and also the broader circle of the hospital's supporters, and any one in the community, in fact, who has a reason to be interested in the hospital's activities. This interpretation of the hospital's work, rules and results, is made partly in the hospital's formal reports and partly through its daily relations with its patients and those interested in them. Too little attention has been given to such interpretation through the channels of the hospital's routine contacts. The patient's lack of understanding of the hospital is too often matched by the hospital's lack of understanding of the patient. The patient can be greatly helped to understand the hospital by the right procedure at the time of admission. Hospitals which maintain dispensaries should use the dis- pensary as the means through which patients are admitted to the wards. The provision of a trained and tactful member of the social service depart- ment in connection with the admission desk of the dispensary will serve to start many patients, who will later be referred from the dispensary to the wards, with some understanding about hospitals in general and this hospital in particular. From this standpoint, the two critical points in the patient's hospital career are the day of admission and the time of or just before dis- charge. A considerable portion of patients are sent to the hospitals by charitable societies. On the Survey census days, it appeared that an average total of 201 patients, or 11.8 per cent, of all patients, had been admitted to hospitals at the request of some charitable agency. In the case of these patients, the charitable society stands to the hospital as an interested party. If its work with the patient and with the family is to be successful, it may need to know the physical condition of the patient, and the prognosis. It Hospitals and Dispensaries 853 is the duty of the hospital to cooperate with the charitable society by fur- nishing the necessary information, consistent with the interests of the in- dividual patient. The hospitals have not always met this responsibility completely or wisely, because of the same deficiency just mentioned, lack of a definite sense of responsibility for interpreting the hospital's work, and failure to assign a sufficiently trained and responsible person to the task. A considerable portion of the patients in some institutions come as in- dustrial accident cases, or are sent through a medical department conducted at some commercial or manufacturing establishment. The special report of the Survey on industrial medicine and hygiene (Part VII), deals with this matter, but in an industrial community like Cleveland its importance justifies mention here. The hospitals need to serve industry, and industry should support the hospitals adequately in return for service. What can the hospital do in relation to the difficult problem of the foreign- born who do not speak English? The calling in of paid interpreters is finan- cially impossible in most of the smaller hospitals. Moreover, no one inter- preter can speak every language and almost any language of western Europe is likely to be called for sometime. Few if any hospitals could afford even one full-time interpreter, or could manage to keep such a functionary busy with the particular patients whose language he could speak. The problem of hospital interpretation cannot be solved by paid interpreters employed by the individual hospitals. The chief practical recommendations to be made are these: If a hospital and its out-patient department are taken together, a sufficient number of patients speaking a given foreign language or group of related languages might come to the institution on an average day to justify and require the entire time of an interpreter, and the work in the two branches could be adjusted so as not ordinarily to conflict. The use of full-time in- terpreters, however, doing no other work, must necessarily be limited to very large institutions, such as the new City Hospital will be. Most hos- pitals which receive patients not speaking English should solve the problem of interpretation by depending on specially trained nurses or social workers or by calling in the aid of outside organizations interested in the foreign- born or of the foreign-born themselves. Hospital superintendents in engaging employes for certain positions should consider ability to speak certain for- eign languages as an asset and a reason for the engaging of a particular individual. Really good interpretation in securing medical and social his- tories and in meeting the patient's human needs while in the hospital, cannot be obtained by calling in an uneducated orderly. The main reliance should be upon nurses and members of the social service department who have a definite professional sense of responsibility for the hospital patients. In communities having a considerable number of foreign-born of any one race group, cooperation can usually be obtained from immigrant organiza- tions themselves. These organizations should be encouraged to serve as 854 Hospital and Health Survey visitors to patients of their own race who have not other friends and in help- ing with the more difficult and special cases in which interpretation is neces- sary and beyond the power of any employe of the hospital. Enough hos- pitals are now utilizing outside cooperation of this sort sufficiently to show that it is gladly provided by immigrant organizations (or by American immigrant welfare societies where they exist) without cost to the hospital and to the mutual benefit of both sides. Such an arrangement with immi- grant organizations would go a long way toward promoting general under- standing of the hospital by the people of that group in the community. These plans, however, cannot be effective unless some department of the hospital and ultimately some individual is definitely charged with organizing and keeping up the system of interpretation. Generally speaking, the social service department should be charged with this responsibility and some member of the staff of the department should be selected to carry out the responsibility who is especially qualified and interested. A hospital which has any con- siderable proportion of foreign-born patients should make a point of having in its social service department someone who is able to speak at least one of the foreign languages common among patients and who has secured special knowledge and training in the backgrounds and characteristics of several immigrant groups so that she is capable of fulfilling these duties. This will involve some inside work with various hospital employes, particularly nurses and other members of the social service department; the use of phrase books; the encouragement of various means by which nurses and social workers may secure knowledge about the backgrounds and characteristics of the chief immigrant groups. An effort should be made to interest internes in the same, and this should have the support not only of the hospital superin- tendent but of the chiefs of the medical staff. It should be made apparent that thus better histories can be obtained, better cooperation of the patient secured, and better medical results achieved. The critical moment for the patient, from the standpoint of disease, is often the time of admission to the hospital, but the critical time for the patient from his standpoint as a person is usually at or a little before dis- charge. In the discussion of the problem of convalescent care (page 000) will be found statistics indicating that a large majority of hospital patients leave the hospital needing some definite form of medical care, either in their homes, in a dispensary, or in an institution for convalescents. The information gathered in Cleveland agrees entirely with the studies and estimates of Dr. Frederic Brush, the leading national authority on con- valescent care, that the medical job is not done at the time the patient leaves the hospital. The hospital's responsibility as a hospital is not always to do this medical job, but it must link the patient with the physician, the dispensary, the convalescent home, or other organization which will perform the needed service. The beginning of this connection is the explanation to the patient (or to his parents, if the patient is a child) of the patient's condition, in terms that will be understood by the lay mind; of what need exists, if any, for further medical supervision; or of what daily routine of diet, hygiene, Hospitals and Dispensaries 855 exercise, and occupation is desirable during the period after discharge. Explanation to the patient or to those responsible for the patient, of the patient's condition on discharge and what may be called the needed pro- gram for after-care, is a definite responsibility which few hospitals in Cleve- land have met, save in exceptional instances. It is part of the hospital's responsibility to have a definite system for meeting this need. At a few hospitals there has been established a so-called follow-up sys- tem, usually modeled upon that of the American College of Surgeons. This aims to secure for the medical staff the results of operations or the condition of the patient at a certain period after discharge, such as three months, six months, or a year. Such information is of medical value to the staff, and in the long run will tend to the advancement of medical science and the improvement of service to patients. But the term "fish-up" instead of "follow-up" should be applied to a method which merely secures facts as to a patient's condition a certain time after he is discharged, and does not in some definite and effective way help to make the conditions during this period what they should be. A follow-up and not a fish-up system is the standard which should be set in a progressive community like Cleveland, which wishes to obtain 100 per cent, value from the medical work of the institutions which it supports. When it is found that six per cent, of £00 patients recently discharged from four of the leading hospitals needed continued hospital care — in other words, had relapsed since their discharge; when it is found that 12.5 per cent., in addition, were living under such home conditions that satisfactory convalescence was unlikely (See Table VII., Appendix), it is apparent that expensive hospital service is easily wasted because of the lack of a little fur- ther service which would have made all the preceding work permanently worth while. "Should the social service department have the responsibility for the problem of after-care?" Xo! The medical staff of a hospital have the responsibility for the care of its patients, and making a medical program for after-care is a part of that responsibility which cannot rightly or effec- tively be delegated. When it comes to carrying out the details of the work, the social service department has a definite place, as will be brought out more fully later in discussing this subject. The social service department can assist the staff of the hospital in securing the facts regarding the pa- tient's personality, family housing, home conditions, neighborhood, and finances, which in conjunction with the medical facts known regarding the patient's condition, will enable the responsible member of the staff to for- mulate a program for after-care. When it comes to assisting in carrying out the program, the social service department generally has been and usually should be called in, either to make explanations to the patient or to arrange for contact with the Visiting Xurse Association, the Department of Health nurses or a charitable society which will be able to exercise super- vision, to assist in improving home conditions or in securing the institu- tional care that may be required. As the facts in the section on convalescence bring out, the need for finan- cial aid during after-care is approximately much less frequent than the 856 Hospital and Health Survey need for explanation and advice., given in terms of the patient's degree of education and understanding, and of the practical conditions of his environ- ment. The dispensary attached to the hospital should be used as one of the means of providing after-care of discharged patients. Reference of the patient to the dispensary should be made in every instance where further super- vision is necessary and the patient cannot pay a private physician. The follow-up system should insure the actual return of the patient to the dis- pensary in a large majority of instances. In summary, the patient's lack of understanding of the hospital needs to be overcome by development of the admission procedure, which should be concerned with more than the elementary procedure of registration, assignment to a definite ward or room, and fixation or remission of fees, and which should include educational and interpretative elements. The special problem of the non-English speaking foreigner should be met at the time of admission, and later through some definite provision for interpretation, both by hospital personnel and through the cooperation of associations interested in immigrants, as above suggested. The utilization of the dispensary as the place of admission for ward patients will, if the dispensary admission system is rightly organized and its personnel rightly selected, enable the average ward patient to go into a hospital bed with some previous understanding of the situation. The hospital has a definite responsibility for interpreting the patient's condition to him or to those responsible for him, in terms which can be understood by laymen and which will be a practical help; also of explaining and of helping at least in the beginning in the needed program for medical after-care. This is part of the medical responsibility of the hospital, and while a social service department is of great assistance both in securing facts regarding the patient's personality and environment, and in helping to carry out the medical after-care or referring the patient to an agency which will do so, a hospital which has no social service department should still be responsible and be able actually to provide for at least the explana- tion to the patient or his relatives, and the definite reference of the patient to the needed sources of after-care. The medical staff of the hospital, through its executive committee, should be expected to define the duty of the hospital in this respect, so the administrators of the hospital can have medical authority behind them for seeing that this responsibility is carried out by visiting and resident staff, nursing and administrative assistants, and by the social service department if there is one. Answering inquiries regarding patients is a definite part of the hos- pital's duty to the community and should be fulfilled according to a defi- nite cooperative policy by carefully instructed members of the hospital's administrative personnel. Cooperation with charitable agencies in behalf of their patients is a particularly significant responsibility of the hospital, affecting no inconsiderable proportion of the ward patients. Hospitals and Dispensaries 857 In the long run, the degree of support of the hospitals of Cleveland will depend upon the degree to which their work is appreciated by the com- munity. The elaborate facilities, equipment, staff, and organization needed for the thorough study and treatment of hospital cases require an increas- ingly high degree of appreciation on the part of the community of just what hospital work is, what it requires, and what it costs. The foundation of appreciation is understanding. Anyone grasps the beneficent service of a hospital to the emergency accident patient, but understanding of the less obvious and more typical cases, which constitute the large majority of pa- tients, is not so easy. The patient's lack of understanding of the hospital is pardonable at the time of entrance. The patient's lack of understanding of the hospital at the time of discharge is a misfortune to the patient and to the hospital as well. Only on the basis of mutual understanding can adequate support for the best hospital work be built up and maintained in Cleveland. 858 Hospital and Health Survey THE MEDICAL PROFESSION AND THE HOSPITALS In the City of Cleveland the American Medical Directory of 1918 gives a list of 1,169 physicians, of whom 1,050 are stated to be in active practice. A tabulation of the staff lists of the members of the Hospital Council showed that 309, or 29 per cent, of the total were on the staff of a hospital or dispen- sary, while 71 per cent, had no such connection. Allowing for the small number of additional physicians on the staffs of the non-council hospitals, it is certainly true that two-thirds of the medical profession appear to have no connection with organized medical service. A similar comparison made about five years ago in Boston indicated that the proportion of physicians having a hospital or dispensary connection was about 50 per cent, larger. In New York, figures collected by the Public- Health Committee of the Academy of Medicine indicated that almost exactly 50 per cent, of the medical profession in New York were on hospital or dispensary staffs. Cleveland thus has relatively more physicians than either of these two cities who are not members of any hospital or dispensary organization. It is apparent that so far as membership on a hospital staff implies ad- vantages for the scientific study of disease, for the use of special equipment, and for consultation with specialists, the majority of physicians of Cleve- land have not these advantages. So far as membership on hospital staff gives control in the use of hospital facilities, tabulation of the Cleveland hospitals by number of beds and size of staff shows that about 25 per cent, of the medical profession have control of about 80 per cent, of the hospital beds. A patient may of course be admitted to a hospital at which his private physician is not a member of the staff, but if the patient is a ward case, the physician then loses the right to treat him. General complaint was made to the Survey during the first months of its work by physicians who were not on hospital staffs, that they often could not secure admission of their pa- tients to hospitals even as private cases, and of course they also complained of the many instances in which the patients were admitted to wards, when the care of the patients had to be resigned to the members of the regular hospital staff. A study of the sources from which patients were admitted to hospitals on the two Survey census days showed the following: Request for Admission Percentage By staff physician 51 .3% By non-staff physician 33 .2% By charitable or relief agency - 11 .8% Source not stated 3.7% Note — In this tabulation City Hospital, Warrensville Tuberculosis Sanatorium, and Rainbow Hospital are omitted, as admissions at these in- stitutions are on a different basis from those at general hospitals. Hospitals and Dispensaries 859 These figures appear to indicate that a considerable number of physicians not members of the hospital staffs may and do send their patients to the hos- pitals and treat them as private cases. It is quite evident, however, that a large number of the 1,050 practising physicians in Cleveland have little if any contact with the hospitals even in this way. There are wide variations shown in the proportion of patients admitted through non-staff physicians. The variation depends less on the size of the hospital than on the number and organization of its regular attending staff. Thus some of the small hospitals have relatively large staffs, and physicians not members thereof apparently rarely secure admission for their patients. On the other hand, some hospitals of similar size showed on the census days a high percentage of patients admitted by non-staff physicians — proportions ranging up to 83 per cent. - Figures for a group of large general hospitals may be of interest, as show- ing the wide variation found. These are shown in Table V. in the Appendix. Part-pay and free cases may be admitted through non-staff physicians, but are rarely treated by other than members of the regular staff. In the group of pay patients, on the other hand, there are a considerable number of private patients among the cases which are admitted through non-staff physicians and who then usually remain under their care. It must be recalled that these percentages relate only to the two census days, but there is reason to believe that the figures are representative of the usual relationships between the patients admitted through members of the staff and those admitted through non-staff physicians. The general attitude of a hospital toward the non-members of the staff is expressed by its admission policy. Most hospitals receive private patients and most hospitals have a rule that such patients are accepted, when va- cancies exist, from any reputable physician. In practice, however, it is rea- sonable and inevitable that the members of the officially appointed attending staff have the closest contact with the hospital and are likely to fill a consider- able proportion of its beds. When such shortage of beds exists as in Cleve- land, the difficulty felt by many physicians not on hospital staffs in secur- ing admission of their private patients is not more than may be expected. There has been no substantial evidence that the administration of the hos- pitals, year in and year out, has been unduly inconsiderate of the private physician of good standing who sought admission for his patient. Mem- bers of the official staff have received reasonable preference but this is only natural. Until more beds are available for private patients of physicians in privately-supported hospitals, present conditions cannot be expected to be radically improved. In a few institutions there has been found a practice, not formally recog- nized by rule, but real nevertheless — of holding beds vacant twenty-four hours or even more because certain members of the staff were likely to wish 860 Hospital and Health Survey to send patients in. A practice of this kind is unjustifiable, but is excep- tional in Cleveland. A study of the degree to which members of hospital staffs overlap revealed the fact that, except in the teaching institutions affiliated with Western Reserve University Medical School, there is no large degree of multiple membership on hospital staffs. Even in the case of University teaching at Lakeside, City, and St. Vincent's Hospitals, there is little actual overlap- ping of the staffs. The number of men holding positions in the staffs in one or more hospitals in Cleveland is shown in the following table: Multiple Membership on Hospital Staffs 233 physicians, or 22.2% of total number, serve on 1 hospital staff 55 " " 5.2% " " " " " 2 " staffs 15 " " 1.4% " " " " " 3 " 5 " "0.5% " " " " " 4 " " These memberships, however, include some inactive as well as active memberships. In general, active membership in more than one hospital staff is not wise, except in the case of multiple membership held for teaching purposes or in the case of men who are engaged in restricted specialties of medicine or surgery and can render these special services to a number of institutions with benefit to all. Of the 42 members of the City Hospital staff, 26 are nominally active members of other hospital staffs. This, how- ever, is a teaching institution. The instances in which a physician is carry- ing several active memberships in hospital staffs in Cleveland are propor- tionately small. Some of these individual instances, however, are worthy of notice, and the Survey, in its reports to the several boards of trustees, has called them to the attention of the individual hospitals concerned. A position involving active service in one hospital ought to be sufficient for a physician and it is wiser for his attention to be concentrated on this institu- tion than to be divided among several. Multiple membership, therefore, with the exceptions noted, should be discouraged. In connection with Western Reserve Medical School, the following figures are of interest. 331 of the 1,169 listed physicians in Cleveland are graduates of Western Reserve University Medical School — 28.3 per cent, of the total. Of the 309 staff positions in the hospitals and dispensaries of Cleve- land, 75, or 24.2 per cent, are held by graduates of Western Reserve Uni- versity Medical School. It will be seen that the proportionate number of positions held by graduates of this medical school is somewhat smaller than the number of graduates of the school among the medical profession as a whole. It should be added that in the hospital and dispensary positions 31 in addition to the 75 just named, are held by members of the medical school faculty who are themselves graduates of other schools. This gives a total of only 106 out of the 309 hospital and dispensary staff positions which are held by graduates or members of the faculty of Western Reserve Medical School. Hospitals and Dispensaries 861 In connection with the so-called "democratizing" of hospital facilities for the medical profession, it should be pointed out that no hospital can be satisfactorily managed without a definite official staff. A medical boarding house, as previously defined, is merely a nursing home in which physicians treat private patients. Any hospital which endeavors to maintain a medical organization, equipment, and personnel, for diagnosis and treatment, must have some medical authority appointed, to be responsible to its managing body. A number of the proprietary hospitals are maintained by one or more physicians who conduct them as their own enterprises, and who are medically as well as financially responsible. The public service hospital with a board of trustees or other disinterested governing body, must appoint an official attending staff. The functions of this staff are not only the care of patients, excluding such patients as are admitted specifically as private patients of non-staff physicians. Its functions also include the determination and main- tenance of the standards of medical practice which shall be observed in the institution. A medical staff of a hospital should not be merely a group of individuals each of whom has a certain ward or number of beds under his charge, for a year or part of a year, but it is or should be an organization — a group of physicians representing different branches of medicine and sur- gery, organized for the joint practice of medicine with the equipment and facilities provided by the hospital, defining and maintaining the profes- sional standards and policies which shall be effective throughout the insti- tution. In some hospitals the medical staff does not fulfill these functions ade- quately. It does not set clearly defined standards which govern the practice of physicians in the institution. Thus in the matter of record keeping, there are a number of hospitals in which fairly accurate and complete records are kept upon ward patients, showing that physical examination was made, laboratory tests performed, and that careful notes were entered at the time of operation or during the course of the patient's treatment. In the same institution, the records of the private patients of physicians may be limited to identifying or financial data, and have almost no medical information of significance. Such a hospital has not maintained (so far as the records show) the same standard of care for private patients as for part-pay or free pa- tients, who come under the charge of the hospital's attending staff without remuneration. Records are not always a complete index of the degree of care actually provided, yet there can be no doubt that particularly in the matter of laboratory tests and consultation with specialists, part-pay and free cases in many hospitals receive more thorough study than do many private patients. Greater privacy and more intimate personal relation of the patient to the family physician are maintained for the private case as a possible counter-balance. In proportion as the general public and trustees of hospitals appreciate that a modern hospital should not be a medical boarding house in whole or in part, but a medical organization in which the best resources which the hospital has to offer in equipment or personnel should be made available for every patient in so far as he needs them, hospital organizations and hospital procedures will be uniform for all classes of patients, private, part-pay, and free. Patients and physicians alike will profit by such a policy. 862 • Hospital and Health Survey With these principles in mind, there have been appended to this chapter certain details which supplement the general principles of hospital organ- ization stated in the section on Organization for Service. The organization of the medical executive committee is for the purposes (a) of providing the medical staff with a small group which will enable it to conduct the routine business of its organization, formulate hospital standards and policies,' and make arrangements for the monthly staff meetings; and (b) of providing* a group for regular conferences with the superintendent of the hospital, and, from time to time, conferences with representatives of the board of trustees, to assist in administering the hospital satisfactorily. The provision of an auxiliary staff is believed important, particularly in view of conditions such as those of Cleveland. It is highly desirable that the number of physicians having some connection with hospital staffs should be increased. On the other hand, it is essential that active attending staffs of every hospital be not so large, in proportion to the number of beds, is to be unwieldy or incoherent. Otherwise standards of service are likely to suffer. The organization of an auxiliary staff provides a means of recognizing in a definite way physicians who are utilizing the institution for their private patients or for consultation purposes, and for giving such physicians a definite channel through their delegates whereby they can express themselves to the official staff or to the hospital trustees. Beyond such machinery of organization, other means exist for opening the facilities of Cleveland hospitals and dispensaries to a larger proportion of the medical profession. It is not only in connection with the surgical operation upon a patient, but also in the medical treatment of acute cases, that physicians need the advantages of the diagnostic equipment of hospitals and dispensaries, and of the skill of specialists on their staffs. The labora- tory, the X-Ray department and other diagnostic equipment, and the service of specialists need to be utilized by the private physician in behalf of his patient. To make the splendid equipment and personnel of Cleveland hos- pitals available for diagnostic purposes to the medical profession of Cleve- land on a large scale is one of the chief goals to be sought for. This must be worked out in practice largely through the increase of dispensary service in the form of diagnostic clinics, to be available for consultation purposes for non-staff physicians. More detailed reference to this is made in the succeed- ing chapters on dispensaries. The enlargement of dispensary service which Cleveland so greatly needs would provide opportunity for a considerable number of physicians to come into close contact with hospital work, as dispensary staffs should be organ- ized in intimate relation with hospital staffs. (See page 846.) The medical advantages of facilities for diagnosis, of consultation, and in general, of intimate contact and co-working with other progressive physicians could be opened to a very large number of physicians not now on the staffs of Cleveland medical institutions. The approximate proportion of physicians connected with hospitals and dispensaries in Cleveland ought surely not to be less than in New York (about 50 per cent.) which would mean the addi- tion of 200 or 250 physicians to the staffs. If dispensary service in Cleveland Hospitals and Dispensaries 863 is developed as it should be during the next few years, this result may be measurably achieved. There are certain groups in the medical profession who feel that their opportunities in the medical institutions of the city are specially limited. Interviews with a number of foreign-born physicians revealed a consider- able feeling that they "hadn't had a chance." A list of 63 foreign -born physicians in Cleveland, furnished by one of the organizations interested in immigrants, is probably considerably less than the actual number. Many of these physicians have a large practice among groups of immigrants and their children, who constitute a considerable proportion of the population of Cleveland. Only nine of these 63 physicians were found to be on the lists of any of the hospital staffs. The foreign-born physicians of the more recent groups of immigrants, such as the Slavic and Italian peoples, are practically unrepresented. It may be felt by many that such a condition will tend to take care of itself with time. However, the unstimulated move- ment of "time" is too slow. A definite effort should be made to give recog- nition on hospital or dispensary staffs to physicians of good standing who are of foreign birth or descent, particularly in institutions which number among their patients large numbers of the foreign-born. As has appeared in the section discussing "The Human Problem of the Hospital Patient," (pages 849-857), a number of the hospitals fall into this group. There is unusual value in dispensary service rendered by well-selected physicians of this type. Physicians of the Negro race constitute a small but definite group whose opportunities to work in medical institutions of Cleveland have been greatly restricted. There are said to be 19 Negro physicians in Cleveland. One of these men is on the dispensary staff of Lakeside Hospital. Representa- tions made to the Survey by physicians and laymen of standing among the colored people of Cleveland are to the effect that the negro physicians and the negro people feel the deprivation brought about by lack of member- ship on the staffs of hospitals and dispensaries. The problem can be dealt with only in one way, by determining that appointments shall be based solely upon merit. It is a fine testimony to the spirit and policy of the hos- pitals of Cleveland that so far as negro patients are concerned, there has been absolutely no complaint by the Negroes about discrimination. The establishment of a special hospital for colored people is believed to be unneces- 1 - sary and undesirable. Perhaps the most important relation of hospital and dispensary to the medical profession is their educational function. The hospital and dis- pensary represent to the physician an opportunity to raise the practice of medicine to a higher power because they bring under his command the use of equipment, the organized professional skill of specialists, and technical assistance such as are very rarely available in private practice, and then only to the rich. The educational function of the hospital and dispensary is only 7 in part exercised through medical schools. The teaching of a medical school like that of Western Reserve University depends in a large measure upon the 864 Hospital and Health Survey hospitals and dispensaries which are affiliated with the school. Under- graduate teaching is and in general can most advantageously be limited to a few selected hospitals. The development of post-graduate instruction under the medical school in the general and special branches should pro- ceed at a rapid rate in the near future, and should involve the use of a con- siderable additional number of hospitals and clinics. The actual value of the hospital as a place of advancing medical science and of the skill of the local profession depends of course largely upon the use made of the advantages offered. Decidedly one of the most important means of self-criticism which a member of a hospital staff can have is the autopsy. Definite knowledge concerning the disease which caused the death of a patient can very frequently be obtained by autopsy as in no other way. It is disappointing to find that according to reports received by the Hospital Council during the year 1919, only 456 autopsies were performed. Reports from some hospitals were a little indefinite, and the true number might have been slightly larger. The figures and details are shown in the following table. Autopsies Performed in 1919 in Certain Hospitals City (approximately) 209 Mt. Sinai _ 50 Fairview. Provident Glenville 1 St. Alexis .number unknown Grace number unknown St. Ann's 20 Huron Road 5 St. Clair 1 Lakeside 110 St. John's 20 Lakewood number unknown St. Luke's _ 5 Lutheran St. Vincent's 27 Maternity 8 Woman's Total - 456 Such a low percentage can only mean one of two things — either failure on the part of the medical staff to appreciate the importance of autopsies, as a real checking up of results, and setting a real standard of self-criticism and self-improvement, or on the other hand, a lamentable deficiency in administration, in failing to endeavor, in each case of death, to secure if possible consent for autopsy from the family of the patient. Experience in many hospitals in other communities shows that it is necessary to fix re- sponsibility upon some definite person for each branch of service, usually on the senior resident or interne, for securing permission. Compliance with the spirit as well as with the form of the standards of the American College of Surgeons demands that the medical profession for its own sake show better results in the future in securing autopsies in the hospitals of Cleveland. It is recognized that the public needs education to understand the great value of autopsies, not only for the physician, but in the long run to improve the treatment of every patient. Percentage of opsies Deaths autopsies to deaths 209 861 24.3 110 320 34.4 50 188 27.1 27 331 8.2 Hospitals and Dispensaries 865 It is particularly interesting to observe that the three teaching hos- pitals (City, Lakeside, and St. Vincent's), together with Mount Sinai, show 396 autopsies out of a total of 456. Taking these four hospitals, the number of autopsies compared with the number of deaths is shown in the following table. It will be observed that the best showing made is of only about one-third of deaths autopsied, and that the average even of these hospitals i s less than 25 per cent. Autopsies and Deaths, Compared, 1919, in Four Hospitals City Lakeside Mt. Sinai St. Vincent's Totals 396 1,700 23:3 Beyond the formal courses recognized as such under the medical school, however, the broader educational function of the hospital and dispensary ought to be fulfilled. Monthly staff meetings for the discussion of cases, review of hospital statistics, and of the result of operation or treatment, are valuable means whereby the physician and the hospital are stimulated, and the service of the institution is advanced. The participation of an auxiliary staff should be of much educational value. The daily contact of physicians with one another in the clinics of the dispensary and in the wards is a less formal but no less effective means for development of knowledge and skill. Finally, the opening of facilities for diagnostic service to the physicians of a community on a broad scale, through diagnostic clinics, and larger pro- vision for treatment of private patients, should serve to render the medical educational functions of the hospitals and dispensaries effective over a much wider range and to a more profound degree. Medical Staff Organization* (a) The members of the Medical Executive Committee should include the chiefs or representatives of the division of medicine and surgery, one or more representatives of the specialties, and a representative from the assist- ants or junior members of the staff. (b) The Medical Staff should establish standards of hospital practice in all departments, including laboratories, X-Ray department, etc. All Medical Staffs should take official action by resolution or pledge in the matter of fee splitting. No member of the Medical Staff should hold mem- bership on the Board of Trustees. Privately organized hospitals with *By W. L. Babcock, M. D. Reference should be made to pages 845-848, to which this is a supple- ment. 866 Hospital and Health Survey Boards of Trustees consisting of medical men should reorganize by arranging for the appointment of a lay Board of Trustees, the physicians interested in the hospital organizing into an Attending Staff. The senior Attending Staff physicians should hold active staff membership in one hospital only. This restriction should not apply to members of the staff engaged in university teaching, or to specialists with limited services, or in small hospitals to clinical assistants. (c) The following additional committees will often be found useful: Library Committee. Resident House Staff Committee. Hospital Records or Program Committees. (d) Provisions should be made for the recognition of non-staff physicians by permitting the use of a limited number of hospital beds under the general supervision of the Chief of the Medical Staff through Chiefs of Departments. It should be recognized that the so-called open hospital is a powerful factor in preventive medicine, a post-graduate school for the general practitioner, and a great influence towards his professional elevation. The practice of non-staff physicians in hospitals should be regulated, scrutinized and carefully supervised by the Executive Committee. (e) The stand taken by the Cleveland Hospital Council to the effect that all hospital bills should be paid before the Attending Physician or Sur- geon collects his bill is to be commended and should be made a rule in every hospital. (f) At least ten staff meetings should be held annually, at monthly intervals, excluding July and August. As many more may be called as are deemed necessary. The Executive Committee should meet monthly or oftener. Regular Staff Meetings should be 90 per cent, clinical. Routine business should be abbreviated and parliamentary discussions avoided, except on important matters of staff or hospital policies. Provision should be made by the Record Committee, or otherwise, for review of clinical records. Reports of unusual or interesting cases should be presented for group dis- cussion, together with results of original research work carried out by indi- vidual members of the staff, or the hospital laboratories. It is also desirable that arrangements be made to serve light refreshments after these staff meetings, which must, of necessity, be held in the evening. It has been shown in at least one instance where this program has been carried out for years that the percentage of staff attendance has averaged 75 to 80 per cent. Hospitals and Dispensaries 867 of staff membership and has exceeded, by several hundred per cent., the attendance at regular meetings of the County Medical Society. Attention is called to the recommendations of the American College of Surgeons as to program for staff meetings. The Associate, Auxiliary and Resident Staffs should meet with the Attending Staff at their monthly clinical meetings. 868 Hospital and Health Survey FINANCES AND ADMINISTRATION To maintain the 21 institutions which are members of the Cleveland Hospital Council cost nearly three million dollars during 1919. About 97 per cent, of this was for hospital care and %Yl to 3 per cent, for dispensary service.* This $3,000,000 represents about 700,000 days of hospital care given, and 120,000 dispensary visits. It represents service to probably 80,000 different individuals. In other words, these hospitals and dispen- saries care for one person out of every twelve in the population of greater Cleveland, and cost about $3.07 for each member of the population. Only a fraction of this cost, however, is a net charge upon the community, for as the third column of Table VI. indicates, the operations of the institutions yielded a very considerable portion of the necessary income. Over two-thirds, in fact, of the expense of the non-municipal hospitals i s repaid by fees from patients and by other earnings. The other third, or between $600,000 and $650,000, has to be provided by interest on endow- ments, by legacies and gifts from the public. Taxation must provide for the municipal institutions to approximately the same amount. It will be ob- served that in these figures relating earnings to expenditure, only the non- municipal hospitals are considered. While there are some earnings in the municipal institutions, they cannot fairly be compared with the other hos- pitals in this respect. The non-municipal hospitals bring upon the public an annual charge of approximately $460,000, after deducting from the total expense the earnings from patients and the amount available from endowments of various sorts. This figure is the estimate for the year 1920, as presented to the public in the Community Chest campaign of November, 1919. The City Hospital, to- gether with Warrens ville Tuberculosis Sanatorium, required in 1919 an appropriation of $625,656.92 from taxation. Adding together the cost for the municipal and the non-municipal hospitals, we find that $1,086,000 is the approximate amount required to maintain the hospitals and dispensaries of Cleveland, in annual contributions by the public or "voluntary" taxation, taken together with legal or compulsory taxation. This is about $1.30 for every man, woman, and child in the city of Cleveland, or about $1.10 per head if the larger metropolitan area which these hospitals serve is taken into consideration. Parenthetically, it should be noted that these figures do not include the cost of the dispensary "Health Centers" maintained by the Division of Health, the cost of the city physicians who care for the sick in their homes, or any of the other expenses of the Division of Health. In the main, the bulk of these vast sums goes for the care of sickness. The total amount expended for education in hygiene and for the prevention of disease is only a fraction of this amount, the expenditure for the Division of Health being less than 50 cents per capita. Expenditures for hospitals are necessary ♦The cost of the dispensaries is not accurately stated in several of the hospital reports, and the above figure is therefore an estimate, merely. Hospitals and Dispensaries 869 and desirable under present conditions, but one may look forward to a day when the proportion between the expenditure to cure illness and expenditure for prevention will not be so heavily weighted against the preventive measures. The cost of hospital service is more accurately expressed in terms of the unit previously defined; namely: average cost per day of care. As will be seen at the foot of Table VI., this average cost for a large group of the non- municipal hospitals was approximately $4.39 in 1919. Hospitals have felt keenly the high cost of living, more heavily in fact than most institutions, because of the large proportion of their expenditure which goes for food, drugs, and supplies of all kinds, which have especially increased in price during the past few years. The public has not appre- ciated how expensive good hospital service must now be. When individual hospitals are compared, the average cost stated in their reports for the year 1919 varied from $2.00 to $5.62. This range is doubt- less too wide, in that it is not believed the lower rate is a true representation of the cost of any hospital. Accounting systems have not always been de- signed so as to charge to annual maintenance all the items which should properly be so entered. It is not believed at the present time that any mem- ber of the Hospital Council is maintaining service at a rate less than $3.00 per diem, and this figure is too low to render adequate service under present conditions. A general hospital properly equipped should expect a per capita cost of fully $4.00 per diem. When a hospital is rendering an unusual grade of service or is conducting medical teaching or research, a. cost of $5.00 a day need not excite objection. In general, the average cost of a day's care, or the so-called "hospital per capita, " must be used with great caution as a basis for either commendation or criticism. It must be known how the per capita cost is made up — whether for instance a low per capita is due to undue crowding, whether a high per capita has been due to a small number of bed days care given because of tem- porary lack of demand or enforced closing of certain wards or rooms, or whether a high per capita is due to unusual quality of service, or on the other hand to uneconomical administration, or again whether a low figure may be accounted for by careful, economical administration, or else by the lack of the proper facilities. As a rule, many different elements must be known and considered before forming any judgment as to the significance of a given per capita cost. The average for the city as a whole is of considerable general interest, particu- larly in view of the need to call public attention to the expensiveness of modern hospital service. The fact that hospitals have been generally charging ward rates (at least until very recently) as low as $2.00 per diem is a little misleading. The average person has somehow taken for granted that if a patient paid the so-called ward rate, the hospital's cost was met. This is far from the truth. Ward rates have generally been put far below cost, and in recent years, most of the hospitals of Cleveland have failed to raise ward rates to correspond with the increase in expense. This has been 870 Hospital and Health Survey due in considerable measure to a desire not to levy a tax upon the sick and suffering, or to make known rates which might keep needy patients from the hospital doors. Time was when hospitals were thought of as charities for the destitute, but at the present time, hospitals are public services receiving the well-to-do and middle classes as well as the poor, in varying proportions. The general public should be brought to the point of understanding that hospital ser- vice ought to be paid for at its cost by those who are able to pay, and that room and ward rates should be adjusted with respect to cost of service. Considering the fact that a hospital of the public service class often has an endowment, it should be expected that the income from the endowment will go to help make up the difference between the cost of service and the earn- ings from operation. A deficiency will be due partly to the fact that the ward rates are put at less than cost, and partly to the fact that many patients should be and are accepted who cannot pay even these rates. As a general principle, ward rates ought to be fixed somewhat below the cost of service, but not very much below. It is believed wise that at the present time the hospitals of Cleveland should not announce rates for ward service at less than $3.00, and in many hospitals or in some divisions thereof, ward rates may be $3.50 a day. The naming of these rates in no case should imply that patients unable to pay them in part or able to pay nothing should be refused admission. A hospital cannot expect financial support from the public unless it makes the patient's need and not the patient's means the basis on which service is offered and rendered. In the following section of this Chapter (pages 877-889) Dr. W. L. Bab- cock has outlined a large number of highly practical suggestions and recom- mendations regarding administration. Many of these relate to finances. It is only fair to point out that the Cleveland Hospital and Health Survey, despite evident eagerness on the part of all members of the Hospital Council to cooperate, found it no easy matter to secure many of the fundamental financial and statistical figures from a number of hospitals. There was no- where lack of willingness, but the accounts had not been kept with a view to critical self -analysis. Methods of hospital cost accounting have been pretty thoroughly worked out during recent years. Many smaller hospitals feel that they cannot readily maintain the trained book-keeping staff to carry out a cost account- ing system. The extra time required by such a system and the extra expense involved seem too much, and the hospital is likely to go without. In the long run, good cost accounting is a money saving enterprise. It points the way to more economies than its own maintenance costs. It also helps in fixing rates so that they bear proper relation to cost, and tends to increase income where income needs to be increased. The needs of the smaller hospitals can be met only by some cooperative enterprise. The Welfare Federation should establish an expert accountant service, available to any of the Cleveland Hospital Council members, for Hospitals and Dispensaries 871 service in the administration of proper accounting systems and for advice periodically or whenever necessary in its maintenance. Such a plan would make available to all hospitals a grade of accountant service which few if any could afford to maintain alone. The plan would have the further great advantage of enabling uniform financial reports to be periodically rendered to the individual boards of trustees, to the central budget -making authori- ties of the Welfare Federation and to the public, which in the long run foots the bills. In matters of financial as well as medical service, trustees need to de- termine exactly what figures they need to have presented to them in their annual or monthly reports, in order that they shall know all they need to know regarding the work of the hospital. The central accounting system proposed would be of great constructive value to every board of trustees, not only in furnishing information, but in helping them to see what infor- mation they need to have furnished. An X-Ray department, for instance, is very expensive to maintain in terms of gross expense, but in many hos- pitals a considerable proportion of the X-Ray work is for patients who can pay a fair fee, so that the net expense of maintaining the department is not large. In a hospital doing a large proportion of its work for patients who can pay few if any fees, conditions are different, but in any hospital, proper ac- counting will show just what the X-Ray department costs, just what ratio the income derived from it in its different classes of work bears to the expense thereof, and the trustees will be able to judge at the end of a month or a year how much net charge this service brings according to the character of work and service rendered, and the rates which patients can reasonably be expected to pay. Perhaps the most fundamental need for trustees is to appreciate that hos- pitals are public services in the broad sense of the word. Two more or less opposite conceptions have dominated hospitals: (1) that represented in its extreme form by the proprietary hospital treating private patients where financ'al return from the patient is largely used in determining his accepta- bility, (2) the charitable corporation in the old sense of the term, according to which hospitals are regarded as rendering benefits to the helpless who neither can or should be expected to make any financial return. At these two extremes we would find hospitals serving private patients only, and hospitals serving only the poverty stricken and the destitute. The outstand- ing development in the relation of hospitals to the community during the last decade or so has been the increase in hospital demand by persons of the middle classes, the self-supporting families of moderate means in fairly comfortable financial condition but with no large property holdings and no large annual margin of income over expenditure. These so-called middle classes are more and more finding that it is better to go to the hospital than to be treated at home in serious illness, surgical operation, or for maternity care. Much testimony has been received in Cleveland that there is great de- mand for beds for these middle classes. Beds are demanded in private rooms or more particularly in two to four-bed rooms or small wards, where fees 872 Hospital and Health Survey will be moderate and service excellent but not of what may be called the exclusive type. The hospitals of Cleveland face such large financial obligations in view of the high cost of living that much anxiety has been felt by many trustees in looking forward to the future. Generous public support for the hospitals through the Community Fund or in other ways is indeed necessary, but the enlargement of the hospital facilities of Cleveland, particularly in providing more fully for the middle classes, will assist the hospitals financially by rendering a larger proportion of their services of a self-supporting nature, and thus help in carrying a general overhead which in itself is a very consider- able part of modern hospital expenditure. The Cleveland Hospital Council is to be, congratulated for having re- cently secured from the Industrial Commission of Ohio, a more satisfactory recognition of the hospital's service to industrial accident cases. In Ohio, as in many other states, the establishment of workmen's compensation took place without adequate recognition of the large part that hospitals and dis- pensaries would need to play in its successful administration. Industries and insurance companies found that prompt and competent medical assist- ance to men who had met with industrial accidents was not only humane but was good business. The promptest possible return of the employe to his work stops the weekly payments and saves more money than it costs. There are no theoretical or practical reasons why hospitals which are sup- ported by the community as public service enterprises should render any service to industry for less than the service costs, when under the very foun- dation principles of workmen's compensation, the industry is supposed to be paying the full amount of the bill for industrial accidents.* Hospitals supported by the community must necessarily receive and care for many patients who are properly public charges of the city or county or of some other county. It is fair and desirable that hospitals be reimbursed for the care given patients who are proper charges upon the public. Since the city of Cleveland maintains its own hospital, the City Hospital is natur- ally the first place to which such patients should be sent, but because of emergency or other reasons, other hospitals will necessarily receive cases which are charges upon the city or county. The law as recently amended renders it proper for the Commissioners of Cuyahoga County to reimburse institutions furnishing care to persons who are public charges. f It is be- lieved that the following principles should govern the administration of this provision : 1 . A policy of paying privately owned and supported institutions for services such as the care of the dependent sick, which is a public function and a means of preventing disease and dependency, instead of providing adequate, publicly owned and operated hospitals out of the general tax rate of the city, is essentially unsound and should be condemned as •Through the efforts of the Hospital Council the State Commission adopted the principle of "hospital cost for service rendered" on July 1, 1920. fThe Hospital Council has already negotiated with the County Commissioners on this subject and negotiations are encouraging. Hospitals and Dispensaries 873 offering temptations to the political use of public monies, and as contrary to the spirit of municipal government. 2. Notable instances of abuse of the practice of subsidizing private hospitals and other privately owned institutions are to be found in the recent history of the state of Pennsyl- vania. In certain cities, however, notably Detroit, Michigan, and New York City, pay- ment to private institutions for the care of public charges has served a useful purpose and has been honestly administered. 3. Only as a temporary expedient and under strict and exact determination of the quality and quantity of services rendered for which payment is made can such a practice be approved for the city of Cleveland. 4. With the city definitely committed to the construction and maintenance of a modern City Hospital, the facilities now under consideration and agreed to by the private hospitals can confidently be expected, if carried out, to offer relief for approximately the next twenty years on the basis of the estimated growth of Cleveland. 