COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD 
 
 HX00030520 
 
 IKi 
 
 The Tuberculosis Problem 
 in Rhode Island 
 
 Ml 
 
 1920 
 
 § 
 
<j7.:s^XAVii<r^ 
 
 KC3(I W73 
 
 Columlria (Hnitier^itp 
 mtljfCttpoflfttitork 
 
 College of ^fjpgicianjs anb g'urgeonfi 
 Hibrarp 
 
 P^WW/is Z. CUnJIer 
 
THE TUBERCULOSIS PROBLEM 
 IN RHODE ISLAND 
 
 A Survey Conducted for the 
 Rhode Island Tuberculosis Association 
 
 BY 
 
 C.-E. A. WINSLOW, Dr.P.H. 
 Professor of Public Health, Yale School of Medicine 
 
 ASSISTED BY 
 
 WILLIS E. CHANDLER 
 
 1920 
 
 Cbe (Providence Ipress: 
 Snow & Farnham Co., Printers 
 
November 24, 1920 
 Mr. Frank N. Phillips, 
 
 President, Rhode Island Tuberculosis Association, 
 Providence, R. I. 
 Dear Mr. Phillips: 
 
 I am enclosing herewith a report on the tuberculosis problem in 
 Rhode Island, prepared in accordance with a request made last 
 spring by the executive committee of the Rhode Island Tubercu- 
 losis Association. 
 
 I have attempted in the survey, upon which this report is based, 
 to estimate the extent, and, so far as possible, the character, of the 
 anti-tuberculosis work carried on by various agencies in the State 
 and to measure this work by objective quantitative standards. I 
 have made four visits to Rhode Island, spending two days in the 
 State on each occasion and have visited the principal clinics, hos- 
 pitals and nursing centers of the State and interviewed the leaders 
 in the anti-tuberculosis movement in Providence, Pawtucket, Woon- 
 socket, Newport, the Pawtuxet Valley and Wallum Lake. The 
 statistical material has been prepared in accordance with my sug- 
 gestions by Mr. Willis E. Chandler, the executive secretary of your 
 association, and I wish to express my warm appreciation of the 
 faithful and effective work which he has done in collecting and analyz- 
 ing it. I wish also to record my gratitude for the assistance rendered 
 by the officials of the State Board of Health, the State Sanatorium 
 at Wallum Lake, the City Health Department of Providence, the 
 Providence District Nursing Association, the Providence Tubercu- 
 losis League, and of many other medical and nursing organizations 
 throughout the State, who have courteously furnished me with 
 data, in some cases at very considerable expenditure of time and 
 trouble. 
 
 On the basis of my findings I have attempted to formulate a gen- 
 eral program for the development of anti-tuberculosis work in 
 Rhode Island, which I trust may receive the consideration of your 
 association, and of the other official and private agencies engaged in 
 this campaign. I believe that the suggestions made are moderate 
 and conservative; but I think that, if adopted, they will lay the 
 foundation for the development of an anti-tuberculosis program 
 
in advance of any that has yet been carried out on a state-wide 
 basis. Rhode Island has unusual opportunities for building a com- 
 plete tuberculosis program, in view of its excellent sanatorium and 
 of the fine clinic and nursing service which has been organized in 
 the city of Providence. These opportunities are not, however, at 
 present fully utilized and the unusually high tuberculosis death rate 
 of the State makes it imperatively necessary that action should be 
 taken to improve existing conditions. Rhode Island has the oppor- 
 tunity to set an example, — to show what can really be accomplished 
 in the saving of human life by a co-ordinated and effective modern 
 anti-tuberculosis program. If your association can secure the co- 
 operation of the State and local officials, and of the private agencies, 
 in bringing about this result it will have rendered a great service, 
 not only to the State but to the country as a whole. 
 
 Yours very sincerely, 
 
 C.-E. A. WINSLOW. 
 
 I. THE PRESENT STATUS OF THE CAMPAIGN AGAINST 
 TUBERCULOSIS. 
 
 The official campaign against tuberculosis in the United States 
 began in organized and definite fashion with the program formu- 
 lated (under the inspiration of Dr. Hermann Biggs) by the New 
 York City Health Department in 1894. The movement spread be- 
 yond the field of administrative effort and became a far-reaching 
 popular propaganda, with the organization of the National Tuber- 
 culosis Association in 1904. 
 