5. Without urging the point to the extent of asking for any public declaration or commitment by the Hospital Council to a policy, it is thought by the Survey that agree- ment should be reached by the hospitals in the Hospital Council to apply funds for the extension of their facilities for part-pay patients equal in amount to the sums received in the year from the County Commissioners. It is particularly the responsibility and privilege of the privately owned hospitals to meet the need of the patient of modest means who expects to pay part, if not the whole cost of hospital care. County payments for the care of the dependent sick should be a resource for increasing part-pay bed capacity and should not be accepted merely as a relief from the burden of raising funds for meeting current expenses. 6. With the understanding that the full influence of the Hospital Council collectively and through its component institutions will be used to accomplish the two objects men- tioned in 4 and 5 above, and in the belief that the necessity for County payments to pri- vate hospitals should cease when adequate provision for the dependent sick is made in publicly owned and operated hospital or hospitals, the Survey endorses the proposed system of contracts with the County Commissioners under the following conditions: namely, that payments by the County Commissioners to hospitals with which they make contracts shall be made only for services of an approved quality, provided for a definite period of time and for specified individual patients who have been shown to be entitled to public relief after investigation of their home or economic condition by representatives acting under the orders of the County Commissioners. 7. Inasmuch as the County Commissioners cannot, without amendment of state laws, employ from public funds investigators to ascertain the quality of services given to patients or to verify claims of hospitals and patients that such and such individuals are proper objects of public assistance, it is suggested that the Hospital Council request the Community Fund to put at the disposal of the Welfare Federation such amount from the unassigned funds as may be needed (tentatively estimated as $5,000) to employ trained social investi- gators to be put at the disposal of the County Commissioners for the purpose above de- scribed. 874 Hospital and Health Survey 8. It is suggested that the Hospital Council bind its members by mutual agreement to enter into contract with the County Commissioners only on the basis of the conditions suggested in 6. The hospitals of Cleveland are in a fortunate position compared with those of most cities, because of joint financing through the Community Fund. The needs of many institutions are brought before the public at a single time in a forceful impressive way. Mutual relationship among hospitals and a better understanding of the broad needs of the community are cer- tainly promoted also. None the less does the work of each hospital need interpretation to the public which supports it financially. There is in- deed a more definite demand for accurate and comprehensive financial re- ports under such a system as exists in Cleveland, since the central financial and appropriating committees of the Welfare Federation are in a position to scrutinize the financial reports of each hospital much more closely than the average contributor will in communities wherein each hospital raises its funds independently. An added stimulus is thus applied toward economy and toward careful financial and book-keeping systems. All the more do the hospitals of Cleveland, particularly the smaller ones, need expert ac- countant service to enable them to work out their book-keeping and their financial reports in the best way. The Purchasing Bureau of the Cleveland Hospital Council is a distinct and notable achievement, indicative of the spirit of cooperation in com- munity enterprises which is characteristic of Cleveland. Through the Pur- chasing Bureau more economical and satisfactory buying of standard hos- pital supplies is made possible. Each member of the Council is thus pro- vided with the services of an expert in buying, who is devoting his entire time to studying markets, making contracts and assisting the hospitals to get the best and the most for their money. It is to be regretted that the use of the Bureau by a number of hospitals has not been as large as it should be. If the purchases of the hospital for all kinds of supplies be taken, and the amount of purchases made in 1919 through the Purchasing Bureau, be expressed as a percentage of this, we have a certain index of the degree to which the hospital has taken advantage of this measure of economy. It is found that the percentages of utilization by the different hospitals were as given in the following table : Hospitals and Dispensaries 875 Proportionate Use of the Central Purchasing Bureau of the Cleve- land Hospital Council Proportion of Maximum* Hospital Purchasing Possibility- Cleveland Maternity l/z Fairview Park.... Less than l/3 Glenville... ..Approximately 4/7 Grace l/6 Huron Road... l/8 Lakeside Maximum Lakewood ....1/13 Lutheran.... ._ ..1/25 Mount Sinai Less than l/3 Provident...... __l/l2 St. Alexis _. l/20 St. Ann's .3/8 St. Clair l/5 St. John's...... l/5 St. Luke's .....About 1/4 St. Vincent's. l/l7 Woman's Approximately l/5 Most hospitals find it convenient to make some purchases independently from time to time, because of the unusual character of the article to be bought or because of the haste with which it must be secured, but given efficiency on the part of the Purchasing Bureau, these objections should be reduced to a minimum. Furthermore, it is obvious that the more fully the Bureau is utilized, the larger will be its purchasing power and the better terms it can make. Doctor Babcock's recommendations regarding the Bureau (pages 882-885) are very pertinent and practical. In this as in helping the hospitals to save money by getting the largest discounts for cash (page 879— section on "Practical Matters of Ad- ministration") the Welfare Federation is in a position to make the money contributed by the public go further than it now does. Hospitals are likely to benefit by taking advantage of every opportunity for expert assistance in any of their many special lines of activity. The School of Pharmacy of Western Reserve University, for instance, is in a position to offer assistance to the hospitals of Cleveland that would be of great benefit in two ways: enabling the hospital to render a higher type of *In 1919 Lakeside Hospital made practically all of its purchases, amounting to exactly one-third of its operating expenses, through the Central Purchasing Bureau of the Cleveland Hospital Council. That figure has therefore been adopted as the maximum purchase percentage, and the purchases of other hos- pitals have been figured on this basis. 876 Hospital and Health Survey service to the public, and lowering the cost of medicines to the hospitals. For a description of the proposed service, see the section on Pharmacy, in Part VIII. Such a plan would take at least a year to perfect, but its value to hospital service should be self-evident. Hospital financing and hospital administration have become technical matters. At best, the average layman is not concerned with or even inter- ested in their details. It is of the greatest importance, however, that the hospitals of Cleveland shall not lose their individuality because of joint re- lations through the Welfare Federation and the Cleveland Hospital Council, and that the work of each hospital as well as of all hospitals taken together shall be properly understood by the public. To take technical reports of income, expenditure, and service rendered, as prepared by the hospital for the use of its trustees, the Cleveland Hospital Council, and the Welfare Federation, and to utilize these reports as the basis of an account of hospital work in which the whole community will be interested, is the duty of a "publicity man." The publicity men and the Welfare Federation which provides publicity service, should constantly bear in mind that the public needs to be helped not only to understand what hospitals do, but that their work is costly and why this is so. Comparisons of the present cost of hos- pital care with the cost in former years will be useful if so presented as to bring home to the reader that the added cost is not only because of higher price levels, but means also a higher quality of service. The business man who thinks in terms of dollars and cents needs to be made to see why the medical boarding house type of institution has a lower cost, and why such low cost is not as good a thing for the community as a hospital costing fifty per cent, more per capita but run as a modern hospital with adequate medical, nursing, and social service facilities for diagnosis and treatment. The public must learn that health can be bought at a price and that the price is worth paying. Hospitals and Dispensaries 877 SOME PRACTICAL MATTERS OF ADMINISTRATION By W. L. Babcock, M. D. 5 Consultant on Hospital Administration for the Cleveland Hospital and Health Survey. In making these statements and recommendations on General Adminis- tration, it is recognized that the Cleveland Hospital Council has had many of them under consideration and in certain instances has actually had com- mittees at work in standardization of supplies, uniform records, accounting, uniform rates, etc. In its contact with the administrative departments of the hospitals within the Council, the Cleveland Hospital Council has de- veloped a working organization of great practical benefit to its members. The projects under consideration by its various committees, as well as the recommendations herein, are practical and logical steps in the develop- ment of economical administration and efficiency. The Council would be of little benefit to its membership unless it adopted standards that would tend to lift the level of the hospitals to an efficient average. The Council can be of the greatest benefit if it leads, plans and organizes in advance of the hospitals. FINANCIAL 1. Financial and Office Records, Bookkeeping, etc. — The Cleve- land Hospital Council has unified and standardized the financial and statis- tical reports of its constituent hospitals. The bookkeeping systems, forming the basis of these reports, which are rendered monthly, have not been standardized in the various hospitals. It is recommended that the book- keeping forms and headings used by the various hospitals be made uniform. This is particularly necessary for cash blotters, and voucher registers, in order to show similarity in distribution of earnings and expenses. The records furnished the Cleveland Hospital Council relating to per capita cost in some of the hospitals have been fallacious from the begin- ning for the reason that many of the extraordinary expenses of some of the hospitals have been charged to special funds and not to maintenance accounts. In several of the smaller hospitals record of receipts and expend- itures only is maintained. No attempt has been made by these hospitals to credit or debit the various departments of the hospitals with their earn- ings or expenses. The per capita costs reported by Cleveland hospitals for 1919 varied from $2.00 to $5.62 per day. In order to determine wherein this difference may be found, it is necessary to check earnings and expenses by departments, such as training school, laundry, housekeeping, building maintenance and current repairs, administration, professional care of patients, etc. The latter should be subdivided into its natural subdivisions, such as laboratory, X-Ray department, surgical department, house staff, etc. 2. Accounting — The monthly and annual accounting for all hospitals should be made by an accountant under the direction of the Welfare Federa- 878 Hospital and Health Survey tion. It may be feasible for the latter organization to maintain the serv- ices of a paid accountant staff who could carry on a month-to-month audit in all hospitals within the Federation and furnish each Board of Trustees with a monthly and annual accounting statement. If the recommendations set forth in paragraph 1 are carried out in all of the hospitals, it will sim- plify the audit and accounting to a great extent. If a uniform system of financial records and bookkeeping is established for each of the hospitals in the Council, the time devoted by auditors on the books of some of the hospitals could be reduced 50 per cent, or more. It should be stated here that the Welfare Federation has provided for these audits heretofore through a firm of auditors. It is understood that the Cleveland Hospital Council is endeavoring to secure a uniform system of accounting for all hospitals in the Council. 3. Statement of Earnings — The monthly and annual statements of earnings of hospitals should be based on cash receipts only. Unpaid per- sonal accounts of hospitals have no place in a statement of earnings. The present earnings and income reported to the Cleveland Hospital Council and Welfare Federation from the various hospitals are not comparable for the reason that some hospitals base their statements on cash receipts only, while others include unpaid personal accounts in their statement of earnings. (Note A.) Note A — The practice of many hospitals in carrying unpaid personal accounts on their balance sheet as an asset is misleading, fallacious and wrong in principle. A vary- ing percentage of most of these accounts are uncollectible because they are largely accounts of part-pay patients. If the statement of earnings includes cash receipts only, such open accounts as are paid after the patient leaves the hospital will appear in the statement of the month during which they are paid. It is impossible to estimate the percentage of unpaid hospital accounts that are uncollectible. The good accounts are usually paid within a few days, while the great majority of the remainder are uncollectible. 4. Appraisal of Property — An appraisal of the physical property, build- ings and equipment, should be made of all Cleveland hospitals on a basis of present values. The reproduction cost of hospital buildings at the present time is in some instances at least 100 per cent, higher than five years ago. A proper percentage for annual depreciation cannot be established without an appraisal. It is also necessary in order to determine valuation for fire insur- ance, etc. It is possible that the expense of an appraisal could be lessened if the Cleveland Hospital Council made a contract for all the hospitals rep- resented in the Council. The expense could then be prorated between the hospitals according to property values. 5. Depreciation — Depreciation of buildings and equipment should be charged off annually. The bookkeeping system recommended in paragraph one should provide for an annual depreciation charge. 6. Per Capita Cost — All expenditures for current repairs, new equip- ment, replacement of equipment and betterments to existing buildings Hospitals and Dispensaries 879 should be charged to maintenance account. The per capita per diem cost of 'maintenance will thereby be placed on a uniform basis for all hospitals. Expenditures for new buildings, and equipment for new buildings, should be charged to capital expenditures. (Note B.) Note B — The per capita cost per diem for maintenance has been reported for Cleve- land hospitals as follows: (a) For 1918, minimum, $1.69; maximum, $4.60 (b) For 1919, minimum, $2.00; maximum, $5.62 (Not including Warrensville Infirmary or the City Hospital). It is believed that the minimum per capitas reported do not actually represent the true per capita cost. 7. Cash Discounts — Cash discounts should be taken on all bills where possible. Experience in hospital accounting has demonstrated that legiti- mate cash discounts will represent one-half of one per cent, of total expendi- tures of general hospitals, or two-thirds of one per cent, of total expenditures for maintenance, exclusive of salaries. (Note C.) Note C- — The practice of holding bills for approval of committees of the Board of Trustees or Managers is pernicious and accounts for failure to obtain some cash discounts. The Board of Trustees should put in the hands of hospital superintendents full authority for approving bills for payment of all current expenses. Extraordinary expenditures could be authorized by the Boards of Trustees before order is placed by superintendents. Hospitals which habitually pay bills after 30, 60 or 90 days cannot purchase to good advan- tage in the open market, and have a poor credit rating. It may be necessary for the Cleve- land Hospital Council to establish a fund to cover the discounting of bills for smaller hospitals. 8. Rate for Wards and Rooms — Ward rates are ridiculously low, aver- aging $2.00 per day. These rates should be raised to at least $3.00 per day, which figure represents only part cost of maintenance. Private room rates in some hospitals are also low and should be advanced. Board bills for ward and room beds should be collected one week in advance for general cases, and two weeks in advance for maternity cases. Therefore, patient's relatives should be billed weekly in advance. Recognition should be given the fact that wages and salaries are materially higher than when these rates were originally established. It should be understood that ward and room rates cover bed, board, pupil nursing, interne service in the larger hospitals, cer- tain routine and diagnostic services, and for free and some part-pay patients, gratuitous medical attendance. 9. Rates — Compensation — The rate formerly allowed by the Ohio State Industrial Commission for compensation cases was outrageously low. Such rates should be established on a basis of cost of maintenance. $3.00 to $3.50 per day, plus charges for all extras, will represent the approximate cost of 880 Hospital and Health Survey ward patients, at present. The Cleveland Hospital Council has taken the commendable stand that hospital cost for hospital service should form the basis for the establishing of hospital rates by the State Industrial Commission, and it is gratifying that the Council has recently secured recognition of this principle from the Commission. 10. Rates for Municipal and County Patients — The charge for the care of these patients should be based on the average cost of maintenance for the preceding year and be a matter of annual adjustment. It should be based on per capita per diem cost. No hospital should accept a lump sum or subsidy from any municipality, state or county authorities. Contract should never be made for the care of the sick on the basis of a lump sum annually. 11. Extra Charge Schedule — A charge schedule for extras should be adopted by all hospitals, and charges made for many supplies and much ser- vice that is now rendered free. Few Cleveland hospitals have an adequate extra charge schedule. Hospital clients think nothing of paying for all ser- vices rendered at a hotel or elsewhere. Extra charges for supplies or ser- vices for part-pay patients can be cancelled or reduced at discretion where patients are unable to pay. The following schedule of charges is suggested: Blood transfusion for private patients $50 . 00 Blood transfusion for ward patients 25.00 Large surgical dressings 1 . 00 to $2 . 00 each X-Ray and stereoscopic examinations 10.00 to $40.00 Board of Special Nurses 1 . 50 per day and up Plaster casts... 2 . 00 to $1 . 00 Services of hired anesthetist... 5 . 00 Nitrous oxide gas and oxygen 5 . 00 per adm. hour Salvarsan administration... 5.00 to $10.00 Proprietary drugs, patent medicines, serums, ampules and special prescriptions Cost plus 10% Splints and surgical appliances Cost plus 10% Meals for relatives of patients. ....'. . 75 to $1 . 00 each Cots... 1 . 00 each Ambulance service Cost First-aid services for out-cases, including dressings 5.00 to $10.00 Operating-room fee 10 . 00 Labor-room fee 5 . 00 to $10 . 00 Special nursing Cost Laboratory fees for Wassermann, blood, stomach, fecal, spinal fluid examina- tion, etc., for private-room patients. Hospitals and Dispensaries 881 12. Credit Investigator — (a) Large hospitals should maintain an in- vestigator or credit man whose duty it shall be to investigate the financial circumstances of patients. Many patients are maintained without cost who are able to pay part cost; many ward patients are cared for at part cost who are able to pay full cost. Ability or disability of ward patients to pay for extras outlined in the preceding paragraph can be established by this in- vestigator. The data accumulated by the Social Service department of large hospitals should be available for the use of the office investigator. It is not considered suitable for the social service worker or department to be used as financial or credit investigator to protect the business credit of the hospital. (6) It is recommended that the Cleveland Hospital Council engage a credit investigator to investigate the economic status of undetermined cases in several small hospitals. The salary and expense of this investigator can be prorated over several hospitals. It is believed that the financial benefit derived from the employment of such a, man would be productive of a definite increase in income to the hospitals. An alternative would be the working out of some arrangement with the local credit association. 13. Classified Wage and Time Schedule — The project of the Cleve- land Hospital Council, through a committee of Council members, to standard- ize hospital wages and hours of duty covering certain groups of hospital employes is commendable and should be carried out. It is probable that some variation in scale will be necessary in order to provide for the differ- ence in responsibility, etc., in certain positions in large and small hospitals. Experience has shown that wages in hospitals may be standardized in the following departments : Training School Department — Floor supervisors, ward orderlies, ward maids. Housekeeping Department — Waitresses, chamber-maids, pantry girls, cleaners (by the month), housemen and porters. Laundry Department — Laundresses, washmen and wringermen. Repair Department — Carpenters, painters, steamfitters and their helpers, wall washers, window cleaners. Engineering Department — Engineers and firemen. Ambulance Department — Chauffeurs. It would not be advisable to extend this classification as to wages and hours into offices, laboratories or professional departments which depend on specialists or certain skilled employes. Owing to the difference in the size of kitchens and variety of personnel employed therein, it is not considered feasible to classify kitchen employes. Hospital and Health Survey 14. Discounts in Room Rates to Privileged Persons — The ma- jority of hospitals in Cleveland give special rates to members of the staff and their families, to graduate nurses of the hospital and the clergy. Hospitals with endowments primarily given for the benefit of people of lower economic status, should limit their room rate discounts to persons who give gratuitous service to the hospital. Such discount rate should not be less than the 1 per capita cost of maintenance. PURCHASING DEPARTMENT 1. Central Purchase Bureau — The majority of Cleveland Hospitals can utilize the services of the Central Purchase Bureau to greater advantage. Several hospitals especially have neglected their duty and opportunities in taking advantage of the Central Purchasing policy. The Board of Trustees of every Cleveland hospital should .satisfy themselves that the hospital under their control takes advantage of this principle to a maximum degree. Their investigation of the subject should include a comparison of prices paid by the Bureau during the last year for like commodities purchased by the superintendent of the hospital during the same period. Full advantage of a central purchasing bureau will not be manifested until the hospitals standardize supplies. The replies to questions referring to the efficacy of the purchasing de- partment of the Cleveland Hospital Council, from the standpoint of the hos- pitals, reveal two chief criticisms : (a) That delays in the delivery of supplies purchased through the Bureau are frequent. (b) That prices obtained by the Bureau are in some instances no better than quotations made the hospital direct. In reference to (a) : it may be stated that many delays have occurred during the past year on account of slow freight, insufficient production and causes beyond the control of the Bureau. It is often necessary, in order to obtain the best prices, to purchase supplies out of town that ordinarily would be purchased by the hospital in the city. It is believed that criti- cisms could be lessened if the hospitals would anticipate their wants further in advance. To meet this criticism, the Bureau should make prompt de- livery a requisite for the acceptance of orders, and aim to consider prompt delivery in conjunction with minimum prices. In reference to (6) : it may be stated that the benefits of Bureau purchas- ing can be increased through larger orders. The nature of many commodi- ties does not enable the central purchasing bureau to obtain a price any lower than might be obtained by the hospital. This fact of itself should not pre- vent placing orders through the Bureau for most commodities, inasmuch as Hospitals and Dispensaries 883 the Bureau's chief advantage lies in the placing of large orders. The Bureau should keep hospitals informed of pending advance in prices. The Cleveland Hospital Council Purchasing Bureau should systematize its Quotation Department so as to furnish without delay quotations that the hospital executive may use in comparison with prices he may have re- ceived. To obviate the lost time element, the following should pertain: (a) Prompt furnishing of quotations. (b) Prompt placing of orders. (c) Prompt delivery of goods. 2. "Warehousing by the Bureau — It is not believed that the full benefits of Central Bureau purchasing will be manifest until the Cleveland Hospital Council provides warehousing and storage facilities. Investigation shows that many of the smaller hospitals are buying in small quantities, or from hand to mouth, for two reasons: (a) Lack of capital requisite for carrying goods in stock. (b) Lack of storage facilities. In view of the cooperative relationship of the hospitals to - the Cleveland Hospital Council and the Welfare Federation, the remedy does not wholly lie within the hospitals. Additional storage space cannot be provided in many hospital buildings without definite building additions. Limited earn- ing power of small hospitals precludes the establishment of a fund sufficiently large to carry a stock of goods. Investigation and study of the cooperative purchasing bureau main- tained under the auspices of the Cincinnati Community Union has thrown new light on this subject. The Cincinnati Community Union has set aside a revolving fund of $50,000 to provide for the expenses, warehousing and stock for the charitable organizations, institutions and hospitals of the city. Although in operation only a few months, the participants in this coopera- tive bureau are enthusiastic over the results. It is recommended that the Cleveland Hospital Council investigate the possibilities' of warehousing to a limited extent in order to encourage greater use of the purchasing possibili- ties of the bureau. It is believed that if the hospitals of Cleveland can be assured of immediate delivery from warehouses of many staple supplies, their bureau requisitions would be greatly increased. The Cincinnati experi- ment has shown that the capital tied up in stock at certain times has only represented a fraction of the amount set aside. In fact, it is believed that during certain seasons of the year a part of the money set aside for warehous- ing stock could be drawing interest or be used for other purposes. In this connection, attention may be called to the fact that provided with warehouse capacity, the Purchasing Bureau of the Cleveland Hospital Council could take advantage of opportunities for seasonable purchases that would be neglected or considered impracticable for hospital executives. 884 Hospital and Health Survey 3. Authorization of Purchases— The purchase of supplies or requisi- tion on Central Purchasing Bureau should be made only with the approval of the superintendent, authorized purchasing agent or steward, the latter of whom should be subordinate to the superintendent. (Note D.) Note D — The practice of direct purchases or Bureau requisitions by heads of depart- ments or dietitians without the authority of the superintendent is pernicious and not good business procedure. The superintendents of certain hospitals first become familiar with some purchases when bills are received. Marketing in open markets by dietitians and heads of departments is good practice when properly authorized and checked by the hospital superintendent. 4. Standardization of Supplies — The project of the Cleveland Hos- pital Council to standardize the majority of hospital supplies is absolutely necessary to the proper development and functioning of the Central Pur- chasing Bureau. Superintendents of hospitals who have preconceived ideas as to standards should come to an agreement with the committee on standard- ization in order that they may participate in the benefits to be derived from the uniformity of specifications, once standardization is accomplished. It will not be possible to extend the principles of standardization over all hos- pital supplies, but it is believed that the same can be extended over most pro- visions, housekeeping supplies and to a certain extent over furnishings. It is also recommended that an attempt be made to extend it over certain staple drugs and surgical supplies. 5. Storage Facilities and Advance Purchases — Hospitals should aim to take advantage of minimum prices that may be obtained through (a) Quantity purchases. (b) Purchases in advance of needs. This plan necessitates increased storage or warehouse capacity for some hospitals. Advantage can be taken of the markets by the seasonable storage of the following goods: canned goods, coffee, tea, navy beans, sugar, soap, starch, laundry soda, flour, butter, eggs, dried fruits; and sometimes crockery, glycerin, lard, narcotics, certain bulk chemicals, manufactured dry goods, etc. Sufficient eggs should be stored in public warehouses in April, and butter in June, for hospital consumption during the months of maximum high prices. (October, November, December and January.) Egg candling and storage should be carried out only by reputable and high class firms who will guarantee quality at time of consumption. Eggs should never be stored in anything but new cartons. 6. Inventories — Physical inventories should be taken on the last day of each month, comprising all material stock in storerooms. The practice of most hospitals of depending on book inventories is fallacious and not justified in commercial practice, except for the drug department. (Note E.) Hospitals and Dispensaries 885 Note E — This recommendation comprehends inventory of unissued stock supplies such as groceries and provisions, household supplies, gauze and cotton, dry goods, laundry supplies, in storeroom awaiting issue. Warehouse supplies should, of course, be included. Once the system of monthly inventories is established on standard inventory blanks, one office employe assisting the steward or proper head of department, can take inven- tory and complete records in one or two days, depending on the size of the hospital and the amount of goods carried in stock. It is estimated that the hospital which does not carry on inventory a stock of supplies equal to 10 to 15 per cent, of its annual purchases, is not taking advantage of seasonable purchases or storage possibilities. In this con- nection, attention is called to the fact that certain suppplies, soaps for example, improve in storage, and that but few supplies deteriorate. 7. Contracts — Annual, limited or quantity contracts should be sought for certain supplies; notably coal, electric lamps and milk from producers. It is strongly recommended that all hospitals make arrangements to obtain their milk supply from the producer rather than depend on commercial distributors. 8. Drugs and Surgical Supplies — It is recommended that the Cleve- land Hospital Council employ or develop a trained drug and surgical supply man as buyer. Expert knowledge of drugs and drug markets, and a prac- tical knowledge of the hospital use of surgical supplies are qualifications nec- essary. It is believed that such a man could develop the purchasing in this department and prove a decided economy after the department is organized. The offer of the School of Pharmacy of the Western Reserve University to cooperate with the hospitals of Cleveland in the standardization and manufacture of certain drug supplies is highly commendable. The hospitals of Cleveland have an opportunity to avail themselves of the use of a drug manufacturing laboratory and expert supervision of their local drug depart- ments that is not vouchsafed to many hospitals in other cities. It is under- stood that the Cleveland Hospital Council has already taken steps to take advantage of this splendid proposition. The venereal clinics of the city should take advantage of the free pro- vision of arsphenamine by the state. 9. Food Service and Directing Personnel — The entire food service of the hospital should be under the direction of a trained dietitian. In small hospitals it is possible to combine the service of dietitian and housekeeper. In this connection, it should be remembered that trained dietitians may make good housekeepers after reasonable experience, but that housekeepers do not ordinarily make good dietitians without special training. The service in employes' and nurses' dining rooms should be under the direction of the dietitian as well as the food service to patients. In large hospitals it is nec- essary to study carefully and provide for the cooperative relationship of the steward's department, main kitchens, which are usually in charge of a 886 Hospital and Health Survey chef, and the dietitian. The details of the hospital food service are too intricate to be covered by a survey of this character. 10. Stewards or Purchasing Agents — In large hospitals stewards or purchasing agents are necessary in order to relieve the superintendent of many of the petty details of purchasing supplies. Where a steward or purchasing agent is employed he should have assigned to him duties and re- sponsibilities similar to those of stewards of large hotels. HOSPITAL ECONOMICS AND SALVAGING 1. Repair Department — Hospitals of over 50 beds can economically support a general repair man for steam fitting, electrical repair and carpenter work. The painter, or painters, should be employed by the month. The repair department can be extended in personnel and equipment as the bed capacity increases. The development of a central surgical instrument repair shop for the use of all hospitals is desirable. These shops should be under the control of one or more of the larger hospitals or of the Cleveland Hospital Council. Experience has demonstrated that surgical instrument and appliance shops can be made self-sustaining almost from the beginning. Prompt, uniform and satisfactory production at a lessened cost will be the inevitable result. Such an activity might well be included among the func- tions of the central brace shop as proposed for the orthopedic center. (See pages 200-201.) 2. Manufacturing — Manufacturing of certain hospital supplies can be extended by individual hospitals in accordance with their needs and the ingenuity of the hospital executives. A central sewing room for manufactur- ing dry goods should have a place in every hospital. It is only necessary here to call attention to the fact that manufacturing can be extended without limit in hospitals that have the requisite repair personnel. Some hospitals manufacture fracture beds, bed elevators, wooden stools, mattresses, cotton waste from recleaned gauze, stretcher canvass, Bradford frames, extension apparatus, splints, etc., without limit. The manufacturing of dry goods adaptable to hospital use is limitless, depending on the facilities provided. The economical manufacture of soap from grease is strongly urged, and can be carried out in the laundry with very simple equipment. Soap thus manufactured should be used for household clean- ing purposes as soft soap. Laundry soap should be manufactured from soap chips. 3. Waste and Salvaging — Lack of attention to waste in hospitals is uniform all over the country. It is not within the province of this Survey to discuss it. Attention is called to the opportunity for salvaging and sale of waste paper, old barrels, waste rubber, old metal, rags, bottles, etc. Sur- gical gauze and bandages should be washed and re- washed until worn out. It can then be reduced to cotton waste or sold with rags. 4. Labor Saving Devices — Labor saving devices should be utilized wherever possible. Electric dish-washing machines are an economy of time Hospitals and Dispensaries 887 and labor in any hospital. In hospitals of sufficient size, the same may be said of electric dough -mizers, meat-cutters and vacuum cleaners. 5. Fire Protection — This subject should be studied carefully by hospital trustees and executives with the assistance of expert advice. Few hospitals have a sufficient number of fire extinguishers, and where these are provided, they are not refilled with proper frequency. Only extinguishers approved by the Underwriters' Association should be used and these should be re- filled twice annually. At each refilling, they should be labelled or tagged with date of refilling. Standpipe with hose connections, fire escapes, fire buckets in attic, should receive attention. Heads of departments should be drilled or instructed in their duties in the event of a fire. Fire drills are desirable, but almost im- possible on account of the frequent changing of employes. 6. Insurance (Fire) — It has been ascertained that many of the hos- pitals surveyed are inadequately insured against fire. After appraisal of buildings, old policies should be cancelled and new policies taken out on the basis of reappraisal. It is believed that fire insurance rates are due to ad- vance and it is recommended that appraisals be made, old policies cancelled and new policies issued so as to take advantage of present rates. Itfis preferable that hospital insurance policies be drawn for five-year periods, which provide for lower rates. Co-insurance policies are not recommended except for fire-proof buildings. For non-fire-proof buildings a maximum cov- erage is recommended by means of straight policies. The contents of hospital buildings should be fully insured as most hospital fires are small and the contents suffer to a greater degree than the buildings. Owing to the recent rapid increase in construction cost, hospitals should examine their fire insur- ance policies without delay and . increase them to a figure approximating present values. Compensation insurance covering employes should be carried by all hospitals. Elevators and automobiles should also be properly covered. GENERAL RECOMMENDATIONS Professional 1. It is recommended that standing house orders be established: (a) For preparation of patients for operation. (b) For after-care of surgical cases. (c) For preparation of patients for confinement and after-care (pre- natal orders); (post-natal orders). (d) For preparation of patients for operation and after-care in tonsil- lectomy. 2. That large hospitals sterilize and manufacture prepared catgut from raw catgut. Hospital and Health Survey 3. That large hospitals manufacture nitrous oxide gas. 4. That arrangements be made to purchase oxygen of local manufac- turers rather than of jobbers. This will necessitate the hospital owning its own tanks which can be sent to manufacturers for refilling. All large cities have a number of plants manufacturing oxygen as a by-product. Its cost under these circumstances should be 50 per cent, less than prices paid job- bers. 5. That rubber gloves be not issued at the expense of the hospital to staff members for use on private cases, or to non-staff physicians. Visitors and Visiting Hours Visiting the sick should be limited as much as possible, especially in open wards. Hospitals where possible, should reduce visiting days to three or four days per week, including Sundays. Two of these days could have visiting hours for wards 6 :00 to 7 :00 or 7 :00 to 8 :00 P. M., and the remaining two days 2:00 to 3:00 or 3:00 to 4:00 P. M. Visitors to private rooms are difficult of regulation. They should be limited if possible to afternoons between 2 :00 and 5 :00 P. M. Xon-professional visitors in the operating room during operations should not be permitted. The practice of allowing relatives of patients to witness operations is dangerous and susceptible of much criticism. It should not be permitted. HYGIENE OF HOSPITAL AND PERSONNEL 1. Health Tests — All employes handling or preparing food either in storerooms, kitchens, pantries, dining rooms, diet kitchens, etc., should have a complete physical examination, including a Wassermann examina- tion, before being accepted for appointment. The medical examination and tests made should be adequate to exclude typhoid carriers from this service. All nurses before admission to the training school, and employes before assuming duties of their positions should give evidence of a recent vaccina- tion against smallpox, or be vaccinated. In the event of development of cases of diphtheria among hospital per- sonnel, all employes and nurses should have the Schick Test to determine susceptibility. The making of a Schick Test as a routine procedure prior to employment or entry to the training school, is unnecessary. It should not be neglected, however, in the face of an epidemic. The authorities of the hospital should provide for and encourage medical exmination of all their employes annually. 2. Milk Supply — Hospital laboratories should install apparatus for testing their milk supply on delivery daily. Determination of quantity of butter fat, bacteria content, temperature and specific gravity will permit Hospitals and Dispensaries 889 checking of contract which would provide for certain minimum standards. Hospital milk should be cooled to 50 degrees immediately after milking, delivered at the hospital before reaching 60 degrees and contain not less than 4 per cent, of butter fat. The milk contract should call for milk for drink- ing purposes known as Class "A" grade. Milk should be delivered to hos- pital raw and provision made at hospital for pasteurization for such milk as may be desired pasteurized prior to use. (Note G.) Note F — Class "A" milk in Cleveland is raw milk from tuberculin-tested herds, scoring 90 per cent, or better, with less than 50,000 bacteria content per c.c. It may be necessary in some instances to use Class "B" pasteurized milk, which conforms with Divi- sion of Health standards. 3. Water Supply — The hospital laboratory should periodically test the water supply. If storage tanks are in use, tests and culture should be made from tanks as well as spigots. 4. Ventilation — During the winter months, hospitals with the plenum system should give rigid attention to the details of this system with frequent examination of air in wards and exposure of culture media. Hospitals using direct-indirect methods combined with heating, during winter, should make weekly examinations of air as a check on the mechanical operation of exhaust fans and the mechanics of the ventilating system. 890 Hospital and Health Survey 111. Dispensaries DISPENSARIES IN CLEVELAND • As outlined in the section entitled "Some Definitions," and as shown in Figure III., Part II., there are two classes of dispensaries in .Cleveland— - those treating the sick and those primarily concerned with preventive work, or 'the clinical and the public health dispensary, as the two types may be called. In Cleveland, five dispensaries treating the sick deal with general diseases; one, the Babies' Dispensary, confines its work to children under three years. There are also a number of industrial dispensaries supported by business establishments for the treatment of accident cases. The indus- trial dispensaries are dealt with in Part VII. of the Survey report, and are merely mentioned here. The public health dispensaries are dealt with in the next section of this chapter. All of the dispensaries treating the sick except the Babies' Dispensary and the industrial clinics are attached to hospitals, and are usually called the out-patient departments of those hospitals. All of the public health dispensaries, on the other hand, are distinct from hospitals, with the excep- tion of a few of the prenatal clinics. The six dispensaries treating the sick are as follows: Dispensaries Dispensary Visits, 1919 Lakeside Hospital — Out-patient Department 59,89 1 St. Vincent's Charity Hospital — Out-patient Department .. 21,863 Mount Sinai Hospital — Out-patient Department.- 19,324 Babies' Dispensary and Hospital 14,977 St. Luke's Hospital — Out-patient Department 13,313 Huron Road Hospital — Out-patient Department.- 5,864 It is probable that the number of different individuals treated was about 30,000 in 1919. From the above table it will be found that the dispensaries of Cleveland are comparatively few in number and small in size as compared with those of other leading cities. In the section on "Policies and Needs," such compari- sons willjbe made. In this section the general work of the dispensaries is reviewed. Location of Dispensaries The six out-patient dispensaries are very unevenly distributed — Lakeside is on the lake at East Twelfth Street; Charity is one mile inland at Twenty- second Street; and Mount Sinai about one mile and a half inland at 105th Street. These three dispensaries treat all kinds of diseases. Huron Road Dispensary, located in the center of the city, does very little except surgical Hospitals and Dispensaries 891 m i -i C K") ui Fig. III. NOTE: — The height of the\black rectangles represents the percentage of dispensary patients living in the district and attending the dispensary designated by the letter above. 892 Hospital and Health Survey emergency work; the same is true of St. Luke's, which is in the middle of an industrial district. The Babies' Dispensary, not far from Charity Hospital, confines itself to sick babies up to the age of three years.* ' A study of locations shows that the dispensaries are not so located as to interfere with one another, but it is obvious that the west and south sides of the city are entirely without provision. The range from which patients come to the dispensaries varies considerably as shown by Fig. III. In Cleveland, as elsewhere, it is found that a dispensary with medical teaching draws from a relatively wider area, since consultation cases are sent to its staff for special study and since the reputation of its staff draws patients. In general the range of a dispensary varies somewhat in proportion to its reputation. People will go long distances to secure expert medical care of which they feel themselves to be greatly in need, but convenience of location and near- ness of a dispensary are of great assistance in bringing people in the early stages of disease under care and in attaining easy supervision of treatment. Classes of Disease Treated Tuberculosis is not cared for in these dispensaries except in so far as diag- noses are made when patients come into the dispensary with other com- plaints, but the supervision and control of cases of tuberculosis are carried on by the Health Centers and the special sanatoria for this disease. The common "contagious" diseases are also excluded from dispensaries. Organization and Executive Control The management of a dispensary of any size, such as those at Lakeside and Mount Sinai, involves the handling of a considerable number of patients and a number of physicians, nurses, social workers, and other assistants, and needs skilled and executive direction. Rarely, however, has there been pro- vided by the hospital any officer responsibly charged with full control of the dispensary and expected to give to it his main attention. At Lakeside and Mount Sinai, an assistant superintendent of the hospital is director of the dis- pensary, but at Lakeside until recently the actual conduct of the dispensary fell entirely upon the head of the social service department. At the smaller dispensaries — at Huron Road Hospital and at St. Luke's Hospital, and also at Charity Hospital, there have been no executive directors. The hospital superintendent is responsible for the dispensary as well as for other depart- ments of the hospital, but no official has been assigned to take charge of the dispensary. Only at the Babies' Dispensary has there been definite and continued executive direction and carefully worked out organization, under the pro- fessor of pediatrics at the University, with a salaried nurse devoting her full time to the detailed administration. This organization has indeed devoted too much attention to its own executive detail and administrative system, *A small number of orthopedic cases receiving special treatment are accepted up to 14 years of age at the Babies' Dispensary. Hospitals and Dispensaries 893 but furnishes on the whole an example of the value of a well-thought-out and well-worked-out plan of dispensary administration under full-time, responsible executive direction. Buildings The Babies' Dispensary is especially well designed for its purpose. The other dispensaries are all hampered for want of room or from old dark build- ings. St. Luke's and Charity function in basements; Huron Road in a rather forlorn annex; Mount Sinai in a small double house; and Lakeside in poorly- arranged, inconvenient rooms. All of the institutions except Charity are planning new buildings, and Lakeside is planning certain modifications of the present plant that will make it much more suitable during the remainder of the time the building is in use. The unsuitable or inconvenient character of the plants is typical of the lack of attention paid to dispensary work in the past, while the increasing interest in this form of service is reflected in the projected developments. Patients As shown on the map (Fig. III.), the existing dispensaries draw their pa- tients largely from the central congested areas of the city. Sufficient num- bers come from a distance to show that when the work and existing value of dispensaries is known, distance is not an insuperable, obstacle. It would be interesting and important to ascertain how far the distribution of dispensary patients by districts agrees with the economic condition of the population in each section. Obviously, the dispensary draws primarily from the poorer elements. There are considerable districts in the west and south sides which appear to contain a large number of people who are financially as much in need of medical charity as those who are near the existing dispensaries. Some light is thrown on this point by the study of nationalities. Thirty- three nationalities were found registered among records studied in the six dispensaries. The proportion of foreign -born found in the more recent of these records of races is smaller than the proportion which these races bear to the total population of Cleveland. Knowledge of dispensaries and willing- ness to go to a strange institution penetrate only slowly among many groups of immigrants. At Lakeside Dispensary, American-born patients consti- tuted over one-half of the total; Charity draws largely from Italians and Negroes; Mount Sinai shows over half of its attendance, Jewish; Babies' Dispensary shows 24 per cent. American-born parents, 18 per cent. Slavic, 16 per cent. Jewish, 14 per cent, colored, and many other nationalities rep- resented in small percentages. Very little has been done at any of the dis- pensaries to provide interpretation for patients not speaking English. There is much complaint from outside charitable agencies that adult patients not. speaking English find it difficult to make themselves understood, or to understand what the doctor finds to be the matter or what he wants them to do. 894 Hospital and Health Survey Fees and Finances It is becoming the general policy of dispensaries throughout the country to charge admission fees at each visit of a patient, the fee usually being of nominal amount (except in "pay clinics") and being remitted in whole or in part where the patient is not able to pay. In Cleveland, only one of the five general dispensaries, Lakeside, has adopted a general admission fee in its daytime clinics. Mount Sinai Dispensary charges ten cents for the first admission but not thereafter, and Charity makes a nominal charge when a person loses his admission card. All make charges for medicines at prices more or less corresponding to cost, and also usually charge for special treatment or appliances. In the evening clinics which are designed for persons who are at work in the daytime and generally aim to be quite or nearly self-supporting, fifty cents a visit is charged by Mount Sinai, Charity, and Lakeside — the three dispensaries which maintain such clinics. Babies' Dispensary has a grade system — the highest class pays fifty cents and the lowest grade nothing for admission. The charging and collection of fees and the designation of what these fees should be and when and why they should be remitted, require an adequate admission system for a dispensary. The present inadequate organization of most of the institutions would make it difficult to administer satisfactorily an admission fee system. It is of course essential that if admission fees are routinely charged, there be a system for receiving and accounting accu- rately for monies, as well as for deciding what fees should be paid by patients or be remitted. Having such a system in a dispensary is always stimulating to better administration and also serves to provide the funds for it. An im- portant by-product, moreover, is the greater attention given to the economic and social condition of patients, promoting more careful attention to the social as well as the medical needs of those admitted, and protecting the medical profession better against those who could properly pay for the ser- vices of a private physician. The exact cost of dispensary service in Cleveland is not ascertainable because no one of the out-patient departments of the hospitals fully sep- arates its expenses from those of the hospital. Immediate expenses are usually charged to the dispensary, but the overhead — heating, lighting, super- vision, and other general expenses — are not usually figured in. It is probable that the average cost per visit does not exceed fifty cents with the exception of the Babies' Dispensary, which is independent of a hospital. The five out- patient departments of the hospitals, with about 115,000 visits, probably cost altogether about $60,000 a year. Really adequate administration of the dispensaries as hereafter recommended would cost more, but the difference would be met or more than met if adequate admission fees were charged. Failure to have proper cost accounting is a serious limitation on dispensary service. What seems cheap, is held cheaply. Hospitals and Dispensaries 895 Medical Work or Dispensaries Physicians work in the daytime clinics of the dispensaries without finan- cial remuneration, except in a few instances of physicians doing special work at Lakeside and at the Babies' Dispensary. These two dispensaries are teaching clinics for Western Reserve University, members of the staff being also members of the staff of the medical school. In the evening pay clinics, all the physicians receive either a regular salary or an amount dependent on the fees received from patients. A large part of the dispensary work in Cleveland is connected with the teaching of medical students, all of the staff at Lakeside and at Babies' Dispensary, and part of the staff of Charity and of Huron Road, being connected with Western Reserve University Medical School. The dispensary staffs are only in a few instances organized satisfactorily in relation to the staffs of the hospital with which the dispensary is con- nected. (See section on "Organization for Service.") The practice of making all appointments annually has been taken advantage of only at Mount Sinai. The Babies' Dispensary is the only one that has an accurate and complete enough system of record keeping to afford a basis for clinical research. Most of the opportunity for the student is lost because of inade- quate records, and much duplication of work among dispensaries and within the same dispensary is necessitated for the same reason. Opportunities for consultation among physicians representing different specialties is an important element in good dispensary work, but this oppor- tunity is relatively small in the Cleveland dispensaries owing to loose organ- ization and to very lax systems of referring and transferring patients be- tween dispensaries or clinics. The making of efficiency tests of the medical work and the accumulation of facts on which to base judgment concerning administrative procedures has yet to be undertaken. Records All of the five general dispensaries excepting Charity have a central filing system — all records concerning each patient being filed together. At Charity, the filing of the records of each particular clinic separately repre- sents a serious drawback since the work of the different specialists upon a case cannot readily be assembled and the needs of the patient studied as a whole. Card record forms for the medical work are in general use, differing widely in detail. Conference and comparison would lead to improvement and standardization. Mount Sinai has a plan for a summary sheet for diagnosis and laboratory tests, an experiment which is worth pursuing. Social Service The too considerable part played by under-staffed social service depart- ments in the administration of several of the dispensaries is described in detail in the section on "Social Service". It may be mentioned here that in relation to cooperation with charitable agencies, the social service de- 896 Hospital and Health Survey partments have usually made an effort to define their attitude toward the social agencies, particularly in relation to the need of patients for material relief. All of the social service departments are avowedly opposed to the giving of material relief, regarding this as the duty of a "family agency" or relief society. In general an exception is made of certain medical needs which the social service departments regard as adequate reason for giving financial aid. Thus at Mount Sinai, it is felt that a patient's inability to pay for glasses or for dental work is an indication that there are other more general financial needs and the case is transferred, by the social service department, to general charitable or relief agency. Lakeside Social Serv- ice Department will give money to patients for carfare and occasionally will make small loans. A very small fund is in the possession of this depart- ment for such purposes. The Babies' Dispensary provides milk at less than cost or free, if necessary. This is provided for babies up to the age of fifteen months; after that if the baby is ill, it will be continued up to eighteen months, but never later. This is also done at the Health Centers. The total deficit for the year 1919 was $18,000, of which the city pays $6,000 and the Babies' Dispensary $12,000. With these exceptions the social service departments do not give material relief, but transfer to charitable agencies all cases in which such needs appear evident or probable. Thus a pretty clear division of function between the social service department and the non-medical agencies has been worked out. On the other hand, there has not been a satisfactory understanding be- tween the dispensaries and the charitable agencies with reference to the examination of patients not acutely ill, but concerning whom a charitable society needs to secure facts as to physical condition, working ability, and the general health needs of the family. In some instances, notably at Lake- side, it has been difficult for charitable societies to secure examination of these cases, who often not being sick, do not interest physicians coming to the dispensaries primarily to see and treat illness. It has also been difficult, at Lakeside almost impossible, for charitable societies and agencies, to secure information regarding the diseases or defects found in patients in whom they are interested. The families known to charitable societies and receiv- ing relief from them, can obviously not afford to pay for medical care, and it is particularly for such families that dispensaries should serve as family physicians. This means providing health examinations and advice concern- ing occupation, nutrition, etc., as well as diagnosis and treatment during illness. The dispensaries have given only a very limited degree of service in this connection, although a real beginning has been made at such places as the Babies' Dispensary and Mount Sinai. An important field for larger service lies here. Reports and Tests of Dispensary Service The annual reports of the dispensaries are most inadequate. The dis- pensaries probably serve altogether, in a year, as many as 30,000 persons — hospital beds, 50,000 to 60,000, or twice as many. Yet the attention devoted to reports of hospital work is not twice as much as that given to dispensary reports, but ten times as much or some such ratio. Even the number of Hospitals and Dispensaries 897 patients served or treatments given in each of the several clinics — medical, surgical, etc., were not obtainable from the dispensary reports, (except from one institution) and had to be specially secured for the Survey. The authori- ties of the institutions have not provided themselves with the elementary data with which to judge even the scope and amount of service rendered, much less its quality. The collection of routine statistics of the work of each clinic is a matter neither difficult nor costly. Deficiencies in Certain Branches Like the hospitals, the dispensaries are undeveloped in certain important specialties in which the public needs service. Clinics for children (over the age of three) are the most notable example. The children's clinics at Lake- side and Mount Sinai are very small; there are none at Charity Hospital, Huron Road, or St. Luke's. The age limit set by the Babies' Dispensary has been an unfortunate restriction. It has served to limit the development of clinics for babies elsewhere, and has indirectly tended to diminish the chance of adequate clinics for older children. Moreover, no one clinic for sick babies can meet the need for a city as large as Cleveland. All sick babies needing dispensary care are expected to come to one spot, the Babies' Dispensary, and even when there they are not treated unless the nurse at the admission desk agrees with the mother, or with the visiting nurse who referred the mother, that the baby is too ill to be at a Babies' Prophylactic Station and that the family is too poor to pay a private physician. A study by the Survey showed that somewhat more than half of a group of cases recently applying at the Babies' Dispensary were referred elsewhere. It is to be strongly recommended that: (1) Babies' Dispensary accept children up to 14 years. (2) Pediatric Clinics treating children up to this age be developed at all present and future dispensaries. Clinic service for cases of heart disease is an undeveloped field in Cleve- land. Mount Sinai appears to have recognized the problem and to have begun efforts to get cardiac cases under care, at Rainbow Hospital. It is highly desirable that cardiac clinics be developed as parts of the general dispensaries which exist or are to be established at City Hospital, Lakeside, Mount Sinai and the proposed central downtown dispensary. Relation of Dispensaries and Hospitals The usefulness of the out-patient department as a means of increasing the efficiency of the hospital has been but slightly recognized in Cleveland. The dispensary should be the link whereby most of the hospitals' contacts with the community are made. Thus the admission of ward patients should be largely through the dispensary, though of course emergency and some other cases will enter otherwise. The medical study given in the dispensary to the patient should be the beginning of the hospital's work with him and not, as now, be usually wasted because the medical organization and the records of the out-patient department are not correlated with those of the hospital. Hospital and Health Survey Fig. IV. Inter-relation Between Hospital and Dispensary. Hospitals and Dispensaries 899 Of equal if not greater importance, is the function of the dispensary in connection with the discharged patient. This subject is studied in detail in the sections on convalescence. Clinic Management The time of doctors, given freely to service in clinics, is much too largely spent in non-medical routine — calling in patients, attending to records, etc. Paid and trained clinical assistants is necessary if the doctor's time in the clinic is to be of maximum value to himself and to the patient. The details of efficient clinic management have been worked out in a number of dispen- saries in other cities. Relations to the Medical Profession There has been for some years an apparent feeling on the part of some members of the medical profassion that dispensaries interfere with private medical practice because they accept patients who could afford to pay a physician. Much of this feeling has been due to misapprehension of the facts; some has been due to the failure on the part of the hospitals to deal with the medical profession on even and open terms. The Survey has found no evidence that cases who are able to pay a private physician have been accepted by the dispensaries except occasionally, by mistake or honest mis- judgment, and the proportion of such mistakes appears no larger than studies in New York and Boston have shown to be practically inevitable. The pro- portion of dispensary applicants who are able to pay private rates for the medical care which they need is believed not to be larger than three per cent, and as the records of the Babies' Dispensary, of Lakeside, and of other insti- tutions show, a number of such applicants are refused treatment. The prin- ciples which it is believed should govern the admission of patients to dis- pensaries are stated in the section on "Policies and Needs." It has been unfortunate that this vital matter of relationship between the dispensary and the physician should not have been made the subject of systematic cooperation, conference and study by representatives of both sides. Had, for instance, a committee of the Hospital Council met with a committee of the Cleveland Academy of Medicine a number of times during the past five years, there would probably never have developed any atti- tude of disagreement. In the section on "Policies and Needs" a recommen- dation is made with the aim of bringing about such cooperative functioning. It is of vital importance to remember that the dispensary (also the hospital) is essentially a cooperative enterprise of the medical profession and the trus- tees and administrators, undertaken for the purpose of community service. The adequate development of dispensaries in Cleveland will offer to the rank and file of the medical profession opportunities of which it is now largely deprived — for consultation with specialists and for aid from laboratories and other facilities in diagnosis and treatment. Physicians may be sure that 900 Hospital, and Health Survey whatever assists the public to give more attention to bodily health and to understand and utilize the most advanced resources for medical care, will also stimulate the use of that primary and best loved resource, the family physician. Hospitals and Dispensaries 901 THE PUBLIC HEALTH DISPENSARIES As previously pointed out, the public health dispensaries differ from those just described in that they lay emphasis on preventive work rather than on diagnosis and treatment of sickness. They also differ in that each public health dispensary limits itself to a definite area, receiving patients only from this district. Generally speaking, the offer of a preventive and educational service will draw persons from a much smaller area than in the case of a clinic treating sickness. The effective range of an infant welfare clinic is quite smill; that is. the area from which it will draw many cases L limited to a comparatively small region around the dispensary. The same is true of the prenatal clinic, while the tuberculosis clinic has a somewhat wider range. In practice the district which a public health dispensary does serve depends largely upon the extent to which it is advertised or the degree to which nurses attached to the dispensary go into homes and interest persons to come to the clinic. These efforts, however, are at a disadvantage if an attempt is made to bring many persons from considerable distances. The public health dispensary has a militant purpose. It aims to combat a definite disease like tuberculosis or a group of diseases such as cause infant mortality. It should make no restriction in receiving patients because of financial status. Properly conducted, a public health dispensary should in no way interfere with the work of private physicians, but tends to send patients to them since disease or difficulties are discovered which dispensaries will not treat and for which patients will be advised to seek treatment. The aim of a public health dispensary is, or ought to be, the reaching of all of the cases within a certain district needing its care. It must measure its work on a population basis and see how far it is able to reach 100 per cent, of the cases of actual or probable tuberculosis in its district, or all the babies or expectant mothers. This in practice would require that a public health dispensary, with a certain staff, must serve only so large a district as it can effectively reach. The time has not yet come when a general statement can be made as to the area which a given type of public health dispensary can cover, and this must be the subject of further study in Cleveland and elsewhere. Reference to Table I. shows that twenty-two different sites are utilized for public health dispensaries or clinics with a public health purpose, and that the purposes served include four types of work: tuberculosis, infant welfare, prenatal care, and dental service. It should be added that the three clinics treating the venereal diseases (at Lakeside, Mount Sinai and Charity Hospitals) fall on the border line between the public health dispen- sary and the dispensary treating the sick. They have or should have the militant purpose of the public health dispensary, but they are largely con- cerned with the diagnosis and treatment of definite disease. Since Part V. of the Survey report is devoted to venereal diseases only this mention is made here. Further reference to Table I. indicates that the first two of the four services, tuberculosis and infant welfare, are under the charge of the Division 902 Hospital and Health Survey of Health, while the other two, prenatal and dental service, are under private agencies. The Survey reports on Child Hygiene (Part III.) and on Nursing (Part IX.) have given considerable attention to prenatal as well as to the other public health services which involve the nurses' work in the home as well as in the clinics, and the report on Tuberculosis (Part IV.) has covered that field. Certain administrative aspects may properly be discussed here Prenatal Clinics In prenatal service the function of the clinic is essentially diagnosis. The examining physician should, so far as possible, be able to decide what special care, if any, each expectant mother requires during pregnancy and at delivery, and to advise her accordingly. The diagnostic and administrative work of the clinic are of relatively limited value without the home work of the nurse. The prenatal clinics also play a certain part in medical and nursing education. It should be apparent, however, that the amount of clinical service or the number of obstetrical cases, needed for such purposes of education, is only a small fraction of the amount of prenatal service needed for the community as a whole. In 1919 there were 19,123 registered births in Cleveland, and of these 1,251 were delivered in their homes by out-patient teaching services connected with the prenatal clinics of Maternity Hospital. This is 6^ per cent, of the total. It is certainly true that not over 10 per cent, of the obstet- rical cases of Cleveland are required, Or could even be directly utilized, for teaching purposes in connection with prenatal clinics. Practically every expectant mother would benefit by such service as is rendered at a well managed prenatal clinic. The need of prenatal care is far broader than the need for "educational material." The two purposes are not at all inconsis- tent. The one fits into the other. The point is of practical importance because of the failure of those respon- sible for the University teaching of obstetrics and for the maintenance of the prenatal clinics connected therewith, to recognize the community need as broader than their own special interest. Four different agencies main- tain eight prenatal clinics. There is room for many more than eight prenatal clinics and for more than four agencies, provided all were working as part of an agreed general program. At present the University agency appears to take the attitude of urging the cessation of the activities of such prenatal clinics as those of Mount Sinai and the University District. The feeling produced on the other side is what may be expected. The effectiveness as well as the extent of the work is substantially diminished by such a situation. As a reductio ad absurdum we find two prenatal clinics, next door to one another, at 2509 and 2511 East Thirty-fifth Street, one conducted by Ma- ternity Hospital, the other by the University District, for the training of its students. The recommendations made by the Survey in the reports on Child Hygiene (Part III.) and Nursing (Part IX.) will remedy this condition if put into effect. It may be added here, as one detail, that there is no justification for two Hospitals and Dispensaries 903 clinics side by side on Thirty -fifth Street. Although the University District prenatal clinic is actually under the auspices of the Division of Health, it, as well as the Maternity Hospital prenatal clinic, is used as a teaching field by the University, and it is largely the responsibility of the University to see that its agents and officers dealing respectively with medical and with nursing education, work in harmony. The two clinics should be combined. It is a matter of indifference which plant is retained and which given up. The University should, as now, appoint the medical and nursing heads of the service; the internal administration of the clinic, for reasons of economy and convenience, should continue under Maternity Hospital; the nursing teaching should be part of the University District plan and be coordinated with the community plan for prenatal and obstetrical nursing service pro- posed by the Survey. (See Part III.) It is generally helpful for a hospital which has a considerable maternity service in its wards, to maintain a prenatal clinic (which should be used also for the supervision of post-partum conditions and be administered as part of the general dispensary attached to the hospital) . Such hospital clinics should, however, work as cooperative parts of the city-wide plan for maternity care. There is need for many more prenatal clinics, however, than are or can be connected with hospitals. Wherever possible the prenatal clinics should be in the same buildings as the Health Centers of the Division of Health. By the bringing together of a variety of different health activities within one building, each service tends to strengthen the others by increasing the con- tact of the neighborhood with the Center, its purposes and personnel; and to correlate many details of work by the medical, nursing and clerical staffs. Such combinations also bring administrative economies in management and save such present wastes as renting rooms for prenatal clinics which are used only i few hours each week. In advance of the assumption by the city of prenatal work as a regular servi 'e in its Health Centers, cooperation between the city and the private agencies may usefully proceed in this manner. Dental Clinics Dental service as a branch of public health dispensaries is a recognized activity in which Cleveland is singularly deficient. The three mouth hygiene dispensaries operated by the Cleveland Mouth Hygiene Association at three of the health centers are operated for fifty weeks of the year, five days a week, and three hours at each session. Each unit in- cludes a dentist and an assistant. The cost of these is met from the Com- munity Fund as a part of the budget presented by the Welfare Federation. These three Mouth Hygiene dispensaries, operated five half days pee week, are the only available and acceptable service (except the private dental practitioner) for thirty to thirty-five thousand parochial school children. It is estimated that fifteen Mouth Hygiene Units operated eleven half days per week would serve this group of children quite well; i. e., would provide the prophylactic service necessary for eighty-five or ninety per cent, of these 904 Hospital and Health Survey children and would provide for from one-third to one-half of the repair service necessary. The grave deficiency of dental service in Cleveland is illustrated by the fact that the total clinic provision in the city includes only that at the three health centers, the six clinics at public schools and the dental clinic at the City Hospital, a total of ten dental chairs running 156 hours a week. In Boston five institutions offer either free, at or below cost, dental service with a total of 247 chairs used for 5,956 hours a week. The present policy of the College of Dentistry of Western Reserve University renders it hardly possible to class it with public service clinics for dental purposes. (See Part VIII. of Survey Report, page 685.) Dental care for the poor in Cleveland is limited largely to extraction and remedy of gross pathological conditions causing obvious inconvenience or pain. Lack of knowledge of the needs and possibilities of oral hygiene is responsible for the neglected teeth of most dispensary patients. Dental clinics where a small fee is charged are badly needed in the congested dis- tricts. It is strongly recommended that dental service be developed as an activity of all the health centers, including the central downtown dispensary, and that each dispensary connected with a hospital should include a dental clinic for both adults and children. The Survey has recommended to each of the major hospitals that a dental surgeon be a member of its staff, with rank as head of a department; and that under his direction a dental clinic be conducted, with the necessary dental assistance. Pay dental clinics for persons of moderate means would be a great public benefit. The "Health Centers" The tuberculosis and infant welfare work of the Division of Health may be studied from the standpoint of the management of its clinics as well as from that of the specialist in the medico-social problems of the diseases concerned. Of the eight "Health Centers," seven include tuberculosis clinics; all have infant welfare clinics, and there are in addition, six "baby prophylactic stations," subsidiary centers for the better covering of more neighborhoods. As to buildings, three of the Health Centers are located in stores, occu- pying the entire ground floor in each case. Two of the stores have light from one side only; one of these two has good light from the rear. The third store stands on a lot aloae and has exc Jlent light and ventilation on all sides. All three have the advantage of unusually good front light. These three cen- ters are the ones selected by the Mouth Hygiene Association for the install- ment of the dental work. Three other centers, Nos. 1, 3 and 4, are located in single dwelling houses. No. 4 has the entire house (allowing a man and wife to occupy the upper floor in exchange for the care of the store fronts); all the rooms have some daylight, making the total result better than in the stores. Health Center No. 5 is the most fortunately located of all, being Hospitals and Dispensaries 905 in a public bath-house, which is also a gymnasium and social club-house; there are here ample space and a fortunate arrangement of rooms. No. 8, the University District center, is in half of a double house. It is neither very light nor roomy and arrangements are poor for the work. The six auxiliary sta- tions are: one in a library — an excellent room designed for a kindergarten room; one in a Y. W. C. A. building; one in a community center; two in public bath-houses; and one in a settlement house. One of the public schools in the downtown section is used in the summer for an extra station. All the clinics are limited to essential equipment. They are all supplied with imported scales for weighing the babies in grams. A new dental equip- ment was being installed in Center 7 at the time of the visit of the Survey investigator. The buildings were not adequately heated in the cases of Nos. 7 and 3, where dependence had to be placed on stoves, with no suitable place to store coal. Nos. 1 and 4 were heated by gas stoves which markedly affected the air. There are 35 tuberculosis clinics a week held in the seven main centers. University District does the home visiting on tuberculosis cases in its area, but gets the cases from the clinics held at Center 2. These clinics are held Monday, Wednesday, Friday and Saturday afternoons from 2 to 4 p. m., and Thursday evenings between 6 :30 and 7 p. m. In the Child Hygiene Department 46 clinics a week are held. Centers 6 and 7 each hold six clinics a week. Center 2 and the auxiliary station at Alta House hold two each a week. The other ten stations each hold clinics weekly. These clinics are held between 9:30 and 10:30 a.m. The nurses reported that Saturday was always the least crowded day. Two other types of clinics are held in the Health Centers, but are under auspices somewhat different from those of the two above mentioned. The district doctors hold visiting hours in three of the clinics from 9 to 10 a. m. each day. An average of about six patients come to these clinics daily for dressings, or to get advice for minor ills. The number is frequently two to three and it is not infrequent for the doctor to have not a single caller. The three dental clinics maintained by the Mouth Hygiene Association in Centers 2, 6 and 7 meet five times a week from 1 to 4 p. m., and are largely used by parochial school children and the families of patients with tuber- culosis. It can be easily seen that these clinics do not use nearly all the available daily hours. With the exception of Station 5 the rooms are idle during the other hours. Stations 6 and 7, both of which have infant clinics six morn- ings a week, and dental clinics every afternoon but Saturday, do not waste much time, but the other buildings could serve useful purposes at other hours. This is true of the evening hours for all stations. The patients attending the clinics are derived from different sources. In a study made of a series of cases attending the Infant Hygiene Clinics, 57 906 Hospital and Health Survey per cent, were found to be referred by neighbors, friends or relatives; 37 per cent, referred by the Health Division and clinic nurses; 2 per cent, by the Visiting Nurse Association; and 4 per cent, by physicians. The practical value of the work is rather well illustrated by the large number of cases sent by apparently satisfied clients. In considering this, the use of the clinic in providing an inspected milk at lower than market prices must be borne in mind. It is* not purely the desire for a health inspection for their children that brings the mothers. In the tuberculosis clinics the largest percentage came in as a result of efforts of the Division of Health nurses, 46 per cent, having come in this way. 14 per cent, were referred by physicians and by friends or relatives; 11 per cent, by dispensaries and hospitals, 7 per cent, by the Board of Education (referred when there is a health problem in relation to the issue of working papers), 3 per cent, by the Associated Charities, and 1 per cent, each from the Red Cross, the Juvenile Court and the Visiting Nurse Association. The source of reference for the other cases was not stated. These figures do not refer to active or positive cases only, but to all patients that came to the clinic for purposes of examination. There were about three times as many visits to the Infant Hygiene clinics as to the tuberculosis clinics in 1918, the last year for which the figures have been calculated. This attendance is out of proportion to the number of active cases, for there are nearly twice as many active cases of tuberculosis under care, as cases in the Infant Hygiene Clinics. This generous attendance in the Infant Hygiene Clinics is doubtless due to the insistence on the part of the clinic that the baby come in every two weeks in order that its milk be continued. In the Infant Hygiene work the nurses give much assistance in the clinics. They weigh each baby, suggest to the mother regarding clothing and visit the cases at home to instruct in milk modification when this seems desirable. They also keep the milk book. This is a big job as well as a very large book. Each patient has to be graded as to the amount he shall pay for milk. There are five grades similar to those adopted at the Babies' Dispensary. The nurses have not established quite such hard and fast regulations as at the Babies' Dispensary, but are free to exercise some judgment. A milk that would retail at 30 cents a quart is sold at the various rates according to the family grade: Rate l Rate 2 Rate 3a. '.. Rate 36 Rate 4 'Synthetic Milk adapted. Cost per Qt. Cost per Pt. Cost S . M. A.*Qt. 22c 15c 30c 17c lie 17c 10c 5c 10c 5c 5c 5c Hospitals and Dispensaries 907 Any families claiming to be in grade 4 who are not referred by the Asso- ciated Charities are cleared through the Social Service Clearing House while the patient is still present. Then if the family is known to some relief agency the agency is consulted to see if the family should receive free milk. The majority of families are in rate 3a or 3b. S. M. A. costs 40 cents a quart retail. It is a special preparation of fats and oils devised by Doctor Ger- stenberger and prepared in the milk laboratories of the Babies' Dispensary. The doctors prescribe the milk for two-week periods. It is delivered by the Belle Vernon Farm Company. The child must return in two weeks or the milk will be discontinued. Work and Personnel The work of the Health Centers may be divided into medical and nursing work. The type of work for each group must be divided into the four de- partments or activities of the clinics. Medical Work The medical work is under the supervision of the Commissioner of Health with a department head in charge of each branch. At present the Bureau of Tuberculosis has no chief. The Commissioner of Health is therefore respon- sible for its activities. He is not able to give the health centers much de- tailed supervision. This is especially unfortunate because there are no spe- cial requirements for the doctors working in the clinics regarding experience with tuberculosis. There are eight physicians in the Bureau, each receiving a salary of $780 per year for attending five clinic sessions weekly. All the cases requiring sanatorium care or hospital admission are passed upon by the clinic doctors. The medical records would indicate that the physicians made a careful lung examination in each case. Re-examinations are seldom recorded. Sputum analysis, though not absolutely routine, is fairly fre- quent. Many records showed that the patients neglected to return the bottles given out for collecting sputum specimens. The doctors seemed interested in the work and there was comparatively little complaint among the nurses that the doctors were not punctual. Tonics, cathartics and cod liver oil are occasionally prescribed at the clinics. The Chief of the Bureau of Child Hygiene takes an active part in the work. He personally conducts one clinic a week at Center 5. He visits the other centers rarely, stating that all the doctors on duty have served in the Babies' Dispensary for at least one year and do not need supervision. Much of the rest of his time is spent in the drawing of charts and collecting statistics, work which might better be undertaken in the Bureau of Vital Statistics. His salary is $3,300 a year and he devotes his full time to the work. The Chief of this Bureau is also responsible for the infant eye work and the inspection of boarding homes for children. These two functions have been so far systematized as to require practically nothing of his atten- tion. He is also responsible for the licensing of midwives, but this is not associated with the clinic work. 908 Hospital and Health Survey The work of the physicians in this bureau is excellent in certain respects, yet lacks much that would make it of vastly greater value. The babies come to the clinic and are undressed and weighed — they are then dressed before they go to the physician. He discusses food with the mother, writes a pre- scription for the milk the child will need for the next two weeks and fills in its formula on a printed detailed slip. If the mother complains that the child has a Qough, she is advised to take it to the Babies' Dispensary where it can receive a chest examination. The Survey investigator noted the fol- lowing case. A mother brought in a two-year-old child, very thin and under- nourished and unable to sleep. A private doctor had told the mother that it had worms and had prescribed medicine. At the clinic the mother was advised to return to the private doctor, although assured that the child did not have worms, and no directions were given regarding diet or general habits, which were admittedly bad. The ability to prescribe diet for infants up to 15 months is highly developed in the clinic physicians, but the giving of other health directions and the diagnosing of cases adequately enough to relieve the mother from trips to the Babies' Dispensary are not usual. The nurses complained of the difficulty in interesting the doctors in the child be- tween 3 and 6 years. These little ones are allowed to come to the clinic for weighing and health directions, but not much information appears to be gained from the doctors which is of aid to the mothers. The only other medical work done in the stations is the work of the dis- trict physicians who make their headquarters at the dispensaries. They are called by the nurses to visit various cases in the district, including con- tagious or tuberculosis cases, as occasion may require. They report to the center each evening for calls that have been left there during the day. Administrative Work This is all in the hands of the supervising nurses. There are two clerical assistants in each center, but the nurses complained that few of them were able to take any responsibility. The nurses do not even trust the care of the milk book and the collection and accounting of the money paid for milk in the clinics to these helpers, but nurses have to be assigned to these duties. Social Work There is no social work as such. All cases coming to the tuberculosis cliiic are cleared through the Social Service Clearing House. All rate 3 and 4 cases coming to the child health clinics are cleared. Referring and consulting about cases depend on the interest and understanding of the nurse carrying the case. All the rating for milk is done by the nurses. The judg- ment used varies in wisdom, depending on the nurse doing the work. The nurses frequently attempt to make social adjustments in a distinctly amateur way. Records and Filing A system of filing by families has been adopted and has a certain distinct advantage. One number is given to the family and each additional member Hospitals and Dispensaries 909 who comes for any cause gets the same number with an additional letter. Thus there are found in the same folder case? for the tuberculosis clinic, for infant hygiene, for acute eye conditions, and possibly for a contagious condi- tion. But keeping families in groups this way makes necessary a rather elaborate daily attendance book and careful cross indices. It is convenient when the nurse writes up the record and keeps all the records of each family together. Where generil home visiting is so vital a part of the clinic work it seems an advisable plan. There is a social family history card filled out for each family at the time of the first visit; this is a form with detiiled headings. There are various forms for the different departments. The infant hygiene card has a weight chart on the b ick and is similar in every way to the card used at the Babies' Dispensary. There are special forms on which diet is prescribed which are worthy of notice. There are forms for city hos- pital admission as well as admission to Warrensville. All the records seemed to be well filled out for the first visit. The routine recording of weight causes the dates of all subsequent visits to be noted, but the facts observed by the doctors were not always recorded. Each nurse keeps a daily record of her work and detailed monthly reports are filed at the Division of Health. Financial It has not been possible to obtain from the Division of Health an itemized expense account of the Health Centers for 1919. It is known that the expenses for the year from the three departments using the health centers was in 1919 as follows: Total Salaries Communicable Diseases... $ 53,526.97 $ 31,171.84 Tuberculosis 72,883.22 60,697.99 Infant Hygiene... r 65,330.05 53,352.09 $191,740.24 $145,221.92 The rates of salaries are as follows : Physicians Chiefs of Bureaus $3,300. Full time (2) District Physicians 3,300. Full time (7) Tuberculosis clinic — physicians 780. 5 clinics (8) Infant Hygiene clinic — physicians 800. 6 clinics (6) Infant Hygiene clinic — physicians 450. 3 clinics (9) Nurses Director of field nurses... $2 , 400 Full time (1) Assistant director ' 1,980 " " (1) Supervising nurses 1 , 660 " " ) Field nurses — 2nd year 1,440 " " [•(78) " " 1st year... 1,320 " " j 910 Hospital and Health Survey Clerical Workers Senior Typists $990 or $1056 Full time (10) Junior Typists 792 Full time (7) Almost 76 per cent, of the cost of the work goes to salaries. There is some incom,e from the work, and there is another large item of expense not included in the foregoing — that is the milk, as mentioned above. The milk report for one month showed that Rate No. 1 overpaid exact cost $106. Rate No. 2, by buying of pints instead of quarts, overpaid $1.83. The other grades all underpaid, making the deficit for the month somewhat over $700. This is a small deficit; it is usually about twice that. The nurses charge $1 or 50 cents to teach milk modification at home. The dental work is charged for — Rate 1 pays 50 cents each time; Rate 2 pays 50 cents at first and 25 cents thereafter; Rate 3a pays 25 cents first and 25 cents thereafter; Rate 3b pays 25 cents at first and 15 cents thereafter; and Rate 4 gets free treat- ment. These dental collections go to the Mouth Hygiene Association. Conclusions In summary, Cleveland has made a real beginning in a public health dis- pensary program. Its health centers meet real needs, and their medical and nursing organization provides in the main a sound foundation both for im- provement in details of service and for future advances in policy and scope. Aside from such general recommendations regarding dispensaries as appear in the next section of this chapter, the following may be made here : 1. There should be coordination between the publicly and privately supported public health clinics; notably by the utilization of publicly main- tained plants (Health Centers) for prenatal clinics (see page 903). This would aid in utilizing the Health Centers to their capacity. 2. The infanc hygiene work should include children up to six years. The present limitation of work to infants and children under three years of age is a great misfortune. With little additional expense better care and supervision could be extended to the children up to six. The supply- ing of milk, a daily necessity which makes return to the clinic vital, has swelled the attendance rather than improved the excellence of the medical work or the pertinence of the health directions. This milk plan is doubtless wise has surely resulted in preventing much illness among infants, and should be continued; but it should be a relatively smaller part of the clinic service. The doctors should develop keener and more intelligent interest in the children over 15 months, and should be prepared to write out as accu- rate a diet for them as for the younger children. 3. The division line between the sick and the well child should be ex- tended a little in favor of the sick child. That is, the doctors should more freely make examinations and give at least health directions to children with colds. Skin conditions are another bone of contention, the prophylactic center doctor feeling they are "diseases" and should go to the Babies' Dis- Hospitals and Dispensaries 911 pensary, and the Dispensary feeling that the mild forms belong in the Health Centers. 4. The Health Centers should utilize clerical service more freely for business management and executive details, and require less of these duties from the nurses. The recommendations of the Nursing Report should be followed in this matter. 5. The Centers should as soon as possible include in their services the examination of the supposedly well, both adults and children. The offer- ing of such periodical "health examinations" may perhaps best begin in the proposed central dispensary (see discussion of that subject), but is a proper function, ultimately, of all health centers. 6. Increase in the number of dental clinics is urgently needed as recom- mende i in Part VIII. of the Survey Report. 7. The Health Centers should include administrative and sanitary activi- ties, such as properly belong to a local office of a Health Division under a district form of organization. This, as well as the much-needed improve- ment in supervision, will be possible only with an advance in efficiency of the Division of Health, its better organization, and larger financial sup- port. 912 Hospital and Health Sttrvey POLICIES AND NEEDS A comparison between the amount of dispensary service in New York, Boston and Cleveland shows a startling contrast. The 115,000 dispensary visits made during last year in Cleveland to the dispensaries treating the sick must be compared with some 3,600,000 in New York City and with some 750,000 in, Greater Boston. In proportion to population, Greater Cleveland has about 14 dispensary visits per 100 population. New York about 60 per 10.0, and Greater Boston about 50 per 100. A further comparison may be made with Chicago, which in 1918 had 835,000 dispensary visits recorded, or about 35 per 100 of population. It will be seen that Cleveland's provision is extremely low. As brought out in the early part of this report, this de- ficiency is reflected in many ways in hospital service, and this will be empha- sized in the following sections of this chapter; but the shortage of dispensary service also means for the community as a whole, deprivation of adequate medical care to many needy groups in the population, lack of specialist service to many more, failure to diagnose and treat many diseases during the early stages, and deprivation of consultant and diagnostic facilities to many members of the medical profession. Preceding a statement of recommendations for improvements or increase of service to meet these deficiencies, a statement is made of certain policies regarding dispensary management and administration. DISPENSARY POLICIES Admission of Patients (a) Policy — In determining admission to a dispensary, the needs of the patients and the protection of the community must be the primary considera- tions. The medical profession has a right to be protected against imposi- tion by persons who seek in clinics the unpaid service of physicians, when they could afford to pay for the medical care which they need. The public has a right to service. (b) Standards — In determining the admission of individual cases to a dispensary, three points need to be considered: namely, the income of the patient or family, the size and responsibilities of the family according to a reasonable standard of living, and the character and probable cost of ade- quate medical treatment for the disease or condition found. It should be added that under certain circumstances public health considerations must be the determining factor, for example, a case of infectious syphilis may demand immediate treatment, irrespective of what later disposition of the case is made. When a difficult or obscure condition must be diagnosed, or when treatment by a specialist is required, patients might be accepted whose cir- cumstances would enable them to pay for the services of a family physician, though not for consultation with or care by specialists. (c) Procedure — The social service department should be responsible for the admission of new patients. Certain practical points connected with this matter will be found in the discussion of social service. Hospitals and Dispensaries 913 Medical Relations (a) Policy — The medical staff of the dispensary and also the organized medical profession of the community have a right to be consulted about policies or problems affecting their interests. In the case of the general profession, this should be possible through conference between represent i- tives of the dispensary and representatives of the Academy of Medicine. The Central Dispensary Committee hereinafter proposed (page 920) would largely accomplish this purpose. (6) Compensation — Hospitals and dispensaries cannot expect to secure enough of prompt, regular and efficient medical service unless compensation is given to the physicians of the staff either in opportunities for study and experience, or in financial remuneration, or in both. The generous willing- ness of physicians to render humanitarian service is traditional and unques- tioned, and should not be unduly explpited. Each dispensary or out-patient department, considering its own type of work and the medical facilities offered, must determine for itself the manner in which it can best attract and retain an adequate medical staff. The advice of central bodies such as the proposed dispensary committee and of the Cleveland Academy of Medi- cine would be of value in this connection from time to time. (c) Consultation — A definite function of the dispensary, particularly of the major institutions, is to provide consultation facilities for physicians. (d) Diagnostic Facilities — In addition to opportunities for consulta- tion, dispensaries should make the services of their laboratories and X-Ray departments available to the private patients of physicians (when referred by them) when such patients cannot afford the rates charged by private laboratories or by X-Ray specialists. Fees from Patients (a) Policy — It is a good policy to charge admission fees and also treat- ment and medicine fees; no patient being denied a needed service because of inability to pay the stated fee in whole or in part. The presence of medical teaching need in no way affect this policy. (/>) Rates — For clinics receiving the gratuitous services of physicians, an admission fee of 25 cents per visit is reasonable at the present time. It is desirable that through the proposed Central Dispensary Committee, fees be made uniform for similar classes of service. For clinics which aim to be self-supporting and whicl/furnish a more than nominal remuneration for the physicians, the fee should be not less than 50 cents a visit, and may be higher for certain classes of services. The basis on which such fees should be adjusted is the cost of service. 914 Hospital and Health Survey Fees for special treatments, apparatus, eye-glasses and medicines, should be fixed at or somewhat above the cost of the materials and immediate service provided. Definite schedules of all the admission and the more usual treatment and medicine fees should be posted in suitable places in every dispensary. (c) Pay Clinics — Clinics charging fees of 50 cents or more a visit should be regarded as pay clinics and should provide financial remuneration for their medical staff. In determining the rates of such remuneration, conference with representatives of the Cleveland Academy of Medicine is suggested, or the proposed Central Dispensary Committee would serve this purpose. Such pay clinics should aim to serve self-supporting families of limited means, particularly in the specialties. There is much need for the further development of such clinics in Cleveland. The admission system in connection with pay clinics should protect the interests of the medical profession as well as of the patient by adopting and carrying out the standards above outlined. (d) Remission of Fees — The admission desk in the smaller dispensaries should be responsible for the remission of all fees. In large dispensaries the admission desk may be unable to attend to all remissions in the case of old patients, and social workers in one or more clinics should be authorized to pass on remissions for the appropriate group of cases. Adaptation of Clinics to Clientele (a) Hours — Evening clinics for working people are desirable in all or almost all dispensaries. These clinics may well be pay clinics. (6) Foreign-Speaking Patients — Special efforts, as outlined in the discussion of the foreign -born, in the section on the "Human Problem of the Hospital Patient," should be made to enable persons not speaking English to receive effective treatment. (c) One important group of the clientele of nearly all dispensaries is that of the beneficiaries of other charitable or medical agencies. It is part of the duty of a dispensary to serve as the family physician for these. This re- quires: (1) examination of patients and families and full reporting of condi- tions found to the society interested; (2) treatment of those needing care, usually without fee; (3) special arrangement whereby the social service de- partment of the dispensary has charge of "steering" these cases and insuring that the work is done and the reports are rendered with a minimum of admin- istrative demand upon the clinic physician. (d) The dispensary should be a main agent in the admission of hospital patients to the wards and in the follow-up of those discharged. (See sec- tions on Convalescent Care ) Hospitals and Dispensaries 915 Inter-relations of Dispensaries (a) Duplication — The pursuance of treatment by a patient or the members of a family at more than one dispensary at the same time should be discouraged and prevented as far as possible by careful admission systems. The inquiry at the admission desk should include question as to place or agency of previous treatment. (6) Reference of Patients — Patients recently under treatment it one dispensary . and not specifically referred to another for consultation, should be referred back to their former place of treatment, except when satis- factory reason is found to exist for the transfer. The same policy should of course be pursued when a patient has been under treatment by a private physician. The use of printed or written slips of reference is of practical oervice. (c) Districting — The limitation of the work of each dispensary treat- ing the sick to a definite area is not practicable, but patients should be en- couraged to seek treatment in the section of the city in which they reside or have their place of business. Well administered admission systems at each dispensary and a common understanding of policy, worked out by the- pro- posed central committee, should reduce to a minimum problems of dupli- cation and of overlapping of areas. Dispensary Administration Essential points of organization are presented in the sections on "Organ- ization for Service" and "The Medical Profession and the Hospitals," and will be merely recapitulated here: An executive head for the dispensary. A medical organization which is integrated with that of the hospital. A dispensary medical committee. A dispensary committee of the board of trustees or, if the board has not a sub-committee system, one or more members of the executive com- mittee who have special responsibility to be in touch with the dispensary. The dispensaries of Cleveland would do well to develop carefully worked out systems of referring patients from clinic to clinic within the dispensary, for consultation purposes; and for transferring patients for treatment from one clinic to another, with due report back to the referring or transferring clinic. The important place of the social service department in dispensaries is outlined in the section devoted to social service. 916 Hospital and Health Survey Medical Care of Children in Foster Homes This has received little attention from the medical agencies of Cleve- land, and the Humane Society itself has not dealt adequately with its re- sponsibility in this matter. As Dr. Mac Adani's report shows, in another portion of the Survey (Part II.), the physical condition of the children boarded out £>y the Humane Society is far from satisfactory. Moreover, the Society's records do not show adequate medical supervision of its children, and indeed the system which it pursues would render adequate medical work quite unlikely. Even in the case of the children under three years of age, which are within the special province of the Babies' Dispensary and which are supervised thereby in behalf of the Society, results are not satisfactory. This is largely because of the lack of a really intimate affiliation, which is required for the successful conduct of any such piece of work. It is essential that the physicians of any dispensary vhich is served in such a capacity shall think of the special problems of a placing-ort society, as well as of the physical needs of each individual baby. The social workers and nurses who are in touch with the foster home need special explanation of the child's needs in terms that they can understand, and the foster mothers need in- struction not only from the field workers but also, from time to time, from the physician himself. Moreover, the administrative system of the dispen- sary must be specially adapted to this work for the placing-out society. Delays must be minimized and records and information be readily and promptly secured. In the case of the older children, present conditions are still less satisfac- tory than with the babies. Satisfactory results cannot be expected unless the Society has a Medical Director, who should be a specialist in pediatrics, and be responsible for the medical standards and policies of all children under the care of the Society. This director should be a member of the staff of the children's clinic of a dis- pensary with which the Society makes a working arrangement for the initial examination, re-examination and much of the interim supervision of the children's health. Preferably he should be also on the staff of a hospital with a pediatric service so that sick children requiring hospitalization could be still under his care. There are substantial advantages in utilizing for examination and supervision the equipment, organization and the group of specialists of a well managed dispensary, instead of a number of doctors in separate private offices. The systems worked out in Boston, by coopera- tion between the Children's Aid Society and the Boston Dispensary, and in Philadelphia by the Seybert Institution, could be studied to advantage as illustrations of method. It is important that there shall be not only intimate coordination between the medical authority of the Humane Society and the medical agents and agencies doing the actual work, but also that the nursing and social service staffs be in similarly close touch. Without this, satisfactory results cannot be expected. The medical workers and the field workers must understand one another and the system under which each group works must be mutually adapted to achieve the needed degree of mutual understanding. Hospitals and Dispensaries 917 It is recommended that: 1. A medical director, a pediatrician, be appointed by the Humane Society, with a financial honorarium, as the authoritative guide and super- visor of the physical condition and development of all its children 2. This director be a member of the staff of either the Babies' Dispensary or of the proposed central downtown dispensary (Pediatric Clinic), whichever the Humane Society decides to be the better organization for such affiliation. 3. Routine medical examination, re-examination, advice and super- vision of health be carried out through the selected clinic, a special salaried medical assistant being requisite for the purpose. The Humane Society should provide this salary. 4. Standards for medical examination, hygienic directions, diet, re-visits, home care in emergencies, etc., be outlined by the medical director. 5. Consultation by the specialists in other departments of the selected dispensary (eye, dental, throat, ear, skin, orthopedic, etc.) be provided as requested by the medical director; treatment also as necessary. 6. The use of the local doctors and of specialists in private offices be reduced to a minimum; that reports from such physicians be required and made part of the central medical record. 7. A special worker be in the selected pediatric clinic, under the adminis- trative direction of the clinic, but with salary wholly or largely from the Humane Society, to attend to the details of assisting in securing examinations and consultations; in effecting transfers; keeping track of needed re- visits; and seeing that the necessary information is furnished by the Society to the clinic doctors and workers on the one hand, and by the clinic to the field workers and foster-mothers on the other. 8. Periodic conferences between the medical director and his assistant or assistants, be held with the clinic worker and the field nurses and social workers who deal with the Society's cases. 9. The records of the clinic concerning each child be regularly furnished the Society and the clinic be provided by the Society with such history of each case as the medical interests require. Record forms should be espe- cially prepared for this purpose. 10. The present system of utilizing public health nurses for home visit- ing of placed-out children be continued and made much more effective through (a) the centralized medical direction contemplated in the plan (b) the closer medical supervision provided for in recommendations 3, 7 and 8. If the Babies' Dispensary will increase its age limit and render its organ- ization sufficiently flexible and adaptable to meet the requirements of effi- cient service to this group of children, it would be desirable that the plan be worked out by the Society in cooperation therewith. The establishment 918 Hospital and Health Survey of some special clinics as well as the general pediatric clinic would be neces- sary, as the Survey has recommended in its special report to the trustees of this institution. If the requisite conditions cannot be met at the Babies' Dispensary, it is recommended that the central downtown dispensary be utilized. It should be pointed out, in conclusion, that while the proposed plan for adequate medical supervision of placed-out children will cost more than the present admittedly inadequate system, the expense of the medical work is after all only a small fraction of the total cost of boarding and general super- vision of such children. Very little permanent result for the present or the future generation can follow from any system of children's aid which does not make the thorough and efficient care of health a primary consideration. DISPENSARY NEEDS OF CLEVELAND Aside from the public health dispensaries for which recommendations were made in the previous section of the report, the dispensaries for the treating the sick of Cleveland universally need improvement in various respects. Recommendations regarding each institution have been presented to its governing body by the Survey. In general, the needs may be sum- marized as: (1) more work to be done; (2) better executive direction through the assignment of a definite officer to be in charge of the dispensary, under the superintendent; (3) representation of the out-patient department so as to secure better recognition of it by the hospital authorities; (4) paid assist- ants for the medical staff (social workers, nurses, clerks) so as to relieve the physicians of non-medical drudgery and improve the grade of service to patients; (5) better records which, would largely be accomplished by^the assistants just mentioned; (6) better plants and equipment. The expense involved in the improvement of services lies chiefly in the salary of ths paid assistants mentioned, and would be largely met by the admission fees recommended. An increase in the amount of dispensary service for the people of Cleve- land is as greatly needed as is an improvement in the quality of service now offered. It may be expected that the work of existing dispensariss will in- crease considerably as more attention is paid to their needs, and better sup- port is provided. But no increase in the work of the six present institutions can obviate the necessity of at least the following additional dispensaries: The City Hospital out-patient department is already provided for in the tentative plans for the enlarged City Hospital. It should be one of the major dispensaries of the city. (See section on "Community Planning"). St. John's Hospital should, as soon as possible, develop a good-sized out-patient department for the benefit both of the hospital and of the west side area which it especially serves and which now has no dispensary. When the re-organization and development at St. Alexis Hospital have been worked out under the new advisory committee, the establishment of a Hospitals and Dispensaries 919 well-equipped out-patient department should be undertaken and this need should be borne in mind by the committee even in the formulation of its plans for the immediate future. The establishment of an out-patient department, now being built by Fairview Park Hospital is approved, although this dispensary will prob- ably remain small and its work restricted largely to certain types of cases, particularly surgical, corresponding to the work of the hospital. The same would probably be true of similar out-patient departments that might well grow up in connection with other hospitals of the same type in the same section of the city, such as Grace Hospital or Lutheran. The plans for the re-location of Lakeside Hospital imply a new dis- pensary, attached to its new plant. This should be another of the few major dispensaries, as described in the community plan, in the section on that subject. The proposed new plant of St. Luke's Hospital will require a dispen- sary, unless the present buildings or parts thereof, are retained as an indus- trial hospital, and a dispensary be operated in connection therewith. The latter plan is recommended. It is not believed that the proposed new plant of Huron Road Hospital on Ambler Heights will require a dispensary for some years to come; but Huron Road might with advantage have at least a medical affiliation with the proposed central downtown dispensary. (See section on downtown dispensary.) A new dispensary will be needed downtown, at least as soon as Lake- side and Huron Road move out, and meanwhile, certain services for the downtown area need immediate development. Cleveland, like most other cities, suffers from lack of any general plan for dispensary service. The different clinics are not coordinated with one another or with the public health and charitable agencies. It is essential to have a plan and effective organization whereby the work of existing dispen- saries shall be improved and the new dispensaries be established in sections of the city now unprovided for. But above all, the aim must be to furnish a basis upon which dispensary service should be better understood by the com- munity and better serve the community. The points of view of the prac- titioner of medicine, of business, and of charitable agencies, of the men, women and children who need adequate service and cannot pay for it, and of the public as a whole, represented by the city government and organized agencies for expression, all need to be considered in framing any forward- looking project of this character. The preventive and educational work of the health centers must be adjusted in conjunction with the curative medical work of the hospital out-patient departments, so as to be mutually helpful and to serve as parts of a developing city plan. 920 Hospital axd Health Survey It is necessary — (a) To create some group of people or machinery whereby the dis- pensary problems of the city can be viewed as a whole, each particular dis- pensary or related agency be brought into touch with the larger problems, and the larger problems themselves directly and adequately dealt with. (6) To have dispensary work rest upon its own financial basis — the financial support of dispensary service being provided in terms of and in pro- portion to such service, and not merely as a part of hospital or medical work in general. It is therefore proposed: 1. That there be a Dispensary Section or Committee of the Hospita Council — this committee or section to include representatives from each of the existing out-patient departments of those hospitals which are mem- bers of the Council; and also representatives from the Department of Public Welfare, the Cleveland Academy of Medicine, and persons interested in visiting nursing and charitable agencies. 