 At the time the national association was formed the attempt to 
 control tuberculosis was regarded as on the road to phenomenal suc- 
 cess. The death-rate from all forms of this disease in the Regis- 
 tration Area had decreased from 326.2 in 1880 to 201.2 in 1900. 
 Dr. Samuel W. Abbot, Secretary of the Massachusetts State Board 
 of Health, predicted that tuberculosis sanatoria would some day 
 remain, like the pest-houses of the middle ages, as monuments to 
 a disease which was only of historical interest. Today the situa- 
 tion is a very different one. The reduction in the death-rate has 
 slackened. A remarkable drop did indeed take place in 1919, for 
 reasons which cannot be evaluated until full statistical data for 
 both 1919 and 1920 are available. Between 1910 and 1918, how- 
 ever, the rate for the Registration Area, for tuberculosis of all 
 
 3 
 
forms, fell only from 160.3 to 148.0. A certain apathy has crept 
 over the unofficial organizations created to deal with this problem; 
 and the healthy departments of most states and cities place little 
 stress upon this disease in their administrative programs. Among 
 leading experts on tuberculos's there has developed an attitude of 
 uncertainty in regard to the fundamental scientific basis of the 
 whole campaign against this disease, — a tendency to attribute past 
 reductions to hypothetical alterations in the biological character- 
 istics of the tubercle bacillus or the human being or to general al- 
 terations in social and economic conditions, — and a scepticism as 
 to the feasibility of taking any definite steps at all toward the pur- 
 poseful control of tuberculosis. 
 
 A full survey of available scientific knowledge, and of accumu- 
 lated practical experience, does not appear to justify an attitude of 
 non possumus. It seems clear from recent researches that in most 
 urban and semi-urban communities the vast majority of children 
 acquire infection with human or bovine tubercle bacilli before the 
 age of fifteen years. A certain proportion succumb to massive in- 
 fection during this period, since in individuals unprotected by mild 
 chronic infection tuberculosis runs a rapid and fatal course. The 
 actual number of deaths from tuberculosis of all forms in New York 
 City between 1913 and 1917 was greater under 1 year of age than 
 for any other year of life outside of the quinquennium, thirty-five 
 to thirty-nine. In England and Wales, for the same period, the 
 number of deaths under 1 year of age was vastly in excess of that 
 recorded for any other year of life. Individuals who do not suc- 
 cumb in infancy or childhood acquire a relative immunity; and 
 tuberculosis in adult life results from a breakdown of this immunity, 
 due to a lowering of general vital resistance, or perhaps to an un- 
 duly heavy new infection from without. We may avoid on the 
 one hand the extreme view that tuberculosis in adults is never due 
 to fresh infection of external origin; and we may perhaps doubt the 
 supreme importance placed on the hospital isolation of advanced 
 cases by others. The safe middle course is to conclude that ex- 
 posure to massive infection, either with the human or the bovine 
 bacillus, is probably dangerous to adults and is certainly dangerous 
 to children. In order to deal effectively with this factor of infec- 
 tion we need to secure: 
 
 (a) The pasteurization of all milk used by children, except that 
 from tuberculin-tested herds. 
 
(b) The education of all open human cases of tuberculosis in 
 regard to the steps necessary for the protection of family and asso- 
 ciates from infection. 
 
 (c) The provision of hospitals for the care of patients who can- 
 not be kept at home without danger to others, and particularly to 
 children. 
 
 (d) The forcible isolation of the few indi\iduals who wilfully 
 or carelessly fail to take the precautions necessary for the safe- 
 guarding of others. 
 
 Passing from the problem of infection to that of resistance, it is 
 clear that in settled communities the vast majority of healthy adults 
 have acquired a relative immunity to tuberculosis and it is highly 
 probable that a failure of vital resistance is in most cases the de- 
 termining factor, which transforms a latent infection into active 
 clinical disease. Overwork, underfeeding, illness of other types, 
 alcoholism, industrial dusts, these are the chief agents which cause 
 the lighting up of isolated local lesions into an acute disease process. 
 In dealing with adult tuberculosis, in communities where tubercu- 
 lous infection is common, the development of general and individual 
 resistance is our chief weapon. The following measures are essen- 
 tial to this portion of the program: 
 
 1. For the community as a whole; 
 
 (e) The building up of vital resistance among the individual 
 members of thecommunity by maintaininga high social and economic 
 standard of li^'ing. 
 