2. That there be a salaried executive officer for this Dispensary Sec- tion or Committee of the Hospital Council. Such officer at first might be required only for part time and in that case had best be selected from some organization other than one of the privately operated out-patient depart- ments. 3. That the Cleveland Welfare Federation require the presentation of request for support for the out-patient departments of hospitals to be made separately from the request for support for hospital work proper; such re- quests to show the work done by the dispensary, the cost thereof (includ- ing a fair allowance for overhead) and the income of the dispensary from fees paid by patients or from other sources. In view of the general importance of dispensaries to the community, and of their special service as the "'family physicians" of the non-medical charities, the Welfare Federation should appropriate monies to dispensaries ('the out-patient departments of hospitals) on the basis of reports of (1) work done, (2) gross expenses incurred, (3) net expense after deducting all dispen- sary income from fees, special endowment, etc. This would mean a con- sideration of the annual dispensary budgets as separate parts of the budgets of the hospitals to which the dispensaries are attached. It would cause ap- propriating, supervisory and administrative bodies to give much more atten- tion to the dispensaries, which have too often been regarded as merely inci- dental elements in a hospital. Cleveland ought to have at least three times as much dispensary service as it now has. In from three to five years this goal can be attained, through the enlargement and improvement of existing dispensaries and the addition of new ones at the City Hospital and on the west and south sides. The gross cost of adequate dispensary service to Cleveland, at present costs of Hospitals and Dispensaries 921 maintenance, would probably be over $300,000 annually. The present gross cost is not over $75,000 (charging in all overhead). The difference is due partly to the limited amount of work and partly to low standards. It should be expected that when proper fee systems are developed, 50 per cent, of the gross cost should be met by fees from patients. It is thus contemplated that the Dispensary Committee or Section of the Hospital Council should be an expert advisory and planning body, serv- ing to improve dispensary standards and administration of the several insti- tutions to work out the larger problems of policy and inter-relation, and to serve also as an advisory body for the Welfare Federation, as the Hospital Council now does. The financial standing given to dispensary work by the proposed action of the Welfare Fedention would be essential if dispensary service is to stand on its own feet. No such Dispensary Section or Committee could be effectn r e unless some definite salaried executive assistance is provided. More and better dispensary service is one of the impo/tj.nt medical needs of Cleveland. The Hospital Council and the Welfare Federation should recognize it as such. 922 Hospital and Health Survey THE CENTRAL DOWNTOWN DISPENSARY The central downtown district of the city presents needs for medical and health service which are now not met, and offers certain unique oppor- tunities for rendering many forms of service. Huron Road Dispensary is excellently located, but the present dispensary is very small, and is in cramped quarters which permit but slight expansion, while the hospital continues as at present. Lakeside Dispensary, while not as well located, though still fairly accessible to the central downtown area, has far more possibilities, but as yet has not measured up to its opportunities. The moving out of both of these institutions will require either the retention of one plant is a central downtown dispensary, and the maintenance in this plant of needed forms of service not now provided, or the establishment of a new plant. In the first place, it is desirable to state the needs to be met. The centr il downtown district of the city requires dispensary service within its own area for at least four reasons : (a) Emergency and industrial surgical work arising from the large day- time commercial and industrial population of the central area of the city. (6) Many special forms of medical services which for the public wel- fare should reach as many persons as possible, and which in the downtown area can be brought to the attention of the large daytime and evening popu- lation which throngs this district for business or recreational purposes. Clinics in this district held at certain hours of the day, for instance at luncheon time and in the evenings, would reach large numbers of persons who are prac- tically inaccessible otherwise. Tuberculosis Clinics, Venereal Clinics, or Mental Hygiene Clinics, are examples. (c) General medical and also special services such as are provided by general dispensaries, ought to be available to this transient population of the central area (as well as to its residents) at hours and under conditions which would make it possible to have these services most effectively used by those who most need them. (t/) This dispensary would serve charitable agencies, providing medical examination and supervision for the families under care in the central dis- trict, or who have to be brought to this district to the society's offices. Cases requiring elaborate study or special treatment would be referred to one of the major out-patient departments. The downtown dispensary is required for a larger reason. If properly organized and made a real center of a variety of health and medical activities such a downtown dispensary would serve as an important educational center along general health lines, assisting the work of many other agencies, not only as a point from which patients would be referred but also as a center of public health education. Hospitals and Dispensaries 923 Such a dispensary would include: (a) A clinic for industrial surgery operated throughout the twenty- four hours. Such a clinic would require special arrangements for its pro- fessional services and be administered so that patients could be admitted without delay, although the clinic might be closely related to the other dispensary services in the same building. The need for such an industrial clinic has been brought out in Part VII. of the Survey Report. (6) A Health Center of the City Division of Health maintaining (1) a tuberculosis clinic, with a special consultation service at periodical inter- vals, (2) venereal clinics, and (3) a division for health education, which should include among its activities the conduct of a clinic for the examination of well people — children and adults. It might perhaps be best to maintain the venereal clinics under private auspices. (See Part V.) (c) A mental hygiene clinic. (c?) A general medical clinic for the examination and treatment of sick persons. (e) Special clinics, such as eye, ear, nose and throat, and surgery, (other than industrial surgery). (/) The "Orthopedic base" or "center" recommended in the orthopedic plan, (Part II of the Survey Report), should be in the same building. Its work would assist all the other branches in the downtown dispensary and would be assisted by them. This orthopedic center would include, besides certain administrative functions relating to the orthopedic plan of the city as a whole, a physical treatment center which would be of city-wide value and would be especially advantageous if located in this central district. (g) The affiliation of this downtown health center with the University is highly desirable. It has been pointed out elsewhere that there is needed a certain small number of hospital beds (20 to 50) in the central downtown area, largely for emergency purposes. This emergency hospital or "relief station" could with advantage be combined with the central downtown dispensary. If both Huron Road and Lakeside Hospitals move to their new sites within a few years the proposed dispensary and the emergency beds will be the more urgently required. The plant of Huron Road Hospital appears to be suitable, with relatively slight modifications, for the combined purposes of emergency beds (30 to 40 in number) and the downtown dispensary. The location is almost ideal. It might be well for Huron Road Hospital, as well as for the public good, that there be a medical affiliation between the Huron Road staff and the dispensary staff; but the problem of staff for the down- town dispensary might be solved in other ways. The industrial surgical clinic should be fully self-supporting, from the in- dustries which it serves and from the workmen's compensation cases. The 924 Hospital and Health Survey staff of this division should be salaried. The senior visiting staff would pro- vide certain supervisory and consultant advantages. The public health clinics of the dispensary would constitute an additional Health Center of the city Division of Health, and would require the neces- sary addition to its budget. The mental disease and mental hygiene clinic should be maintained, at least at the start, by the organization especially concerned with this interest. The orthopedic clinics and physical treatment center should be supported likewise by the orthopedic group referred to else- where in the Survey report (Part II.) The Community Fund would properly be called on for the financial sup- port of the general medical clinics for adults and for children, and for the special clinics which are required. Xot only as meeting a general public need and a broad purpose in health education, but also as assisting charitable societies to secure better medical examination, advice and supervision for their beneficiaries, the central downtown dispensary has a peculiar demand upon the Welfare Federation. This dispensary, among other benefits, would make money spent for many other charitable agencies count for more. In estimating the cost of this dispensary, it must be borne in mind that the medical staff in all clinics should receive financial compensation, except for merely consultant or infrequent visiting services. The gross maintenance expense of conducting the industrial surgical clinic, public health clinics, general medical, pediatric and special clinics, with a used capacity of 50,000 visits a year, should not exceed $60,000. Deducting the cost of the industrial and the public health clinics supported by industry and by the city, respec- tively, the gross charge upon private funds would be about $35,000, of which some $15,000 might be expected to be returned through fees from patients. The net charge should not exceed $20,000 a year. It is apparent that the initiative in putting this dispensary under way must come from some privately organized group having a special interest in the matter. It is recommended that shortly after the proposed Central Dispensary Committee has been organized, this committee initiate discus- sion of the matter and call together a conference of such individuals and interests as may be necessary. Some one committee or organization would have to assume definite responsibility for the plant. This committee might be a joint body of the organizations providing various services, or a more specialized body which made arrangements with the other groups to use the plant for certain purposes at specified times. The plan will be restricted in its service in proportion as few activities are included, and will be broad and far-reaching as the number of activities and interests is increased, always assuming their harmonious coordination. The combination of the public- health and preventive clinics with the curative clinics, for instance, is of vital importance. It would not be unnatural that Lakeside or Huron Road, particularly if their moving plans are delayed, should suggest that their present dispensary be the basis of the proposed central dispensary. Such a plan is not imprac- tical, provided there be sufficient flexibility and readiness for cooperative Hospitals and Dispensaries 925 adaptation in the existing organization which is made the basis. It will be well to remember that such a central dispensary represents a Health Center in a somewhat advanced sense of the term; that it might ideally contain administrative offices of public and private health agencies, meeting rooms and auditoria for public health education; and stand before the people of the city as a visible expression of the communal interest in health. Through its own activities, in which curative and preventive functions should be cor- related, and through its connections with the Central Dispensary Committee, the municipal health work, the business, educational and philanthropic interests, the proposed dispensary might be a constructive force as well as a service to many individual lives. Only by grasping the possibilities of the project in the future can any institution or any committee justify an assump- tion of responsibility for its leadership in the present. 926 Hospital and Health Survey IV. Special Problems THE CONVALESCENT AND THE HOSPITAL By Mary Strong Burns, R. N. INTRODUCTORY NOTE Mrs. Burns, as a member of the staff of the Survey, presents in this chapter a study of convalescent patients recently discharged from the hospital. Few if any cities have as yet met adequately the need for convalescent care. The most notable work in the country is that of the Winifred Masterson Burke Foundation at White Plains, New York, under the direction of Dr. Frederic Brush, whose significant contribution as collaborator in the Cleveland Hospital and Health Survey will be found in the next chapter. The bulk and general bearing of the convalescent problem in Cleveland is discussed in that place. Mrs. Burns' contribution is a series of vivid pictures of what may happen to patients after they leave the hospital doors, and drives home the point that a sick man's sojourn in the hospital is only one stage in the journey between illness and health. Too easily does the hospital forget this truth. Too often do hospitals in Cleveland as elsewhere feel or at least act as though they felt that their responsibility ended when "discharged" is written on the record and the patient is no longer within the building. The care of convalescents is a much larger problem than that of a hospital or insti- tution for convalescents. The bulk of convalescence takes place in the home, and parti- ticularly in medical cases, the whole course of the illness, from onset thr^u?h acute stage, convalescent stage, and final restoration to health and vigor, may take place within the home. From this broader standpoint of the community, the convalescent problem is approached in the following chapters. In Mrs. Burns' study emphasis is laid upon the hospital patient and his need after discharge. Her very practical recommendations should be compared with what has been said in the chapter on the Human Problem of the Hospital Patient, with reference to hospital provision at the time of discharge and the use of the dispensary therewith. A STUDY OF HOSPITAL CONVALESCENTS LN THEIR, HOMES In attempting this study two things were very quickly apparent: (1) that convalescence is as much a state of mind as of body, and that environ- ment which does not provide for the needs of both is inadequate; (2) that the background of convalescence is laid, the texture of it stretched and woven, while the patient is still lying abed in hospital. His mind is a sensitive shuttle threading with tireless insistence every impression of the hospital ward, whether grave, radiant, trivial, or profound, and coloring each with his mood of the moment. On the "date of discharge" (when shall we find a more gracious phrase?) the patient takes this mental "sam- pler" and during the time that he must "remain inactive" as the house physician says, he wonders over it all. If left to himself he makes few alterations in this plan of return to health which the hospital has spread Hospitals and Dispensaries 927 out for his interpretative copying. Every impression is traced and retraced and his conception of health and of his part in holding it is framed in his idea of hospital service and remains pictured as a never-to-be-forgotten experience. In seeing over two hundred such " pictures' ' one could often exult that the hospital had been interpreted favorably and with gratitude. When the interpretation had been distorted through mutual distrust and misunder- standing, regret was always followed by the conviction that a broader con- ception of the hospital's responsibility was possible, indeed necessary, and that it would more and more make the way straight for patient and hos- pital alike. Two points of view will illustrate: (1) A Polish woman, after three weeks in a hospital ward, thus voiced her opinion on the Hospital Bond Issue, "She is like a great and wonderful mother who cares for many sick children, this City Hospital. If more money she needs let us say yes and give." (2) A man sensitive at being temporarily without money bitterly resented the hospital's attitude that he should pay his bill there because he had hitherto paid his private doctor, "Why would they think I should go to that place if I could any longer pay a doctor? Would anyone go who did not have to? I burn with shame when I think what questions they ask." Thus convalescence is the state of mind and body on which the hos- pital may set its stamp as a friend and helper or as an autocrat without sympathy. The real service to the patient is but half done on the date of discharge. The test then comes, to decide whether the final stage of convalescence shall be to each of its patients a stimulating, worth-while experience or a lonely and difficult task to be faced against great odds. The cases studied were two hundred discharged patients from four of the principal hospitals of Cleveland: Charity, City, Lakeside, and Mount Sinai. They were nearly all classified as free or part-pay patients. A few had apparently paid the full charge for treatment. They included a variety of foreign nationalities, of which Cleveland offers many: Armenian, Aus- tralian, Bohemian, Chinese, Greek, Italian, Lithuanian, Polish, Slovenian, Swedish, etc., a number of native American whites and a fair proportion of Negroes. The environment of patients seen ranged from that of wretched housing and extreme poverty to the completely comfortable house of the well-to-do. The types of illness from which these patients were convalescing were contagious and general diseases, surgical operations and accidents. There were also a few maternity cases. Their length of stay in hospital varied from five days to two months. Half of the cases were seen within three to four days after discharge. The others were seen within ten days after discharge with the exception of six surgical cases who had been told not to resume work for four weeks. In the homes the reaction of the hospital upon the patient was noted: (1) whether the diagnosis and medical advice had been understood, and was being followed with satisfactory results; (2) whether assistance of any sort 928 Hospital and Health Survey would more certainly assure the result for which the hospital had worked. In a word, was the best sort of convalescence possible for that particular patient in that particular home? The convalescents seen were classified as follows: Total Cases Total Per cent. 12.5 Cases with Home Environment 1. Favorable and adequate 2. Favorable with minor adjustments, eco- nomic or personal 3. Unfavorable but remediable by economic or other assistance _ 4. Unfavorable and not remediable, needing institutional care in convalescent homes 5. Acutely needing further hospital care — relapse after return from hospital 25 71 48 44 12 200 35. 5"| >59.5 %" 24.0 J 22. °1 87.5% 28. 0%^ 6.oj 100.0% Thus, with only 12.5 per cent, in suroundings favorable and adequate for convalescence, the remaining 87.5 per cent, of these cases returned to homes which were unfit in varying degrees for their convalescence. With proper advice or assistance, conditions could have been remedied in about two-thirds of these cases (59.5 per cent, of the total number) while with the other third (28 per cent, of the total number) conditions were irremediable and the patients required institutional care in convalescent homes or still longer care in hospitals. Charity Hospital Considering the convalescent cases of each individual hospital as a group, those of Charity Hospital presented the following distinctive char- acteristics : ' Cases with Home Environment Total Cases Total Per cent. Favorable and adequate _ 15 30.0 Favorable with adjustments „ 21 42.0 Unfavorable but remediable 6 12.0 Unfavorable and not remediable 6 12.0 Acutely needing further hospital care 2 4.0 50 100.0% As permission was given to choose the patients from the complete files of those discharged there were by chance more pay or part-pay patients and among these were people of intelligence and personal capability who Hospitals and Dispensaries 929 had been able to adjust their homes to provide adequately for convalescence. This had sometimes been accomplished by pre-arrangement, before going to the hospital, with some competent friend of the family who possessed the special mental or moral force needed for the situation. (It was notice- able that this force was as often absent in the more prosperous homes as in those of otherwise discouraging surroundings.) Practically no form of social service had been offered to this prosperous type of patient, but the patient's evident appreciation of the idea as a possibility was impressive. The prevalent feeling among the 82 per cent, of operative cases among women was that they had had the benefit of wonderful surgery, but were no wiser than before the operation as to what had been the matter with them or what was to be done to prevent further difficulty. The "head doctors" or attending surgeons were described with awe, yet regret, as "too important to be bothered"; "he's so busy he can't listen"; "it seems he's not the kind of a man to give you much talk." A gynecological case returned to her home without instruction from the hospital, and within two weeks had housecleaned her tenement, painted furniture, papered two rooms, and was doing the cooking under a sloping ceiling too low to allow her to stand upright at the stove. The doctor having said she was "all right," she did not understand how she felt worse than before the operation. Concluding it was all a failure, she had begun treat- ing herself with Lydia Pinkham's remedy because the newspapers said it would help anyone who felt as she did and she didn't want to waste any more money on the hospital. Another operative case returned weak and wondering why the old pain was just as bad, while all she "could get out of the nurses and doctors was that they had gotten what caused the trouble." Still another, in a wretched but pathetically neat tenement, lay abed, mystified at feeling worse than ever before, while the family questioned her, "What happened? Have we paid $86 for this?" The cost in money loomed larger than any visible return in health. Of the women who were uninformed as to their condition only one had not asked to know. At seventy years she was tranquil and not inquisitive. The men also had doubts. A neurasthenic, aggrieved at the little atten- tion bestowed upon him at the hospital, had gone home to a combination of quack electrical treatments and doses of No. 99 at Doctor Simpson's Medical Institute. His protest was, "Why didn't the doctor say what would do me some good?" Another came home to wretched lodgings from a long siege of lead- poisoning, pneumonia, and an operation for empyema. While he was ex- plaining that the incision had been allowed to close too. soon because the hospital was short of beds, the doctor who had sent him to Charity Hos- pital came to take him to St. Alexis, there being a vacant bed where the surgeon who had operated first would open up the incision. 930 Hospital and Health Survey A man, whose money was low after seven weeks in the hospital, was travelling a distance of seven miles for dressings because he knew a doctor who would not charge much. A sturdy Irishman ' with facial paralysis after a mastoid operation was embittering his days with thoughts of sueing the hospital, while his wife wailed, "Sure, they have destroyed him entirely. 'Twould draw tears from a stone." The White Motor employes who after leaving the hospital were cared for at the dispensary of their works, seemed well informed except in the case of one man. A dressing of his foot had not been changed for four days. Having been told that he was "all right now," he had taken this literally, until the pain and swelling led him to doubt. He had recently been burned out of his home, and as the only support of a wife, mother, and five children under twelve years, had gone on a ten-hour night shift to get the extra pay of $11.85 a day. He was slowly coming to the conclu- sion that his foot, by its delayed recovery, was costing more than his hospital bill: Summary of Charity Hospital Convalescents — Since hospital service dominates convalescence to such a degree that it has no present but only a past, these cases have indicated: (1) That more nursing care, if only for its educational value, ard better night service, particularly for men, should be offered. (2) That more time should be given to instructing all types of pa- tients as to their part in carrying on convalescence, returning to dispensaries or physicians, etc. (3) That after-care in the homes is often indispensable. (4) That there should be more real interpretation through Social Service of the problems of foreign-born patients, so that "Tony" would not have felt it possible to get out of bed and walk off without saying, "By your leave." (5) That the cash value of health should be explained to those patients who reluctantly offer their fees. With the help of Social . Service every patient should be made proud to contribute his charity to the common good. City Hospital City Hospital presents the following showing: Cases with Home Environment Total Cases Total Per cent. Favorable and adequate 5 7.0 Favorable with minor adjustments 19 26.8 Unfavorable but remediable.. 21 29.6 Unfavorable and not remediable _ 20 28.2 Acutely needing further hospital care 6 8.4 71 100.0 The large portion of those having unfavorable and irremediable sur- roundings corroborated the superintendent's statement that almost half of Hospitals and Dispensaries 931 their patients have no homes and must be kept in hospital until ready for work, the only alternative being the Warrens vi lie Infirmary. Even a superficial contact with the various types of lodgings, rooming- houses, and rooming hotels, with their forlorn attempts at light housekeep- ing, brings swift conviction that they can never offer a fair chance to con- valescents. The atmosphere of isolation, the indifference as to what hap- pens to the lodger after he pays for his room, the long flights of stairs to be reckoned with whenever a meal is needed — these, aside from the unwhole- some living conditions, proclaim the lodging system as "fatiguingly futile" for convalescent use. The patients themselves evidently realize this fact and many did not return to their given address. Others had never lived at the given address, but had been known to the owner of the lodging house or to some of the lodgers. A few gave an impossible street number selected with evident care. The Salvation Army, the City Mission, a corner store, or a former saloon will sometimes be given as an address where nothing- definite could be remembered of the patient. One man was found on the corner near the restaurant which he had given as his address and explained there was "generally some one round that corner who knew where he hung out." Such were the frail links to home and the greater reasons for con- valescent care in institutions or at least for continued hospital supervision. Another tremendous claim for convalescent supervision of the most far- reaching and efficient sort was made by the fact that many other patients came from homes which were totally unfit for convalescence or continued health, unfit for the minimum requirements of normal living — on the edge of the dump, in gullies thick set with smoke, in leaky shacks — the cracks stuffed with newspaper and the room reeking with kerosene fumes, in dark tenements, four or five of which would open on a court filled with the ac- cumulated refuse and garbage of the winter, where the convalescent child was left to "play. " The hopeful note in many instances was the persistence of the family in keeping its tenement clean within in spite of the disheartening mess without. In several such homes on Orange Avenue there was as keen an interest and sense of personal concern in the Survey of the Hospital Council as at a Chamber of Commerce meeting, thus bearing out the idea of Doctor Frederic- Brush on convalescence that "health service should be offered where people live and work and play.* * * Of abiding value in this period of convalescence is the process of normalizing, in all ways which may hold throughout life." It is hard to prove which will finally claim the most patients, the influence of the hospital or that of the home on the edge of the dump beset by every health hazard and bereft of every help to sanitation, but it is only when Social Service shall present overwhelming evidence of the limitation of hos- pital skill before such handicaps that these entirely eradicable conditions will be swept away. The surgeon, who has conscientiously given his intelligence and skill to renew life, should realize that the condition of the home to which he is send- 932 Hospital and Health Survey ing his patient, will play a vital part in the final success of his work. To have a mind to insist that dwellings and their surroundings should be fit for the minimum requirements of ordinary living would be to open up many possi- bilities in home convalescent care which, as yet, are untried, and the import- ance of gain in the general health of the community and in health education, should not be overlooked. Still other 1 types bespeak the follow-up work of the hospital. The drug addict, returning to lodgings with little moral support; the child with chorea celebrating her home-coming with a "regular meal" of coffee, sausage and pie; the heart case who has spent most of his small life in hospitals and pleaded, "Oh, Muz, my business is always hospitals! Can't I stay home and get well?"; the fourteen-year-old runaway with mumps whose pride had thus resented his being put in the "kids' ward" where his feet stuck out through the bed-bars; the child of five whose mother had never been able to find out from the hospital what its illness had been — these and many others proclaimed their necessity for further care without which a large part of the hospital's work goes for naught. Summary of City Hospital Convalescents — These cases present the following well-defined needs: (1) Increased institutional convalescent care; (2) Instruction of patient at discharge; (3) Social Service, to adapt the homes of patients for convalescence therein. Lakeside Hospital Lakeside Hospital showed: Cases with Home Environment Favorable and adequate Favorable with minor adjustments Unfavorable but remediable Unfavorable and not remediable Acutely needing further hospital care._ 57 100.0 The cases were offered with ample records and in the spirit of the fullest cooperation. Probably because of this it was more noticeable that the instructions to patients by the doctor were most often "none in particular" or "return to dispensary." The "none in particular" probably indicated that to the doctor the case did not stand out in his mind as needing any instructions other than those of routine convalescent care after a pneumonia, a laparotomy, or whatever else the disease or operation might be. The patient, however, assuming this role for the first time, finds everything strange about being "a pneumonia" and things stranger still as "a laparotomy. " He is full of interest in himself. He wants to make a success of getting well and there are many questions to Total Cases Total Per cent. 4 7.0 21 36.8 14 24.6 16 28.1 2 3.5 Hospitals and Dispensaries 933 which he wants to know the answers. He is hoping there will be time for one of the doctors to have a talk with him about it all before he leaves the hospital. But often the last day comes unexpectedly, his bed being needed for a more urgent case, and he finds himself at home several miles from the hospital, wondering why he managed to find out so little of what the hos- pital knew so well. When special instruction had been given the patient on discharge, the effect was almost magical. To have been instructed to carry on what the nurses have begun, to have responsibility for one's own treat- ment, gave a new zest and importance to convalescence. Particularly was this noticeable in patients who were returned to the dispensary for the treat- ment of syphilis. Alert and intelligent, they were too much in earnest to be self-conscious and presented convincing evidence of wise and inspired teaching. With the exception of these cases there was little evidence of hos- pital Social Service other than visiting nursing among the patients seen from Lakeside. The ambulance experiences of many held a large share in their convales- cent thoughts. The negro who, after an automobile accident, regained consciousness in "Hogan's dead wagon," "don't never expect to get over that wake up. " He thought he was being taken to the undertaker's estab- lishment as dead. Often neighbors have "chipped in" to collect the money for an invalid carriage so that the police emergency need not be called, and with a naive idea of gradual descent to the mundane, some announced that in leaving the hospital, they took a taxi to the nearest car-line and transferred to the trolley for the rest of the way home. Another impression noted among the women was remembering the fa- tigue of that first complete dressing to leave the hospital. Apparently this was often done without assistance as the nurses had other duties and the friends of the patient were not allowed to come to the ward. (This was also noted in patients from other hospitals. An old negro woman with an aortic aneurism was being sent home from the City Hospital on the ambulance stretcher. She described the fatigue of preparation and added "The head lady nurse told them, 'Don't bother if it is a hospital gown — let her go while the spirit is in her.' I sure was grateful. She certainly had wisdom, that lady nurse. ") Two other shadows of convalescence were: (1) the long uncertainty and final disappointment over the amount of the hospital bill, and (2) the fact that patients sometimes came away resentful because they had been the "interesting case" used to teach others. They felt that they were being detained in hospital for this purpose. These may seem minor details in the immense and complex scheme of administration which the hospital must embrace, but with the sensitive imagination of one half sick — "behold, a little cloud ariseth" and the whole of his convalescent sky is darkened. The amount of the bill could be approximately decided before the day of discharge and preferably nearer the day of admission so that this "indeter- minate sentence" might be cleared up. If the patient has not been able to 934 Hospital and Health Subvey pay, it is perhaps not the happiest sort of envoi to haYe "the last one you see at the front door saying, 'I hope you will be able to work soon and pay your bill.' ' Social serYice at the front door might perhaps have given the deft touch to incentive which would have brought the patient to say as much for himself, with gratitude and courage. Again, in the matter of the resentful "interesting case" the house phy- sician who is a vital influence for energizing convalescence, could in a few words, with perhaps a touch of cameraderie, present the idea of an imper- sonal yet chivalrous appeal for humanity, and the patient might become at once the "interested case," ready and a little grateful to contribute to the advancement of clinical medicine and scientific research. The foreign-born patients who had had bedside lessons in English in the hospital and who had heard their own language understood and trans- lated by a sympathetic interpreter, beamed with appreciation at the re- membrance. This happy cooperation with the Board of Education can be developed so that the often empty hours of convalescence will be brimming with interest. Summary of Lakeside Hospital Convalescents — Almost without ex- ception the Lakeside cases showed that the completion of the hospital's work can only be accomplished outside of the hospital and through the ex- tension service of social work. Whether this is rendered in the guise of institutional convalescent care or of home service, there is every indication that the expense would be less than a protracted stay in the hospital. The patients are quick to testify that after the first urgent need of acute illness the hospital atmosphere is not helpful. Its ceaseless movement is too intense and vivid for rest. To the patient with a problem waiting at home, institutional convales- cence, however luxurious, has little charm — "For what good should I go away. The worry for the kids would go with me," said a mother amid a clutter of babies, washtubs and general disorder. "This is the best for me here." Her peace of mind arose triumphant over the scene of distraction, for her problem was within her grasp. The unanimous opinion among such convalescents was that any help in household administration would be welcomed. Mt. Sinai Hospital The cases referred from Mt Sinai came to the investigator slowly and were possibly a more or Jess expurgated edition, as there seemed some appre- hension lest the hospital's social work should be duplicated. Maternity cases were excluded. For this reason the number of cases for consideration was smaller than from the other hospitals, only thirty-five being offered. Of Hospitals and Dispensaries 935 these thirteen were not seen, leaving the following percentage compiled on a basis of the twenty -two cases seen: Cases with Home Environment Favorable and adequate _ Favorable with minor adjustments Unfavorable but remediable Unfavorable and not remediable Acutely needing further hospital care Total Cases Total Per cent 1 4.5 10 45.5 7 31.8 2 9.1 2 9.1 22 100.0 One characteristic of this group as a whole was that the patients seemed to have achieved a definite idea of the hospital's plan for them and their repeated trips to the dispensary were playing an important part in their convalescence. The majority were looking upon the situation as a business proposition without imagination. The evident system and efficient working of the ward routine had impressed them and they were ready to do what was required. They seemed less susceptible to untoward surroundings at home because of the definite goal toward which they were working. Pos- sibly this unanimity may have been more evident because of the smaller number, but it was too marked to escape notice. The Collected Groups Among the patients of all four groups were some who had been treated at two or more different hospitals for the same or different causes — the patient, not having mentioned this in giving her medical history at the hospital be- cause she did not know, or "was not sure how to tell it," and thought "the next doctor would find out. " In large families the hospital affiliation was widespread, several hospitals having been used by three or four members, and experience meetings when all talked at once brought out a variety of hospital lights and shades. This suggested the possibility of extending the scope of the Social Service Clearing House to include on its registry cards a note of any dispensary or hospital care which the patient had received — the technical details to be furnished by each medical agency as the occasion arose, as the patient is often unable to give an accurate account of past illness or surgical operations. The very prevalent protest of the women patients against being kept in ignorance of the nature of their surgical operations deserves a word. The patient wants to know how she stands physically, even if she faces a serious handicap, and she can the better adjust herself to meet it if informed. The hospital service which shirks, evades, or refuses this after-treatment so neces- sary to the peace of mind and progress of convalescence has put the hardest part of the operation and its results on the patient, and has missed its best chance of rehabilitation. Why bother at all if the game is not worth the candle — if the work is not to be carried through to completion and the seal set upon restored health 936 Hospital and Health Survey and higher spirit? If the patient is well enough to worry herself about her condition she is well enough to know what she has to worry about. She will then be more willing to put aside imaginings and prepare to recuperate in earnest. Those who have had the fertile experience of a perfect convalescence have realized that there is much to be learned from contact with pain and weakness and returning strength. The convalescent patient should be helped to find these values, to lay aside a few worries and to take on a few new aspirations for the future. Inspiriting companionship may often be found in one's nearest neighbor with a wholesome philosophy to share. In becoming acquainted with the convalescent in his own home we must let him state the difficulty of convalescence as he sees it, along with his own idea of rehabilitation before blocking the way with too many suggestions. Often the patient must either resign himself to a reduced "health bank account" or remonstrate at untoward conditions; again, the uncertainty as to what his depleted strength is equal to, makes any definite undertaking precarious. This is no time for platitudes in words or actions. No "re- turn to dispensary" slip will fill the need. Advice to "rest and take it easy" will not answer. Reinstatement into the type of life to which the patient is equal must be wisely planned and the very present helps of com- munity life pressed into service, so that the thrill of ambition, the impetus to new life which rightfully belong to convalescence may not be entirely lost. SUMMARY Visits to two hundred patients discharged from the wards of Cleveland hospitals showed eighty-seven and one-half per cent, in home environment unfavorable for convalescence. In two-thirds of these homes, conditions were remediable if adequate and adaptable Social Service could be supplied. This service is almost entirely lacking at present. In one-third, conditions were not remediable, and care in a convalescent home was needed. With present resources it is impossible to meet this need. The hospital faces a choice of evils — it must either retain the patient, using a bed needed for a case of acute illness, or return the patient to a home un- fitted to complete the cure. Possible means by which the hospital may assist convalescence in the home: 1. Treatment and instruction in hospital towards securing the patient's confidence and cooperation — the instruction to include understanding of present illness and means of preventing recurrence. 2. Making with the patient a definite plan for his after-care and rein- statement into active life, and enlisting his best effort to carry out such a plan. Hospitals and Dispensaries 937 3. The function of the Social Service Clearing House might be broad- ened so as to include a record of dispensary and hospital treatment received by the patient, with names of institutions and dates. This record could be used by medical agencies concerned as occasion requires. 4. The function and value of the Convalescent Home, when suitable and available, should be explained to the patient as an opportunity. 5. Social Service (if a Convalescent Home is not available or desirable) should create the same essential values of convalescence in the patient's own home. 6. Teaching the patient while most receptive to suggestions — because of recent contact with the hospital technic of sanitation — how he may fur- ther the hospital's work to insure permanent good health. This would include the" use of dispensary and other hospital resources, as well as of the family physician. A patient thus successfuly involved becomes a valuable field agent who will set forth the work of the hospital in terms of appreciation which his neighborhood will not fail to understand. 938 Hospital and Health Survey A COMMUNITY PROGRAM FOR CONVALESCENT CARE An institution is not the ideal place for convalescence from disease. The home, when conditions are satisfactory, is the ideal place. The possibilities of home convalescence are only beginning to be dealt with. In the pre- ceding chapter home convalescence was touched upon in relation to the hos- pitals, with reference to planning the after-care for the patient, instructing him or his family properly at the time of discharge, using the dispensary to provide medical after-care, and social service. The last-named function served either by the social service department of the hospital, or by cooperat- ing agencies such as the Visiting Nurse Association or the Associated Chari- ties, is a necessity. It should further be borne in mind that the aid of social service is not called for merely in homes of poverty. Much work needs to be done in middle class homes by the Visiting Nurse Association or by a representative of the social service department to give the necessary instruc- tion and friendly advice about the details of home management, diet, hy- giene, etc., without which the family will usually not carry out the necessary routine outlined by the physician. Cooperation with the employer or the industrial physician, is not infrequently of great importance. The vast num- ber of medical cases which are cared for in their homes by private phy- sicians, and which convalesce at home need such advice no less than do hospital cases. In a word, the broad problem of convalescence involves private medical practice, the hospital, the dispensary, the Visiting Nurse Association, and social service in many branches. Many individuals and many agencies must share in creating better opportunities for both home and institutional convalescence than now exist in Cleveland. An essential element to any real advance is an adequately maintained convalescent institution. Such an institution does much more than provide care for the particular patients who can be admitted to it. It would serve to stimulate medical study of convalescence, now a field much neglected, and would promote throughout the community, interest in the problem of convalescence which will add to the efficiency of all kinds of medical care in hospitals, dispensaries and in the home. For an authoritative picture of the need for convalescent care in a com- munity such as Cleveland, and a program for a central representative in- stitution for convalescents, the Survey turned to Dr. Frederic Brush, Medical Director of the Burke Foundation at White Plains, New York, the leading institution in the United States for the efficient treatment and scientific study of convalescence. The following memorandum was prepared by Doctor Brush: CONVALESCENT CARE For an American City of One Million Population 1 By Frederic Brush, M. D. The Need There is a convalescent period in illness, with fairly distinct medical and social borders, and now recognized as a particularly favorable time for skilled Hospitals and Dispensaries 939 aid in rehabilitation. The patient's home is the desired, the cheapest, and best place for most convalescence, but institutional convalescence is needed for a certain percentage, in large cities. Such an institution in its modern conception functions widely beyond mere recuperative rest — in prevention, education, refinement, and Americaniza- tion, occupational adjustment, vocational direction, encouragement, and all- round set-up for better living. It complements home care, and notably completes and fortifies social service. It shortens the hospital stay, with large increase of product, and with inspiration to the staff. It saves money directly (convalescent cost being but little over one-half hospital cost per day,) and makes large long term returns to the community in bettered per- sonnel. Numbers Needing Country Convalescence Various estimates have been attempted based upon the number of hospital patients in the community, plus a small percentage from dispensaries, pri- vate physicians, employers, etc. These may be summarized into an ideal requirement of convalescent beds for ten per cent, of all hospital patients — varying greatly, of course, depending upon each city's conditions. To this should be added about one-fifth for dispensaries and other sources (as at present organized; but this ratio should be increased). Thus a city discharg- ing 100,000 hospital patients yearly should provide institutional care for 12,000 convalescents. Number of Beds and Apportionment of Patients Assuming that the city in question presents the better living conditions, we'may well take 5,000 hospital patients, plus 1,000 from other sources, as a planning basis. About twenty-one days proves to be the average stay in convalescent homes. The requirement for the 6,000 patients is accordinglv 350 beds. We may base an estimate upon the long and abundant experiences in our greater cities, and apportion them as follows: 1. The Main Institution, for adults — 120 beds; men and women — ages, from fifteenth birthday upwards to old age, including 15 per cent, plus of heart disease, with standard surgical (with dressings), pi~ventive and hold- ing (chronic handicapped) convalescence. 2. Children's Home — 100 beds, taking girls from 6 to 15 and boys from 6 to 10 years, receiving surgical dressing and orthopedic cases, and heart disease up to 20 per cent, of total, along with the standard lines as above outlined. 3. Boys' Place — 30 beds, ages 10 to 15; disease classification as in the Children's Home (Very important but not to be large). 940 Hospital and Health Survey 4. Mothers with infants and young children — 30 beds, averaging 60 patients. 5. Special Heart Institution — 40 beds, for the seriously ill, giving bed care at first, etc. Age and sex as in Number 2. The Plants i New or expensive buildings are not essential. An old mansion, a large farmhouse with its many outbuildings, or a disused hotel adapt readily. Tents serve well at times; extensions are happily made; much equipment may be improvised. Five acres of land is minimum; the larger areas giving considerable advantages. These Homes might be conducted upon one large plot of 100 acres if the topography, etc., gave essential separation of patient's activities. A location well within 20 miles of the city's center should be chosen, if possible. Costs W A per day capita cost of $1.75 may be expected, even under post-war conditions, giving $225,000.00 yearly operating expense for the 350 beds, as approximate. This includes transportation, and maintenance of a City Admission Office. Selection of Patients, Follow-up, etc. Careful selection of patients by one City Officer, given authority and support, is of first importance. This officer may be on part-time only. The necessary follow-up, including occupational and vocational direction, is usually well done by the city organization which sends patients, and the back- to-health-and-to-normal-life cycle is only thus completed. Convalescent home planning, organization, and procedure are becoming fairly well standardized, with detailed information readily available. Those of the Staff of the Survey who have been engaged in the local study of convalescent institutions and the convalescent problem can only add to Doctor Brush's statement some suggestions relating his program more in detail to present conditions and probable future development in Cleve- land. In most cities the convalescent problem, so far as it has been dealt with, has been taken up by bits and snatches. Here a group of kindly people have taken a large dwelling house and made it into a "convalescent home" for some twenty -five men; another committee of the charitable maintain a building donated by one of their number, in which sickly and tired mothers may recuperate after illness or operation; still another group has under its wing a small institution for children; and yet another a small "preventorium" for the pre-tuberculous child. Hospitals and Dispensaries 941 One of the great lessons which the Burke Foundation has taught is the greater efficiency gained through the use of a large institution instead of a number of little ones. The small independently managed convalescent home, accepting ten to fifty patients, secures with difficulty expert medical service of physicians who are particularly interested in the convalescent problem and scientific study of convalescent cases; it cannot possibly pro- vide elaborate therapeutic equipment or a staff of special workers and teachers. In the large institution, therapeutic equipment, personnel and continuous service of a medical staff whose members are selected especially because they are interested in convalescence are all possible within reasonable limits of expense. In a letter transmitting his outline, Doctor Brush remarks: "It may be well to bring to the attention of those becoming interested in this branch, some of the important points of this proposal: that preventative tubercu- culosis comes in under numbers 1, 2, and 3; convalescent orthopedics, bone diseases, etc., likewise in these three places; that cardiac children well enough for reconstructive treatment enter under numbers 2 and 3; that adolescents (the group most successfully dealt with and most neglected in convales- cence) are especially well planned for. * * * "Perhaps the most characteristic and radical part of my conclusions is the recommendation, based upon definite experience, for the care of many different classes and ages, etc., in one Institution (see numbers 1 and 2.)" The recommendation to be made regarding the convalescent problem of Cleveland is that it be dealt with not by bits and snatches, but by one central and representative group of persons who will study the whole problem and, with a long range program in mind, will take each practical step as funds are made available. So far as institutions are concerned, there should be one, rather than many, or rather, as Doctor Brush's outline indicates, a group of related institutions managed as one. At present Cleveland has : Rainbow Hospital, with 85 beds, taking children between 2}/f concern to every person, but it is cer- tainly only reasonable to insist that at least the same degree of humane care be rendered to human patients who through illness or accident are forced to use an ambulance. ... The matter of disinfecting an ambulance which has carried a patient suf- fering from contagious disease, is one of importance. Some provision is made for disinfecting the police emergency cars by formaldehyde spray, but conference with the policemen in charge of these cars convinced the investi- gator that very little real disinfection was done. Disinfection of the City Hospital ambulance by wiping out with cloths moistened in creolin solution, and change of pillow case and blankets, is carried out on return from trans- porting a case of contagious disease only when the case next to be called for is one of a different contagious disease. From numerous complaints by phy- sicians it would seem that undertakers often fail to* make any provision for disinfection, although no data on this matter were obtained. One thing which has impressed itself most forcibly upon the Survey, staff is the general unwillingness of the dependent sick to use the Police Emer- gancy ambulance. Well-to-do patients can of course, afford to pay the fee charged for the use of undertakers' cars. Innumerable cases were found however, where patients who could ill afford the five or ten dollars, summoned the private ambulance rather than endure the stigma of riding in the police emergency. It must be remembered that to all practical appearances there 964 Hospital and Health Survey is no distinction between the sick man in the police emergency and the man who has been engaged in a street fight or some less commendable pursuit. Natural pride and self-respect resent such a method of transportation in case of sickness or injury, and this feeling of resentment is justifiable. Cer- tainly a more dignified and considerate method of conveying a patient to the hospital needs to be provided. On the other hand, it seems just as unfortunate that an undertaker's wagon should be used for carrying patients. No ambulance service is provided for taking patients to Warrensville Infirmary or, in case a contagious disease develops there, for removing the patient to City Hospital. In the latter case a delivery truck is used, an arrangement hardly to the credit of the city of Cleveland. It is believed by the Survey that at least the Cleveland hospitals main- taining over 200 beds should provide their own ambulances, and that the smaller hospitals might combine in some manner under the Hospital Coun- cil. In order to maintain such a system of ambulance service in a satisfac- tory manner, it is necessary to have some central organization. In Cleve- land, so long as the present police emergency ambulances will doubtless remain in use for some time, even though individual hospital ambulances are provided, it would doubtless be best to retain the present central call bureau under the jurisdiction of the police department, assigning an emergency dis- trict to each hospital providing such service. The method of handling ambu- lance calls used in New York City may be taken as the basis of a system for Cleveland. In New York the city is districted for emergency ambulance service and there is a central bureau to which all emergency calls are made. This central bureau is at all times informed of the movements of each ambu- lance, whether it has gone for a patient, or whether it is available for use on a call. When an emergency call is received it is relayed to the proper district office. With a little modification the present central call bureau of the Cleveland Police Department could be adapted for the use of an efficient city -wide ambulance system. The following recommendations are considered essential to the improve- ment of the ambulance service of Cleveland: RECOMMEND A TIONS The police patrol wagons should be replaced by ambulances for use in emergency work, and the use of police patrol wagons for ambulance transportation should be dis- continued as rapidly as possible. Each ambulance should be provided with a stretcher, blankets and ordinary first aid equipment, including a Thomas splint. At least four such cars should be provided and stationed in appropriate sections of the city. The policemen assigned to ambulance service should be required to pass a thorough course in first aid, consisting of both theory and practice. This instruction should be Hospitals and Dispensaries 965 under the direction of the Division of Health. Assignment to the ambulance branch of the police service should be continuous. At least two more ambulances should be provided at the City Hospital to be used for transportation of contagious cases from all parts of the city to the City Hospital, and for transferring cases to and from Warrensville Infirmary and Sanatorium. Twenty-four hour service should be provided by the City Hospital for the trans- portation of contagious cases. Hospitals of over 200 beds should provide their own ambulance service, smaller hos- pitals combining with one another under the Hospital Council to provide such service. The larger hospitals also might find it advantageous to come into some such joint scheme. As ambulance service is provided by individual hospitals, an agreement should be reached with the Chief of Police by which an emergency district would be assigned to each hospital providing such service. The existing centralized system of calling for ambulances at the Police Information Bureau should be continued for all emergency work. M The hospitals and public health agencies should discontinue the use of undertakers' invalid carriages for ambulance service. 