 (f) The dissemination of knowledge in regard to personal 
 hygiene, including the hygiene of nutrition, air conditioning, exer- 
 cise and rest, and of a knowledge of the early signs and warnings of 
 tuberculous disease. 
 
 (g) The control of industrial processes which invoke the ex- 
 posure of the worker to hard crystalline dusts, a hazard of the first 
 importance as a contributory factor in tuberculosis, 
 
 2. For the infected individual; 
 
 (h) The prompt detection, through skilled pri\ate medical at- 
 tendance and ani|)le free dispensary service, of cases of tubercu- 
 losis in their early and curable stages. 
 
(i) Organized machinery for searching out probably infected 
 individuals in the entourage of known cases and for bringing such 
 individuals to physicians or dispensaries for prompt examination. 
 
 (j) The systematic supervision of patients living in their homes, 
 through regular contact with dispensaries and through regular visits 
 for home instruction by trained public health nurses. 
 
 (k) Sanatorium treatment for all patients who cannot main- 
 tain a high standard of hygienic living in the home. 
 
 (1) Supervision by public health nurses of all cases discharged 
 from sanatoria and the provision for such cases of an environment 
 in which normal family life may be maintained with a maximum 
 of self-support, and yet in a physical and social environment which 
 permits and facilitates hygienic living. 
 
 The program outlined above is essentially implied in the more 
 modern legislation regarding tuberculosis. Thus Sir Arthur News- 
 holme (Public Health and Insurance) says, 
 
 "Under the English Tuberculosis Regulations the medical officer of health 
 or an officer of the local authority acting under his instructions is required to 
 make such inquiries and take such steps as may be necessary or desirable for 
 investigating the source of infection, for preventing the spread of infection, 
 and for removing conditions favourable to infection. The action required in- 
 cludes inter alia 
 
 1. Attention to the personal hygiene of the patient, including instruction 
 in the necessary precautions as to coughing and expectoration. 
 
 2. Any assistance needed to ensure for the patient 
 
 (a) Skilled medical attendance and nursing as required while he is 
 
 treated at home; 
 
 (b) Institutional treatment when required; 
 
 (c) Supplementation of the convalescent patient's funds, when needed, 
 
 to obviate the necessity for him at once to embark in full-time 
 work; to provide additional bedroom accommodation when 
 needed; and to ensure that the patient and his family are not 
 undernourished or overworked. 
 
 3. Remedial action for any insanitary conditions of the home, such as un- 
 cleanliness, dampness, overcrowding; or of the patient's workplace, especially 
 for dusty occupations. 
 
 4. Examination of home contacts with the patient." 
 
 As yet however such a program remains little more than a counsel 
 of perfection, — at least in the United States. We are not securing 
 general pasteurization of milk. We are not controlling careless 
 
consumptives, or officially supervising tuberculous patients of any 
 group. We are not systematically detecting incipient tuberculosis. 
 We are getting our cases into sanatoria too late, and sending them 
 out too early. We are failing to provide the essential conditions of 
 after care. We may say of the anti-tuberculosis program as the 
 philosopher said when told that Christianity had failed, "It has not 
 failed. It has never been tried." 
 
 The Health and Community Demonstration at Framingham, 
 Massachusetts, is the first thoroughgoing attempt to carry out a 
 complete anti-tuberculosis program; and the death rate in Framing- 
 ham has fallen from 121.5 between 1907 and 1916 to 79.8 for 1917- 
 1920. (Last four months of 1920 missing.) 
 
 The results obtained in this instance are not as yet conclusive; 
 for the period of four years is too short to avoid the possibility of 
 statistical errors in so small a community. Yet, as they stand, the 
 Framingham data are most encouraging; and they are in entire 
 accord with the conclusions to be drawn from a consideration of 
 the whole body of our present knowledge. The general program 
 outlined above is indicated, by theoretical considerations and prac- 
 tical experience, as essential to success in dealing with tuberculosis,, 
 and as calculated to bring definite and tangible results if carried out 
 with reasonable effectiveness. 
 
 II. THE INCIDENCE OF TUBERCULOSIS IN RHODE 
 
 ISLAND. 
 