966 Hospital and Health Survey V. Hospital and Dispensary Planning COMMUNITY PLANNING From the standpoint of the community, hospitals and dispensaries in Cleveland have been planted, rather than planned — planted each by itself instead of being planned as part of a community scheme for organized medi- cal service. ■y The hospitals thus planted have grown, but have not grown fast enough to keep pace with the development of the city. This is even more true of the dispensaries, the starved children of the hospitals. The outstanding, almost tragic, fact in the situation of Cleveland is the shortage of 1,500 beds below present community needs, . and the deficiency in dispensary service, which at present is not more than one-third of the needed amount. These major needs are a challenge to the courage and resources of a pro- gressive, self-confident city such as Cleveland. The passage of the City Hospital Bond Issue during the spring of 1920 for $3,500,000 gives assurance that when the necessary steps of making plans, selling bonds and putting up buildings have been taken, at least one-third, or possibly half, of the needed 1,500 beds will be provided. It was originally expected that the $3,500,000 would be sufficient to con- struct 900 beds and a dispensary, tearing down the present psychopathic building of 200 beds, which is unfit for hospital use; and thus making a net addition of 700 beds. The City Hospital would then have practically 1,500 beds, and it should have this number as soon as possible. Since the figure $3,500,000 was decided upon by the authorities, building costs have continued to rise, and (while the future course of prices cannot safely be predicted) it is probable that the sum will be insufficient to build any such number as 900 beds, besides a dispensary and necessary enlargements or improvements in nurses' home, power plant, kitchen, etc. The present city administration should proceed as rapidly as possible with plans and construction, making the $3,500,000 go as far as it can, and all public officials and private persons who have the hospital interest of the city at heart should continue their efforts until the City Hospital has reached the needed size. Privately supported hospitals must expect to provide 750 to 900 beds of the needed 1,500, as soon as possible, and also the dispensaries, as outlined in the discussion of that subject. An expenditure of probably $12,000,000 for buildings must be faced by the people of greater Cleveland during the next few years.* This figure does not include such special provisions for research and medical teaching as may be provided in connection with the University Hospital. Of the $12,000,000 it may be expected that two-thirds, or a little less, will have to be provided by private gifts, and about one-third, or some- what more, by the municipality. *This sum includes $3,500,000 bond issue. At the time of concluding the Survey the bonds had been authorized but not marketed. Hospitals and Dispensaries 967 In one of the striking financial "campaigns" of recent years, the Jewish Community of New York City, with a population only slightly more than the total population of Greater Cleveland, raised more than $7,000,000 for building funds for its various institutions. Cleveland has let its population grow faster than it has permitted its hospitals to grow. Atonement for the neglect of yesterday can only be made by dipping more deeply into the pocket today. Delay means only the incurring of still heavier future obligations. It is greatly to be desired that in securing these building funds Cleveland shall pursue the policy already so finely established through the Welfare Federation in raising annual expenses. Joint campaigns for hospital building funds are the desirable method. Otherwise Cleveland will|be weary with one hospital "campaign" following another, with the almost inevitable result that those which happen to have been unable to make campaigns first will suffer, and the response will be influenced more largely by chance than by relative need or merit. What is of even more importance is that balanced development will be less likely, because joint campaigning implies in F a con- siderable measure joint planning, the mutual adjustment of plans^to the broader needs of the community. It is true that the present year, 1920, does not seem a propitious one for a large financial "drive" such as this building fund campaign would have to be. There are just two practical recommendations for those who ought to voice the need and lead the campaign to meet it: conviction and courage. There must be profound belief in the urgency of the need for more hospital beds and more dispensaries, and firm determination to meet this need at the earliest possible date. Projected Enlargement The Survey found that a number of Cleveland hospitals had made plans for expansion. Three notable examples are the following: The project of Lakeside Hospital to move from its present site near East Twelfth Street and Lakeside Avenue, to Wade Park, enlarging its capacity from 289 beds to 500 beds. In connection with this is to be men- tioned the desire to move Maternity Hospital to the same area, and to enlarge it to 100 beds, as a part of the University Hospital group; and, the building of a hospital of 150 beds for babies and children, as part of the same group. The total for the group is 750 beds, making a net increase over present pro- visions in the same group of institutions of 400 beds. The project of St. Luke's, to move from its present site on Carnegie Avenue to Ambler Heights, and to enlarge from its present capacity of 139 beds to 300 beds, a net addition of 161 beds, or, if the present hospital were retained and used for an enlarged dispensary and an industrial hospital of perhaps 100 beds, a net addition of about 250 beds. The project of Huron Road Hospital to move from its present site on Huron Road, to Ansel Road and Wade Park, enlarging its present capacity of 84 beds to 250 beds, a net addition of 166 beds. 968 Hospital and Health Survey The plan of Lutheran Hospital to enlarge from 50 to 100 beds has already been put before the public in a campaign for the needed funds. A number of other hospitals have stated to the Survey in more or less specific form their desires or projects for expansion. It will be observed that on the minimum basis of calculation the projects of Lakeside, Maternity, the new Babies' and Children's Hospital, Huron Road and St. Luke's would together bring J a net increase of 727 beds minimum, or 816 beds maximum. In other words, these projects alone, if carried out, would provide most of the 900 beds which must come from private funds. It is to be desired, how- ever, if a joint campaign for building can be organized and successfully accomplished, that the legitimate desires of some of the small institutions be recognized. It is particularly important that if funds cannot be asked for or secured sufficient to provide for the total amount required for the needs of all the institutions, that some of the smaller hospitals whose present buildings and equipment are now notably inadequate, shall be allotted sufficient amounts to enable them to make needed changes or improvements of a permanent or semi-permanent nature, even if their substantial program of enlargement must be postponed, and if the plans for the three largest hospitals have to be somewhat curtailed. For example, the improvement of the nurses' home at St. Vincent's or the provision of a dispensary at St. John's, are urgently required by present needs for better service, irrespective of increase in the number of beds. In the rounding out of Cleveland's hospital facilities through the develop- ment of specialties, the increase of service to children is the most urgent need in both hospitals and dispensaries. The building of the proposed Babies' and Children's Hospital is perhaps the most greatly needed of Cleveland's hospital facilities, after the enlargement of the City Hospital. There is need of enlargement of facilities for maternity care, and the pro- gram of Maternity Hospital to increase its size from 60 to 100 beds is approved. This, however, is not so urgent as a number of other needs, such as for chil- dren's beds, for an eye and ear hospital, or for the improvement in the plants and nurses' homes of several other institutions, such as St. Vincent's, St. Alexis, etc. In the case of diseases of the eye, ear, nose, and throat, the deficiencies in Cleveland, as pointed out in the early part of this Report, are unusually serious. Many other cities have found it desirable to establish eye and ear hospitals. New York provides 608 beds; Boston, 219; Baltimore, 153; Portland, Maine, 100; Washington, 94; Philadelphia, 58; Pittsburgh, 40; and Chicago, 32. In Cleveland one hospital only (Lakeside) makes any special reservation of beds for eye cases. Six hospitals maintain an ear, nose, and throat service. There is no throat ward in the city. There are cared for in hospitals and dispensaries a relatively small portion of the eye, ear, nose, and throat work required by a population as large as that of Cleveland and its vicinity. No center exists for the training of physicians and nurses in these specialties. There are exceedingly numerous industrial eye injuries. All but one of the twelve oculists who responded to the Survey's letter of Hospitals and Dispensaries 969 inquiry stated that industrial eye injuries came to them with evidences of having been mishandled. Of the 545 persons in the city known as totally blind, 306 cases may be considered as due to preventable diseases or injuries. In addition to this number, 121 cases are to be classed as curable. It is therefore recommended that beds to the number of 100 be established for eye, ear, nose, and throat cases; these beds to be maintained preferably as a branch of an existing general hospital, or, if established as a separate hospital, to be in close cooperation with a general hospital, in order to secure the most economical administration and the mutual advantages of coopera- tion between the staff of the general hospital and the specialists in eye, ear, nose, and throat. It is essential that there be such freedom and independ- ence for the eye, ear, nose, and throat staff as to enable the fullest develop- ment of the special facilities, technic, and educational opportunities, and if these conditions cannot be met were the beds to be part of a general hospital, the beds should be established as a separate hospital, with the affiliation indicated. It is desirable that the hundred beds be divided between the ear, nose, and throat service, and the eye service, in the proportion of three to two; and that there be maintained a dispensary eye clinic and a dispensary ear, nose, and throat clinic, in connection with these beds. The clinics had best be parts of. a general dispensary, but in any case the hospital staff should have direct medical control. It is of course highly important that the eye, ear, nose, and throat beds and clinics be used for medical teaching purposes, under-graduate and post-graduate, and for nurses. It would be well that there be provision among the institutions affiliated with these special beds for an exchange of visiting physicians and surgeons, and of nurses in training. Provision for all other specialties, such as orthopedics, and laryngology, should be made by the development of services in general hospitals, with an assigned number of beds and with possibly the addition of more beds or pavilions at a future date, rather than by the construction of new important specialized hospitals. The special hospital has a place during the period of development of the technic of a specialty; but the permanent provision of hospital facilities in special branches is better and more economically made by divisions of general hospitals. Locations and Re-Locations The study made by the Survey of the locations and inter-relations of hospitals in Cleveland has led to approval of the plans of Lakeside, Huron Road, and St. Luke's hospitals to move from downtown locations to sites in the eastern part of the city, in or near Wade Park. Prevailing winds in Cleveland are from the west, and sites in the eastern part of the city will continue to be dirtier than locations on the western edge, until Cleveland deals effectively with its obnoxious coal smoke. It must be pointed out, however, that the moving-out of these hospitals and the closing of St. Clair 970 Hospital and Health Survey Hospital, which the Survey has recommended, will leave the central portion of the city practically unprovided with local hospital facilities. With ade- quate ambulance service, such as Cleveland should demand and secure (see discussion of this subject), location will be rendered a secondary factor in a large proportion of hospital cases, yet the tremendous volume of hospital cases arising out of the downtown area cannot but require some local pro- vision. ■j It will be necessary to retain either at Huron Road or at Lakeside, or in perhaps a new hospital, from thirty to fifty beds, preferably affiliated with a larger out-lying institution so as to secure the advantages of lowered cost and better medical service. It would be more economical if the present site and part of the present buildings of Lakeside or Huron Road were utilized for this purpose instead of requiring new construction. As outlined in the section on the downtown dispensary, this downtown hospital should be part of the same plant as the new proposed downtown dispensary. In the chapter on dispensaries and in the chapters just preceding, the need for the development of several additional dispensaries, particularly on the west and south sides was pointed out, and the particular institutions named. All of these points regarding the location of hospitals and dispensaries and their inter-relation need to be thought out as part of a comprehensive plan for providing general service to the city as a whole, and also local facili- ties of various kinds, readily accessible to each district. In previous sections of the report it has been brought out that certain of the larger hospitals have a wide range, drawing patients from all over the city and from outside the limits of Cleveland; that other hospitals are largely local in their clientele. The same is true of dispensaries, some being city-wide in their range, others serving few patients outside of one general section of the city, while the health centers are definitely restricted to a certain comparatively small area, as preventive work must be in order to be effective. Certain principles under- lying community planning of the number and location of hospitals and dis- pensaries may be formulated as follows, as the conclusion of this section. Principles of Community Plan There should be a small number of what may be called major hospitals and dispensaries, equipped with everything in the way of modern diagnostic and therapeutic equipment. These major hospitals and dispensaries are expected to be city-wide in their range, and to serve particularly for receiving difficult cases from within and outside the city, for consultation purposes and for diagnosis. In Cleveland the new City Hospital with its dispensary should serve as such an institution for the west side. Lakeside, in its present location or in its enlargement as part of the University group, would serve in this capacity also. Mount Sinai and St. Vincent's may be mentioned also, and a few other hospitals, such as St. Luke's, may develop on a similar Hospitals and Dispensaries 971 grade, although the teaching hospitals and dispensaries should be the dis- tinctive institutions of this class and every effort should be made to render them capable of measuring up to this responsibility fully. What may be called the district hospital, with its district dispensary or out-patient department, may next be mentioned. In this group may be in- cluded the bulk of the hospitals of Cleveland, the range of which is not strictly confined to a given district but which are more local in character and which may not usually expect any large consultant or diagnostic service such as would go with the teaching institutions. Somewhat less elaborate and ex- pensive equipment and a less high degree of specialization in medical organi- zation may be expected in this group of institutions. It may be pointed out that such institutions fill a necessary and most worthy place in the scheme of hospital and dispensary care to the people of large cities. Finally come the health centers, primarily preventive in their activities. More and more as the years go on, various therapeutic services of the simpler kind need to be located in as many neighborhoods as possible, because the more localized is their range, the more intensively and effectively can they reach 100 per cent, of the population with a message of hygiene, with period- ical examinations for the detection and prevention of disease, with service for the prevention of infant and maternal mortality, the discovery and control of tuberculosis, and the detection of remediable physical defects of school children. The health center should aim to reach the entire population of its district for preventive purposes, sending cases in which defect or disease is discovered, either to the family physician or to an appropriate dispensary or hospital, or in the case of difficult problems, directly to the major institutions for diag- nosis. The combination of some of the simpler forms of curative work with the educational and preventive services is a necessary development of the health centers of the future. It may be pointed out that the proposed down- town dispensary and emergency hospital which will be permanently needed in the downtown section after Lakeside and Huron Road move, will be largely a reference center for preventive as well as for diagnostic and curative pur- poses. Particularly in a city like Cleveland, with its important medical school, the institutions doing the teaching must bear the primary responsi- bility, in hospitals and in out-patient clinics, for diagnostic service for the patients of private physicians as well as for the patients who cannot afford to pay a physician. The medical profession should reap the benefit of the de- velopment of more extensive services in the health centers and in the dis- trict hospitals and dispensaries. Appointments therein as staff or auxiliary members and the benefits of their facilities for consultation and diagnosis, should supply the most serious present deficiencies in what the local prac- titioner has to offer his patients. It is evident that the danger of a "community plan" is that it leads us to glittering generalities merely. But it ought to be obvious that the ab- sence of a community plan leads to anarchy. Cleveland has taken a long step away from the state of anarchy which characterizes the medical institu- 972 Hospital and Health Survey tions of most large cities, through its Hospital Council and its Welfare Federa- tion. Any community plan which exists not merely on paper but which is a living thing with muscles and teeth, requires that individual institutions must adapt their policies and programs accordingly. Sacrifices of policies or programs which seem desirable and legitimate from the standpoint of an individual institution may be called for by its proper adjustment to larger community needs. It seems hard, at times, to expect a worthy institution to say "no" to the eager desire of its staff for a program of expansion which a community Survey shows is more than is required by the institution's district or by the particular kind of need which it serves; yet at times such negative prescriptions are wise and necessary, and should be self-imposed. It is not too much to expect of the hospitals and dispensaries of Cleveland that they have a community plan. It is not too much to expect that they abide by it, living not as bachelors and spinsters who have only themselves to consider, but as members of a family each of whom shares, nourishes, and is nourished by the life of the whole. Hospitals and Dispensaries 973 INDIVIDUAL HOSPITAL PLANNING The wise planning of a hospital's policy involves at least four elements: 1. Adaptation of the work, as to kinds of service offered, rates charged, etc., to the community, the district and the hospital's special clientele. This adaptation should be based on knowledge, perhaps requiring special study of the social as well as the medical character of the hospital clientele, as outlined in the section on "The Human Problem of the Hospital Pa- tient". The Cleveland Hospital and Health Survey has rendered to the governing authority of each hospital in the Council a report, the recom- mendations of which, as to policy and administration, are the result of such a study. Each hospital has thus had a cross section of the situation and demands of 19-20, as judged by the Survey. 2. Periodical Self-Surveys, based on continuous critical observation of the institutions work, by its trustees, staff and executive officers, and fortified by annuil reports and special studies. As urged below, annual reports should not be the basis for annual self-contemplation, but for a critical review and a vigorous effort toward better service. 3. Long-range planning of program. Each hospital should look as jar ahead as possible, studying out its present and future needs, (a) as to kinds of service which it should render and (6) as to the building, equipment, organiza- tion, and personnel which it needs to have in order to render these services. Not a few hospitals of Cleveland are suffering today because no com- prehensive plan was made in the past, and additions have been made to hos- pital buildings which now make a badly balanced plant. Often the service buildings, the nurses' home, or the power plant were not provided for suffi- ciently when additions were made to bed capacity, or were not planned with a view to easy enlargement when the number of beds should be in- creased. A comprehensive plan which may be many years in realization will prevent one-sided and ill-judged extensions either in plant or in branches of service. Expert advice and assistance could be provided for many in- stitutions by the Hospital Council or the Welfare Federation in connection with this long range planning of each hospital, although of course in case of large institutions, or where extensive future building plans are involved, the special aid of a hospital architect or consultant may be desirable. h. Annual Reports to the Welfare Federation and to the Public. Until recently, each hospital in Cleveland, as elsewhere, depended on its own particular list of financial supporters. Each hospital usually prepared its annual report more or less especially designed to express that quality of gratitude which has been described as a "lively expectation of favors yet to come." The situation was radically changed when there came about joint financing through the Community Fund. The individual hospital no longer makes a direct public appeal for its own support. Such joint financing is highly desirable on the whole, but certain minor defects or difficulties must 974 Hospital and Health Survey be guarded against. One of these is ■ , diminished incentive t3 prepare an annual report. It is true that under such a system as that of the Welfare Federation, each institution must present its budget and the financial and service data required by the Welfare Federation so that the appropriating committee shall be in a position to reach a wise decision. Nevertheless, there is no longer the same sense of direct relationship with the public, and a more or less definite public at that. After all, one of the great values of periodical reports ought to be the stimulus to the people who make them (which mere compilations of financial and statistical data do not provide). Preparation of a report ought to mean the formulation of fairly definite ideas about the work and needs of the matter reported on. It will mean this if the basal scheme of the report is properly designed. Recognizing this, the Welfare Federation and the Hospital Council should expect their member institutions to render not only the necessary statistical and financial data but also real reports to the public. The future of joint financing depends upon maintaining active public interest in the work to be financed. There must be meat upon which this interest may feed. Concrete facts are the basis. Theje should be three types of reports furnished to the public either di- rectly or through the Welfare Federation or the Hospital Council : 1. Summary report of hospital and dispensary work in Cleveland, taken as a whole, including the elementary data showing bulk and general types of service rendered, income and expenses. This should be prepared under the auspices of the Hospital Council and published by the Welfare Federation. A form for such a report is suggested and may be found in the appendix, Table IX. This may well be compared with the Summary Annual Report of the United Hospital Fund of New York City, the pioueer undertaking of its kind in this country. 2. A report from each hospital to the Hospital Council and the Welfare Federation,' giving the technical figures not only of bulk and general types of work but the details of service and results; of cost in relation to units of service: and of income and its various sources. The monthly and annual report forms prepared by the Hospital Council for the use of its members have served a highly useful purpose. They may be slightly developed further to advantage, and should be made uniform with the reports required by the Welfare Federation. The Hospital Council annual report form is believed to furnish so desirable a basis that no other form will be outlined here. It is suggested that the form might be somewhat smaller and easier to use if some of the items which are extended over many lines were put into more condensed and tabular form. These and other de- tails should be adjusted so far as possible in order that this form shall be comparable with that required by the State Department of Health. Thus the labor of filling out two forms will be reduced to a minimum. Hospitals and Dispensaries 975 It is recommended that the following items be included in the report form: Percentage of bed days care given in comparison with total possible number of days care in each division of the hospital, and for the hospital as a whole (monthly and annual.) The extent to which it is poLsib'e to sub- divide the different sections of the hospital will depend on the degree to which the hospital is itself sub-divided into buildings or separate units, and the degree to which groups of wards or rooms are definitely assigned to par- ticular services or classes of patients. The number of visits ^and number of new patients in each clinic or division of the dispensary should be shown as well as the figures for the dis- pensary as a whole; the average number of visits per patient for each, and the average attendance per clinic day. Thus in tabular form: Clinic Report for Month (or Year) for Dispensary of — Name of No. of No. of New Av. No. of Visits No. of Av. No. of Clinic Visits Patients per Patient Clinic Days Visits per Day Medical Surgical Pediatric % Eye Dermatological.— Etc Total If evening clinics are conducted on a different financial basis (pay clinics) from the corresponding day clinic these should be shown separately. The cost of the dispensary and the income from its operation in relation to'cost should be shown. Income from operation may well be classified into admission fees, treatment fees, fees for medicines. As soon as the accountant service of the Welfare Federation (as recom- mended in the sections on administration) is in effective operation, all hos- pitals would be in a position to show the costs for the main divisions of their work, as well as for the hospital as a whole (average daily per capita) and for the average daily cost for provisions per capita. In so far as it is pos- sible to state relative costs for private room and for ward service, this should be done. As soon as possible a report on results of service should be developed. The usual report of "condition on discharge" as "cured," "improved", "unimproved", "died", is definite only in the last item; has practically no medical or social value and is not worth including in hospital reports. Real 976 Hospital and Health Survey reports of results of care of patients can develop only as the outcome of a real follow-up system. As individual hospitals develop these, a summary report of results of care should be included in the annual report form. It would be well at once to include the following items in the form under the heading : "Disposition of Patients at Discharge." Total patients discharged - Of these, patients died to the number of.... Remainder , Disposition of these as follows : Private Ward or Staff Patients Patients No. Per cent. No. Per cent. 1. Referred to home under care of private physician 2. Referred to another hospital 3. Referred to convalescent home 4. Referred to dispensary supervision 5. Referred to patient's home without arrangement as to care 6. Other reference 7. Left against advice 8. Unknown or no record ; Total The use of such data showing administrative action at the time of dis- charge will be a definite stimulus toward better follow-up and convalescent care. 3. The third form of report from the hospitals should be not statistical but interpretative: a statement of progress and of problems, of accomplishment and of needs. The traditional annual report has done this in a measure but has often been written by committee members who had little first-hand contact with the facts, or very slight conception of what should be said except thanks to other committee members and to staff and supporters, so that it largely failed to accomplish any real purpose. An annual report should be built from the ground up. The medical executive committee and the head of each main administrative department should be asked to turn in a report Hospitals and Dispensaries 977 for their several fields six weeks before the report is to be issued. It should be expected that besides certain statistical or other facts relative to the work of the department, these reports shall contain a summary of (a) accom- plishments of the year — -items felt to be indications of progress; (b) present problems and needs; (c) definite requests and recommendations for action. In some hospitals, each chief of a medical, surgical, or special division, the head of the laboratory, and the head of the X-Ray department will be asked to render reports as well as the medical executive committee. The reports from the head of the nursing, and from the head of social service, should pass through the training school committee or the social ser- vice committee, respectively, before coming to the superintendent and to the trustees. The committee may write its own report if desired, but in any case should state its comment upon the recommendations presented by the executive. It is recognized that securing reports from many medical and depart- mental heads is not always easy and that the reports are not always well prepared or to the point. Much of this difficulty has been due to failure on the part of the Superintendent or trustees to give to those writing reports a definite idea as to what was expected. The superintendent's report to the trustees should be a real survey of the hospital, its accomplishments, problems and needs, and should include recommendations. Trustees who do not receive that type of report either do not know how to get, or do not get, the best out of the man or woman whom they employ as superintendent. On the basis of such reports from their executive officer and their depart- ments, and of conference with them, the trustees should be in a position to know what they need to know to plan the coming year's policy and program, and the amount of money they need to secure. The reports should be the basis of the presentation of the hospital's needs to the Welfare Federation and should be accessible to those having a basis for definite interest therein. The trustees ought not to have to prepare a detailed report, but merely a brief statement of decisions or recommendations for which the other re- ports are the foundation. A group of reports thus prepared should con- stitute a real annual self-survey. This need rarely be printed as a whole. There is required something less technical for a published report. Interpreting Hospital to Public It is essential from the standpoint of maintaining the interest of the pub- lic in a hospital and dispensary and of stimulating boards of trustees of the institution itself, that technical facts of such reports be interpreted in terms of ordinary items of interest and of every-day human standards of health and well-being. This is not usually within the capacity of the hospital ad- ministrator or trustee. 978 Hospital and Health Survey The hospital needs, and the Welfare Federation should furnish each hos- pital, the service of a publicity expert, just as it provides the service of an accountant for the technical data. The publicity man would help the hos- pital to put its technical facts in common terms, to connect them with ideas and interests which the average man readily understands and appreciates. The use of such a statement, put into form with the advice of the pub- licity man, would be partly for those particularly interested in the hospital, and partly for other hospitals and the general public, reached through the Welfare Federation and the press. The custom of presenting reports at an annual public meeting of the trustees or members of the hospital corporation is useful if only that it gives to reports a certain news value. Under present conditions in Cleveland, the trustees of hospitals are freed from the necessity of the continuous pursuit of the vocation of honor- able begging, the most characteristic occupation of trustees in most com- munities. They may ordinarily concentrate their financial efforts within a brief period of the year, and be free at other times to give their attention to administration, and planning for the hospital. It is above all, important that in working out and planning the present and future policy of individual hospitals, the trustees, the staffs, and the executive officers keep always be- fore them the conception that the hospital is an agent for service to the com- munity, and not an institution with all its roots in its own soil. There is marked danger that those who work within the four walls of an institution lose touch with outside interests and agencies, and develop the ingrowing rather than the outlooking mind. This danger is particularly apparent in such a highly specialized technical service as that of a hospital. A well- managed dispensary tends to assist hospital trustees, staffs, and adminis- trators to keep in touch with the community, because a dispensary is less rigid, less walled-in than a hospital proper, and helps in achieving a prac- tical combination of administrative efficiency with human adaptability. Hospitals closely connected with a church organization appear in some cities particularly prone to be over-institutionalized. The public spirit and com- munity interest manifested by such hospitals as St. Vincent's and St. John's should be mentioned as notable illustrations of a different point of view in Cleveland. Such a cooperative organization as the Cleveland Hospital Council has undoubtedly assisted all hospitals to think in terms of larger units than themselves. Hospitals and Dispensaries 979 ORGANIZATION TO CARRY OUT PLANS Planning for individual hospitals and planning for the hospitals and dispensaries of a community as a whole will yield little practical result unless there is community organization of the right sort. In Cleveland we may classify the community functions and organization in two groups, those under public auspices (municipal or state) and those under private auspices, affiliated as members of the Welfare Federation and the Cleveland Hospital Council. An institution dealing with so serious a matter as treatment of illness has a responsibility to the public which should be recognized by a certain degree of public supervision. By a recent law, the Department of Health of the State of Ohio was empowered to register, define, and classify all hos- pitals and dispensaries, to require hospital reports, and to license maternity hospitals. It is deemed desirable that these public supervisory powers be extended as follows: (a) Every hospital and dispensary should be required to obtain a license to operate from the State Department of Health.* (b) Such license should be issued for a term of one year, renewable by the Department. (c) Licenses should be revocable for cause, provided that notice of reasons shall be given in advance to the institution and also an opportunity for a public hearing when requested. (d) Hospitals and dispensaries incorporated as charities should be licensed without fee and a small license fee should be charged to institutions which are incorporated for profit. (e) Inspection by the State Department of Health should be provided for and appropriation made for a staff to perform this work. The State Department of Health should be empowered to outline and prescribe requirements or standards under which licenses should be issued and under which hospitals and dispensaries may operate. The administrative powers of the State Department of Health should be exercised by this Department throughout the State, except in chartered cities. Such cities should be authorized to pass laws or ordinances (the con- stitution provides that they shall not be inconsistent with the existing state laws) and to administer the licensing and inspecting powers above provided for under its own local authority. *It is the opinion of Doctor Babcock, who has collaborated on this study, that this is an undesirable administrative responsibility to place on state authorities. 980 Hospital and Health Survey The State Department should administer the law directly in those cities or other political subdivisions which do not maintain their local administra- tion under their own auspices. The State Department of Health should in all cases continue to receive annual reports from hospitals and dispensaries and to maintain a register of all licensed institutions. No chartered city should be permitted to prescribe or tolerate standards for the maintenance or licensing of hospitals or dispensaries which fall below those prescribed by the State Department of Health. If there were no other reason than the existence in Cleveland of a num- ber of commercial hospitals, this would be sufficient for the extension of the powers of the state and the administration of these powers in Cleveland by the municipal government. The inspection made by the Survey of the sixteen institutions not members of the Cleveland Hospital Council revealed the fact that while a few are of the public-service class and a few others are well conducted proprietary institutions giving a fair standard of care to their patients, the remainder are utterly unworthy of existence. In six cases no graduate nursing service whatever was provided for the sick patients. In more than one instance, the buildings were dirty and the patients appeared to be physically uncared for. Proprietary hospitals have a legitimate place, but making a profitable business out of the improper care of the sick is intolerable, and can be pre- vented only by public authority. The State, utilizing as proposed the ma- chinery of the city government in the larger communities, has the right and duty to set minimum standards to which every institution treating the sick shall conform, and to enforce such standards through appropriate agents. Such a policy does not mean interference in hospital management by the state or city, or public regulation of hospitals in any detailed sense of the term. 'It means the securing of such facts as shall enable the public to be protected against an unworthy and improper class of institution — leaving the majority, which are far above this class, free to conduct themselves as they will. It is important in a community program for dealing with hospitals and dispensaries, that the municipal agencies caring for the sick shall be properly related to the private agencies, and this has been notably achieved in Cleve- land through the Hospital Council. The City Hospital is a member, as well as the privately supported institutions. The broader interests of the city in public health (in which the hospitals are also concerned) should be brought into closer touch with private agencies interested in such subjects, through some such means as the proposed Cleve- land Public Health Association (see Part II.). In the opinion of the Survey, the relations between the Welfare Federation, the Cleveland Hospital Coun- cil, and the individual institutions should be somewhat as follows: Outlines of Community Organization 1. It is the function of the Welfare Federation to deal with questions of general policies in relation to large groups of welfare agencies and in particu- Hospitals and Dispensaries 981 lar to provide machinery for joint financing and suitable apportionment of funds raised. It is highly desirable and has been elsewhere recommended by the Survey (Part II.) that the Welfare Federation have on its executive staff an assistant to its general director, who will be an expert in the health field, and who will be able to advise the director on the many problems in this field to which the Federation devotes over one million of the four million dollars raised annually by the Community Fund. 2. Within the hospital and dispensary field, the Hospital Council should outline standards for hospitals and dispensaries, covering minimum require- ments in: (a) Organization (board of trustees, superintendent, staff, nursing, etc.) for hospitals and dispensaries. (b) Medical work (examinations, use of laboratories, records, internes, private and ward patients). (c) Finance and accounting. 3. Only hospitals complying with these standards should be admitted or retained as members of the Council. 4. Only hospitals in the Council should be assisted by the Federation. 5. Financial support by the Federation should be on the basis of chari- table work, which should be taken to include free service and also part-pay service, rendered in hospital beds or in dispensary clinics. 6. Appropriations for the support of dispensary work should be separated from those of hospital work, since the units of service are different. 7. Municipal hospitals, and also hospitals not doing charitable work as above defined but complying with the standards, may be members of the Council and the Federation, and receive the benefits of such membership (they will not of course need financial aid) . Place of Hospital Council The Cleveland Hospital Council has been of such great value to Cleve- land and indeed to the state and the country that too much emphasis cannot be laid upon the importance of its adequate maintenance and development. It has brought the hospitals of the city together for cooperative work, and for mutual improvement in many respects. Advantageous legislation in connection with hospital service and public health work has been promoted by the influence of the Council and by the activities of its executive secre- tary. Certain of the technical standards, forms of report, etc., as outlined by the Council have been made use of by institutions and by official bodies in other parts of the United States. 982 Hospital and Health Survey The Central Purchasing Department of the Council has been and is a valuable contribution to the economy of hospital administration. The amount of purchasing done (for hospitals alone) for the first half of the year 1919 was $90,890.89; for the entire year of 1919, $268,503.07; and for the first six months of 1920, $222,278.97. It will be noticed that the purchases for the first half of 1920 almost equal the purchases for the entire year of 1919. It is estimated by the Department that there has been a saving on the large purchases for the first half of 1920 to the amount of $10,000.00, and that there was also considerable saving on the small purchases, although no definite estimate can be furnished of this. Consideration should be given to the transfer of the Purchasing Depart- ment from the auspices of the Hospital Council to those of the Welfare Fed- eration, in order that the range of service of the Department may be widened; or the Council might offer the services of the Department to Federation organizations which are not members of the Council. The opportunities for service by the Council to the hospitals of Cleve- land are increasing steadily in proportion as the hospitals appreciate more and more the advantages of cooperative activity in administrative direc- tions, for the sake of economy and efficiency, and of conferences and discus- sion for more effective formulation of policies concerning hospital service. The development of a dispensary section of the Hospital Council for purposes of improvement of dispensary service which is recognized as an urgent need throughout the city, is now an important activity wjiich natur- ally belongs within the general scope of the Cleveland Hospital Council. Almost endless opportunities exist for service to hospitals through the expert services of the executive staff of the Council, which should assist the members in an advisory way through their own efforts and through as- sembling information, arranging conferences, securing expert advice from other sources, etc. Many of the recommendations made by the Survey to indi- vidual hospitals, particularly those of moderate or small size, will doubtless cause these hospitals to appeal to the Hospital Council for advice in helping them to work out details of such recommendations as are approved in gen- eral by the hospital trustees. The interest of the hospitals in legislation will continue to call for some activity in this direction on their part each season. The organization and staff of the Hospital Council does not appear ade- quate at present to meet these demands, but it is of the highest importance to the best advancement of hospital and dispensary service in Cleveland that the Council equip itself to carry its increasing responsibilities. It may be noted that the time has probably arrived when a substantial share of the work in initiating and promoting legislation, in which the Courcil has achieved so much success, may be taken over by the Ohio State Hospital Association. This would seem a logical development. It is recommended that the proposed Central Dispensary Committee be made part of the activities of the Hospital Council as soon as the Council staff is able to carrv the additional work. Hospitals and Dispensaries 983 Hospital Standards Membership in the Hospital Council should mean to other hospitals and to the public, the acceptability of the hospital according to standards of good organization and management. The chief present deficiency of the Council is due to the fact that hospitals have been accepted as members whose stand- ards have been too far below those of the average maintained by the Council, and not as high, in one or two institutions, as a few hospitals not members of the Council. It is recognized, however, that in the initial formation of the Cleveland Hospital Council, it was not practicable to define or enforce standards very definitely. The time has now come, however, when definite minimum standards of admission should be publicly known as well as pro- fessionally enforced. The Council, through its committees, officers, and executive staff, should be the democratic professional agent of the hospitals and dispensaries, themselves, for their own improvement; and should be the advisor of the Welfare Federation on technical questions concerning hos- pital and dispensary functions and standards. The state 1 and city governments, through the regulative acts proposed, should set minimum standards and an institution which does not comply with these should not be allowed to operate at all. Between the minimum standards and the desirable hospital standards is a considerable zone. The Hospital Council should not take in this twilight zone, but should always encourage and assist institutions which are within its shadow to move as rapidly as possible up into the light. With such relations between the state and city governments, the municipal hospital, the Welfare Federation, and the Cleveland Hospital Council with its hospital and dispensary experts, it is believed there will exist in Cleveland the machinery for the continued advance of hospital and dispensary standards of administration. If such progress is suitably reported to the public through the individual hospitals and through the general ac- tivities of the Council and Federation, growing interest and backing for hos- pital and dispensary work should be annually manifested, expressing itself in more intelligent policies, fuller cooperation, and larger funds for main- tenance and for permanent improvement. But organization after all is only machinery. It is the ideals and spirit of individuals and of small coherent groups working together, which pro- vide the motive power that drives institutions and communities onward. The schemes of organizers, publicity men, and financiers, can make the path easier and lessen friction during the forward movement, but the goal-posts, guides, and impelling forces, for community and institution alike, depend upon the intangible elements of the individual soul and the civic spLit. Cleveland impresses every investigator with its eager readiness for cooper- ative activity. With such a community spirit, there is indeed the danger that attainment shall be measured too easily in terms of catch-words and externals, and not enough by the more abstract but more fundamental tests 984 Hospital and Health Survey of technic. It is for the development of a high degree of Avell -founded pro- fessional achievement with no loss of its present splendid tradition of com- munity endeavor that every lover of Cleveland must hope. TABLE I HOSPITALS AND DISPENSARIES IN CLEVELAND Institutions Members of Cleveland Hospital Council Dis- pensary Hospital Visits, Beds 1919 Babies' Dispensary and Hospital — 2500 East Thirty-fifth Street. 34* 14,977 Cleveland City Hospital — Scranton Road ._ 785 Cleveland Maternity Hos- pital — 3735 Cedar Ave..... 60 3,688 Fairview Park Hospital — 3305 Franklin Avenue 85 Glenville Hospital — 701 Parkwood Drive... 74 Grace Hospital — 2307 W. Fourteenth Street 35 Huron Road Hospital — 748 Huron Road 84 5 , 864 Lakeside Hospital — East Twelfth and Lakeside Av. 289 59 , 891 Lakewood Hospital — 14519 Detroit Avenue 53 Lutheran Hospital — 2605 Franklin Avenue 50 Mount Sinai Hospital — 1800 East 105th Street... 225 19,324 *In summer only. Dis- pensary Hospital Visits, Beds 1919 Provident Hospital — 624 East 103rd Street 29 Rainbow Hospital — South Euclid, Ohio... 85 St. Alexis Hospital — 5163 Broadway 250 St. Ann's Maternity Hos- pital — 3409 Woodland Av. 55 St. Clair Hospital— 4422 St. Clair Avenue..... 43 St. John's Hospital — 7911 Detroit Avenue _ 150 St. Luke's Hospital — 6606 Carnegie Avenue 139 13,313 St. Vincent's Charity Hos- pital — Central and East Twenty-second Street 290 21,863 Warrensville Tuberculosis Sanitarium, Warrensville, Ohio 270 Woman's Hospital — 1948 East 101st Street 37 Hospitals and Dispensaries 985 Institutions Not Members of the Cleveland Hospital Council Dis- pensary Hospital Visits, Beds 1919 fCarnegie Avenue Hospital — 8714 Carnegie Avenue.. Unknown fClass Mineral Fumes Treat- ments — 8101 Hough Ave.. Unknown Cleveland Emergency Hos- pital— 1780 East Fifty- fifth Street 22 Cleveland Home Hospital — 5107 Prospect Avenue . 10 fDelmont Hospital and Sana- torium — 1770 Delmont Avenue Unknown Dorcas Invalids' Home — 1380 Addison Road 46 East Cleveland Hospital — 14420 Euclid Avenue 31 East Fifty-fifth Street Hos- pital — 2415 East Fifty- fifth Street 60 East Seventy-ninth Street Hospital — 1873 East Sev- enty-ninth Street 24 Eliza Jennings Home for Incurables — 10603 Detroit Avenue 2 6 fEuclid Avenue Hospital and Sanatorium — 9810 Euclid Avenue Unknown Florence Crittenden Home —523 Eddy Road 12 Mrs. Hitchcock's Private Hospital — 5013 Prospect Avenue 1 5 Hospital Beds Dis- pensary Visits, 1919 Holy Cross House: — 9014 Cedar Avenue 50 Joanna Private Hospital — 933 East Seventy-eighth Street... 9 Kate Castle Rhodes Babies' Dispensary — 12611 Madi- son Avenue, Lakewood fNeal Institute Company — 3920 Euclid Avenue.. ...Unknown fOhio Sanitariums Com- pany — 14822 Terrace Road - Unknown fOrthopedic Institute — 1936 East Sixty-sixth Street Unknown fReliable Invalid Home — 2222 East Eighty-ninth Street. Unknown Rest-Cure Hospital and Sanatorium — 2453 East Fifty-fifth Street... 16 (in use) St. Mark's Hospital— 629 Eddy Road 45 Salvation Army Rescue Home — 5905 Kinsman Road --:- 54 U. S. Marine Hospital — 1041 Lakeside Avenue 86 4,493 Windsor Sanatorium — 4415 Windsor Avenue 38 Wright's Hospital— 18902 Nottingham Road 10 Y. W. C. A. Retreat— 4916 St. Clair Avenue Temporarily Closed ■{■Institutions not reported as registered with the State Department of Health up to June, 1920. 986 Hospital and Health Survey -502 Central Ave. 3 — 2810 Seymour Public Health Health Center No. 1 — 1510 East Forty ninth Street. Health Center No. 2 Health Center No. Avenue. Health Center No. 4 — 5825 Cable Ave. Health Center 'No. 5 — 9206 Woodland Avenue. Health Center No. 6 — 10126 St. Clair Avenue. Health Center No 7 — 6100 Pear Avenue. University Health Center — 2739 Orange Avenue. Prophylactic Baby Stations — 5706 Clark Avenue. 7654 Broadway. 12510 Mayfield Road. Dispensaries 4247 Pearl Road. 833 East 152d Street. 3008 Bridge Avenue. 2511 East Thirty-fifth Street. Prenatal Clinics— Maternity Hospital Dispensary — 2509 East Thirty-fifth Street. (Sub-stations) 2749 Woodhill Road. Alta House, 12510 Mayfield Road. 2317 Lorain Avenue. Goodrich House, 1420 East Thirty- first Street. East Forty-ninth and Fleet Street. Mount Sinai Hospital — 1800 East 105th Street St. Luke's Hospital — 6606 Carnegie Avenue. TABLE II PERCENTAGE OF OCCUPANCY OF HOSPITAL BEDS HOSPITAL City : Fairview Park. Glenville. Grace._ _ Huron Road Lakeside Lakewood Lutheran..... Maternity Mount Sinai... Provident. St. Alexis St. Ann's... St. Clair St. John's St. Luke's. St. Vincent's.... Woman's..— Beds* 1919 Per Cent. Occupied 1919 Per Cent. Occupied 1918 Per Cent. Occupied Census Days Averaged 785H 60.3 82.2 70.0 85 60.4 62.3 67.6 74 66.3 72.3 69.0 35 66.8 52.7 94.3 84 75.0 68.2 86.9 289 90.8 82.6 72.9 53 45.9 40.7 68.0 50 80.9 70.5 93.0 60* 79.9 70.3 71.7 225f 72.4 81.7 84.2 29 40.5 49.4 65. 5 J 250 78.1 78.0 97.8 55** Unknown 75.0 93.7 43 40.2 58.6 33.7 150 Unknown 79.0 90.1 139 75.8 71.6 95.3 290 66.9 58.1 73.0 37 76.0 Unknown ff Unknown *For maternity cases, adult beds only were included, except for Maternity Hospital for 1919, which was figured on a basis of 60 mothers and 33 cribs, as the bed days reported included both mothers and babies. tMt. Sinai for 1918 was figured on a 155-bed basis; for 1919 on a basis of 155 beds for February and March, and 225 for the remaining ten months. tProvident furnished data for the first Survey Census day only. **St. Ann's figures for 1919 were not furnished. ttNo definite information was available regarding beds at Woman's for 1918. tJCity was figured on basis of 650 beds until December, 1918, and 785 beds thereafter. Since the field work of the Survey was completed, figures were furnished by the City Hospital Administration, based on 725 beds which were available for 1919, instead of 785. This gives the percentage occupied for the year in the hospital as a whole, as 66.5 per cent. Further details of importance regarding City Hos- pital will be found in the foot-note, page 834. Hospitals and Dispensaries 987 TABLE III HOSPITAL BEDS ACCORDING TO HEALTH DISTRICTS* District Type of District I Factory Popula- tion of District 82,185 Beds to Hospital Cases 1000 of to 1000 of Pop- Population ulation of of District District (Census I) (Census I) Total Hospitals Hospital in Beds in District District Lakeside 429 . St. Clair Cleveland Emergency Huron Road 84 City 820 Grace St. Alexis.... 293 East 79th Florence Critten- den Joanna Private St. Luke's 280 Holy Cross Salvation Army Rescue Home Woman's Glenville 373 Mount Sinai Provident St. Mark's Fairview Park 285 Lutheran St. John's Maternity 490 St. Ann's St. Vincent's East 55th Street Cleveland Home Mrs. Hitchcock's Private Lakewood .. 53 Rainbow 85 Warrensville Tu- berculosis Sana- torium 270 Wright's.. 10 East Cleveland .... 31 *It will be observed that the population figures are those which were furnished the Survey from loca estimates, and are higher than those given in the 1920 census. For the sake of uniformity, these esti- mated population figures have been used throughout this table since its purpose is primarily the com- parison of different districts, and census figures for anything except the city as a whole were not available at the time of writing this report. II _ .Factory, Congested 42 , 159 III_ Near Congested...... 130 , 775 IV Factory, Congested 164,094 V Part Congested ...... 136,294 Part Residential VI ...Industrial 176,836 Residential Congested VII Semi-congested 90 , 766 Residential VIII Congested 72 , 168 Outside City Limits .... 5.2 2.0 6.3 1.8 2.1 2.1 3.1 6.8 2.7 3.5 1.2 1.2 1.9 2.1 2.1 4.1 988 Hospital and Health Survey TABLE IV PERCENTAGE OF HOSPITAL PATIENTS COMING FROM HEALTH DISTRICT IN WHICH HOSPITAL IS LOCATED (First Survey Census Day) Cleveland City...... 4.6 Cleveland Maternity .....13 . 7 Fairview Park ...36 . 7 Glenville 46.7 Grace .3 2 . 3 Huron Road 6 . 6 Lakeside* Lakewoodf.. Lutheran _ 44.2 Mount Sinai 31 . 2 Provident 78.9 St. Alexis 35 . 9 St. Ann's 59 . 8 St Clair... .28 . 6 St John'sJ St. Luke's.. 15 . 6 St. Vincent's 0.0 Woman's .26.0 *Address not furnished for 52 per cent, of patients. fHospital outside city limits of Cleveland. JAddress not furnished for 59 per cent, of patients. TABLE V PERCENTAGE OF CASES, CLASSIFIED ACCORDING TO COMPENSATION FOR CARE, ADMITTED THROUGH VARIOUS SOURCES TO THREE LARGE GENERAL HOSPITALS Patients Admitted to Hospital No. I., Classified According to Compensation for Care, and Source of Reference Percentage Percentage Percentage Percentage of total referred by referred by referred by Percentage admissions staff non-staff by charitable not physicians physicians agencies classified Patients paying full cost of care 41.9 53.0 43 .2 2.2 1.6 100^ Patients paying part of cost of care..... 20 . 8 Patients paying nothing for care 30 . 1 Patients not classified 7 . 2 100% Percentage of total admis- sions 37.9 44.3 15.6 2.1 100% (excepting patients not classified as to compen- sation) 9.3 40.5 20.2 0.0 100^v 4.8 45.8 35.7 3.7 ioo c ;, 0.4 34.4 65.2 oo ioo c ; Hospitals and Dispensaries 989 TABLE V— Continued PERCENTAGE OF CASES, CLASSIFIED ACCORDING TO COMPENSATION, FOR CARE, ADMITTED THROUGH VARIOUS SOURCES TO THREE LARGE GENERAL HOSPITALS Patients Admitted to Hospital No. II, Classified According to Compensation for Care, and Source of Reference Patients paying full cost of care Patients paying part of cost of care. Patients paying nothing for care. Patients not classified Percentage of total admis- sions (excepting patients not classified as to compen- sation) Percentage of total admissions Percentage referred by staff physicians Percentage referred by non-staff physicians Percentage referred by charitable agencies Percentage not classified 27.9 67.5 32.5 0.0 0.0 100% 40.9 68.0 30.9" 1.1 0.0 100% 15.5 47.7 29.2 20.0 3.1 100% 15.7 77.3 22.7 0.0 0.0 100% 100% 59.0 35.5 4.2 1.3 100% Patients Admitted to Hospital No. Ill, Classified According to Compensation for Care, and Source of Reference Patients paying full cost of care _ _ Patients paying part of cost of care Patients paying nothing for care Patients not classified Percentage of total admis- sions (excepting patients not classified as to compen- sation) Percentage of total admissions Percentage referred by staff physicians Percentage referred by non-staff physicians Percentage referred by charitable agencies Percentage not classified 30.5 56.4 43.6 0.0 0.0 100% 49.3 50.0 50.0 0.0 0.0 100% 20.2 73.5 26.5 0.0 0.0 100% 0.0 0.0 0.0 0.0 0.0 0.0 100% 68.9 31.1 0.0 0.0 990 Hospital and Health Survey TABLE VI FINANCES OF HOSPITALS IN CLEVELAND HOSPITAL COUNCIL, 1919 Municipal Total Expense Total Earnings Percentage Ex- for Hospital from Operation penses are of Total Earnings Cleveland City Hospital $428 , 636 . 77 Warrensville Tuberculosis Sanatorium 197 , 020 . 15 7,000 10.4% 58,802 65.0 65,000 76.5 Total Municipal... $625 , 656 . 92 Non-Municipal *Babies' Dispensary. _ 67 ,305 ♦Cleveland Maternity 90,435 *Fairview Park 85 , 000 tGlenville... *Grace 33,000 33,000 100.0 *HuronRoad 117,600 83,800 71.3 *Lakeside 480,000 264,000 55.0 *Lakewood..._ ■ , 58,000 52,000 89.7 JLutheran _ fMount Sinai 332 , 000 200 , 000 60 . 4 *Provident 14,000 13,000 92.9 ♦Rainbow 63,445 12,910 20.4 *St. Alexis _ 108,800 70,000 64.3 *St. Ann's , 107,125 84,888 79.2 *St. Clair.... 36,975 28,390 76.7 *St. John's 169,342 120,200 70.9 *St. Luke's... 207,120 176,820 85.4 *St. Vincent's 249,350 204,800 82.1 ♦Woman's 50,083 39,600 79.2 Total Non-Municipal $2 , 269 , 580 . 00 Grand Total $2 , 895 , 236 .92 $1 , 514 , 210 Summary for Non-Municipal Hospitals (so far as calculable) Subtotal, Expense for Hospitals $1 , 927 , 993 . 00 Subtotal, Earnings from Operation. 1,296,214.00 Bed Days Care, 1919 _ 439,700 Average Cost per Day of Care $4 . 39 Average Earnings per Day of Care $2 . 95 Percentage of Average Cost per Day of Care Earned from Operation 67 . 2 *Budget for these institutions covers the year from October 1, 1919, to September 30, 1920. tBudget for this institution covers the year from January 1, 1920, to December 31, 1920. tin order to estimate the average cost and average earnings per day of care for non-municipal hos- pitals, it is necessary to omit the following hospitals from the calculation: Glenville and Lutheran, as at the time of preparing the table, the total cost and total earnings of these institutions for 1919 could not be ascertained; and also Rainbow, St. Ann's, and St. John's, as at the time of preparing the table, the num- ber of bed days care for the year 1919 could not be ascertained. The figures in the summary therefore do not make a total as large as in the non-municipal group in the table. Hospitals and Dispensaries 991 TABLE VII SUMMARY OF CONVALESCENT CASES Charity City Lakeside Mt. Sinai Cases with Home Environment Cases. Per ct. Cases. Per ct. Cases. Per ct. Cases Per ct. Favorable and Adequate 15 30.0 5 7.0 4 7.0 1 4.5 Favorable with minor adjustments 21 42.0 19 26.8 21 36.8 10 45.5 Unfavorable but remediable 6 12.0 21 29.6 14 24.6 7 31.8 Unfavorable and not remediable 6 12.0 20 28.2 16 28.1 2 9.1 Acutely needing further hospital care.— 2 4.0 6 8.4 2 3.5 2 9.1 Cases with Home Environment Favorable and Adequate Favorable with minor adjustments.. Unfavorable but remediable Unfavorable and not remediable Acutely needing further hospital care 50 100.0 71 100.0 57 100.0 Total cases 25 71 48 44 12 22 100.0 Total Per ct. ' 12.5 35.5 24.0 22.0 6.0 200 100.0 TABLE VIII PATIENTS REMAINING IN HOSPITAL OVER TWO MONTHS Number of patients Percentage of patients Number of patients remaining over two remaining over two HOSPITAL on Survey census months on census months on census days, averaged days, averaged days, averaged Cleveland City.... 549 .5 162 . 5 29 . 6% Cleveland Maternity 43 . 0.0 0.0 FairviewPark 57.5 2.5 4.3 Glenville 51.0 1.0 2.0 Grace 33.0 2.0 0.6 Huron Road 73.0 6.5 8.9 Lakeside ,. 215.5 26.0 12.1 Lakewood 36.0 3.0 8.3 Lutheran 46.5 0.5 0.1 Mt. Sinai 160.0 8.0 5.0 Provident 19.0* 0.0 0.0 St. Alexis 244.5 22.5 9.2 St. Ann's 51.5 0.5 0.9 St. Clair 14.5 1.0 6.9 St. John's 137.0 9.5 6.9 St. Luke's 132.5 4.5 3.4 St. Vincent's _ 210.0 15.0 7.1 Woman's 43.0 0.0 0.0 Totals... 2,117.0 265.0 7.9 ""Information was received from Provident Hospital for'the first Survey census day only. Hospital and Health Survey PROPOSED FORM FOR SHOWING HOSPITAL AND DISPENSARY SERVICE OF CLEVELAND As Rendered by the Members of the Cleveland Hospital Council During 19 Hospital— Number of Beds Total Hospital Days Care Percentage of Possible Days Care Classes of Patients Pay Patients Number Part-pay Patients Number Days Care Free Patients Number Days Care Percentages of Days Care Pay Part -pay Free Equivalent Free Days Sex and Age of Patients Women Children under 15 Average Days Stay per Patient Total Number of Patients Income From Operation From Endowment From Community Fund From Other Sources Percentage from Operation Percentage from Community Fund Expenditures Total for Hospital Average per Days Care Average per Day for Food Only Dispensary Total Visits New Patients Women Children under 15 Total Average Visits per Day Average Visits per Patient From Operation From Endowment From Community Fund From Other Sources Percentage from Operation Percentage from Community Fund Total Average per Visit Ambulance Calls Made Total Average per Day Total Cost Average Cost per Call Personnel Total number on December 31st, of Visiting Medical Staff Resident Medical Staff Employes N. B. — The above form for a table is deiigr which should be tabulated, for each hospital, name of the institution. The right-hand column will show the total for all the members of the Hospital Council taken together. An additional column might be added, giving for comparison the totals of the preceding year. It should be understood that the above condensed form, printed here as illustration, shows only two columns for hospitals, whereas the form actually to be used would include a column for each member of the Council. THE CLEVELAND HOSPITAL AND HEALTH SURVEY REPORT List of Parts and Titles I. Introduction. General Environment. Sanitation. II. Public Health Services. Private Health Agencies. III. A Program for Child Health. IV. Tuberculosis. V. Venereal Disease. VI. Mental Diseases and Mental Deficiency. VII. Industrial Medical Service. Women and Industry. Children and Industry. VIII. Education and Practice in Medicine, Dentistry, Pharmacy. IX. Nursing. X. Hospitals and Dispensaries. XL Method of Survey. Bibliography of Surveys. Index. The complete set may be obtained at a cost of $5.50 plus the postage and single parts at 50 cents each plus the postage, from THE CLEVELAND HOSPITAL COUNCIL, 308 Anisfield Building, Cleveland, Ohio Printed by The Premier Press Cleveland, O. Method of Survey Bibliography of Surveys Index Part Eleven Cleveland Hospital and Health Survey Copyright, 1920 by The Cleveland Hospital Council Cleveland, Ohio Published by The Cleveland Hospital Council 308 Anisfield Bldg Cleveland - Ohio Preface The Hospital and Health Survey of Cleveland was made at the request of the Cleveland Hospital Council. The Survey Committee appointed to be directly responsible lor the work and through whose hands this report has been received for publica- tion consisted of the following: Malcolm L. McBride, Chairman; Mrs. Alfred A. Brewster, Thomas Coughlin, Richard F. Grant, Samuel H. Halle, Otto Miller, Dr. H. L. Rockwood, Howell Wright, Secretary The staff responsible for the work were: Haven Emerson, M. D., Director, and the following collaborators : Gertrude E. Sturges, M. D., Assistant Director; Michael M. Davis, Jr., Ph. D., Director of the Hospital and Dispensary Survey; Josephine Goldmark, B. A., Director of the \Nursing Survey; Wade Wright, M. D., Director\of the Industrial Hygiene Survey; Donald B. Armstrong, M. D., Director of Tuberculosis Survey; S. Josephine Baker, M. D., D. P. H., Director of the Infant and Maternity Survey; T. W. Salmon, M. D., Director of the Mental Hygiene Survey; W. F. Snow, M. D., Director of the Venereal Disease Survey; Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey. The expenses of the Survey and of the publication of the report have been met by appropriations received from the Community Chest, through the W T elfare Federation, of which the Hospital Council is a member. The report as a whole, or by sections, can be obtained from the Cleveland . Hospital Council. A list of the parts will be found in the back of this volume, together with prices. TABLE OF CONTENTS I. Method of Making a Community Diagnosis Page Introduction — Why a Survey is Necessary 1003 Preliminary Steps: Realization of the Need 1004 Cost to be Considered.... 1004 Committee 1004 Choosing the Group of Diagnosticians 1005 Scope : History of Survey 1005 Factors Influencing Scope 1007 Aims*and Methods : Interpretation of Results :... 1009 Education of the Patient 1009 Community History Taking 1010 Quantitative Estimate of Needs 1010 Law and Law Enforcement 1010 Coordination and Functional Control 1011 The Associated Health Professions and Their Training.... 1012 Quantitative Determinations of Functions 1012 Quality of Function 1013 Resources for Prevention 1015 Checking up the facts for Diagnosis.. 1015 Conclusion : Treatment and Follow-up 1016 Appendix : Form Letters and Questionnaires 1018 II. Bibliography of Surveys Health Administration Surveys..... 1038 Mental Hygiene Surveys... 1044 Infant Mortality Surveys.... 1049 Social Surveys 1052 Industrial Hygiene Surveys... 1054 Tuberculosis Surveys 1057 Sickness Surveys _ 1059 Unclassified 1060 III. Index 1061 Method of Making a Community Diagnosis By Haven Emerson, M. D., and Gertrude E. Sturges, M. D. INTRODUCTION: WHY A SURVEY IS NECESSARY WHAT is a survey, and why does Cleveland or any other city need the luxury of a diagnosis? A diagnosis implies the presence of ill health. Is Cleveland sick? Even as the careful and thrifty owner has his car overhauled to prevent delay upon the road or accident under strain, and as the young husband looks far into the future and insures his life, so a city may well indulge in community insurance by a periodical searching for weak joints in its organization, loose bolts, missing parts, proof of wear and tear, need of replacement and reinforcement of its structure. While all the world is clamoring for production, it is worthy of great praise that a community should determine that, in one place at least, the producer shall rank ahead of the produce in their thoughts and plans. Property will always have its protectors and promoters. It is persons who are chiefly neglected, and for these the community health diagnosis takes thought. How may their sickness be prevented, their lives made longer and happier and if sickness overtakes them, how may skill and gentle- ness be put quickly at their service? To survey is to view with attention as from a height — to prospect, to examine, and in so doing to make a review and retrospect, to use history and present experience as a basis for programs for the future to insure prog- ress. • The community physician should detect the presence of all factors affect- ing health and formulate all practical and economical measures to decrease disease and increase comfort. The public, as investors in the Community Fund, are stockholders in the various institutions supported by this fund, and as stockholders, are entitled to a statement of results — as to the per capita costs as well as the quality and quantity of the output. The contributing public and. more particularly the boards of trustees of the various institutions, have a definite respon- sibility also in seeing that the funds which are provided are made to serve the best interests of the community. They should make sure that the high- est degree of professional service is rendered through the institutions for which they are responsible and that the same principles of organization and efficiency are carried out as in up-to-date business enterprises. To this end it is essential that both the character of professional service and the type of business administration receive the thorough investigation of experts from time to time. It is also pertinent for the investors to know whether there is any over- lapping of effort or duplication of function by existing institutions that could 1004 • Hospital and Health Survey be obviated by more clearly defined policies or by a division of the territory to be covered by each institution. What preventive or curative needs are not being provided for adequately: i e., measured by the estimated service required for prenatal care, for dispensary service, for hospitalization, etc., what failures to meet the need are apparent? What services are not being rendered at all? In an extensive view of all the city's activities for preven- tion and treatment of disease, for education of physicians and members of the allied professions, what distinct gaps exist in the service? Is there an understanding of the precise problems to be solved and of the ways and means by which they may be solved? Are all modern information and experi- ence in the prevention as well as the treatment of sickness, sufficiently under- stood by each agency serving the public? Until every doctor, nurse and health visitor working among the sick is aware of the resources and applica- tion of preventive medicine to health protection, no possible increase in hospitalization of the sick will meet the needs of the city. Each case of sick- ness presents a problem of prevention as well as of relief, of education as well as of treatment, of the family and the home as well as of the individual patient. And, finally, is there adequate provision made for coordinating the activities of the private health agencies to the end that they may provide the maximum service with the minimum of effort and of overhead expense? PRELIMINARY STEPS With some of the problems in mind to be answered by the community diagnostician, what are the preliminary steps to be taken? Realization of the Need First the patient must realize that he needs the services of a physician and must be prepared to render him every assistance. Without not only the patient's consent but his eager and willing assistance, no physician can get all the facts needed before prescribing. A community differs in this respect chiefly in quantity, not in elements for diagnosis, from the individual patient. Cost to be Considered Sufficient financial support must be assured to "pay the doctor's bill." In Cleveland adequate provision for financing the Survey was made from the Community Fund, at the request of the Cleveland Hospital Council through the medium of the Welfare Federation. A sum of $53,000 was appropriated for this purpose of which $52,668.98 was spent.* It is interesting to note in this connection that service, conservatively estimated to be worth over $10,000, has been given to the Cleveland Survey by cooperating national and local organizations. The Committee in Charge The organization or committee under whose auspices the community study is to be conducted is another matter for preliminary consideration. In •This amount was estimated at the time of going to press. Method 1005 order that every institution may feel itself an integral part of the group con- ducting the Survey, the committee should be as representative as possible and, that good feeling may be assured, men and women known to be broad in their judgments should be chosen. In Cleveland the Survey has been conducted under the direct supervision of a special committee of the Hospital Council, consisting of public-spirited business men, a woman representing the nursing interests, the Commissioner of Health and the secretary of the Hospital Council. The Hospital Coun- cil itself is a cooperative organization consisting of representatives of the boards of trustees and superintendents of the public and private hospitals in the city. The committee must be able, as this one was, to open all the doors of the city. By the position, character, professional, business and social standing of its members, it must be able to give access for the sur- veyors to all important public and private groups who can give information or spread it. The editorial offices of the daily papers, the offices of city gov- ernment, the clubs, churches, professional, business and social groups must be readily accessible and hospitable to the inquiries that lead into the in- timacies of community history, and willing to take trouble to see that needs and recommendations are frankly discussed and acknowledged. The Group of Diagnosticians Choosing the doctor and his colleagues is the first problem with which the committee is confronted. The group of diagnosticians should possess not only knowledge of the field to be studied, but wide experience with conditions in other cities, in order that they may have a background for guaging local problems. Impartiality will generally be better assured by selecting the entire Survey staff from outside the city. The Cleveland Hospital and Health Survey has been particularly fortu- nate in securing the cooperation of many national agencies which, because of the wealth of their experience, are in an ideal position to survey any locality. SCOPE The scope of a survey may be either intensive or extensive; either an analysis of one phase or agency of health service or a general health survey; i. e., the examination of a single part of the body, one of the special senses or a general medical examination. Historical It is interesting in this connection to study briefly the range of previous surveys. A study of available literature at the Russell Sage and medical libraries brought out the fact that surveys of health administration and allied subjects are numerous. (See bibliography of surveys). These are the case histories of community patients. Eighty such surveys have been made in thirty different states (several covering more than one state) and also in 1006 Hospital and Health Survey two foreign countries. New York, Illinois, Ohio, Pennsylvania and Min- nesota ranked in that order in the number of public health studies that had been made upon various of their communities. These investigations have been conducted chiefly by the United States Public Health Service, by state or local health departments, by the New York or local bureaus of municipal research, by the Russell Sage Foundation and by local Chambers of Com- merce. ■> Mental hygiene was the subject next in order of attractiveness to the surveying mind. Results of sixty-three studies of this subject were found. Many of these have been made by the National Committee for Mental Hygiene and several by state or local charitable organizations. Search brought to light thirty-eight infant mortality and child health studies. The largest number of these had been prepared by the United States Children's Bureau, although the Russell Sage Foundation and the National Child Labor Committee had each conducted several studies of this type. Thirty-four social surveys were found, made by a wide variety of groups. This number includes only the most important contributions along this line. The list could be greatly increased, no doubt, by the addition of all the local social studies that have been made, reports of which were not sought for particularly in this review of the litarature. There were records of twenty-nine industrial hygiene investigations, half of which were made in New York City, six by the New York City Depart- ment of Health. Many studies of industrial hazards have also been made by the United States Public Health Service and by the United States De- partment of Labor. There were records of twenty-five tuberculosis surveys, many of them made under the auspices of the national or local anti-tuberculosis societies. The effect of industry on the incidence of tuberculosis is the subject of many of these investigations. The influence of housing and economic conditions, nationality and race were some other main points covered in these studies, The amount and character of sickness in various communities have been the object of twelve investigations — most of them conducted by the Metro- politan Life Insurance Company. The most comprehensive surveys that have been made are : the Pittsburgh Survey, the record of which is published in six volumes, embracing the fol- lowing among its major topics — civic improvements, industrial hygiene, housing, schools, playgrounds, libraries, social agencies — and The Spring- field, Illinois, Survey which includes studies of schools, mental hygiene, rec- reation, housing, charities, industrial conditions, city and county ad- ministration, public health and the correctional system. One hundred and eighty-four authors were responsible for the two hun- dred and eighty-one investigations above summarized. There are many Method 1007 authors of several surveys — L. K. Frankel and L. I. Dublin, studies of sick- ness incidence; C.-E. A. Winslow, Carrol Fox and Franz Schneider, Jr., health administration and sanitation; Thomas W. Salmon, T. H. Haines, E. O. Lumberg, W. L. Treadway and S. D. Wilgus, studies in the field of mental hygiene; J. W. Schereschewsky and L. I. Hanes, surveys of industrial hygiene; Shelby M. Harrison, social surveys; W. H. Slingerland, studies in prevention of infant mortality. The report of a study made by the Northeastern Hospital Association, of the hospital facilities in an area of about 4,000 square miles with a population of 2,500,000 in the North of England, comes nearer to including many of the points upon which, the Cleveland Hospital Council wished information than any survey reported in the United States. This English study which was summarized in the Edinburgh Medical Journal in December, 1919, did not, however, enter the field of health administration or deal with the social and medical problems of a large industrial city such as Cleveland. This study is well worth reading by hospital associations in this country, especially such as have to do with rural and small town community services for the sick. Factors Determining Scope The scope of a survey will be decided by many factors, particularly by the extent of previous surveys. Cleveland, for instance, had adequate cur- rent information on recreation, education and housing and it was unneces- sary to elaborate upon these accessory features of a health survey. Sick- ness surveys had been made in other cities by the Metropolitan Life Insur- ance Company, the results of which were applicable to Cleveland, and so it was not thought necessary to collect duplicate data in this field. The scope of a survey will also be determined to some extent by the aims of the group conducting it, by the special problems that are immediately facing the community, and by the financial resources of the sponsors of the investi- gation. In general, it may be said that, since many separate agencies both pri- vate and public are involved in protecting or serving the city's health, all must be coordinated in an attack upon disease. As many of them as pos- sible must be analyzed and described in order to arrive at a community picture. The general scope of the Cleveland Hospital and Health Survey, as outlined in the letter of authorization, included: 1. Study of education in medicine and in the allied professions. 2 . Study of the facilities for the treatment of the sick. 3. Study of measures for the prevention of disease. The scope of the individual parts of the survey will be decided again by the special community problems involved, as well as by the nature of the institution or. service. As the chief problems brought to the attention of 1008 Hospital and Health Survey the present survey lay along the line of hospital and dispensary treatment these services received a large share of attention. Detailed plans of the ground to be covered and the character of the re- port should, as far as possible, be worked out before the survey is far ad- vanced — for the sake of economy in time and money. Method 1009 AIMS AND METHODS OF DIAGNOSIS AND TREATMENT The aim of the community physician should be not only to arrive at a diagnosis and prescribe a course of treatment but to explain thoroughly both diagnosis and treatment to the patient, and where possible to assure avoid- ance of repetition of the difficulty. In general, the Cleveland survey has been undertaken in a spirit of practical application rather than as a tech- nical, statistical or research problem. That is, every effort was made to ex- plain all criticisms and recommendations to the governing bodies and execu- tives of each institution concerned, as by personal conference with these groups the community physician had his best opportunity for influencing the family of the patient to assist in carrying out the treatment prescribed. Often the executives themselves were able to point out deficiencies that were not apparent to our investigators. On the other hand, they frequently made situations clear that might, without interpretation, have given rise to undeserved criticism. Besides numerous more or less informal and in- complete conferences on details of the work during the year, a week was devoted to formal conferences with groups of trustees of hospitals, to present and discuss the survey findings after they had been formulated and ma- tured. The preliminary recommendations and constructive criticisms were so well received that many recommendations of the survey had already been put into effect before the findings were published. The diagnostic procedures employed by the community physician are similar to those used by the regular medical practitioner, i. e., history tak- ing, physical examination, laboratory analysis. Education of the Patient It will be necessary to make use of educational methods, first, last and always, to win the confidence of the patient's family and friends. The methods employed in community education are those of publicity, i. e., newspaper and magazine articles, circular letters and addresses and lectures by members of the staff. It is essential that the public recognize the pur- pose and scope of the investigation and by personal contact with the diag- nostic group develop confidence in those who are conducting it, so that when the findings are ready, an educated and receptive public opinion will have been prepared. The Cleveland Hospital and Health Survey was fortunate in obtaining the services of the publicity experts on the staff of the Welfare Federation, who have been most useful in making contacts with the public through the local press. During the first month, the Survey sent form letters to various groups (medical practitioners, social agencies, hospitals, labor unions, industries, men's and women's clubs, and fraternal organizations), to obtain their in- terest and cooperation. In some cases, specific information was asked for so that the letters served two purposes. (For two typical letters, one [to physicians and one to social agencies, see Appendix 1 and 2.) 1010 Hospital and Health Survey During the course of the Survey members of the staff addressed over sixty meetings of various sizes, including the Academy of Medicine, the Men's and Women's City Clubs, the Chamber of Commerce, church congre- gations and groups of physicians, nurses and dentists. -j Community History Taking In order that the community diagnosis may be based on all the facts, and present problems understood in the light of the past, the personal his- tory of the patient must be secured. Facts as to the history of public health in Cleveland were obtained by conferences with those who have been inter- ested in this work for many years. A conception of the special problems of the community which rel ite to public health, or a knowledge of the history of the present illness, must be formulated from rather intangible material obtained in personal conferences, or questionnaires which ask specifically for criticisms of institutions which are not serving the public in a satisfactory manner. The information so obtained, although inconclusive, will often serve to suggest avenues of study that might otherwise be overlooked. Also an institution's relations with the public are an important index of the effectiveness of its service. In analyzing such information it is important to differentiate criticism stimu- lated by personal animosity, from that which is confirmed by similar i obser- vations from other and varied sources, pointing towards a real undermining of health or at least a defective structure or function. Quantitative Estimate of Needs It is necessary to gauge the extent as well as the quality of service needed along various lines. That is, an estimate must be made, based on local figures compared with those from other cities, of the number of women who need prenatal care, out-patient delivery or institutional confinement, the number of children of pre-school age who need free medical supervision, the number of tuberculous who should be under observation at health centers, the num- ber and character of those who need dispensary service, the proper propor- tion of hospital beds to the population, and so forth. It is obvious that no final answers to these questions can be made, but in order to decide the need for extension of the various preventive and treatment facilities the extent of the problem must be measured and recorded. Laws and Law Enforcement Study of the adequacy of state and local laws relating to the professions and dealing with public health agencies, and the efficacy of their enforce- ment, is essential. In connection with the mental hygiene and social hy- giene studies investigations were made also of the provisions for detention Method 1011 of individuals and their treatment in the courts. Does the sanitary code of the city contain all modern provisions for health protection? Are the laws adequate which regulate conditions in industry affecting health? Compar- ing the existing laws with model laws in other states and cities, it will be possible to recommend additions to or changes in the existing statutes. Some of the questions of law enforcement that are fundamental to health protection follow: Are physicians and midwives practising without a license; do they report births, deaths, contagious and infectious disease as the law requires; are housing and sanitary regulations upheld; are children allowed to work on streets and in factories in violation of the Child Labor laws; is the ordinance against dense smoke commonly observed? A birth registration check was made at the Division of Health covering about 800 children under two years of age, who had been born in Cleveland, to see if their births had been recorded. The form on which the information for checking was collected will be found in the Appendix (3). Coordination and Functional Control The actual analysis of the organization and accomplishments of the different institutions may well be compared to the physical examination of the patient. It is quite obvious that it is impossible to differentiate sharply the various methods of procedure, as they often overlap or are combined. In studying any institution attention must first be given to its type of or- ganization and functional control (the nervous system). Of whom is the board of trustees composed? Do the trustees take a personal interest in the details of hospital administration? Do they see that the same principles of efficiency on which they pride themselves in their private enterprises are carried out in the public institutions under their supervision? Is the execu- tive authority of the institution divided? The organization of the medical staffs of hospitals and dispensaries also was studied in detail. How is the medical staff nominated? How are the members appointed? How often are staff meetings held and what is the purpose of these meetings? Has the staff an executive committee? Is there an auxiliary staff? These and similar questions were put, and special recom- mendations as to hospital organization were made when the answers were obtained. The administrative procedure of private philanthropic institutions is very often their weakest spot. Methods of efficiency and practical economy are often lost sight of in well meaning attempts to render service. Are purchases made in large quantities? Are storage facilities ample? Are cash discounts taken? Are accounting and bookkeeping methods standardized? Are all reasonable time-saving devices in use? These are 1012 Hospital and Health Survey some of the questions which interest the investigator. Questionnaires used in 1. Study of organization and administration of private and public health nursing agencies and j 2. Study of hospital administration are reproduced in the Appendix (4 and 5). The Associated Health Professions and Their Training The brain needs here as in the case of the individual patient the most delicate and tactful approach, and the psychology of professional groups must be studied, as well as the crude facts of their numbers and accomplish- ments. As the entire undertaking of preventive medicine and all the care of the sick depend upon the quality of licensed practitioners of medicine, nursing, dentistry and pharmacy, full knowledge of the limitations in the education of students both before and after graduation must be sought and described. If one element rather than another in the examination of the community has been incomplete, it is the study of professional training of physicians, dentists and pharmacists. For the nurses the information is quite complete. Quantitative Determinations of Functions It is necessary to ascertain the number and the size of the different types of institutions and to decide whether the available service is sufficient to meet the actual and potential demand. Are there enough hospital beds to care for the community sick? The answer to this question was sought in various ways. The hospitals were asked to keep for two months a record of the cases to which they refused admission. Printed pads were furnished the hospitals on which to record this information (Appendix 6). The re- sults of this investigation were tabulated as follows : Type of service — medical, surgical, etc. Economic status of patient — pay, part-pay, or free. By whom request for hospitalization was made — self, agency, doctor or family. Whether or not patient was placed on waiting list. The public health agencies were asked to furnish statistics as to the number of patients under their care during a certain month, who were properly hospital cases. Social agencies and district physicians were asked whether they were able to obtain hospital care for their patients promptly. Questionnaires, sent to physicians, inquired whether they found it difficult to obtain hospitalization and if so for what class of patients. The number of available beds was compared with the estimated population to be served, and comparison was made also with the ratio of hospital beds to population Method 1013 in other cities. The number of existing beds for various special services, e. g., orthopedics, tuberculosis and maternity was ascertained and a compari- son made with the estimated need in Cleveland and with the number of beds available for similar services elsewhere. A special investigation to determine the need, if any, for an institution to care for convalescents, was made by visiting the homes of 200 patients recently discharged from four leading hospitals to see if conditions were proper for their prompt convalescence. Is there enough social service work provided by hospitals and dispen- saries to make the medical service most effective? Is the ambulance service ample so that the location of hospitals in the outskirts of the city is feasible? Are there enough dispensaries and are they properly located? Are the special dispensary services, i. e., prenatal, prophylactic, babies', orthopedic, industrial, tuberculosis, venereal, and so forth, adequate? Is sufficient medical service provided by child-caring institutions, by schools and by industrial plants? Are there enough diagnostic laboratory facilities, both public and private? The method of investigation to determine the answers to these questions was in each case somewhat similar to that described above for determining the needs in hospitalization. That is, a study was made of the number, location and amount of service of the existing institutions. The question- naire that was used in determining the amount and character of medical service in industry is given in the Appendix (7). All reasonable avenues of inquiry were followed to learn whether the local need was being adequately met. The amount of service was compared with the estimated number of people to be cared for and with the extent of similar service provided by cities of approximately the same size. Hospital superintendents, physicians, representatives of nursing and social agencies were asked by questionnaire and in conference, whether their needs for ambulance transportation were being promptly and satisfactorily met. Inquiries were sent to other cities for facts as to the number of ambulances provided by the city hospital, by the police and by private hospitals; as to the number of dental chairs for free service and the hours they were in use; as to the number of hours of medical service provided weekly in free clinics for the treatment of tuber- culosis; and so forth. The amount of potential dispensary service and of medical service in schools and industry is obviously determined not by the number of dispensaries but by the number of physicians and nurses and the amount of time devoted by each to this service. The actual amount of service rendered is shown by such records as the number of patients cared for annually and the number of different treatments given. Again the value of the service is not measured by the amount but rather by its charac- ter which is a less tangible factor to analyze. Quality of Function The output of a hospital or dispensary cannot be measured by exact standards, but there are certain recognized methods by which medical and 1014 Hospital and Health Survey nursing procedure may be analyzed as to quality. These are: a study of personnel and equipment, an analysis of the records of patients, a personal observation of technic and a statistical analysis of results. Upon the character as well as the training and experience of the personnel in charge of any service depends the quality of the product. Personality is, of course, an^intangible factor to evaluate, but the training and experience of the workers are or should be a matter of record, available to the investi- gator. In the nursing survey, and the study of the health department especially, particular attention was given to these factors (Appendix 8). The employment of trained persons is essential to assure standard service in the professional lines. Inquiry was therefore made as to whether anaes- thetist, dietitian and laboratory technicians were employed in hospitals. In some instances the character of service must depend largely upon the adequacy of equipment. Laboratory and hospital nursing technic, for in- stance, require certain minimum equipment to produce a high grade of service. In measuring these services observation was made to see if standard equipment was available. (Appendix 9.) In order to determine whether the physical defects of children in insti- tutions were being detected and corrected, several hundred children, some taken from each institution, received both physical examinations and mental tests. For the form used for recording physical examinations see Appendix 10. As the records of patients constitute the only means by which an ob- jective presentation of medical work can be accomplished, the analysis of a considerable number of the records of an institution gives a fairly accurate picture of the clinical procedure obtaining there. Therefore, in evaluating the quality of various professional services, the study of records received considerable attention. Fifty records from each of twenty hospitals were analyzed to find whether they contained the following items: personal his- tory, physical examination, working diagnosis, laboratory findings, operation or treatment, progress notes, final diagnosis and condition on discharge. One hundred records were studied in each of the dispensaries with the above points in mind and also to ascertain the nationality of the patients, the number of revisits, and so forth. Several hundred health records of school children were analyzed to find the proportion of corrections that had been made to the number of defects found, and the average number of nurses' home visits and parents' consultations on each case. Health center records were analyzed to find the average number of patients' visits to the clinic and of nursing visits to the home; the records of nurses' time were studied to find the relative proportion spent in clerical and other duties. Prenatal records were analyzed to find the month of pregnancy during which the patient was brought under care, as well as the number of patients' visits to the dispensary, and of nurses' visits to the home. A comparative analysis of the records of the school census, of the work certificate office and of the state industrial commission to learn the number of children employed in industry, was made. Data were secured from a census of 100 newsboys Method 1015 attending a down-town school as to their age, health, mental capacity; — as stated by their teachers — and the number of hours they worked at might. An investigation was made of the content of industrial health records and the method of compiling and analyzing the data recorded. The method of filing and indexing hospital and dispensary records was also ^investigated, and inquiry made as to the means of assuring compliance with thejiospital rules for the completion of histories. Extensive personal observation was made of nursing service both in hos- pitals, dispensaries and in public health nursing districts, and of the work of school medical inspectors. In the Division of Health also the method of evaluating the quality of service by personal observations was found useful. Members of the Survey staff accompanied sanitary and dairy inspectors and collectors of laboratory samples in their trips, and made observation of routine laboratory examina- tions and other functions at the central office. Resources For Prevention In studying the adequacy of health protection and the prevention of disease the following questions must be faced. Are sanitary conditions in child-caring institutions, schools and industrial establishments such that the health of children and employes is safeguarded? Is the city water supply from a safe source and protected from contamination? Are sewage and gar- bage disposal satisfactory? Does the method of control of communicable diseases minimize the danger of their spread? Does the inspection of food products and drugs protect the public against adulterated or contaminated products? Are nuisances controlled and the contamination of the air pre- vented? Is the community being constantly educated in the methods of health protection, both public and private? The methods of ventilation and cleaning, of adjustment of blackboards and seats, the general construction, lighting, cubic air capacity and toilets of public school buildings were investigated. The temperature was read in a series of rooms and the force of the drinking fountains in many buildings was noted by the investigator. Investigation of working conditions was made in several hundred industrial establishments. (For the questionnaire used in studying working conditions for women, see Appendix 11.) A study ofjthe amount and character of health education was made (for questionnaire,' see Appendix 12.) Checking Up the Facts for Diagnosis Statistical study may well be compared with the laboratory method of diagnosis — the methods^of investigation are more exact and the findings more definite. If the processes are accurate the results permit certain de- ductions to be drawn with precision. 1016 Hospital and Health Survey Some of the statistical studies made by the Survey were as follows: A study of data regarding age and sex distribution and nationality of the popu- lation; a study of general mortality and mortality from the chief causes for a period of years; a comparison of mortality and morbidity rates, as well as hospital and dispensary attendance, by health districts; a study of tuber- culosis mortality by age, sex, form and occupation; a comparison of the death rate under one month, the maternal death rate and the stillbirth rate of a series of cases under prenatal care with that for the city as a whole; a study of the records of The Industrial Commission of Ohio relating to accident frequency and accident severity rates in industry and to the em- ployment of women and children in industry; the preparation of pin maps locating the various types and sizes of industrial establishments; a study of milk consumption in connection with the tuberculosis survey (for the form used in collecting the material, see Appendix 13). The records of 1,000 families were tabulated as to types of illness, amount of milk consumed, the kind of milk purchased and how milk is cared for. In order to obtain statistical information, a census was taken on Decem- ber 3, 1919, and again on January 15, 1920, of the patients in the hospitals of the Cleveland Hospital Council and in four other institutions which were willing to furnish the necessary information. These results were averaged and tabulated as follows: (Census blank, Appendix 14). Percentage of beds in use. Type of service, i. e., medical, surgical, etc. Length of stay of patients in hospital. Location of residence of patients. Economic status of patients. Percentage of cases admitted by staff and non-staff physicians. Percentage of free, part-pay and pay cases admitted by staff and non- staff physicians. Age of patients. Nativity of patients. Economic status of patients according to nativity. CONCLUSION Treatment and Follow-up When the community diagnosis has been made and, after a consultation of specialists, the method of treatment is outlined, how shall the prescrip- tion be prepared, by whom the operation be performed, and who shall be the victim? A detailed report of a survey is of much more than local interest. Communities of comparable size have much the same problems to face as has Cleveland. Study of the results of a survey in one city will often serve to suggest the answer to problems in another community. Method 1017 It was thought useful to have the Cleveland Survey printed in the present inexpensive form in order that copies might, at small expense, be made available to state and local health departments, to medical and general libraries, to hospitals and nursing organizations, to medical and other prac- titioners in the allied professions, to public health societies and others. The final action of the survey staff is to prepare their report for publi- cation. It is left to the patient — the public — to do the rest. The survey will prove of no avail unless the community is ready to carry out the plan proposed. If, as in Cleveland, there is no permanent organization extant to which a follow-up of the community's case may be left, it will be necessary to recommend, as the Cleveland Survey has done, the formation of a cooper- ative group composed of representatives of all organizations interested in public health, to which — with their other duties — will be left the task of seeing that the community takes its medicine. The proposed Cleveland Public Health Association must provide follow-up and convalescent care for the community patient, the great city of Cleveland! 1018 Hospital and Health Survey APPENDIX FORM LETTERS AND QUESTIONNAIRES (1.) November 28, 1919. Dear Doctor: We are at your service and we need your counsel and support. Take a moment to answer the queries below and we can assist your patients through you to better service. 1. Have you found difficulty in obtaining hospital care for your own patients? 2. If so, for what kinds of patients, i. e.: Surgical or medical. Pediatric or orthopedic. Neurological or mental. Obstetrical or gynecological. 3. What solution have you to suggest for remedying the hospital sit- uation from the point of view of the patients or of the medical profession? 4. During the past 12 months, approximately how many patients with venereal disease have you had, under your private care (syphilis — gonorrhea — chancroid)? 5. How many of these patients discontinued the treatment you advised without your consent, and why? These reports will be kept confidential and no names quoted in reporting the totals received in the answers. Come in and watch the process of taking the family and personal history of Cleve- land, making the physical examination of the city and trying out laboratory methods for a Community Diagnosis. It is your community and the treatment will be in your hands in any event. Give us the "once-over". It does us good to be criticized. Yours cordially, Director. (2.) November 20, 1919. Dear Sir: The Hospital and Health Survey wants to look at the medical and health service of Cleveland from the outside as well as the inside. We need very much to have the infor- mation and opinion of the Social Agencies. As you call upon the hospitals, dispensaries and Health Department for medical aid in behalf of your people, you can therefore give us many practical points which are most important. On a separate sheet we have put a few questions or topics. We should like very much to have your answers or comments on any or all of these. Method 1019 In case you prefer to go over the matter personally with a member of the staff of the Survey, will you kindly cal 1 us so we can arrange for a conference? Any information given by you as to names, quotations, etc., will be treated as con- fidential by the Survey. Very truly yours, GS-JHS Assistant Director. 1. Patients refused admission to hospital. Do you find many patients in whom you are interested who cannot be admitted to hospitals? Among what classes are these the more frequent? We would be glad to have comments, reasons, etc., for refusal or other conditions, which might help to bring out the nature or extent of the shortage of hospital beds if such exists. 2. Have you felt there is inadequate dispensary service? If so, along what lines of work or in what parts of the city? 3. Do your agents find it difficult to secure answers to inquiries for medical informa- tion concerning hospital and dispensary cases in which you are interested? Are the diffi- culties uniform among different hospitals or dispensaries? 4. The work of the City District Doctors. Are they prompt in answering calls? Do they give continuous care on your cases? Can you secure medical information from them when needed? Do you distinguish between the type of patient you refer to City Physicians and to the other medical relief agencies, such as dispensaries and private doc- tors, as to whether they are ambulatory or bed ridden, contagious or non-contagious, etc.? Do you think that patients who can afford to pay anything for medical care should be referred to City Physicians? 5. What patients feel or say about hospitals. Any "stories" or examples of experi- ences that patients in hospitals have had which would serve to bring out the rc-al difficul- ties, needs or deficiencies, would be welcome. 6. What policy exists between the Social Service Department of the hospitals and your agency with regard to furnishing material relief? What points do the Social Service Departments turn over to your agency for general work with the family or how far do they carry this themselves or do you both handle this phase of the work at the same time? (3.) BIRTH REGISTRATION SURVEY Fill out only for children under 2 years of age born in Cleveland. Name of child (Family name) (Given name). Date of birth: Month Day Year Place of birth (address of residence or institution). Name and address of attending physician or midwife, Signed by person making report 1020 Hospital and Health Survey (4.) COMMITTEE FOR PUBLIC HEALTH NURSING EDUCATION OFFICE REPORT: PRIVATE AGENCIES A. I. Name of Association Address... j. Year founded B. Organization I. Types of work. 1 .^General visiting nursing. (a) Specify what kinds of work are included .■. (b) What types of sickness are refused or referred to another organization for nursing care? 2. Specialized Services (a) Infant or child welfare; up to what age?. Specify what kinds of work are included... (b) Anti-tuberculosis work Supervision Instruction.... Placement Bedside care. (c) Industrial nursing II. r 1. Total number of visits made during last fiscal year 2. Total number of cases 3. Cost of a visit 4. Average number of visits per day per nurse 5. Number of patients paying: (a) Full cost (b) Part cost (c) Nothing III. Personnel 1. Board of Managers: Title (a) How many are men? (b) How many are women? _ (c) How often does the board meet? — (d) Does the nurse superintendent meet with the board? 2. Nursing Committee (a) How many members? (b) How often does it meet? Method 1021 3. What committee determines policies?... 4. What committee controls the budget?. 5. Staff: (a) Superintendent: Name and title (b) Assistant superintendents, how many?. (c) Supervisors, (d) Staff nurses, (e) Student nurses, (graduate) (f) " " (undergraduate) " (g) Attendants or practical nurses, (h) Nurses employed in clerical work (full time), " " (i) Dietitians - 6. By whom are the following engaged and dismissed? (a) Supervisors (b) Staff nurses._ (c) Clerical workers.- 7. What are the minimum professional and educational requirements for a Staff position? 8. Are staff nurses assigned to special services? Describe: C. Administration I. Supervision 1. Number of staff nurses to afield supervisor: minimum maximum 2. How often do staff nurses report to the supervisor in the main or branch office or station? _ - 3. Does the supervisor visit in homes, (a) with the staff nurse? (b) without " " " 4.~Are printed or written standard practice instructions used? II. Conferences 1. Are meetings of entire staff held regularly? (a) How often? (b) Who calls the meeting? (c) Who presides? (d) Who attends? 2. Are case conferences held regularly? (a) How often? (b) Who presides? (c) Who attends? 3. What conference of other organizations are regularly attended by members of the staff? 102 c 2 Hospital and Health Survey III. Efficiency 1. What methods are used to judge efficiency of nurses? _..__.__ 2. (a) Are efficiency records kept? (b) Has the nurse access to her record? _ (c) 'If not, how is the nurse informed of her standard? IV Salaries 1. Staff nurses: Minimum Maximum Rate of increase 2. Supervisors: " " " " " 3. What is the length of vacation on salary?....... 4. Are the following furnished in addition to salary?: (a) Uniforms (b) Board (c) Lodging (d) Other Allowance V. Hours of work 1. What are the hours of work daily? (a) Sunday? 2. Is time spent in record keeping included in working day?... 3. Is there one complete day of rest in seven? 4. Is there a weekly half-holiday in addition? 5. Overtime work: average per week per individual during last month 6. Is night work expected? (a) For what cases?.- _ (b) Is time off allowed for night work?. VI. Recording 1. How many hours weekly are spent in recording, (a) by supervisor? (b) by staff nurse? 2. How many clerical workers (not nurses) are employed? D. What is the superintendent's conception of the function of the Association in regard to the education of (a) Patients and families? _ (b) Nurses? E. Comment by superintendent on education, training, and personalty of staff nurses? F. Obtain two copies of the following: 1. All record forms. 2. Practice instructions. 3. Efficiency record. 4. Annual report for last two years. 5. Publicity material published within the last year. Method 1023 G. Remarks: Name of Investigator. Date.. (5.) SURVEY OF ADMINISTRATIVE DEPARTMENTS OF CLEVELAND GENERAL HOSPITALS FINANCIAL ADMINISTRATION (a) Per capita per diem cost of administration — 1918? ..1919? Do you charge all expenditures for current repairs, new equipment and betterments to expense account so that it will appear in your per capita per diem cost of main- tenance? Do you charge off annually a percentage for depreciation?... (b) Do you discount certain bills for cash? Total earnings from cash discounts for 1919? (c) Have you an income from endowments? (d) What rate charged for private rooms? Ward beds? (e) Do you charge extra for the following? Blood transfusion? Rate? Large surgical dressings? ._ Rate? X-Ray plates and stereoscopic examinations? Rate? Nurses' board? Rate? Surgical dressings, such as perineal, abdominal and prostatic pads, plaster bandages, etc.? Rate? Plaster casts? Rate? Services of anesthetist?..... Rate? All laboratory examinations? Rate? Fancy foods, such as squabs, broilers, frog legs, etc.? .....Rate? First aid services in emergency cases? Rate? Salvarsan administration? _ Rate? Drugs and prescriptions? Rate?.... Splints and surgical appliances? Rate? Ambulance services?. Rate? Meals and cots for relatives and friends of patient? Rate? (f) Do you collect board and room accounts one week in advance? Do you bill patient's responsible relative weekly thereafter? (g) Have you an office clerk, investigator or credit man for investigating financial stand- ing of patients? 1024 Hospital and Health Survey (h) Do you admit county or city patients at regular rates? (i) Do you use a budget system in estimating your expenses for the ensuing year? (j) Do you have an annual accounting by a firm of accountants? Have you installed a modern bookkeeping system adapted to hospitals? If a standardized system of hospital bookkeeping and financial reports were recom- mended, would you endeavor to have same carried out in your hospital? Have you an accounting system in use in your hospital? PURCHASES AND SUPPLIES (a) Are all purchases made by or with the personal approval of the superintendent?. Have you a steward who makes purchases? Are heads of departments permitted to make purchases? (b)fHave you saved money through the purchasing bureau of the Cleveland Hospita Council?. (c) Do you obtain quotations or ask assistance of the purchasing bureau of the Cleveland Hospital Council when about to make purchases of any size? Can you increase the amount of your purchases through the bureau to advantage? (d) Have you sufficient store room capacity for One year supply of canned goods? Three to six months of gauze and cotton?.. Three to six months soap supply? Three to six months supply of dry goods? (e) Do you store fresh eggs or fresh butter in public refrigerator storage house in April or May for use during the period of maximum high prices? (November, December, January) (f ) Have you contracts for the purchase of coal? Electric lamps? Milk from producers? (g) Would you cooperate with the Cleveland Hospital Council and the American Hospital Association in a standardization of hospital supplies?. HOSPITAL ECONOMICS, SALVAGING, ETC. (a) Have you a house carpenter? Steamfitter?..... Painter? (b) Have you a surgical appliance or instrument repair shop? _ Do you salvage, wash, and reclaim, gauze and bandages?..... Do you bail and sell waste paper? Grease? Garbage? Barrels? Old Rubber?. Old metal? Rags? Bottles? Method 1025 (c) Do you make soft soap from grease? From soap chips? — (d) Do you utilize labor-saving devices? Vacuum cleaner? Electric floor scrubber? Electric dough mixers, meat cutters, etc.? Dish washing machines? (e) Do you maintain a sewing room and manufacture part of your dry goods?. DEPARTMENTAL EXPENSES Engineering Department (a) Do you manufacture your own electric current? (b) Is your boiler plant and machinery up-to-date? (c) Do you maintain a refrigerating plant? And are your ward and corridor ice boxes refrigerated therefrom? * (d) Do you manufacture ice? - Laundry (a) Is your laundry machinery in good order and modern in type? (b) Have you a steam tumbler? Steam presses? (c) Have you a trained laundry man or woman in charge? (d) Do you manufacture your laundry soap from soap chips or grease and alkali?. Ambulance (a) Do you maintain a hospital ambulance service? --— If not, what ambulance do you utilize? (b) Do you consider the Cleveland ambulance service satisfactory? (c) Should a central ambulance service be managed By the municipality? By private ownership? - By the Cleveland Hospital Council? Dietetic Department (a) Have you a dietitian? (b) Does she arrange all menus for patients, nurses and employes? (c) Does she have general supervision of all cooking and food service in the hospital?. 1026 Hospital and Health Survey (d) Does your dietitian purchase food supplies? Professional and Staff Service (a) Have you an organized Attending Staff? (b) Has the Attending Staff an Executive Committee with authority in professional mat- ters? .1 , (c) Is the Superintendent a member of the Executive Committee? _ (d)_Do you furnish rubber gloves for your attending surgeons for use on private cases? — If so, why? (e)_Do you purchase manufactured catgut, or do you prepare your plain and chromic catgut from raw gut? _ (f) Has any member of your Attending Staff authority to purchase equipment or sup- plies? (6.) APPLICANTS FOR HOSPITAL CARE NOT ADMITTED Name of Hospital _ Date __ Sex. _ .Age Nature of disease (or diagnosis) Address (or location in city) Was applicant for Free Part Pay Pay. (Check) Was request for admission made_by Patient's self. Family of patient Agency in behalf of patient. (Check) If request by agency, please state name of agency. Was applicant put on waiting list Name of organization giving information (7.) MEDICAL SERVICE IN INDUSTRIAL ESTABLISHMENTS 1. Firm name Date 2. Address Method 1027 3. Nature of product 4. Total number of employes Male Female Children, 15-18 5. Medical Service Dispensary Location in plant No. rooms , Size Plant hospital No. beds Personnel Physicians, full time, during service Part time Names and addresses - Nurses, trained, male, female No on dressings, visiting, other, mixed Type of medical service First aid Kits where? Average no. dispensary visits daily.