 Tuberculosis (of all forms) caused between 10.4 and 11.0 per cent 
 of all the deaths in the state of Rhode Island for each of the eight 
 years, 1910 to 1917. In 1918 the ratio fell to 8.6 per cent on ac- 
 count of the large number of deaths from influenza and pneumonia. 
 In this latter year (1918) tuberculosis was the third greatest factor 
 in the death-rate. In 1912, 1914, 1915 and 1916 it stood second to 
 heart disease. In 1910, 1911, 1913 and 1917 it caused more deaths 
 than any other disease. The control of tuberculosis continues there- 
 fore to be a social problem of the first magnitude. 
 
 In attempting an exact analysis of tuberculosis mortality in 
 Rhofle Island we were confronted by serious difficulties, since both 
 of the factors upon which mortality tables depend, — population and 
 reports of deaths, — were subject to some uncertaint>-. 
 
In estimating the population of the state and of its various pohti- 
 cal divisions we have at our disposal the results of three censuses, 
 the Federal censuses of 1910 and 1920, and the State census of 1915. 
 The Federal census of 1910 indicated a total population for the 
 state of 542,610. The state census of 1915, which local authorities 
 believe was conducted in a thorough and conservative fashion, gave 
 the state a population of 595,986, an increase of 53,000 in five years. 
 The Federal census of 1920 revealed a population of 604,397, an in- 
 crease of less than 9000 for the second quinquennium. The accu- 
 racy of the 1920 enumeration is questioned by local authorities and 
 it is believed by many that on account of the severe winter weather 
 during which the count was made many individuals and families 
 were overlooked. In estimating the populations for intervening 
 years one might compute from the 1910 and 1915 enumerations, 
 ignoring the last Federal census, or from the two Federal censuses 
 alone, ignoring the State census, or one might use all three. I have 
 chosen the latter course as the lesser of three evils, feeling that the 
 Federal census of 1920 could scarcely be dismissed from considera- 
 tion since it will certainly be used for offtcial statistical analj^ses in 
 the future. On the other hand there seems good reason to believe 
 that the State census of 1915 was essentially correct. The popula- 
 tion for each administrative unit for the years 1910 to 1920 has 
 therefore been computed by Mr. Chandler on an arithmetical basis, 
 using all three enumerations, and the results are presented in Table 
 I below. The effect of the discordant results of the two last cen- 
 suses is of course to produce the effect of a rapid rate of increase in 
 population between 1910 and 1915 (about 10,000 a year for the 
 state as a whole) with a slow rate of increase between 1915 and 1920 
 (less than 2000 a ^ear for the state as a whole). For the city of 
 Providence an increase of 4600 a year is indicated for the first quin- 
 quennium, and a decrease of 2000 for the second quinquennium. It 
 is possible that this represents fairly well the actual facts, since vital 
 statisticians recognize a similar reduction in the normal growth of 
 the population of other states and cities as a result of decreased 
 immigration, and increased mortality due to the war and the in- 
 fluenza epidemic. The results of the computation of population 
 made by Mr. Chandler on the basis of the three censuses are pre- 
 sented in Table I. 
 
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Our second problem was to determine the number of deaths from 
 tuberculosis which could properly be credited to each political unit 
 for each of the years covered by our study. In order to obtain 
 accurate data it was necessary to redistribute the deaths occurring 
 in institutions for the care of tuberculosis, so that they might be 
 charged to the city or town where the patient resided and was 
 taken ill. Mr. Chandler has therefore gone over in detail all the 
 records for the past ten years at Wa lum Lake, Hillsgrove and Crans- 
 ton, and at the City and Rhode Island Hospitals in Providence 
 and, after assigning each death to its place of legal residence, has 
 obtained the data presented in Table II, which we believe give a 
 true picture of the actual variations in the ncidence of tuberculosis 
 within the state. 
 
 In order to gain an idea of the general incidence of tuberculosis 
 in Rhode Island we have compared the figures for each year with 
 corresponding statistics for the Registration Area in general and for 
 the State of Connecticut, which should furnish a reasonably fair 
 basis of comparison on account of general similarity in climate and 
 in racial and social and economic conditions. 
 