— Total no. accident cases per month Surgical, n. o. s Medical Accessibility of disp. Verbal, written permission of foreman Noon visits? ~ After working hours On company time? Physical examination, required, optional, applicants, employes, periodic, transfers? Causes and percentage rejections No. handicapped employed... Own employes? Medical records, day sheet Permanent individual record : Daily individual record _. Special services Dental service Limits... Cost Laboratory. X-Ray Visiting nursing — Absence follow-up ....Sickness. Dressing assistants Clerks. Interpreters Ambulance service, own.. equipment, personnel — Hospital for severe cases Service satisfactory?. Why? Contract? Supplementary compensation? Complaints? Do you favor establishment of industrial wards? Of industrial clinics? : — Care of eye injuries? No. cases tuberculosis yearly Disposal Disposal communicable diseases Venereal disease program 1028 Hospital and Health Survey 6. Relations of medical department. To whom is chief surgeon responsible? To whom are nurses responsible? Relation to employment _ Relation to safety Relation to other employes' services. 7. Personal Service Activities Mutual benefit fund Control Self insurance Sick benefit Sick absences Accident absences Rest rooms Equipment Lockers Location Lunch room Food sold, heated Recreation Education, health, general „ 8. Health hazards of operation. 9. Labor unions _ Shop committees 10. Cost of medical service Salaries - Equipment- Maintenance Does it pay? How?. 1 1 . Information from Position 12. Statistical reports. Record forms Photographs Blue prints Method 1029 (8.) COMMITTEE ON PUBLIC HEALTH NURSING EDUCATION; INDUSTRIAL NURSING SERIES PERSONAL HISTORY A. 1 . Name and Address of Employer.. 2 Name of Nurse 3. Age..... 4. M. S. W — 5. Are you registered? 6. If so, give state and year 7. Name of present position (specify staff nurse, supervisor, head nurse, assistant, etc.) 8. Length of service in present position. .years months. B. 1. Did you hold a paid position before beginning nurses' training?. (Describe last two positions only) Nature of Work* Length of Service Years Months *Specify exact position held, e. g., teaching, clerical work; employment in store or factory other than clerical; personal service, such as caring for children, social work, etc. 2. Paid positions held after completing nurses' training — Have you done private nursing? If so, for how long? years months. Positions other than private nursing — 1030 Hospital and Health Survey Name of Employer Place Nature of Work* Length of Service Association, Company or Individual City or Town and State Yrs. Mos. ■J (a) (b) (c) (d).. (e) _ (f) *Give name of position and kind of work , e. g., head nurse; operating room; staff nurse; infant wel- fare work, etc C. 1. General Education NAME City or Town and State Year of graduation If not grad- uate No. of yrs. attended Grammar or Par- ochial School High School College.. Other Schools Not Nurses' Training Schools 2. Hospital Training (Undergraduate): Name and Address of Nurses' Training School. Year of Graduation Length of Course. Numb_r of Hospital beds at time you graduated Method 1031 Were pupils sent out of hospital to do private nursing? If so, for how long were you thus employed? Did your training include work with the following: (a) Men (b) Women (c) Children (d) Sick Infants under 2 yrs (e) Medical Cases (f) Surgical Cases (g) Obstetrical Cases (h) Nervous and Mental Cases (i) Venereal Diseases (j) Tuberculosis (k) Other Communicable Diseases (specify which) ..... 3. Postgraduate Courses: School or College City and State Length of Time Attended Year Subjects Studied Nurses' organizations of which you are a member: Date. 1032 Hospital, and Health Survey (9.) WARD EQUIPMENT Service Rooms — 1. Bathroom: (a) Is it clean? (b) Adequate facilities? ,, 2. Utility Room: Are the following present and adequate? Slop hopper. Instrument sterilizer Utensil sterilizer If not, what is done in usual cases? Bedpan and stool sterilizer If not, what is done in usual cases? In infectious cases?. In infectious cases? Gas burner Cans for rubbish Sink Linen hampers Chests. Bedpan hopper Table „ Shelf—. Care of infectious linen , 3. Portable Equipment — Is it adequate? Basins : Cleaning Thermometers Bathing Tray treatment system Hot water bags Ice caps._ Provision for medication. Rubber rings 4, Diet Kitchen: Sink Gas or electric plate Ice chest Dish sterilizer Steam table Trays and equipment of same: Excellent Good Fair Poor 5. Linen Closet: Supply of linen Arrangement Cleanliness 6. Broom or Maids' Closet: Hopper Condition of brooms and mops. Method 1033 (10.) MEDICAL EXAMINATION OF CHILDREN IN INSTITUTIONS Institution Address — Name ^ Age Date of Admission Date Height Weight. 1. Vision: OD OS 2. Hearing 3. Defective Teeth: Primary Permanent 4. Defective Nasal Breathing... 5. Hypertrophied Tonsils 6. Defective Nutrition._ 7. Cardiac Disease : Functional Organic 8. Pulmonary 9. Orthopedic Defect.. 10. Nervous Disease.... 1 1 . Miscellaneous (11.) INDUSTRIAL DIVISION Women and Industry Questionnaire Firm Address Product 1. Number Employes (on production) — Male Female Boys 15 to 16_ Girls 16 to 18 2 . Regularity of employment 3. Transportation... 4. Hours: to Lunch to Saturday to. 1034 Hospital and Health Survey Maximum daily Total weekly Overtime 5. Night work : ; 6. Women first employed „ 7. Operations found unsuitable for women and why 8. List of operations now performed by women. Check those on which women replace men. Operation No. Employes Wage rate ■ Piece or TimeWork Wkly. earnings \9. Comparison with men or boys on same work as to wage and efficiency 10. Minimum or guaranteed wage 11. Work, how learned — Training school, forelady, other workers 1 2 . Opportunities for advancement _ 13. Types of women workers — nationality, color, age, civil state Educational requirement, Male Female 14. Absences Lates... 1 5 . Length of service Transfers 16. Accident incidence Sickness incidence 17. Medical service Hospital used Home visits ; 18. Supervision of women by Extent Employment woman Doctor (M. F. full, part time) Hours Nurse Service worker.. Forelady 19. Working conditions (a) Type of building , (b) Ventilation (c) Cleanliness : (d) Sanitation (e) Light (f) Distribution of women Crowding (g) Standing.. Chairs Method 1035 (h) Lifting _ (i) Fatiguing movements (j) Special health hazards (k) Lockers, dressing room (1) Uniforms, optional, required, provided laundered type- Cm) Couches (n) Lunch room Food sold, heated (Rest Periods) 20. Physical examination, partial, complete, applicants, employes, periodic, transfers. Care of pregnant V. D 21. Health education.. vs. special hazards Safety instruction 22. Vacations 23. Recreation 24. Benefit association 25. Shop committee. Union... Information from By Date- Comment: (12.) PUBLIC HEALTH EDUCATION Name of Organization Type of education given — Anti-tuberculosis Social Hygiene _ Etc Way information given — Literature Lectures Etc... How many people reached? .... What age and sex reached? Any racial adaptation? Consistent or spasmodic effort? Conception of future activity along this line? Samples of literature (13.) MILK CONSUMPTION SURVEY Date of visit ..... Nationality (7) No Street Agency visiting (1). Family receiving relief (2) yes no Kind of relief (3) _ No. in family: (4) Adults (15 and over) Lodgers..... Children (6-14 incl.) .Children under 6 Illness in family at time of visit (8) 1036 Hospital and Health Survey Members (6) Nature of Illness Milk: Daily amount (qts.) Bottle Bulk Canned (5) Otherwise. Check Kept cold Covered Is it pasteurized: by dealer or at home is it certified?. Check Remarks: Investigator.. 1. Initials only 2. Other than home nursing care. 3. Financial, clothing, food, medical care, etc. 4. Include any relative living in family as adults or children as case may be. 5. Condensed — evaporated, etc. 6. Mother, lodger, etc., call all persons 14 and under, children. 7. Be particular to specify negroes. 8. Include — (a) Sickness requiring the attention of physician, (b) Sickness requiring treatment at hospital or dispensary, (c) Sickness preventing work, (d) Sickness preventing attendance at school. Method 1037 h ■ o x "I > TO 2 to > a a - Pay, Free or Part Pay Type of ward (medical, sur- gical, etc.) 5 era 3 % SB rr c a ■-h n> CO No. of days already in Hospital n On i B<< 1038 Hospital and Health Survey Bibliography 01 Surveys By Julia T. Emerson HEALTH ADMINISTRATION SURVEYS UNITED STATES Harmon, G. E. A comparison of the relative healthfulness of certain cities in the United States based upon the study of their vital statistics. American Statistical Association, Quarterly Publication v. 15 no. 114 pl57-174 June 1916. Lumsden, L. L. Rural sanitation; a report made in 15 counties in 1914, 1915, 1916. Treasury Department, U. S. Public Health Service, Public Health Bulletin no.94, 1918. 336p. Schneider, Franz, jr. A survey of the activities of municipal health departments in the United States. (Begun August 1913) Russell Sage Foundation. Reprinted American Journal Public Health v.6 no.l January 1916. Warren, B. S. and Sydenstricker, Edgar. Statistics of disability; a compilation of some of the data available in the United States. U. S. Public Health Service Public Health Reports v. 31 no.16 p989-999 April 1916. ALASKA Haines — Craig, H. M. and Lambie, J. M. Medical survey of an Indian village. Military Surgeon, July 1914 pi 1-16. COLORADO Fox, Carrol. Public health administration in Colorado. Reprint 383, U. S. Public Health Service, Public Health Reports, December 1916, p3485-3520. CONNECTICUT Middletown — Greenberg, David and Joel, I. D. Health survey, under direction of C-E. A. Winslow, 1918. 73p. New Haven — Fisher, Irving. Health of New Haven. New Haven Civic Federation 1913. 8p. FLORIDA Fox, Carrol. Public Health administration in Florida. Reprint 340,^U. S. Public Health Service, Public Health Reports, June 2, 1916, pl359-1407. GEORGIA Atlanta — Lindholm, S. G. Report of survey of the Department of Health. New York Bureau of Municipal Research, 191 2. 44p. Atlanta — Schneider, Franz, jr. Survey of the public health situation. Atlanta Chamber of Commerce, 1913. 22p. Bibliography 1039 ILLINOIS Grubbs, S. B. Public health administration in Illinois. Reprint 275, U. S. Public Health Service, Public Health Reports, May 21, 1912. Mathews, J. M. Report on public health administration. State Efficiency and Economy Committee, Springfield, Illinois, 1914. 54p. Chicago — Perry, J. C. Public health administration in Chicago. U. S. Public Health Service, Public Health Reports v.30 p2536-2561 August 27, 1915. Freeport — Sanitary and health survey of the city of Freeport; conducted by Depart- ment of Public Health in cooperation with civic organizations of Freeport. Super- vised by P. L. Skoog. Illinois Health News v.4 n. s. no. 5 p75-106 May 1918. Quincy — Fox, Carrol Public health administration in Quincy. Reprint 428, U. S. Public Health Service, Public Health Reports, October 5, 1917, pl665-1679. Springfield — Palmer, G. T. Sanitary and health survey. Reprint from Academy of Political Science Publications v.2 no.4 1912. 50p. Springfield — Schneider, Franz, jr. Public health in Springfield. Russell Sage Foundation, Department of Surveys and Exhibits, 1915. 159p. White County — Foster, I. A. and Fulmer, Harriet Health survey of White County; made under auspices of Illinois State Board of Health and Illinois State Associa- tion for the Prevention of Tuberculosis. Springfield Board of Health, 1915. 23p^ INDIANA East Chicago — Hendrich, A. W. Public health in East Chicago. East Chicago Department of Health, 1916. 42p. South Bend — Fox, Carrol Public health administration in South Bend. U. S. Public Health Service, Public Health Reports v.32 p776-805 March 25, 1917. KANSAS Sumner County — Sumner County sanitary and social survey. Kansas State Board of Health Bulletin v.9 no.5 May 1915. Topeka — Schneider, Franz, jr. Public health survey of Topeka. Russell Sage Foun- dation, Department of Surveys and Exhibits, 1914. 98p. KENTUCKY Crane, Mrs. C. J. (B) Sanitary conditions and needs of Kentucky. Kentucky Medical Journal v.7 no.13 August 1, 1909. 44p. MAINE Lewiston and Auburn — Pratt, A. P. Public health administration in Lewiston and Auburn; a report of a survey made under direction of the State Department of Health for Public Health District Health Officer, Augusta. State Department of Health Bulletin v.l n. s. nos.10-11 pl51-170 October-November. 1040 Hospital, and Health Survey Portland — Pratt, A. P. Public health administration in Portland; a report of a survey made under the direction of the State Department of Health. State De- partment of Health Bulletin, v.l n. s. no.3 p58-75 March 1918. MAR YLAND Fox, Carrol Public health administration in Maryland. Reprint 166, U. S. Public Health Service, Public Health Reports, January 30, 1914. 80p. Baltimore — Fox, Carrol Public health administration in Baltimore. Reprint 201, U. S. Public Health Service, Public Health Reports, June 12, 1914. 80p. MASSACHUSETTS Springfield — McCombs, C. E. Organization and administration of the health de- partment of Springfield. Springfield, Bureau of Municipal Research, 1914. 48p. (o. p.) Taunton and Quincy — Horowitz, M. P. A synoptic report on a comparative sanitary survey of two Massachusetts cities. Reprint, American Journal of Public Health v.7 no.8 p698-711. Sanitary Research Laboratory of Massachu- setts Institute of Technology, Cambridge, Massachusetts. MICHIGAN Ann Arbor — Folin, J. W. Health survey. U. S. Public Health Service, Public Health Reports v.4 n. s. p536-539 October 1916. Saginaw — Crane, Mrs. C. J. (B) Sanitary survey of Saginaw. 1911. Kalamazoo, Michigan. The author. 42p. MINNESOTA Crane, Mrs. C. J. (B) Report on a campaign to awaken public interest in sani- tary and sociologic problems in the state of Minnesota. State Board of Health, 1911. 239p. Fox, Carrol Public health administration in Minnesota. Reprint 223, U. S. Public Health Service, Public Health Records, October 2, 1914. Minneapolis — Biggs, H. M. and Winslow, C-E. A. Ideal health department. Minneapolis, Civic and Commerce Association, 1912. 36p. (o. p.) St. Paul — Efficiency and next needs of St. Paul's Health Department. New York Bureau of Municipal Research, 1913. 48p. St. Paul — Flint, E. M. and Aronovici, Carrol Health conditions and health service in St. Paul. Amherst H. Wilde Charity, 1919. lOp. St. Paul— Young, G. B. Public health administration in St. Paul. U. S. Public Health Service, Public Health Reports v.32 no.2 p41-71 January 12, 1917; and 2d U. S. Public Health Service, Public Health Reports v.32 no.3 p99-138 January 19, 1917. Bibliography 1041 MISSOURI St. Joseph — White, J. H. Report of a sanitary survey of St. Joseph. Reprint 185, U. S. Public Health Service, Public Health Reports, August 24, 1914. NEBRASKA Fox, Carrol Public health administration in Nebraska. Reprint 348, U. S. Public Health Service, Public Health Reports v.31 no.27 pl750-1775 July 1916. NEVADA Fox, Carrol Public health administration in Nevada. Reprint 317, U. S. Public Health Service, Public Health Reports, December 31, 1915, p3802-3823. NEW JERSEY Glen Ridge — Horowitz, M. P. Sanitary survey of the Borough of Glen Ridge. Massachusetts Institute of Technology, Department of Biology and Public Health, 1916. 41p. Hoboken — Sanitary survey of Hoboken. New York Bureau of Municipal Research, 1913. 31p. NEW MEXICO Kerr, J. W. Public health administration in New Mexico. U. S. Public Health Service, Public Health Reports v.33 no.46 pl976-1995 November 15, 1918. NEW YORK Report of special public health commission, Albany, New York, 1913. 36p. Durbea, C. J. Preliminary inquiry into the health needs of rural people of the state of New York. 36th Annual Report of State Department of Health v.3 p79-138 December 31, 1915. Amsterdam — Terry, C. E. and Schneider, Franz, jr. Report of health inventory of the city of Amsterdam, 1917. lip. (Delineator 7th Baby Campaign) Ithaca— Schneider, Franz, jr. Survey of the public health situation. Russell Sage Foundation, Department of Surveys and Exhibits, 1914. 34p. New York City — Baker, S. J. Classroom ventilation and respiratory diseases among school children. Reprint Series 68, New York City Department of Health, February 1918. lOp. New York City — Neal, J. B. Work of the meningitis division of the Bureau Labora- tories; illness census taken in Health District no.l. New York City Department of Health Bulletin v.6 no.3, p67-86 March 1916. Onondaga — Sears, F. W. Study of sanitary conditions on the Onondaga Indian Reservation. Health News, Indian Conference number v.14 no.4 April 1919. Rochester — Crane, Mrs. C. J. (B) Sanitary survey of Rochester, 1911. Kalama- zoo, Michigan. The author. 119p. 1042 Hospital and Health Survey Syracuse — Shipley, A. E. Report on Syracuse Board of Health. New York Bureau of Municipal Research, 1912. 12p. NORTH CAROLINA Brooker, W. H. Teaching health by motion pictures. North Carolina State Board of Health Bulletin v.31 no.2 April 1916. "How public health is being taught in rural districts by means of traveling motion pictures." Raleigh — Terry, C. E. Health survey of Raleigh. Wake County of National De- fense, Child Welfare Department, 1918. 29p. NORTH DAKOTA Fox, Carrol Public health administration in North Dakota. Reprint 315, U. S. Public Health Service, Public Health Reports, December 1915, p3658-3688. OHIO Dayton — Organization and administration of the Department of Health. Dayton, Bureau of Municipal Research, 1913. Piqua — Fox, Carrol Public health administration in Piqua. U. S. Public Health Service, Public Health Reports v.32 no.25 p974-986. June 22, 1917. Portsmouth — Southmayd, H. J. Health survey. Ohio Public Health Journal v. 8 p398-411 September 1917. Springfield — Fox, Carrol Public health administration in Springfield. Reprint 417, U. S. Public Health Service, Public Health Reports, August 10, 1917, pl255- 1278. Toledo — Fox, Carrol Public health administration in Toledo. Reprint 284, U. S. Public Health Service, Public Health Reports, June 25, 1915. Youngstown — Fox, Carrol Public health administration in Youngstown. U. S. Public Health Service, Public Health Reports v.31 no.39 p2653-2685 Septem- ber 29, 1916- OKLAHOMA Norman — Mahr, J. C. and Ellison, Gayfree, comp. Report of the sanitary survey of the town of Norman, made in September 1914. State Board of Health. 37p. PENNS YLVANIA Erie — Crane, Mrs. C. J. (B) General sanitary survey of Erie, 1910. Kalamazoo, Michigan. The author. 22p. Pittsburgh— Report of a survey of the Department of Public Health, Bureau of Municipal Research. Pittsburgh City Council 1913. 62p. (o.p.) Reading — Report on Department of Health. New York Bureau of Municipal Re- search. Reading Chamber of Commerce, 1913. 46p. Bibliography 1043 Uniontown — Crane, Mrs. C. J. (B) Sanitary survey of Uniontown. Women's Civic League, Uniontown, 1914. 51p. RHODE ISLAND Gilbert, R. W. A study of a typical mill village from the standpoint of health. Rhode Island Anti-Tuberculosis Association Report, 1910. 15p. Pawtucket — Gunn, S. M. Report on the public health activities of the city of Pawtucket, Pawtucket Business Men's Association, 1913. 18p. TENNESSEE Nashville — Crane, Mrs. C. J. (B) General sanitary survey of Nashville, 1910. Kalamazoo, Michigan. The author. 24p. TEXAS El Paso — Rich, J. P. and Arms, B. L. Preliminary report of the health survey of El Paso; and, Grossman, J. H. Housing health survey. El Paso Chamber of Commerce, 1915. 8p. Galveston — Report of a sanitary survey of Galveston. Galveston Commercial Asso- ciation, n.d. 30p. WASHINGTON Crane, Mrs. C. J. (B) Report of sanitary conditions of cities of Washington. State Board of Health Quarterly Bulletin v.4 no.l pl-36. January, February, March 1914, incomplete. Fox, Carrol Public health administration in the state of Washington. Reprint 255, U. S. Public Health Service, Public Health Reports, February 5, 1915. 56p. WEST VIRGINIA Clark, T. Public health administration in West Virginia. Reprint 252, U. S. Public Health Service, Public Health Reports, January 22, 1915. Charleston — Tolman, Mayo Survey commission of sanitary survey, 1917. 168p. WISCONSIN Milwaukee — Gunn, S. M. Health department, Milwaukee, Milwaukee Bureau of Economy and Efficiency, 1912. Bulletins 13, 15, 18. Milwaukee — New York Bureau of Municipal Research. April 1913. 131p. Health part 13p. ITALY Traveling dispensaries of Italy. The Public Health Nurse. November 1918. p261-262. Three illustrations of trucks used for dental and dispensary purposes. RUSSIA Winslow, C-E. A. Public health administration in Russia in 1917. Reprint 445, U. S. Public Health Service, Public Health Reports, December 28, 1917, p2191- 2219. 1044 Hospital and Health Survey MENTAL HYGIENE SURVEYS GENERAL Fernald, W. E. What is a practical way for prevention of mental defect? Na- tional Conference of Social Work. Proceedings, 1915. p289-297. Fernald, W. E. Standardized fields of inquiry for clinical studies of borderline defectives'. National Committee for Mental Hygiene. Reprint 8, 24p. Mental Hygiene, April 1917. Wallin, J. E. W. Scheme for the clinical study of mentally and educationally unusual children. Yale University Press, 1914. 20p. Mental Health of the School Child, Chapter 19 p429^150. UNITED STATES Bowen, A. L. Legislative provision for the feeble-minded; what should it be? A study made of the plans and ideas of public and private organizations in Massa- chusetts, New York and Indiana for better provision for the feeble-minded. Spring- field, Illinois, Public Charity Service of Illinois, Institutional Quarterly v.7 p66- 78 December 31, 1916. Davenport, C. B. Feebly inhibited, violent temper and its inheritance. Eu- genics Record Office, Bulletin no.12 September 1915. Reprint, Journal of Nervous and Mental Disease v.42 no.9 p593-628 1915. ALABAMA Haines, T. H. Report, December 1918. (not published) ARKANSAS Treadway, W. L. Feeble-minded, their prevalence and needs in the school population of Arkansas. Reprint 379, U. S. Public Health Service, Public Health Reports, November 1916, p3231-3247. CALIFORNIA Bridgman, Olga Experimental study of abnormal children with special refer- ence to the problems of dependency and delinquency. Berkeley University, Cali- fornia. Publication in Psychology v.3 no.l March 30, 1918. 59p. Terman, L. M., Williams, J. H., Fernald, G. M. Surveys in mental deviation in prisons, public schools and orphanages in California; brief description of local conditions and need for custodial care and training of dependent, defective and delinquent classes. California State Board of Charities and Corrections, 1918. 87p. COLORADO Hamilton, S. W. Care and treatment of the insane in Colorado. Report to Na- tional Committee for Mental Hygiene, December 19 16- January 1917. (not published) CONNECTICUT Wilgus, S. D. Survey of Connecticut. Report made to National Committee for Mental Hygiene, (not published) Bibliography 1045 DELAWARE Richardson, C. S. Dependent, delinquent and defective children of Delaware. Russell Sage Foundation, 1918. 88p. New Castle County — Lundberg, E. O. Social study of mental defectives in New Castle County. U. S. Children's Bureau, Dependent, Defective and Delinquent Classes Series no.3 Bureau Publication no.24, 1917. 38p. New Castle Court fv— Mullan, E. H. Mental status of rural school children. Re- print 377, U. S. Public Health Service, Public Health Reports, November 1916, P3174-3187. Sussex County — Treadway, W. L. and Lundberg, E. O. Mental defect in a rural county; a medico-psychological and social study of mentally defective children in Sussex County. U. S. Public Health Service and U. S. Department of Labor, Children's Bureau, Dependent, Defective and Delinquent Classes Series no.7 Bureau Publication no. 48. 96p. DISTRICT OF COLUMBIA Lundberg, E. O. Mental defectives in District of Columbia. U. S. Children's Bureau Publication no. 13, 1915. 39p. GEORGIA Anderson, V. V. Mental defectives in a Southern state September 1918-Decem- ber 1919; report of the Georgia Commission on feeble-mindedness and the survey of the National Committee for Mental Hygiene; studies made mostly in institu- tions and schools. 38p Reprint from Mental Hygiene v.3 p527-565 October 1919. Hutchings, R. H. Care and treatment of the insane in Georgia; report based on survey of the state in September-November 1916 for National Committee for Mental Hygiene, 161 typew. pages, (not published) ILLINOIS Chicago — Ransom, J. E. Study of mentally defective children in Chicago; an investigation made by the Juvenile Protective Association, Chicago Association, 1915. 72p. Cook County — Adler, H. M, And the mentally handicapped; a study of the pro- visions for dealing with mental problems in Cook County. Report of survey 1916-1917. National Committee for Mental Hygiene Publication no.13, 1918. 224p. Springfield — Treadway, W. L. Care of mental defectives, the insane and alcoholics in Springfield. Russell Sage Foundation, Department of Surveys and Exhibits, 1915. 46p. (Springfield Survey) INDIANA Butler, A. W. Mental Defectives in Indiana; second report of the Indiana Com- mittee on mental defectives to the Governor ; a survey of 8 counties. Indianapolis, 1918. 56p. 1046 Hospital and Health Survey Wilgus, S. D. Survey of public care of the mentally diseased and defective in Indiana, October 1916-December 1917. National Committee for Mental Hy- giene. 186p. (not published) Porter County — Clark, Taliaferro, Collins, G. L. and Treadway, W. L. Mental studies of rural school children of Porter County. Reprint, U. S. Public Health Service, Public Health Bulletin no.77 1916. 127p. KANSAS The Kallikaks of Kansas; report of the Commission on provision for the feeble- minded. Topeka, 1919. 31p. KENTUCKY Haines, T. H. Report on the condition of the feeble-minded in Kentucky to the State Commission on Provision for the Feeble-minded. Frankfort, 1916. 23p. LOUISIANA Haines, T. H. 1920. (under way) MAINE Report of the Maine commission for the feeble-minded and of the Survey by the National Committee for Mental Hygiene. September 1917-September 1918. 95p. MAR YLAND Anderson, V. V. 1920. (under way) Baltimore — Campbell, C M. Subnormal child; a survey of the school children pop- ulation in the Locust Point District of Baltimore. National Committee for Mental Hygiene, Mental Hygiene v.l p96-147 January 1917. MASSACHUSETTS Community supervision of the feeble-minded; an analysis of 300 families in which there is mental defect, by welfare agencies, members of the League for Preventive Work. Boston, 1918. 14p. Report of the commission to investigate the question of the increase of criminals, mental defectives and degenerates. Boston, 1911. 50p. The mental defective and the public schools of Massachusetts; a study of special classes for mental defectives in the public schools of Massachusetts. League for Preventive Work, Publication no. 2, 1917. 16p. MICHIGAN Report of the commission to investigate the extent of feeble-mindedness, epilepsy and insanity, and other conditions of mental defectiveness in Michigan. Lans- ing, 1915. 175p. MISSISSIPPI Haines, T. H. Mississippi mental deficiency survey, February-May 1920. Jackson. 45p. Bibliography 1047 MISSOURI Hamilton, S. W. October 1919-April 1920. (to be published by State Board of Charities) NEW JERSEY Wilgus, S. D. 1920. (under way) NEW YORK Defective delinquents; facts about defective delinquents, nature, prevalence, institutional and legislative needs in the state of New York. Memorandum submitted to the Hospital Development Commission by the New York Committee on Feeble-mindedness and the Mental Hygiene Committee, State Charities Aid Association, 1917. 15p. Moore, Anne Feeble-minded in New York; a report prepared for the Public Education Association of New York. New York State Charities Aid Association, 1911. Hip. Nassau County — Rosanoff, A. J. Survey of mental disorders in Nassau County. National Committee for Mental Hygiene Publication no.9 1916. 125p. New York City — Irwin, E. A. Study of the feeble-minded in a west side school in New York City. Public Education Association Bulletin no. 21 December 8,' 1913. 15p. New York City — Kirby, G. H. Classification and treatment of mental defectives; a preliminary report with recommendations to the Mayor. September-October 1916. 41 typew. pages. New York City — Toas, E. M. A report of a survey of the children in the ungraded classes of the Borough of the Bronx. Ungraded Teachers' Association of New York City, "Ungraded" no.3 p75-82 104-107. January-February 1918. Oneida County — Carlisle, C. L. Causes of dependency ; based on a survey of Oneida County. State Board of Charities, Division on Mental Defect and Delinquency, 1918. Eugenics and Social Welfare Bulletin, no. 15. 465p. NORTH CAROLINA MacDonald, S. D. February-May 1920. (under way) OHIO Sessions, M. A. Feeble-minded in a rural county of Ohio. Bureau of Juvenile Research, Bulletin no.6, Publication no.12 February 1918. 69p. PENNS YLVANIA Finlayson, A. W. Dack family; a study in hereditary lack of emotional control. Eugenics Record Office Bulletin no.15 May 1916. 46p. Haviland, C. F. Treatment and care of the insane in Pennsylvania. Philadel- phia Public Charities Association, 1915. 94p. 1048 Hospital and Health Survey Key, W. E. Feeble-minded citizens in Pennsylvania. Philadelphia Public Charities Association, 1915. 63p. Philadelphia — Three pamphlets: 1 — Fate of the friendless feeble-minded women, 8p; 2 — Number of the feeble-minded, 13p; 3 — Public provision for the feeble- minded, a symposium, 16p. Philadelphia Department of Health and Charities. J. S. Neff, Director. Philadelphia— Salmon, T. W. June 1920. (under way) Scranton — Salmon, T. W. Treatment of the insane in the Scranton poor district. 1916. SOUTH CAROLINA Report on the State Hospital for the Insane at Columbia. January 1915. A. P. Herring, investigator. 20p. Columbia — Report sent to Hon. Richard I. Manning, Governor of South Carolina, on the State Hospital for the Insane at Columbia, with recommendations by A. P. Herring, 1915. 20p. TENNESSEE Haines, T. H. Department of State Charities and Tennessee Society for Mental Hygiene, January-April 1919. Wilgus, S. D. Report to National Committee for Mental Hygiene, October- December 1915. (330 typew. pages, not published) TEXAS Salmon, T. W. Most urgent needs of the insane in Texas; an address, February 1916. Grayson County — Salmon, T. W. Insane in a country poor farm. National Com- mittee for Mental Hygiene. 9p. Reprint, Mental Hygiene v.l no.l p25-33. Jan- uary 1917. WISCONSIN Anderson, V. V. 1920. (under way) Hart, H. H. Wisconsin system of county asylums for the insane proposed for adoption in Oklahoma; a special report. Racine. The author. 1908. 12p. Haviland, C. F. County care. September-October 1913. Gillen, J. L. Some aspects of feeble-mindedness in Wisconsin. University of Wisconsin Bulletin Serial no.940, General Series no.727, June 1918. 30p. CANADA )ntario— MacMurchy, Helen The feeble-minded in Ontario. Toronto, 1913. 52p. Bibliography 1049 INFANT MORTALITY AND CHILD WELFARE SURVEYS GENERAL Meigs, G. L. Infant welfare in wartime. American Medical Association. Re- print from the American Journal of Diseases of Children v.14 p80-97 August. 1917. UNITED STATES Baby-saving campaigns; a preliminary report on what American cities are doing to prevent infant mortality, 1913. U. S. Department of Labor, Children's Bureau, Infant Mortality Series no.l, Bureau Publication no.3. 93p. Infant mortality and its relation to the employment of mothers, prepared under the direction of C. P. Neill v.13 174p. Report on condition of women and child workers in the United States, U. S. Senate 61st Congress Second Session, Docu- ment 645. 19 vols. Infant mortality and milk stations; special report dealing with the problem of re- ducing infant mortality; work carried on in ten cities in the United States together with details of administration of public and private agencies in New York State during 1911 to determine the value of milk station work as a direct means of re- ducing infant mortality. New York City, Milk Committee, 1912. 176p. Hibbs, H. H. jr. Infant mortality; its relation to social and industrial conditions. Russell Sage Foundation, 1916. 127p. Phelps, E. B. Statistical survey of infant mortality's urgent call for action. American Statistical Association, Quarterly Publication, v.12 no.92 p341-359 De- cember 1910. Van Ingen, Philip Recent progress in infant welfare work. American Medical Association, 1914. 23p. Reprint from the American Journal of Diseases of Children v.7 p471^93 June 1914. ALABAMA Child welfare in Alabama; an inquiry by the National Child Labor Committee under the auspices and with the cooperation of the University of Alabama, E. N. Clopper, director. New York City. The committee. 1918. 249p. CONNECTICUT Waterbury — Hunter, E. B. Infant mortality; results of field study in Waterbury, based on births. U. S. Department of Labor, Children's Bureau, Infant Mor- tality Series no.7, Bureau Publication no.29 157p. ILLINOIS Chicago — Guild, A. A. Baby farms in Chicago; an investigation made for the Ju- venile Protective Association. Chicago. The association. 1917. p27-34. Chicago — Kingsley, S. C. Steps in the evaluation of baby welfare work in Chicago. Elizabeth McCormick Memorial Fund, 1914 32p. 1050 Hospital and Health Survey Springfield — Geister, Janet The child welfare special; description of child welfare special of Children's Bureau and its tour. Springfield, Institution Quarterly, December 31, 1919. pl20-125. KANSAS Moore, Elizabeth Maternity and infant care in a rural county in Kansas. U.S. Children's Bureau, Rural Child Welfare Series, no.l, Bureau Publication no. 26, 1917. 50p. KENTUCKY Slingerland, W. H. Child welfare work in Louisville; a study of conditions, agents and institutions. Louisville Welfare League, 1919. 152p. LOUISIANA New Orleans and Louisiana — Slingerland, W. H. Constructive program of organ- ized child welfare. work for New Orleans and Louisiana. An address delivered before the Social Workers' Section Southern Sociological Congress at New Orleans, April 1916. Russell Sage Foundation, 1916. Reprint from proceedings of the Congress for the Department of Child Helping, Russell Sage Foundation, July 1915. 36p. MASSACHUSETTS Phelps, E. B. Infant mortality and its relation to women's employment; a study of Massachusetts statistics. Women and Child Wage Earners in the United States v.12 part 1 pl-121 1911. Safford, M. V. Influence of occupation on health during adolescence. U. S. Public Health.Service, Public Health Bulletin no.78, August 1916. 51p. Brockton — Dempsey, M. V. Infant mortality; results of a field study in Brockton, based on births in one year. U. S. Department of Labor, Children's Bureau, In- fant Mortality Series no. 6, Bureau Publication no. 37, 1919. 82p. Fall River — Dublin, L. I. Infant mortality in Fall River; a survey of the mortality among 833 infants born in June, July and August 1913. American Statistical Association, Quarterly Publication v.14 p505-520 June 1915. Fall River — Keisker, L. M. Infant mortality and its relation to the employment of mothers in Fall River. Women and Child Wage Earners in the United States v.12 part 2 p75-174 1911. MONTANA Paradise, V. I. Maternity care and the welfare of young children in a home- steading county in Montana. U. S. Department of Labor, Children's Bureau, Rural Child Welfare Series no.3, Bureau Publication no.34, 1919. 98p. NEW HAMPSHIRE Young, A. A. Birth rate in New Hampshire. American Statistical Association, Quarterly Publication v.9 p263-281 September 1905. Bibliography 1051 NEW JERSEY Essex County — Infant mortality report of the Public Welfare Committee of Essex County. Newark. The committee. 1912. 32p. Montclair — Infant mortality; a study of infant mortality in a suburban community. U. S. Department of Labor, Children's Bureau, Infant Mortality Series no. 4, Bureau Publication no. 11, 1915. 36p. NEW YORK New York City — Boarded-out babies, L. D. Wald, director. The Association of Neighborhood Workers of the City of New York, n. d. 7p. New York City — Infant mortality and the milk situation; special report of the Com- mittee for the reduction of infant mortality of the New York Milk Committee, New York City Milk Committee, 1912. 176p. Ogdensburg — Wakeman, B. R. Survey of the infant mortality and stillbirths of the city of Ogdensburg, for the year 1915. 36th Annual Report of the New York State Department of Health v.3 p44-73 1915. NORTH CAROLINA Bradley, F. S. and Williamson, Margaretta Rural children in selected coun- ties of North Carolina. U. S. Department of Labor, Children's Bureau, Rural Child Welfare Series no.2, Bureau Publication no.33, 1918. 118p. Child welfare in North Carolina; an inquiry by the National Child Labor Com- mittee for the North Carolina conference for social service. W. H Swift, director. New York City. The committee. 1918. 314p. OKLAHOMA Child welfare in Oklahoma; an inquiry by the National Child Labor Committee for the University of Oklahoma. E. N. Clopper, director. New York City. The committee. 1917. 285p. OREGON Slingerland, W. H. Child welfare work in Oregon; a study of public and private agencies and institutions for the care of dependent delinquents and defective chil- dren for the Oregon Child Welfare Commission. University of Oregon Extension Division Bulletin, July 1918. 131p. PENNS YLVANIA Child welfare symposium; 25 special papers contributed by leading Pennsylvanians, supplement to Child Welfare Work in Pennsylvania. Russell Sage Foundation, 1915. 138p. Hart, H. H. Summary of child welfare work in Pennsylvania. Russell Sage Foundation, 1915. 34p. Slingerland, W. H. Child welfare work in Pennsylvania; a cooperative study of child helping agencies and institutions. Russell Sage Foundation, 1915. 352p. 1052 Hospital and Health Survey RHODE ISLAND Aronovici, Carrol Some nativity and race factors in Rhode Island. Provi- dence, 1910. Reprint from Annual Report of the Commission of Industrial Sta- tistics of Rhode Island, 1909. p2 19-423. WISCONSIN Brown, F . ,B- and Moore, Elizabeth Maternity and infant care in two rural counties in Wisconsin. U. S. Children's Bureau, Rural Child Welfare Series no. 4, Bureau Publication no.46, 1919. 92p. CANADA Ottawa — Traveling baby clinic; Ottawa trucks used as clinics. Conservation of Life, July 1919. p60-62. ENGLAND Unwin, T. F. Second report on infant and child mortality in London. 42nd Annual Report of the Local Government Board, 1912-1913. 411p. Supplement in continuation of the report of the medical officer of the board for 1912-1913. SOCIAL SURVEYS UNITED STATES Taylor, G. R. Satellite cities. New York, Appleton, 1915. 333p. ALABAMA Birmingham — Kellogg, P. U., Harrison, S. M. and others. Smelting iron ore and civics. Survey v.27 pl451-1556 January 6, 1913. CALIFORNIA Los Angeles — Bartlett, D. W. Better city; a sociological study of a modern city. Los Angeles, 1907. 248p. San Diego — King, E. S. and F. A. Pathfinder social survey of San Diego. San Diego College Women's Club, 1914. 48p. CONNECTICUT Bridgeport — Report on welfare work in Bridgeport and elsewhere. Committee of Manufacturers' Association, 1918. New Haven — Documents of the civic federation. 15 pamphlets. The Federation, 1909-1915. ILLINOIS Chicago — Reports of the Bureau of Social Surveys. Chicago Department of Public Welfare, semi-annual report, 1914-1915. , Springfield — Springfield survey. S. M. Harrison, director. 10 pamphlets. Russell Sage Foundation, Department of Surveys and Exhibits, 1915. Treadway, W. L. Care of mental defectives, the insane and alcoholics. 46p. Schneider, Franz, jr., Public health. 159p. Bibliography 1053 KANSAS Belleville — Burgess, E. W. and Sippy, J. J. Belleville social survey. University of Kansas, n. d. 70p. Lawrence — Blackmar, F. W. and Burgess, E. W. Social survey of Lawrence, 1917. 122p. Minneapolis — Elmer, M. C. Survey by, 1918. 39p. Topeka — Topeka improvement survey. S. M. Harrison, director. 4 pamphlets. Russell Sage Foundation, Department of Surveys and Exhibits, 1914. Schneider, • Franz, jr., 3rd part — Public health. MASS A CHU SETTS Lawrence — Todd, R. E. and Sanborn, F. B. Report of the Lawrence survey. Trus- tees of the White Fund, 1912. 262p. Covers milk supply and housing. Lou;eZZ— Kengott, George Record of a city. New York, Macmillan, 1912 257p. MISSOURI Kansas City — Reports of public welfare board. 1913. 104p. Springfield — Springfield social survey, W. T. Cross, director, R. H. Leavell, field worker. Springfield Social Survey Council n. d. 33p. NEW JERSEY Montclair — Burns, A. T. Need and scope of a social survey. Montclair. Survey committee, 1912. 23p. NEW YORK Albany — Hun, M.V. Some facts about Albany. Albany. The author. 1912. 30p. Buffalo — Daniels, John Americanizing 80,000 Poles. Survey v.24 p373-385 June 4, 1910. Newburgh — Newburgh survey. Z. L. Potter, director of field work. Russell Sage Foundation, Department of Surveys and Exhibits, 1913. 104p. NORTH DAKOTA Fargo — Social survey of Fargo, by Social Science Department, Fargo College, under M. C. Elmer. Fargo Associated Charities, 1915. 46p. PENNS YLVANIA Coopersburg — Morrison, T. M. Coopersburg survey. Easton, Moravian Country Church Association, 1915. 34p. Pittsburgh — Holdsworth, J. T. Economic survey of Pittsburgh. Pittsburgh. The author. 1912. 229p. Pittsburgh — Kellogg, P. U., editor Pittsburgh survey. New York Charities Pub- lishing Committee, 1909-1914. 6 vols. Russell Sage Foundation publication 6 parts. 1054 Hospital and Health Survey Reading — Report on a survey of the municipal departments and the school dis- trict. New York Bureau of Municipal Research, 8 pamphlets. Reading Chamber of Commerce, 1913. 1 — Department of Health. 46p. Scranton — Harrison, S. M. and others. Scranton in quick review. Scranton Cen- tury Club, 1913. 31p. RHODE ISLAND Newport — Aronovici, Carrol Newport survey of social problems, Newport Sur- vey Committee, 1911. 59p. Providence — Kirk, William Modern city. University of Chicago Press, 1909. 363p. TEXAS Austin — Hamilton, B. Social survey of Austin. 1913. Bulletin University of Texas, Humanistic Series no. 15. Austin — Terry, C. E. and Schneider, Franz, jr. Social survey of the city of Austin. 40p. (Delineator 7th Baby Campaign, 1917.) WISCONSIN Milwaukee — Bureau of Economy and Efficiency. Bulletins 1-19. 1911-1912. (o. p.) CANADA London — Riddell, W. A. and Myers, A. J. W. Survey. Toronto Board of Social Service and Evangelism, Presbyterian Church, 1913. 99p. Regina — Woodsworth, J. S. Report of a preliminary and general social survey of Regina. Toronto Board of Social Service and Evangelism, 1913. 48p. Sydney — Stewart, B. M. Preliminary and general social survey of Sydney. To- ronto Board of Social Service and Evangelism, Presbyterian Church, 1913. 29p. INDUSTRIAL HYGIENE SURVEYS UNITED STATES Danger to workers from dusts and fumes, and methods of precaution. U. S. Department of Labor, Bureau of Labor Statistics, Bulletin Industrial Accidents and Hygiene Series no. 3 whole no. 127 August 12, 1913. 22p. Eye hazards in industrial occupations; a report of typical cases and conditions with recommendations for safe practice. National Committee for Prevention of Blindness no.12, 1917. 145p. Hygiene of the painters' trade. U. S. Department of Labor, Bureau of Labor Statistics, Bulletin Industrial Conditions and Hygiene Series no. 2, whole no. 120 May 13, 1913. 68p. Lead poisoning in the manufacture of storage batteries. U. S. Department of Labor, Bureau of Labor Statistics, Bulletin Industrial Accidents and Hygiene Series no. 6 whole no. 165 December 15, 1914. 38p. Bibliography 1055 Lead poisoning in potteries, tile works and porcelain enamelled sanitary ware factories. U. S. Department Commerce and Labor, Bureau of Labor Statistics, Bulletin Industrial Accidents and Hygiene Series no.l whole no. 104 August ,7, 1912. 95p. Lead poisoning in the smelting and refining of lead. U. S. Department of Labor, Bureau of Labor Statistics, Bulletin Industrial Accidents and Hygiene Series no. 4 whole no.141 February 17, 1914. 97p. Schroeder, M. C. and Southerland, S. G. Laundries and the public health. U. S. Public Health Service, Public Health Reports v.32 p2 2 5-246 February 9, 1917. Boston, New York City, Philadelphia, Baltimore, Washington, Chicago, St. Louis — Hamilton, Alice and Verrill, C. H. Hygiene of the printing trades. U. S. Department of Labor, Bureau of Labor Statistics Bulletin Industrial Accidents and Hygiene Series no. 12 whole no. 2 09. 118p. Orange Valley, Newark, Danbury, Philadelphia, Fall River — Sanitary standards for the felt hatting industry. Trenton. The state. 1915 INDIANA White, M. J. Sanitary survey of Indiana industries employing women labor. U.S. Public Health Service, Supplement 17 to Public Health Reports, July 17, 1914. 44p. MASSACHUSETTS Hygiene of the boot and shoe industry in Massachusetts. Boston. The state. 1912. 31p. 7 plates. Report of the State Board of Health upon the sanitary condition of factories, workshops and other establishments where persons are employed. Boston. The state. 1907. 144p. NEW YORK New York City — Goldmark, Pauline. Notes on an industrial survey of a selected area in New York City, with respect to sanitary conditions in the factories. 1917. Reprint of appendix 5 to preliminary report of the New York State Factory Investigating Commission. Submitted to Legislature March 1, 1912. p297-363. New York City — Guilfoy, W. H. and Wynne, S. W. Illness census taken in Health District no.l. New York City Department of Health Bulletin v. 6 no.2 p71-80 March 1916. New York City — Harris, L. I. Clinical and sanitary study of the fur and hatters fur trade. New York City Department of Health Bulletin v.5 no.10 p267-298. October 1915. New York City — Harris, L. I. Clinical study of the frequency of lead, turpentine and benzine poisoning in 400 painters. New York City Department of Health reprint, surveys no. 65, August 1918. 1056 Hospital and Health Survey New York City — Harris, L. I. Health of workers in garages; a preliminary study. New York City Department of Health Bulletin v.8 no.ll. November 1918. New York City — Harris, L. I. and Swartz, Nelle Cost of clean clothes in terms of health; a study of laundries and laundry workers in New York City, 1916. 96p. New York City — McMillan, M. B. Sanitary survey of a "Trial" city block. New York City Department of Health Bulletin v.6 no.8 p215-220. August 1916. New York City — Pratt, E. E. Occupational diseases; a preliminary report on lead poisoning in the City of New York with an appendix on arsenical poisoning. 1912. Reprint of appendix 6 to preliminary report of the New York State Factory Investi- gating Commission. Submitted to Legislature March 1, 1912. p365-596. New York City — Price, G. M. General survey of the sanitary conditions of the shops in the cloak industry. Reprint from 1st Annual Report of the Joint Board of Sanitary Control in the cloak, suit and skirt industry of Greater New York, 1911. 40p. New York City — Price, G. M. Special report on sanitary conditions in the shops of the dress and waist industry; a preliminary report made by the Joint Board of Sanitary Control in the dress and waist industry, 1913. 23p. New York City — Report on the sanitation of bakeries in New York City. New York Commissioner of Sanitation of Bakeries, 1911. 16p. New York City — Schereschewsky, J. W. Health of garment workers. U. S. Pub- lic Health Service, Public Health Reports v.31 no.21 pl298-1305 May 26, 1916. New York City — Schroeder, M. C. and Southerland, S. C. Laundries and the public health. U. S. Public Health Service, Public Health Reports v.32 no.6 p225-246 February 9, 1917. New York City — Studies in vocational disease: Schereschewsky, J. W., Health of garment workers; and, Schereschewsky, J. W. and Tuck, D. H., Hygienic con- ditions of illumination in workshops of the women's garment industry. U. S. Public Health Service Bulletin no.71, 1915. New York City — Wynne, S. W. Second illness census in the experimental health district. New York City Department of Health Bulletin v.6 no.ll p289-314 November 1916. OHIO Hayhurst, E. R. Industrial health hazards and occupational diseases in Ohio. Columbus State Board of Health, 1915. 438p. GREAT BRITAIN Hours, fatigue and health in British munition factories. U. S. Department of Labor, Bureau of Labor Statistics Bulletin Industrial Accident and Hygiene Series no.15 whole no.221 April 1917. 147p. Bibliography 1057 TUBERCULOSIS SURVEYS GENERAL Homan, J. Instruction of the public in anti-tuberculosis measures by a traveling exhibit. Journal American Medical Association v.55 pl072-1073. September 24, 1910. i Ransome, Arthur International researches in tuberculosis. The Weber-Parkes Prize Essay, 1897. London, England, 1898. 84p. ALASKA Michel, H. C. Tuberculosis survey of an Alaskan Eskimo village, using children under the age of 15 years as an index. Reprint 90, Medical Record, October 14, 1916, p663-666. Wm. Wood & Co. GEORGIA Anti-tuberculosis activities in Georgia. Atlanta Raoul Foundation, 1916. Folder no.3 . (unpublished) ILLINOIS Chicago — O'Neill, E. J. School survey as observed at Stock Yards dispensary. Municipal Tuberculosis Sanitarium Monthly, Bulletin no.l pl3-15 March 1918. Chicago — Robertson, J. D. Tuberculosis problem in the city of Chicago. Reprint, American Journal of Public Health, April 1918. lip. INDIANA Richmond — Perry, J. C. Report of a survey to determine an incident of tubercu- losis. U. S. Public Health Service, Supplement 26 to Public Health Reports, October 8, 1915. 62p. MASSACHUSETTS Barnstable County — Billings, B. W. Tuberculosis survey. Boston State Depart- ment, Health in Commonwealth v.5 p207-210 August 1918. Boston — Locke, E. A. and Floyd, Cleaveland Economic study of 500 consump- tives treated in the Boston Consumptive Hospital, 1911. Reprint, Transactions of the New York Association for the Study and Prevention of Tuberculosis. 9p. Framingham — Armstrong, D. B. Community health and tuberculosis demon- stration; a series of pamphlets Monograph 1 — The program, Medical series 1 — The sickness census, 2 — Medical examination campaign, 3 — Tuberculosis findings. 1917-1918. MICHIGAN Report of the tuberculosis survey of the State Board of Health for the 12 months from October 1915 to October 1916. Lansing. The state, 1917. 89p. MINNESOTA Minneapolis — Lampson, H. L. Study of the spread of tuberculosis in families. University of Minnesota studies in Public Health Bulletin no.l, December 1913. 50p. 1058 Hospital and Health Survey MISSOURI Joplin — Lanza, A. J. and Higgins, Edwin Pulmonary disease among miners in the Joplin district and its relation to rock dust in the mines; a preliminary re- port. Department of Interior, Bureau of Mines, Educational paper 105, 1915. 47p. NEW JERSEY Tuberculosis survey of New Jersey and report. Newark, New Jersey, Anti- Tuberculosis League, 1917. 48p. NEW YORK Amsterdam — Brown, U. D. Houses of Amsterdam with some notes on the prev- alence of tuberculosis. State Charities Aid Association, 1917. 61p. Clinton County — Smith, J. A. A tuberculosis survey of Clinton County. New York State Department of Health, Health News, March 1919, p56-62. New York City — Dispensary control of tuberculosis in New York City. 11th Annual Report of the Association of Tuberculosis Clinics of the City of New York, 1918. 35p. Saranac Lake — Ames, F. B. A tuberculosis survey of the residents of Saranac Lake. National Tuberculosis Journal, American Review of Tuberculosis v.2 no.4 p207-236 June 1918. OHIO Survey of the tuberculosis situation in the state of Ohio; prepared by the Ohio State Society for the Prevention of Tuberculosis. State Board of Health, 1912. 49p. Cincinnati — Nelson, N. A. Study of tuberculosis mortality, 1910-1917, with special reference to the Negro. Anti-Tuberculosis League allied drive for Public Health, pl8-29. Cincinnati — Robinson, D. E. and Wilson, J. G. Tuberculosis among industrial workers. U. S. Public Health Service, Public Health Bulletin no. 73, 1916. 143p. PENNS YLVANIA Pittsburgh — Steward, A. E. and Simmonds, V. S. Tuberculosis League; first sur- vey report of Dispensary Aid Society on tuberculosis and infant welfare; a study of 8 city squares, 1916. 65p. RHODE ISLAND Gilbert, R. W. A study of a typical mill village from the standpoint of health. Rhode Island Anti-Tuberculosis Association report, 1910. 15p. VERMONT New features in the anti-tuberculosis campaign. Vermont State Board of Health Bulletin v.13 no.3 p71-75 March 1, 1913. Bibliography 1059 GERMANY Care of tuberculosis wage earners in Germany. U. S. Department of Commerce and Labor, Bureau of Labor Bulletin Workman's Insurance and Compensation Series no.l, whole no.101 July 1912. 183p. SICKNESS SURVEYS MASSACHUSETTS Boston — Frankel, L. K. and Dublin, L. I. Sickness survey of Boston. New York City, Metropolitan Life Insurance Co., 1916. 23p. MISSOURI Kansas City — Frankel, L. K. and Dublin, L. I. Health census of Kansas City. New York City, Metropolitan Life Insurance Co., 1917. Up. NEW YORK Dutchess County — A sickness survey in Dutchess County. New York, State Chari- ties Aid Association, Publication no.136, 1915. 102p. Dutchess County — Weber, J. J. A county at work on its health problems; a statement of accomplishment by the Dutchess County Health Association during the 16 months from August 1916 to December 1917, inclusive. New York, State Charities Aid Association. 27p. New York City — Health census of Chelsea neighborhood by Metropolitan Life Insurance Company and Chelsea Neighborhood Association. New York City, Metropolitan Life Insurance Co., 1917. 16p. Rochester — Frankel, L. K. and Dublin, L. I. Community sickness survey. New York City, Metropolitan Life Insurance Co., 1917. 22p. NORTH CAROLINA Frankel, L. K., and Dublin, L. I. Sickness survey of North Carolina. U. S. Public Health Service, Public Health Reports v.31 no.41 p2820-2844 October 1916. OHIO O'Grady, John Public care of sick and diseased; a survey of hospital care in Ohio infirmaries. Board of State Charities, Ohio Bulletin of Charities and Cor- rection v.24 no.4 December 1918. 19p. PENNSYLVANIA AND WEST VIRGINIA Frankel, L. K. and Dublin, L. I. Sickness survey of the principal cities in Penn- sylvania and West Virginia. New York City, Metropolitan Life Insurance Co., 1917. 78p. PENNSYLVANIA Pittsburgh — Frankel, L. K. and Dublin, L. I. Sickness survey of Pittsburgh. New York City, Metropolitan Life Insurance Co., 1917. 22p. 1060 Hospital and Health Survey SOUTH CAROLINA Sydenstricker, Edgar, Wheeler, G. A. and Goldberger, Joseph Disabling sick- ness among the population of seven cotton mill villages of South Carolina, in re- lation to family income. U. S. Public Health • Service, Public Health Reports, v.33 no.47. November 22, 1918. 14p. WEST VIRGINIA Frankel, L'. K. and Dublin, L. I. Sickness survey of West Virginia cities. New York City, Metropolitan Life Insurance Co., 1917. lip. WEST VIRGINIA AND PENNSYLVANIA Frankel, L. K. and Dublin, L. I. Sickness survey of the principal cities in Penn- sylvania and West Virginia. New York City, Metropolitan Life Insurance Co., 1917. 78p. UNCLASSIFIED Armstrong, D. B. Methods of investigation in social and health problems; necessity of health standards, 1917. 24p. Aronovici, Carrol Suggestions for social surveys of small towns and cities. 1913. 77p. Aronovici, Carrol The social survey. 1916. 255p. Health 228-230, bibliography. Bannington, B. G. English public health administration. 1915. 330p. Dublin, L. I. The application of the statistical method to public health research. Fisher, Irving National vitality. 1910. 130p. Harrison, S. M. Community action through surveys. Russell Sage Foundation, Sep- tember 1916. 29p. Peabody, S. W. Historical study of legislation regarding public health in the states of New York and Massachusetts. Journal of Infectious Diseases, 1909. Schneider, Franz, jr. Some shortcomings of socio-sanitary investigations. Index By Elizabeth R. Cummer Absenteeism due to sickness, 541-42 Accident and health hazard, construction trades, 535; department stores, 593; domestic service, 603; metal trades, 560; printing, 592; telephone work, 571, 594; textile and knitting mills, 561 Accident incidence, see Industrial acci- dent and sickness statistics Academy of Medicine, 136-37, 141, 214, 401, 403, 413; history and activities, 664-65; suggested cooperation with Dispensary Committee, 899-900, 913 Administrative areas, 42, 46 Agricultural and domestic service, for children, 602-3 Ambulance service, in industry, 533; necessity for adequate, 458; no pro- vision for City Infirmary, 964; plan for city-wide, 964; present facilities, 961; promptness, 961-62; provisions in other cities, 961; recommendations, 964-65; requisites for efficient, 962-63 American habit of mind or work, from practical to theoretical, 25 American Medical Association, pamphlets on nostrums and quackery, 677 American Society for Control of Cancer, program for prevention and cure, 221-25 Animal Protective League, factor in con- trol of rabies, 137; provisions for transportation of dogs, 963 Anti-spitting ordinance, enforcement, 332, 354 Anti-Tuberculosis League, 193; activities, 362 ; development of educational work in industry, 363; extension of pro- gram, 369; follow-up of cases, 367 Arsphenamine, provision by state, 885 Artificial feeding, see Infant care Associated Charities, activities, 196-97; cooperation with health centers, 363; families with mental disorders under care of, 498; mental test registry, 500; psychological approach to problems of individuals, 497-98 Association for the Crippled and Disabled, 193 ; organization and functions, 204-6; responsibility for adequate follow-up work, 208; social service, 204-5, 953. See also Care of cripples Association for Prevention and Relief of Heart Disease, cooperation in prepar- ing program, 213 Autopsies, importance, 864; number in hospitals, 1919, 667,864; percentage, 668,865 Autopsy, use not appreciated, 667; means for increasing use, 669 Babies' Dispensary, building, 893; clinic training for University District stu- dents, 751; cooperation with Humane Society, 917-18; extension of scope, 897; fees and finances, 894; location, • 892; medical supervision of boarded- out children, 177; medical work, "895; organization, 892-93; orthopedic fa- cilities, 203; patients, 893; social service, 895-96, 953; visits, 1919, 890. See also University Hospital Group Baby prophylactic stations, 826, 986. See also Health Centers *The subjects listed in the Index are given for the report as a whole and are not classified by the various Parts. The pages of the report are numbered consecutively throughout the eleven Parts: Part I, 1-96; Part II, 97-260; Part III, 261-324; Part IV, 325-388; Part V, 389-436; Part VI, 437-516; Part VII, 517-644; Part VIII, 645-700; Part IX, 701 to 812; Part X, 813-996; Part XI, 997-1082. 1062 Hospital and Health Survey Bar Association, Americanization Com- mittee, 677 Bathing beach waters, pollution by sew- age, 62 Belle vue Hospital, 956 Benjamin Rose Institute, provision of funds for cafe of crippled children, 204 Birth registration, check of, 167; in- adequacy of, 276-77; method of secur- ing 100%, 278; relative number of births reported by midwives and physicians, 277. See also Bureau of Vital Statistics Births, 1919, 275-76 Blindness, see Prevention of blindness; Board of Education, special classes; Society for Blind Board of Education, cooperation in pre- vention of heart disease, 214, 218, 305; cooperation with Division of Health, 272; physical training, 296-97, 312-13; provision for crippled children, 206; provision for tuberculous children, 362 ; psychological clinic; 462, 486, 488; sani- tary supervision, 297-301, 315-18; special classes: cardiac, 295; for blind, 294; for cripples, 206, 294-95; for deaf, 294; for mentally defective, 295, 488-90; nutrition, 295; open-air, 293-94; speech defects, 295, 494-95 See also Department of Medical In- spection; Health education Boarding homes, dental work for children, 178; medical supervision of children, 177-78; supervision, 178, 287, 762-63; suggested procedure for placing-out of children, 178-80 Bodily mechanics, need for community education in, 198 Boston, City Hospital, 956; hospital service per 1,000 population, 830 Boys' School, 486 Brace shop, present, 203; proposed cen- tral, 200-1 Bratenahl Village, school nursing service, 778 Breast feeding, see Infant care Bureau of Child Hygiene, 143; activities, 280-83. See also Prenatal care; Ma- ternity care; Infant care Bureau of Communicable Disease, 122-38; cards used, 124-25; Charter provi- sions for, 122; control of rabies, 137; culturing in diphtheria, 125; disinfec- tion after smallpox, 127; disinfection of library books, 126; duties of chief, 122; extension of scope, 122; im- munization against diphtheria, 126; need for skilled intubator, 136; per- sonnel, 122; quarantine, 125, 137-38; regulations of Sanitary Code, 123-24; reporting by physicians, 124; results of control measures, 127; supervision of district physicians, 140; vaccination, 126-27 Bureau of Food and Dairy Inspection, 148-54, 357; classification of milk dealers, 153; control of communicable diseases in animals, 122; control of rabies, 149-50, dairy inspection, 151; defects in milk control, 150-1; organ- ization, 148; appointment of person- nel, 154; present separation of food inspection service, 154; recommenda- tions for milk and dairy inspection, 154; summary of work for 1919, 148- 50; supervision of slaughtering and sale of meat, 150 Bureau of Industrial Hygiene, need, 554; proposed activity for Division of Health, 185 Bureau of Juvenile Research, see State Bureau of Juvenile Research Bureau of Laboratories, 155-61; chief criticisms of bacteriological laboratory, 157; duties of chief, 155; functions, 155-56; inspection work, 160-61; main distributing stations for outfits, 157-59; microscopic and serological examina- tions for venereal diseases, 400; milk examinations, 155-56; organization, 155; patent medicines, 161; summary of results of examination of city water, 1919, 15,9; work of bacteriological lab- Index 1063 oratory, 156-57; work of chemical lab- oratory, 160-61 Bureau of Preventable Diseases, scope of such a bureau, 122-23 Bureau of Sanitation, 144-47, 357; activi- ties, 144-45; actual work, 146-47; excuse for lodging house conditions, 53; indifference to enforcement of tenement ordinances, 48-49; lack of constructive and preventive work, 144, 145; method of receiving com- plaints, 144; organization, 144; re- sponsible for abatement of nuisances relating to dumps, 74; control of fly- breeding places, 83; study of field work, 145; supervision of field force, 144; tenement house code, 145-46 Bureau of Tuberculosis, closer relations with Medical School, 369; need for full-time chief, 368: organization and activities, 355-56 Bureau of Vital Statistics, 165-72; ap- propriation, equipment and personnel, 1 66 ; cooperation with Bureau of Com- municable Disease, 168; duties of registrar, 168-69, 171; three elements of a reorganized service, 167; formulation of new system, 167-72; inadequacy of present records, 165; lack of enforce- ment of birth registration, 276-77; nature of data for tuberculosis, 357; need for improved statistical work, 369; need for intelligent supervision, 168; present ,methods of operation, 166; recommendations, 172 Candy factories, employment of women, 562; employment of children, 590 Cancer, prevention and cure, 221-25 Cardiac disease, see Heart disease Care of convalescents, study of 200 dis- charged hospital cases, 927-37; com- munity program for, 938-43 Care of cripples, 197-212; funds provided by Benjamin Rose Institute, 204; lack of orthopedic supervision in schools, 197; points considered in problem, 201: present needs, 207-8; program, 208-9; recommendations, 209-12; re- habilitation of industrial cripples, 198, 547, 550; vocational therapy, 205; facilities: brace-making, 203; con- valescent, 203; coordination by Asso- ciation for Crippled and Disabled, 204-6; dispensary, 202-3; educational, 206; hospital, 202, 832; hydrotherapy, 202; physiotherapy, 202-3; social service, 203-4 Care of chronic illness, at City Infirmary, 948-50; lack of provision for, 946-48; medical service, 944; need for institu- tion for, 945; nursing service, 944; problem distinguished from that of canvalescence, 945; responsibility of city, 946, 948; summary, 951 Care of sick, factors determining choice of resources, 820-21; resources, 27, 820 Census tracts, see Sanitary areas Central Child Hygiene Council, Commit- tee on Infant Care, 283; Committee on Maternity Care, 278; Committee on Prenatal Care, 274; functions, • 270, 272; membership, 270 Central Committee on Public Health Nursing, activities, 757; composition and activities, 112-13; organization, 756; recommendations, 757-58; sug- gested inclusion of industrial nursing representative, 807; plan for factory service, 777; valuable asset to public health nursing, 756 Central downtown dispensary, estimated cost, 924; financing, 923-24; industri- al clinic in connection with, 553; initia- tive for starting, 924-25; needs to be met by, 922; suggested connection with orthopedic center, 200; sug- gested site and services, 923 Chamber of Commerce, housing survey, 353; quotation from report on Housing Conditions of War Workers, 43; smoke prevention, 85 Charity Hospital, see St. Vincent's Char- ity 1064 Hospital and Health Survey Child-caring institutions, licensing, 287; medical survey, 287; number and capacity, 287; number planning new buildings, 175; objects of study of, 174-75; problems of delinquency, 487; recommendations, 176-77, 287; sani- tary survey, 287; summary of medical service, 175-76 Child health work, four great features of present program, 268; lack of pre- ventive health functions, 267-68; measure of its effectiveness, 319-20; need of central control, 267-270; pres- ent organization, 267-68; proposed organization, 270 73; recommenda- tions, 274-75, 278-80, 283-84, 285-87, 287-88, 301-18; summary of problem, 269-70; summary of report on, 29-30; two fundamental bases, 268. See also Central Child Hygiene Council; Pre- natal care; Maternity care; Infant care; Pre-school age care Child Labor Laws, age and educational requirements, 582-83; enforcement, 583, 585-86; health requirements, 583; reasons for evasion, 586-87; reasons for inadequate enforcement, 586; rem- edy for lack of enforcement, 587; spe- cial vacation certificate, 583; street trades, 583 Childhood, importance of adolescent period, 580 Children and industry, brief outline of study, 581; education's responsibility, 613-18; need for junior vocational department, 596-97, 615; reasons for including study in survey, 579; recom- mendations, 619-21; summary of re- port, 31-32; three general considera- tions involved in health study, 579-80 statistics: sources of information, 583-84; number of children at work, 584; ages and number of children ap- plying for work, 585; occupations employing children, 588 See also Occupations employing chil- dren; Street trades; Agricultural work and domestic service; Child Labor Laws Children's Fresh Air Camp, dental serv- ice, 687; preventorium advantages, 361; provisions for convalescents, 941 Children's Placement Bureau, proposed new activity for the Division of Health, 178-80 Chronic cases, classification, 947-48 City Charter, provisions, 106-9; suggested changes, 119, 654, 839-40 City Farm, description, 465 City Hospital, admission procedure for tuberculosis cases, 356; ambulance service, 961 ; approval of bond issue for, 458, 966; charter changes sug- gested, 654, 839-40; deficiency of nursing service, 838; number of beds, 828; out-patient department needed, 918; plans for expansion, 966; pro- posed psychopathic department and "outposts", 458, 462, 479, 481, 486; social service, 953, 955; study of con- valescent cases from, 930-32; sug- gested plan for a venereal disease service, 410; facilities: contagious cases, 832; dental surgery, 684-85, 687; mental cases, 446-47, 458; tuberculosis cases, 360; venereal diseases, 402, 410, 832 training school for nurses: organiza- tion, 714; minimum entrance require- ments, 715-16; capacity of hospital and services offered, 717-18, 724; in- struction in nursing procedures, 724- 27; instruction in' sciences, 728-32; instruction in other subjects, 732-35; ratio of nurses to patients, 735; day duty, 736; night duty, 737-38; vaca- tion, 738; living conditions, 740-41 City Infirmary, insufficient service, 839, 949; location and capacity, 948; per- sonnel, 948; provision for mental cases, 465.-66; utilization for chronic cases, 949 City Plan Commission, 48, 353 Climate, 46-47 Clinics, cardiac, 215, 219, 897; dental, 293, 684-86, 903-4; industiial 553, Index 1065 923; need for psychiatric, 462, 479, 481, 486; prenatal, 274, 826, 902-3, 986; psychological, 462, 486, 488; venereal disease, 401, 404, 885. See a!so Dispensaries College of Dentistry, see Dental School Commissioner of Health, appointment, 111; part-time office, 111; powers and duties, 109 Commissioner of Publicity and Research, duties, 108; reasons why position should be filled, 110 Commissioner of Smoke Prevention, 88-89 Committee for Prevention and Relief of Heart Disease, 214 Committee for vice investigations, 426-27 Committee on Nursing Education, studies of hospital training schools, 712 Community, attitude toward hospitals and dispensaries, 820-21; complaints regarding provisions for mental cases, 444-45; interest of, 576-77; planning of hospitals and dispensaries, 966-72; spirit, 377, 983-84; supervision of mentally defective, 495-96 Construction trades, accident and health hazards, 535-36; accident incidence, 542 Consultation service, establishment of, 366 Consumers' League, campaign for en- forcement of street trades ordinance, 598 ; cooperation in study of Children and Industry, 581; investigation of milk situation, 347; program for in- creasing use of milk, 352 Consumption, see Tuberculosis Contagious diseases, estimated number of hospital beds needed, 832 Control of drug addiction, new activity proposed for Division of Health, 189-90 Control of tuberculosis, see Tuberculosis Control of venereal diseases, see Venereal diseases Convalescence, two things apparent in study, 926-27; problem of, 938: in- stitution needed for some cases, 938-39; methods of dealing with problem, 940- 41 Coroner system, recommendations, 191 Correctional agencies, 482-87 Cost accounting, in hospitals, 870-71, 877- 79 County commissioners, 872 County jail, provision for mental cases, 464-65 Courts, 476-82; relation to problem of mental diseases, 476 Cripple School, 206, 294-95 Day nursiiies ; admission procedure, 181- 82; attendance, 181, 285; discussion of social worth, 574-75; licensing, 181; medical service, 182-83; number, 180- 81, 285; ordinances regulating, 181; recommendations, 184-85; summary of conditions found, 184; supervision of, 181 Dental hygienists, licensing, 810; train- ing and legalization, 689 Dental Research Laboratory, 689 Dental School, graduate education, 689; present needs, 688-89; public dental clinic, 685 ; work for boarded-out chifdren, 178 Dental service, dispensary facilities, 293, 684-86; inadequacy, 686; in hospitals, 686-88; in industry, 545, 688; in schools, 293, 684, 685; need for pay clinics, 685; need for supervision in dispensary, 686; surgical, 684-85, 685-86 Dental Society, 689 Dentistry, Ohio Dental Practice Act, 683 ; private practice of, 683-84; recom- mendations, 690; summary of report, 32; two movements important in ad- vancing, 683 1066 Hospital and Health Survey Dentists, education, registered, 683 5-89; number Department of Buildings, responsible for school sanitation, 297-301; recom- mendations, 315-18 Department of Health, see Division of Health Department of Medical Inspection, clin- ical facilities, 293; conferences, 295; correction of physical defects, 290-92; examination for and issuance of work permits, 605-7; examination of teach- ers, 297; health records, 295-96; medical personnel, 289-90; organiza- tion, 289; school dispensaries, 295; supervision of control of communi- cable diseases, 296; recommendations, 302-15 nursing service: analysis of activi- ties, 783-86; conferences, 788; duties, 290-92; field nurses, 292-93, 786-87; junior health workers, 293, 787; scope of work, 782-83; staff, 783; staff nurses, 787; supervisor, 786 Department of Physical Training, activi- ties, 296-97; recommendations, 312-13 Department of Public Welfare, Charter provisions for, 108-9; divisions, 110 Detention Home, 481-82, 484 Detention Hospital, 476 Diphtheria, reasons for high death rate, 136-37 « Director of Public Service, plans for changes in organization, 81; respon- sible for cleanliness of city, 67 Director of Public Welfare, general powers and duties, 108; appointment, 111 Dispensaries, adaptation of clinics to clientele, 914; administration, 915; admission of patients, 912; buildings, 893; classes of disease treated, 892; classification, 826, 890; clinic manage- ment, 899; deficiencies, 897; fees and finances, 894, 913-14; for mental diseases, 462; in industry, 533, 536; in schools, 295, 311-12; location, 890, 892; inter-relations, 915; means of ad- mission to hospital wards, 852; means of providing after-care for hospital patients, 856; medical organization, 846; medical relations, 899-900, 913; medical work and records, 895; need for general plan, 919-21; need for en- largement of service, 862-63; needed improvements in service, 918; organ- ization and executive control, 892-93; patients, 893; public health, 901-2, 986; relation to hospitals, 897, 899; reports and tests of service, 896-97; shortage of service, 912; social serv- ice, 895-96; supervision, 417-18. See also Central downtown dispensary; Clinics; Health centers; Hospitals and dispensaries Dispensary, definition of term, 826 District physicians, duties, 139; method of receiving calls, 139; offices, 139; organization, 138-39; recommenda- tions, 141-42; records, 140; summary of complaints of service, 141 ; super- vision, 140; volume of work, 140 Division of Health, administrative dis- tricts, 114-16; appointment of per- sonnel, 111, 112-13; appropriation for 1920, 113; board or advisory com- mission lacking, 110; bureaus, 112; conferences, 116; cooperation with Board of Education in child health matters, 272; educational campaign for control of venereal disease, 410-11; filing, 119; hours of service, 111; legal action, 119; library, 116-19; morale, 121; need for full-time executive, ill; number of employes, 114; organiza- tion, 355-57 f ; per capita cost 1884- 1920, 113-14; per capita cost com- pared with Detroit's, 114; rules for regulation of laboratories, 416-17; Sanitary Code, 119; services not offered, 112; supervision of dispen- saries, 417-18; supply system, 111 activities proposed: 173, 214; con- trol of drug addiction, 189-90; exten- sion district, 769; industrial hygiene, 185; institutional inspection, 173-85; Index 1067 licensing of child-caring institutions, 287; medical examination for city employes, 185-86; public health edu- cation, 186-89; supervision of board- ing-out homes, 287; Venereal Disease Bureau, 413-14 nursing service: appointments of field nurses, 112-13; chronic illness, 944; communicable diseases, 759-60; child hygiene, 281-83, 761-62; instruc- tion of new nurses, 768; midwife supervision, 277, 762; organization, 764; proposed extension district, 769, 803; parochial schools, 763; prenatal, 763-64; prevention of blindness, 762; recommendations, 769-73; scope of work, 758-59; staff, 759, 764, 767-68; summary, 768-69; supervision of boarding homes, 762-63; tuberculosis, 356-57, 760-61; uniforms, 768 See also Bureau of Child Hygiene; Bureau of Communicable Diseases; Bureau of Food and Dairy Inspection ; Bureau of Laboratories; Bureau of Sanitation; Bureau of Tuberculosis; Bureau of Vital Statistics; Health centers Division of Police, ambulance service, 961; modern conception of functions, 426; proposed Women's Bureau, 424- 26; test of efficiency in controlling vice conditions, 427-28 Downtown dispensary, see Central down- town dispensary Draft boards, figures for venereal disease, 398; findings of medical examiners, 541-42 Education and practice in medicine, sum- mary of report, 32 Endemic Index, 127 Epileptics, laws relating to, 469; state hospital for, 473 Extension district, 769, 803 Fairview Park Hospital, number of beds, 828; out-patient department, 919; provisions for mental cases, 461 ; training school for nurses: organiza- tion, 714; minimum entrance require- ments, 715-16; capacity of hospital and services offered, 723; teaching of nursing procedures, 724-27; teaching of fundamental sciences, 728-32; in- struction in other subjects, 732-35 ratio of nurses to patients, 735-36 day duty, 736; night duty, 737-38 vacation, 738; living conditions, 740- 41 Farm School, 484 Federal Bureau of Labor Statistics, 540 Federal Census Bureau, census units or sanitary areas, 42 Federal Children's Bureau, summary of standards of physical fitness for work- ing children, 611-13 Federal Fraud Order Law, scope and limita- tions, 676; suggested means for more aggressive use, 677 Feeble-minded, see Mentally defective Feeding of infants, see Infant care First aid, training necessary for ambu- lance crews, 962 Flies, 83-84 Foreign-language press, advertisements of quacks, 672-75; income from quack and patent medicine advertisements, 678; opportunities for Americaniza- tion of immigrant, 678; patent medi- cine advertisements, 675 Garbage collection and disposal, 67-73, 75, 80-82 Garment trades, earnings of employes, 562; number of women employed, 561; regularization of employment, 561-62; type of women in, 562 General environment and sanitation, summary of report, 28 Generalized public health nursing, 115; definition, 281, 334, 366-67, 754; dis- cussion, 357, 754;' need for change in organization, distribution and super- vision of nurses' work, 283; need for 1068 Hospital and Health Survey specialized supervision, 367; neglect of infant hygiene work under, 282-83; prenatal and postnatal work, 801-2; standard ratio of nurses to population, 375, 755; success of system, 754; prime requisite of, 755; some causes of failure, 755-56; used in University public health nursing course, 746 Girls' Home, 484-85 Glenville Hospital, number of beds, 828; training school for nurses: organiza- tion, 714; minimum entrance require- ments, 715-16; capacity of hospital and services offered, 723, "724; teach- ing of nursing procedures, 724-27; teaching of fundamental sciences, 728- 32; instruction in other subjects, 732- 35; day duty, 736; night duty, 737-38; vacation, 738; living conditions, 740- 41 Goiter, detection and abatement, 291-92; endemic, 46 Gonorrhea, see Venereal diseases ■ Government Diagnostic Clinic, 400-1 Grace Hospital, number of beds, 828 Griswold Act, authorization of institu- tional inspection, 173; reference to, 124 Health administration surveys, aims and methods, 1009-17; factors determining scope, 1007-8; history of, 1005-7; preliminary steps, 1004-5; reasons for making, 1003 Health centers, administrative work, 908; case classification, 343-44; dental work, 684; description, 115; districts, 114; extension, 283-84, 971; facilities for tuberculosis work, 355; financial administration, 909-10; infant welfare work, 280-83, 761-62; location and clinics, 904-5, 986; medical work, 280- 81, 907-8; method of referring babies to, 282; nursing service, 765-66; pa- tients, 905-6; personnel, 907; pre- ventive rather than curative, 826; provision of milk by, 906-7; really branch offices, 115; reasons for de- crease in number of new tuberculosis cases, 344; records, 119, 767, 908-9; recommendations, 190, 910-11; social work, 908; supervision of children of pre-school age, 285-86; supplementary equipment needed, 366; tuberculosis attendance, 344; tuberculosis nursing, 356-57, 760-61 Health Department, see Division of Health Health districts, location of hospitals, 835; proposed use of one as extension dis- trict, 769; facilities for prevention and treatment of sick, 116; statistics for report based on, 42 Health education, anti-tuberculosis, 346, 363, 368; function of a downtown dis- pensary, 922; importance in training for industrial life, 614-15; important part of industrial nursing, 805-6; in industry, 363; in the public schools, 297; means of combating quackery and patent medicines, 677; for pre- vention of heart disease, 218; recom- mendations, 189, 313-14; resume of present services, 186-89; under Divi- sion of Health, 108, 110, 112, 188; views of International Red Cross in regard to, 188-89; weapon against disease and disability, 26-27. See also Sex education ; Mental hygiene Health hazards, see Accident and health hazards Health services, recommendations, 226-28; summary of report, 28-29 Health supervision in industry, see Medi- cal service in industry Health supervision in schools, see School health supervision Health supervision of children at work, medical examination for work permit, 603-7; suggested content of Ohio law re health certificate, 607; subnormal children, 608-10; summary of stand- ards of normal development and physi- cal fitness, 611-13. See also Work permits Index Heart disease, prevention and relief, 213- 21 Holy Cross House, facilities for care of non-pulmonary tuberculosis, 361; pro- visions for convalescents, 941 Home conditions of working people, rela- tion to health, 557 Home work, a method used by factories to increase output, 573; advantages in special cases, 574; various kinds, 573 Hospital beds, for children, 831-32; for contagious diseases, 832; for eye, ear, nose and throat cases, 831; for ob- stetrical cases, 275, 831; for orthopedic cases, 202, 832; for tuberculosis, 361- 62, 366; for venereal diseases, 402, 832; shortage, 832-33, 836; total number available, 828-29; utilization, 833-35, 836 Hospital census, economic status of patient according to nativity, 851 length of stay of patients, 844, 946 location of residence of patients, 829 nativity of patients, 850; percentage of bed occupancy, 833; sources of admission of patients, 852-53, 858; type of service, 831-32 Hospital Council, 193, 214; activities, 872, 981-82; membership in, 981, 983; number of beds in hospitals of, 828; opportunities for service, 982; pro- posed Dispensary Section, 406, 920-21, 982; Purchasing Bureau, 874-75, 882- 84; recommended interest in increase of post-mortem examinations, 671; report forms, 974; suggested coopera- tion with Academy of Medicine, 899- 900 Hospital hygiene, milk supply, 888-89; ventilation, 889; water supply, 889 Hospital statistics, autopsies, 667-68, 864-65; compilation thro a central office, 169-71; number of beds per 1,000 population, 829; service per 1,000 population in other cities, 830. See also Hospital census 1069 Hospital survey, in northern England, 1007 Hospital training schools, capacity of hos- pitals and services offered, 716-24; conditions of work, 735-38; cost ac- counting, 714; extent of study, 709; general characteristics, 709; instruc- tion, 724-35; living conditions, 740-41; minimum entrance requirements, 715- 16; money allowance to students, 714; organization, 713-14, 842; provision of ward helpers, 738-40; recommenda- tions, 742-45 Hospitals, assistance in home conva- lescence, 936-37; attitude toward non- staff physicians, 858-60; authority of superintendent, 843; autopsies per- formed in 1919, 864-65; days of care, 833; deficient in provision for special classes of cases, 83 1 ; democratization of facilities, 862-63; difficulty in secur- . ing admission for venereal disease cases, 402; distribution, 835, 837; facilities for mental cases, 446-47, 458- 62; basis of organization, 838-40; principles of organization, 845-48; pre- dominantly devoted to surgery, 831; planning of policy, 973; rate for in- dustrial cases, 872; reimbursement by county or city for public charges, 872-74; reports, 973-77; services of pub- licity expert needed, 977-78; shortage of beds, 830-31; social service depart- ment, 843, 855; administration: economics and sal- vaging, 886-87; financial, 869-71, 877-82; general recommendations, 887-888; purchasing, 874-75, 882-86; board of trustees: breadth of vision needed, 978; complete authority of, 841; composition, 840, 841-42; duties, 843-45, 871; classification: by diseases treated, 822; by relation to community, 822, 824; by quality of service, 824-26; by range of service, 835-36; medical staffs: foreign-born physi- cians, 863; functions, 861; member- ship, 664, 858, 860; necessity for, 861; 1070 Hospital and Health Survey negro physicians, 863; organization, 846-47, 862, 865-67; relation to community: admission procedure, 852; giving information about patients, 851-52; problem of the foreign-born patient, 850-51, 853- 54; problem of after-care, 854-56; cooperation with charitable organiza- tions, 852-53; cooperation with in- dustrial establishments, -853 ; financial support dependent upon, 857; human problem of the patient, 849-50; serv- ice for middle classes, 871-72 See also Detention Hospital; Indus- trial hospitals; State Hospital for In- sane Hospitals and dispensaries, attitude of community toward, 820-21; classifica- tion of, 822; cost of maintenance, 868-69; educational function, 863-65; method of approach to study of, 820; primary purpose, 819; problem of in- terpreting to community, 827; sum- mary of report on, 33-34; unit for measurement of service, 826-27; planning by community: 971-72; building fund campaign, 966-67; ex- tension of health centers, 971; loca- tions and re-locations, 969-70; pro- jected enlargements, 967-68; special services needed, 968-69; social service departments: coopera- tion with charitable agencies, 956-57; development, 952; functions, 954, 958, 959-60; importance of person- ality and training of head worker, 957-58; lack of definite policy, 953-54; organization, 843, 848, 957; recom- mendation, 955 Hotels, earnings of women employes, 570; present method of employment, 570; supervision of, 570 House of Correction, 482-84 House of Good Shepherd, 485-86 Housing, advantages of zoning, 48; char- acteristics of residential districts, 42, 43; conditions in lodging houses, 53- 55; conditions in tenements, 48-49, 53; legislation, 346-47; proximity of home to industry, 43; recommenda- tions, 55-56; records of Division of Buildings, 353-54; results of over- crowding, 48; survey by Chamber of Commerce, 48, 353; violation of ordi- nances, 53 Housing Conditions of War Workers, quo- tation from report by Chamber of Commerce and U. S. Home Registra- tion Service, 43 Humane Society, child placement work, 178; intelligence tests, 499; medical supervision of boarded-out children, 916-18 Huron Road Hospital, number of beds, 828; plans for expansion, 967; dispensary: building, 893; classes of disease treated, 892; deficiencies, 897; fees and finances, 894; location, 890; medical work, 895; organiza- tion, 892; records, 895; visits, 1919, 890 training school for nurses: organiza- tion, 714; minimum entrance require- ments, 715-16; capacity of hospital and services offered, 723-24; teaching of nursing procedures, 724-27; teach- ing of fundamental sciences, 728-32 instruction in other subjects, 732-35 ratio of nurses to patients, 735-36 day duty, 736; night duty, 737-38 vacation, 738; provision of ward helpers, 738-40; living conditions, 740-41 Hydrotherapy, 202 Industrial accident and sickness statistics, analysis of reportable accidents, 540; computation of frequency and severity rates, 540; importance, 539; investi- gation of absenteeism due to sickness and non-industrial accidents, 541-42; tabulation of, 540; time loss in small ■ industrial establishments, 550-51 Industrial clinic, advantages of associat- ing with department of industrial Index 1071 hygiene, 553; proposed in connection with central dispensary, 553, 923 Industrial cripples, 198, 547, 550 Industrial dental service, 545, 688 Industrial establishments, number and size, 525-26; employing women: 558-59; acci- dent and health hazards, 560, 561; benefits, 564-65; earnings of employes, 561, 562, 564; hours of work, 561, 563; nature of women's work, 560; number of women employes, 559, 561, 562, 563; physical conditions of work, 567-68; physical examinations, 560; regularization of employment, 561-62; supervision, 562, 565-66; type of worker, 561, 562, 563; uniforms, 560 See also Medical service in industry; Small industrial establishments Industrial health supervision, see Medical service in industry Industrial hospitals, 552 Industrial hygiene survey, purpose and methods, 525 Industrial medical records, forms used, 538-39; lack of essential data, 537; standards for, 537-38; value in pre- paring accurate reports and tables, 539 Industrial nurses, administration of medi- cation by, 530; contribution to in- dustrial hygiene, 529-30; home visit- ing by, 531; need for counsel and technical assistance, 531; number, 803; some causes of failure, 806-7; training, 529,553; type of service, 804-6; used for absence follow-up, 531-32 Industrial Nurses' Club, value of, 531 Industrial ocular service, importance, 545-46; need for eye hospital, 546 Industrial physicians, in advisability of combining official and personal prac- tice among employes, 528; special training, 553; types, 527 Industrial psychiatry, value, 544-45 Industrial unrest, 544-45 Industrial visiting nursing, 531, 777 Industry, its interest in health of employes, 557, 558 Infant care, carried on thro 14 health centers, 280, 761-62; committee on, 283; field not covered by health cen- ters, 281; "generalized" '[nursing un- fortunate type in, 281; great value of home visiting by nurses, 282-83; im- portance of breast feeding, 282; meas- ure of its effectiveness, 319; need for agency to supply wet nurses, 283; number of children in need of, 281; recommendations, 283-84; too great emphasis placed on artificial feeding, 282. See also Bureau of Child Hy- giene; Health Centers Infant mortality, reduction in, 273, 282 Institute of School Hygiene, 752 Institutional deliveries, in 1919, 275-76 Institutional inspection, proposed activity for Division of Health, 173, 287 Institutions, study of, 174-85 International Red Cross, views in regard to health education, 188-89. See also, Red Cross Insanity, see Mental diseases and de- ficiency Jewish Orphan Asylum, dental service, 687 Juvenile Court, Detention Home, 481-82 management of delinquency, 480 method of disposal of cases, 480-81 need for psychiatric clinic, 481; sources of information regarding cases, 480 Laboratories supervision, 400, 416-417. See also Bureau of Laboratories Lakeside Hospital, dental service, 688; number of beds, 828; orthopedic facili- ties, 202; provisions for mental cases, 460-61; social service department, 952; study of convalescent cases, 932-34; 1072 Hospital and Health Survey dispensary: building, 893; classes of disease treated, 892; deficiencies, 897; fees and finances, 894; location, 890; medical work, 895; future plans, 919; organization, 892; orthopedic facilities, 202; patients, 893; proposed psychiatric clinic, 461; records, 895; venereal disease clinic, 401, 406-7; visits, 1919, 890; training school for nurses: organi- zation, 714; minimum entrance re- quirements, 715-16; capacity of hos- pital and services offered, 718-24; teaching of nursing procedures, 724-27, 728; teaching of fundamental sciences, 728-32; instruction in other subjects, 732-35; ratio of nurses to patients, 735-36; day duty, 736; night duty, 737-38; vacation, 738; living condi- tions, 740-41 See also University Hospital Group Lakewood Hospital, number of beds, 828; provisions for mental cases, 461; training school for nurses: organi- zation, 714; minimum entrance re- quirements, 715-16; capacity of hos- pital and services offered, 723 ; teaching of nursing procedures, 724-27; teach- ing of fundamental sciences, 728-32 instruction in other subjects, 732-35 day duty, 736; night duty, 737-38 vacation, 738; living conditions, 740- 41 Lakewood Visiting Nurse Association, affiliation, 778 Laundries, earnings of employes, 570; ob- jectional features of work, 569 ; scarcity of female labor in, 569; working hours, 570 Legislation, anti - tuberculosis, 346-47; housing, 346-47; milk, 346; relating to Bureau of Juvenile Research, 473- 74; relating to insane, 468-69; re- lating to mentally defective and epi- leptic, 469; sex delinquency, 419-24. See also Child Labor Laws; Pharmacy Laws Lutheran Hospital, number of beds, 828; plans for expansion, 968 Manufacture of hosiery and knit goods, employment of children, 590-91; Massachusetts General Hospital, ortho- pedic social service, 199 Maternity care, committee on, 278; hos- pital facilities,. 275, 279, 831; measure of its effectiveness, 319; out-patient service, 276; recommendations, 278- 80. See also Prenatal and maternity nursing service Maternity Center Association of New York City, accomplishments, 274 Maternity Hospital, number of beds, 828; nursing service, '799-801; prenatal clinics, 902-3; training school for nurses: instruc- tion, 727-28; day duty, 736; night duty, 737-38; vacation, 738 See also University Hospital Group Maternal mortality, see Mortality sta- tistics "Medical boarding house", services offered by, 825 Medical education, see School of Medicine Medical examination, see Physical exami- nations Medical Journal, 666 Medical Library Association, history and activities, 665-66 Medical practice, institutional, 822. See also Physicians Medical School, see School of Medicine Medical service in industry, administra- tive relations, 534-35; ambulance serv- ice, 533; beyond the plant, 536-37; clerical personnel, 532; cost of service, 533-34; dispensary equipment, 533; needed in small establishments, .550; number of firms offering, 526; oppor- tunities for health education, 547; physical examinations, 542-44; present inadequacy, 363; purpose and methods Index 1073 of survey, 525; quality, 526; recom- mendations, 554-56; special services, 544-47; summary of report on, 31. See also Industrial medical records; In- dustrial nurses; Industrial physicians; Small industrial establishments Medical service in non-industrial estab- lishments, 535-36 Medical service in schools, see School health supervision Medical social service, 895-96; assistance in cases of chronic illness, 947; for cardiac patients, 218-19; at City Hospitals elsewhere, 956; City Hos- pital, 953, 955; cooperation with charitable agencies, 956-57; develop- ment, 952; functions, 954, 958, 959-60; • lack of definite policy, 953-54; Lake- side Hospital, 952; for orthopedic cases, 203-6, 207; Mt. Sinai Hospital, 952; needed for convalescent care, 930, 932; problems, 954-55; recommenda- tion, 955; St. Vincent's, 952, 953; value in orthopedic departments, 199 Medical staff appointments, see Hospitals Medico-social service, contribution to study of, 25 Mental diseases, need for local society for prevention of, 225 Mental diseases and deficiency, com- plaints in regard to provisions for, 444- 45; methods of dealing with problems presented, 443; part played in prob- lems of social agencies, 497; preven- tion, 501-2; recommendations, 503-11; scope of survey, 444; summary of re- port on, 31; city facilities for care: dispensaries, 462; hospitals, 446-47, 458-62; infirm- ary, 465-66; jail, 464-65; private sanitaria, 462-64 state facilities for care: Board of Administration, 467-68; Bureau of Juvenile Research, 473-75; Hospital for Epileptics, 473; hospitals for in- sane, 469-71 ; Institution for Feeble- minded, 471-73; laws, 468-69 See also Courts ; Correctional agencies ; Red Cross; Associated Charities; Humane Society; Women's Protec- tive Association Mental hygiene, 501-2 Mental medicine, facilities for teaching 460-61; lack of attention given to problem of, 460 Mentally atypical children, in schools, 488-96 Mentally defective, estimated number in state and city, 471-72 ; laws relating to, 469; need for supervision, 472, 495-96; need for increased institutional pro- vision, 472; special classes, 488-90; state institution for, 471; two out- standing needs in care of, 473; work permits, 490-93 Mercantile establishments, earnings of em- ployes, 568, 569; educational depart- ments, 568; employment of children, 592-93; health departments, 568; hours of work, 568; number of women employed, 568 Metal trades, accident hazard, 560; acci- dent incidence, 542; employment of boys, 591; number of children em- ployed, 591; women employes: earnings, 561; hours of work, 561; nature of [work, 560; number, 559; physical examina- tion, 560; type, 561; uniforms, 560 Midwifery, comparison of courses in, 277 Midwifery control, evils of present system, 277-78; suggested program, 279-80 Midwives, inadequate supervision, 277; number,'277; social need filled by, 277; stringency of regulations for licensing, 277; supervision, 762 Milk, dietary and nutritional value, 348, 351-52; results from study of its con- sumption, 348-51; the problem in Cleveland, 347. See also Legislation 1074 Hospital and Health Survey Milk supply, control, 148-49, 150-51; in hospitals, 888-89; reasons for unsatis- factory condition, 154; results of bac- teriological examinations in March and June, 1920, 151-53 Modern hospital, services offered, 825 Morbidity statistics', compilation, 169; contagious diseases of children, 284- 85; ratio of active tuberculosis cases to deaths, 345; reporting of tuber- culosis, 343, 345; venereal diseases, 398 Mortality statistics, general death rates, 1910-19, city, 338; heart disease death rate for state and city, 213; leading causes of death in city and state, 339; maternal, 274 tuberculosis: at Division of Health, 357; distribution of deaths by age, sex, occupation and form, 342-43; death rates, 1865-1911,, 339; residence factor in figures, 343 Mosquitoes, 83-84 Mothers' pensions, inadequacy, 575 Mount Sinai Hospital, number of beds, 828; orthopedic facilities, 202; pro- visions for mental cases, 461 ; social service departments, 952; study of convalescent cases, 934-35; dispensary: building, 893; classes of disease treated, 892 ; deficiencies, 897; dental clinic, 686-87; fees and finances, 894; location, 890; medical work and records, 895; organization, 892; ortho- pedic facilities, 202; patients, 893; social service, 895-96; venereal disease clinic, 401, 408; training school for nurses: organi- zation, 714; minimum entrance re- quirements, 715-16; capacity of hos- pital and services offered, 718-24; teaching of nursing procedure, 724-27, 728; teaching of fundamental sciences, 728-32; instruction in other subjects, 732-35; ratio of nurses to patients, 735-36; day duty, 736; night duty, 737-38; vacation, 738; provision of ward helpers, 738-40; living condi- tions, 740-41 Mouth hygiene, need, 686; value, 685 Mouth Hygiene Association, activities, 689; clinics at Health Centers, 684, 903-4; extension of dental service needed, 685 Municipal Court, need for psychiatric clinic, 478-79; Parole Board, 479-80; work of Probation Officer, 479 New York City, hospital service per 1000 population, 830 New York State, provisions for licensing and inspecting private institutions for mental cases, 463 Night work, its problem, 571-73 Northern Ohio Druggists' Association, co- operation with Division of Health, 694 Nursing, summary of report, 32-33. See also Nursing education; Public health nursing; Private duty nursing Nursing education, recommendations, 741- 45 ; standards of comparison for study, 709-10; study by Committee on Nurs- ing Education, 712. See also Univer- sity School of Nursing; Hospital training schools; University course in public health nursing; Institute of School Hygiene Nutrition classes, 295, 362 Occupations employing children, 588-89; comments of employers, 596; educa- tional requirements, 595-96; functions of medical service, 591; health haz- ards, 592, 593-94, 596-97; hours of work, 589; nature of work and oppor- tunity for advancement, 590-95; wages, 589 Ophthalmia neonatorum, see Prevention of blindness Open-air classes, 293-94, 362 I X D E X 1075 Orthopedic center, association with down- town clinic, 200, 923; central brace shop, 200-1; main physiotherapeutic plant, 200; organization, 208-9. Orthopedic Council, responsibility for all medical and social follow-up work, 208 Orthopedic organization, functions and essentials for fulfillment, 198-99 Orthopedic surgery, at Medical School, 197, 201-2, 207-8; convalescent beds needed, 199-200; hospital beds, 832; departments in general hospitals, 199; field, 197-98; functional rehabilitation of injured wage-earners, 198; need for children's service, 199; number of specialists, 197, 663; possibilities, 197; value of social service in clinics, 199 Outdoor Relief Department, admission routine for Infirmary, 949 Out-patient departments, see Dispensaries Parochial schools, dental service, 685; medical inspection, 288, 301; nursing service, 763 Patent medicines, advertisement, 675; capital invested in manufacture and sale, 161-62; cooperation of druggists and City Chemist regarding, 694; distribution and sale, 162-63; manu- facture, 162; need for classification, 162; recommendations, 164, 682; local situation, 163-64 Per capita per diem cost, in hospitals, 869-70, 878-79 Pharmacists, indispensable auxiliaries to physicians, 691; number registered, 691 Pharmacy, recommendations, 697-98; summary of report, 32 Pharmacy laws, 691-94 Physical defects, correction, 290-92, 784- 85; emphasis on prevention, 308; in- cidence in school children by age periods and sex, 304 Physical examinations, for hospital per- sonnel, 888; in industry, 542-44; for city employes, 185-86, 544; for oper- ators of conveyances, 544; for food- handlers, 543. See also School health supervision Physiotherapy, care provided by Associa- tion for Crippled and Disabled, 206; main and branch plants, 200; present facilities, 202-3, 207 Physicians, diagnostic training for, 366; foreign-born, 863; hospital staff ap- pointments, 664, 858, 860; negro, 863; number and classification by specialty, 663; professional oppor- tunities, 664, 666-67; professional or- ganization, 664-66 Pilgrim Church, nursing service, 777-78 Playgrounds, streets used as, 67 Police Department, see Division of Police "Police Emergency", method of sending in calls, 961 ; provisions for ambulance service, 962-63; stigma attached to use of, 963-64; used as ambulance, 961 Population, history of city's growth', 39 Population statistics, age and race distri- bution, 41 ; city and county subdivi- sions, 1918, 44-45; city and suburbs, 1900-18, 41-42; density, 42-43 Post-mortem examination, see Autopsies Prenatal and maternity nursing service, 902-3; present facilities, 797; types of cases in need of, 797-98; types of care needed, 798; agencies considered for city-wide, 798-803; recommendations, 803 Prenatal care, clinics, 274, 826, 902-3, 986; committee on, 274; measure of effectiveness, 319; need for increase of facilities, 274; number of mothers provided for in 1919, 273; object, 273; plan for city-wide service, 274-75; 797-803, 902-3; present provisions, 1076 Hospital and Health Survey 273; recommendations, 274-75; re- duction in death rate from puerperal sepsis, 274; reduction in infant mor- tality, 273; reduction in stillbirth rate, 274. See also, University District; Division of Health, nursing service; Visiting Nurse Association Pre-school age care, gap in child health program, 285; lack of facilities, 285; measure of its effectiveness, 319; need for, 284-85; recommendations, 285-87 Prevention of blindness, 793; activity of Division of Health, 762 ; program pre- pared by the national committee, 195-96; results from follow-up of ophthalmia neonatorum cases, 278 Prevention of disease, devices for, 26-27 Printing and publishing, employment of children, 592 Private duty nursing, study of unneces- sary employment of full-time graduate nurses, 808-9; employment of trained attendants, 809-10 Probate Court, cost of committing mental cases, 477-78; function in regard to mental cases, 476; method of com- mitment of mental cases, 476-77 Provident Hospital, number of beds, 828 Psychiatric clinics, in general hospitals, 461-62; needed in connection with courts, 479, 481, 486; proposed uni- versity, 461, 462; of Red Cross, 497 Psychiatry, definition of, 545. See also, Industrial psychiatry; Mental medi- Psychological clinic, 462, 486, 488 Psychology,' definition of, 544-45 Psychopathic hospitals, see City Hospital; State Psychopathic Hospitals Public Health Association, 980; recom- mendation for creation, 104; section on Child Hygiene, 270 Public health education, see Health educa- tion Public health nurses, present number in- adequate, 366 Public health nursing, elements of success, 753, 754; scope of survey, 753. See also Division of Health; Depart- ment of Medical Inspection; Visiting Nurse Association; University Dis- trict; Industrial nurses; Generalized public health nursing; Central Com- mittee on Public Health Nursing; Pre-natal and Maternity service; Uni- versity course in public health nursing Public health organization, additional non-official agencies needed, 212; im- portance, 25; official and non-official, 103 Public service organizations, employing women, 569-71 Public utilities, employing women, 571 Pure Food Law, provisions of, 675 Quacks, dental, 683-84; medical: peril to immigrant, 672; advertisements in foreign-language newspapers, 672-73, 679-82; expert psychologists, 678; methods of evad- ing the law, 673; methods of appeal, 674-75; instrument for detection of, 676; recommendations, 682 Rabies, control, 137; 149-50 Rainbow Hospital, convalescent care, 203, 941; enlargement of scope of work suggested, 942; facilities for care of non-pulmonary tuberculosis, 361; limited in field of action, 207; number of beds, 828 Rapid Transit Company, quotation from report, 43 Recommendations, 55-56, 59, 66, 81-82, 83-84, 90, 104, 141-42, 164, 172, 176- 77, 184-85, 189, 190, 191, 209-12, 219- Index 20, 226-28, 274-75, 278-80, 283-84, 285-87, 287-88, 301-18, 334-35, 370-76, 401, 403-4, 404, 406, 407-8, 409, 412, 421-22, 503-11, 554-56, 575-76, 619-21, 669-71, 682, 690, 697-98, 741-45, 751- 52, 757-58, 769-73, 781-82, 788-89, 796-97, 803, 887-88, 910-11, 917, 964- 65; summary, 35-38 Recreation, employment of a director, 429; importance in venereal disease cam- paign, 395, 429; suggested improve- ment of facilities, 396 Red Cross, health education, 314, 363; neuro-psychiatric clinic, 497. See also International Red Cross Restaurants, earnings and hours of work of waitresses, 571 Rubbish and ashes, 73-75, 80-81; recom- mendations, 81-82 St. Alexis Hospital, number of beds, 828; orthopedic facilities, 202, 203; out- patient department needed, 918-19; training school for nurses: organiza- tion, 714; minimum entrance require- ments, 715-16; capacity of hospital and services offered, 718-23; teaching 727; day duty, 736; night duty, 737- 38; vacation, 738; living conditions, 740-41 St. Ann's Maternity Hospital, number of beds, 828; training school for nurses: teaching of nursing procedures, 727-28; day duty, 736; night duty, 737-38; vaca- tion, 738; St. Clair Hospital, number of beds, 828 St. John's Hospital, number of beds, 828; orthopedic facilities, 202; out-patient department needed, 918; provisions for mental cases, 461; training school for nurses: organiza- tion, 714; minimum entrance require- ments, 715-16; capacity of hospital and services offered, 718-23; teaching of nursing procedure, 724-27; teaching 1077 of fundamental sciences, 728-32; in- struction in other subjects, 732-35 ratio of nurses to patients, 735-36 day duty, 736; night duty, 737-38 vacation, 738; living conditions, 740- 41 St. Luke's Hospital, dental service, 687; number of beds, 828; orthopedic facili- ties,\202; plans for expansion, 967; dispensary: building, 893; classes of disease treated, 892; deficiencies, 897; fees and finances, 894; future plans, 919; location, 892; medical work and records, 895; organization, 892; patients, 893; social service, 895-96; visits, 1919, 890; training school for nurses: organiza- tion, 714; minimum entrance require- ments, 715-16; capacity of hospital and services offered, 718-24; teaching of nursing procedures, 724-28; teaching of fundamental sciences, 728-32; in- struction in other subjects, 732-35 ratio of nurses to patients, 735-36 day duty, 736; night duty, 737-38 vacation, 738; living conditions, 740-41 St. Vincent's Charity Hospital, dental service, 688; number of beds, 828 social ^service department, 952, 953 study of convalescent cases, 928-30 dispensary: building, 893; classes of disease treated, 892; deficiencies, 897;' fees and finances, 894; location, 890 ; v medical work and records, 895; organization, 892; orthopedic facili- ties, 202; patients, 893; social service, 895-96; venereal disease clinic, 401, 408, 409; .visits, 1919, 890; training school for nurses: organiza- tion, 714; minimum entrance require- ments, 715-16; capacity of hospital and services offered, 718-23; teaching of nursing procedure, 724-27; teaching of fundamental sciences, 728-32; in- struction in other subjects, 732-35 ratio of nurses to patients, 735-36 day duty, 736; night duty, 737-38 vacation, 738; living conditions, 740 41 1078 Hospital and Health Survey Sanitaria, for mental cases, 462-64 Sanitary areas, definition, 42; number, 46; reasons for adoption, 114-15 Sanitary Code, 119; authority for control of acute communicable disease, 122; regulations in regard to communicable diseases, 123-24; suggested section about laboratory and dispensary super- vision, 416-18i Sanitary Index, 127 Sanitation, see Collection and disposal of garbage; Collection of rubbish and refuse; Flies; Housing; Mosquitoes; Smoke; Water supply; Milk supply Schick test, used in institutions, 126 School attendance department, 583, 586 School doctors, see Department of Medical Inspection School for deaf, 294 School health supervision, measure of its effectiveness, 319; parochial schools, 288, 301, 763; private schools, 301; recommendations, 301-18; public schools: health education, 297; lack of coordination of different types of health work, 301-2; medical inspections, 288-96; physical training, 296-97, 312-13; sanitary supervision, 297-301; nursing service, 782-88 School hygiene, see Department of Build- ings School nursing, see Department of Medical Inspection School of Medicine, community relations, 655-56; curriculum and instruction, 656-59; Dean, 659; deficient recogni- tion of many specialties, 651; depart- mental distribution of teaching staff, 660; distribution of graduates, 660-61; educational vJue of hospital and dis- pensary, 863-65; facilities for clinical teaching, 653; faculty organization, 657-58; graduates on hospital staffs, 860; history, 659; hours of work re- quired, 660; inadequacy of educa- tional facilities in orthopedics, 207-8; lack of recognition of orthopedics, 197; post-graduate instruction, 662; facili- ties for teaching mental medicine, 460-61 ; problems of construction and endowment, 653-55; proposed depart- ment of industrial hygiene, 553, 656; recommendations, 669-71; statistics, 661-62; suggested activities in re- search and teaching, 368 School of Pharmacy, faculty, 695; finances, 695; history, 694-95; hos- pital service offered by, 696-97, 875- 76, 885; needs, 695-96; standard, 697 Sewage disposal, 60-66; recommendations, 66 Sex delinquency, institutional care of offenders, 430; laws and machinery for enforcement, 419-27; preventive work, 429; probation work, 425, 429; protective work, 425, 429-30 Sex education, method for control of venereal disease, 396; for children, 431-32; for young men and women, 432; permanent measures for, 432-33; social hygiene information for parents and leaders of public opinion, 432 Shortage of labor, reasons, 559 Sickness, cost, 26; relation to dependency, 26; three services necessary for care and prevention, 26; studies of, 819 Sickness incidence, see Industrial accident and sickness statistics Small industrial establishments, 550-51 Smallpox, problem, 126-27 Smoke, effect of air pollution on health, 88; effect on climate, 47; necessity for prevention, 85; present expendi- tures for prevention, 89; present or- ganization for prevention, 88-89; rec- ommendations, 90; soot-fall studies, 85-87 Index 1079 Smoke investigation of Pittsburgh, quota- tion from Bulletin S, 85 Social hygiene, see Venereal diseases; Sex education Social service, see Medical social service Social Service Clearing House, functions, 958-59; suggested extension of scope, 935; use, 959 Society for the Blind, 193-95 Soot-fall studies, analyses, 86-87; appa- ratus used, 86; extent, 86; purpose of, 86 State Board of Administration, direction of care of insane, 467-68 State Board of Pharmacy; lack of in- spectors, 693 State Bureau of Juvenile Research, 473- 74 State Dental Practice Act, need for amendment, 683 State Department of Health, registration of hospitals and dispensaries, 822; suggested extension of supervisory powers, 979-80 State Fire Marshal, control over sanitaria, 463 ; responsible for health among food handlers, 544, 570 State Hospital for Epileptics, 473 State Hospital for Insane, dental service, 688; description, 470-71; facilities for care of tuberculosis cases, 360 State Industrial Commission, analysis of reportable accidents, 540, 550; Depart- ment of Factory Inspection, 583, 586, 587; hospital rates for accident cases 872; powers to safeguard health and safety of working-people, 553; statis- tics for eye injuries, 546 State Institution for Feeble - minded, capacity, 471 State Medical Board, detection of quacks, 676 State Psychopathic Hospitals, description of one located in city, 470-71; need for second in city, 470; number, 469-70. See also State Hospital for Insane State Sanatorium, 360 Statistics, health districts used as basis in report, 42; list of statistical tables, 19-20; list of graphs, 21-22; wastage from sickness and premature death, 25-26. See also Children and industry; Federal Eureau of Labor Statistics; Hospital statistics; Industrial acci- dent and sickness statistics; Popula- tion statistics; Vital statistics Statistical analysis, importance, 338 Street cleaning, 78-82 Street trades, extent and general charac- ter of newsboy trade, 599-601; ordi- nance, 597-98; reasons for non- enforcement of ordinance, 598; recom- mendations, 601-2; undesirable nature of wcrk for children, 598-99 Surveys, child health, 1006; industrial hygiene, 1006; mental hygiene, 1006; Pittsburgh, 1006; sickness, 1006; social, 1006; Springfield (Illinois), 1006; I tuberculosis, 1006. See also Health administration surveys Syphilis, see Venereal diseases Telegraph work, employment of children, 595; number of women employed, 571 Telephone work, employment of giris under 18, 593; earnings, 571; health hazard, 571, 594; hours of work, 571; scarcity of operators, 571 Textile and knitting mills, health and accident hazards, 561; number of women employed, 561 1080 Hospital and Health Survey Tobacco factories, difficulty of learning trade, 563; number of women em- ployed, 563 Topography, 46 Tuberculosis, detection, 365-66; equip- ment for control, 331, 346; expert consultation service needed in indus- try, 547; follow-up of cases, 367; im- mediate needs for prevention and control, 332-34; importance of ma- terial relief in treatment, 367; impor- tance of nursing in treatment, 366; institutional care, 357, 360-62; means of prevention, 364-65; past accom- plishments in control, 331-32; preva- lence in industry, 546; recommenda- tions, 334-35, 370-76; research and teaching, 368; summary of report, 30; treatment, 366-67; work at health centers, 344, 355. See also Health edu- cation; Legislation; Morbidity sta- tistics; Mortality statistics Tuberculosis nursing, 356-57; 366-67; 760-61; 775; 791-92 Tuberculosis survey, methods, 336-37; primary objects, 336 Undertakers, ambulance service, 961 United States Home Registration Service, quotation from report on Housing Conditions of War Workers, 43 United States Marine Hospital, provisions for mental cases, 461-62 United States Public Health Service, ac- tivity in combating venereal diseases, 547 University course in public heal th'nur sing, field work, 748-51; finances, 746; in- struction, 748; measure of success achieved by, 751; organization, 745- 46; origin, 745; staff, 746-47; stu- dents, 747-48 ^recommendations. 751- 52 University District, a community service, 789-90; description, 115-16; factor in success of public health nursing course, 746; plan of administration, 790; prac- tice field for public health nursing course, 745; recommendations, 796-97; results of prenatal care in, 273, 274; staff, 790; summary of work, 795-96; supervision, 795; supervision of work of students in University course, 747, 749-50; activities: visiting nursing, 790-91; child hygiene, 791; tuberculosis, 791- 92; communicable disease control, 793; prevention of blindness, 793; supervision of boarding homes, 793; prenatal nursing, 793-94; school nurs- ing, 794; clinics, 794-95, 902-3 University Hospital Group, 967; order of precedence in erection, 654-55 University psychiatric clinic, 461, 462 University School of Nursing, a shorter basic training for nurses, 712; im- portant contribution to solution of problem of nursing education, 710; recommendations, 741-42; some bene- fits, 710-11; special function, 711-12 Vaccination, 126-27 Venereal diseases, diagnosis, 400-1; draft board figures for, 398; follow-up of treatment, 414-16; hospital beds for care of, 401-2, 410, 832; method of combating in industry, 547; preva- lence, 398-99; prevention, 411-12; recommendations, 401, 403-4, 406, 407-8, 409, 412, 421-22; summary of report, 30; treatment by private physicians, 402-3; treatment in dis- pensaries, 401, 404, 406-9; control: campaign for, 410-11; methods, 396-97, 429-30; needs, 225, 395-96; past accomplishments, 395; present facilities, 395 See also, Sex delinquency, Sex educa- tion; Recreation Index 1081 Venereal Disease Bureau, proposed or- ganization, 413-14 Ventilation, in hospitals, 889; in schools, 298 Vice conditions, investigation, 427-28 Vice investigation, proposed committee for, 426-27 Visiting Nurse Association, 193, 214; ad- ministration, 778-81; agency for city- wide prenatal service, 802-3; care of chronic illness, 944; experience with trained attendant service, 810; pres- ent equipment, 774; recommendations, 781-2; scope of work, 773-74; sug- gested annual classification of patients, 945; activities: care of sick, 774-76; prenatal nursing, 776; maternity serv- ice, 776-77; industrial nursing, 777; out-patient maternity affiliation, 777; Pilgrim Church service, 777-78; serv- ice outside city, 778 Vital statistics, definition, 165; state law regarding, 167; suggestion for institu- tion of a system, 167-72. See also Birth registration, Morbidity statistics; Mortality statistics Vocational guidance, advantage of bu- reaus connected with schools, 616; development in England and the United States, 615; need, 596-97; outline for department, 617-19 Vocational therapy, facilities, 205 Vocational training, 614 Warrensville Children's Camp, 361 Warrensville Tuberculosis Sanatorium, case bookkeeping, 368; living condi- tions, 367: location and equipment, 357, 360; method of admission, 366; number of beds, 361, 828; per cent of cases leaving, 367-68 Water supply, 57-59; in hospitals, 889; recommendations. 59; summary of results of examination of city water, 1919, 159 Welfare Federation, 197, 499; appropria- tion of money to dispensaries, 920; establishment of expert accountant service, 870-71; functions, 980-81; history, 104-6; present equipment for public health service, 104; proposed organization for health service, 104; publicity service, 876, 978 Western Reserve University, education subject to three main limitations, 651; feeling" of public for, 652; lack of in- struction in bodily mechanics, 198; material resources for teaching and research, 652; only local institution preparing physicians, dentists and pharmacists, 651; trustees, 652. .See also m University School of Nursing Wet" nurses, see Infant care Wholesale and retail trade, see Mercantile establishments Woman's Court, 424-25; establishment, 427 Woman's Hospital, number of beds, 828 Woman's Police Bureau, 424-25; func- tions, 429 Women's Protective Association, 425, 429; need for facilities for mental examina- tions, 499; social investigations for Probate Court, 476 Women's work, method of surveying, 558 Women and industry, day nurseries, 574- 75; home work, 573-74; mothers' pensions, 575; night work, 571-73; recommendations, 575-76; summary of report, 31. See also, Industrial es- tablishments; Mercantile establish- ments; Public service organizations; Public utilities 1082 Hospital and Health Survey Work permits, examination made by De- partment of Medical Inspectio n, 605-6 ; Federal Children's Bureau health standards for children entering in- dustry, 603-4; information as to mental deficiencies, 608-9; issuance by Department of Medical Inspection , 606-7; for the mentally defective, 490-93 Working environment of women, reasons for safeguarding, 557 Workmen's Compensation Act, 543 Year Book, suggested publication, 171 Zone, definition of term as used in Child Health report, 272 Zoning ordinance, advantages, 48 THE CLEVELAND HOSPITAL AND HEALTH SURVEY REPORT List of Parts and Titles I. Introduction. General Environment. Sanitation. II. Public Health Services. Private Health Agencies. III. A Program for Child Health. IV. Tuberculosis. V. Venereal Disease. VI. Mental Diseases and Mental Deficiency. VII. Industrial Medical Service. Women and Industry. Children and Industry. VEIL Education and Practice in Medicine, Dentistry, Pharmacy. IX. Nursing. X. Hospitals and Dispensaries. XL Method of Survey. Bibliography of Surveys. Index. The complete set may be obtained at a cost of $5.50 plus the postage and single parts at 50 cents each plus the postage, from THE CLEVELAND HOSPITAL COUNCIL, 308 Anisfield Building, Cleveland, Ohio Printed by The Pbemieb Pbess Cleveland, O.