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 si 
 
 
 II 
 
170 
 
 169 
 
 182 
 
 147 
 
 139 
 
 153 
 
 146 
 
 116 
 
 142 
 
 146 
 
 148 
 
 
 TABLE III. 
 Mortality from All Forms of Tuberculosis in Rhode Island, in Con- 
 necticut, AND in the Registration Area. 
 Deaths per 100,000. 
 Year 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 
 
 R. I. 181 172 160 164 160 159 
 
 Conn. 150 148 142 140 146 139 
 
 Reg. Area 160 159 149 148 147 146 
 
 Table III and Fig.l indicate a marked and continuous excess in 
 the tuberculosis death rate of Rhode Island, as compared with both 
 the State of Connecticut and the Registration Area as a whole. In 
 view of the assumption that the 1920 populat'on estimates were ab- 
 normally low I have calcu'ated what the population of the state 
 would have been in 1919 if the rate of increase indicated by the 1910 
 and 1915 censuses had been continued. Using the annual incre- 
 ment of 10,675 indicated by the two earlier enumerations we ob- 
 tain the folowing populations: 1916, 606,661 ; 1917, 617,336; 1918, 
 628.011 ; 1919, 638,686. On the basis of these populations we have 
 computed the mortality rates indicated for 1916-1919 by the dotted 
 lines in F'g. 1. E^ven on this basis it is clear that the tuberculosis 
 death-rate of Rhode Island has been consistently about 20 per 
 100,000 higher than that for the State of Connecticut or the Regis- 
 tration Area as a whole. It is very probable that this excess is due 
 to differences in racial, social or economic conditions rather than to 
 relative inadequacy in the machinery available for combating the 
 disease. Rhode Island is an intensively urban state with an un- 
 usually large foreign born population. According to the 1910 
 census, for example, 67.7 per cent of the population of Rhode Island 
 lived in cities of over 25,000 population against 48.5 per cent ki the 
 case of Connecticut; while native whites of native parentage made 
 up a smaller proportion of the population (29.5 per cent against 
 35.^ per cent) native whites of foreign or mixed parentage a larger 
 proportion (35.9 per cent against 33.6 per cent), and foreign born 
 whites a larger proportion (32.8 per cent against 29.5 per cent); 
 Rhode Island in each case being compared with Connecticut. 
 
 Whatever may be the cause of the conditions which exist, the 
 problem remains; and it is clear that Rhode Island faces, in dealing 
 with tuberculosis, a problem which is not only intrinsically of large 
 magnitude but one which is relatively more serious than that of 
 neighboring states. 
 
 12 ■ 
 
FIG. I. 
 
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 13 
 
In order to indicate more clearly the variations in incidence of 
 tuberculosis among the various political subdivisions of the state 
 the rates for the six principal cities and for the rest of the state have 
 been computed in Table IV for the two quinquennia, 1910-1914 
 and 1915-1919, and for the whole decennial period. It appears 
 from these figures that the rate in Providence has been materially 
 higher than that recorded for any other section of the state (196) 
 with Woonsocket second (173), and Central Falls (165), and Paw- 
 tucket (158) third and fourth respectively. The combined smaller 
 towns of the state have a rate well below the average (137), while 
 Newport (132) and Cranston (96) exhibit an even more favorable 
 
 TABLE IV. 
 Average Death Rate from all Forms of Tuberculosis. 
 
 
 Provi- 
 
 Paw- 
 
 Woon- 
 
 New- 
 
 Crans- 
 
 Central 
 
 Rest of 
 
 
 dence 
 
 tucket 
 
 socket 
 
 port 
 
 ton- 
 
 Falls 
 
 State 
 
 1910-1914 
 
 194 
 
 171 
 
 176 
 
 133 
 
 100 
 
 165 
 
 141 
 
 1915-1919 
 
 199 
 
 145 
 
 170 
 
 131 
 
 93 
 
 166 
 
 133 
 
 1910-1919 
 
 196 
 
 158 
 
 173 
 
 132 
 
 96 
 
 165 
 
 137 
 
 record. Marked reductions in the second quinquennium, as com- 
 pared with the first, are shown only in Pawtucket, the small towns, 
 and Cranston. Pawtucket is one of the few areas in the state 
 which showed a marked gain in population in 1920, and if this census 
 was greatly in error in Providence, Woonsocket and Central Falls, 
 but not in Pawtucket, the observed differences would be in part ex- 
 plained. The data for the quinquennium 1910 to 1914 are in any 
 case of unquestioned validity and they indicate exactly the same 
 relative rank for the six cities as the figures for the whole period. 
 
 It can not be in any way concluded that the high death rates 
 from tuberculosis in the four cities which lead in Table IV is due to 
 special neglect of anti-tuberculosis measures. On the contrary 
 Providence is better equipped with anti-tuberculosis machinery 
 than any other city and Pawtucket and Woonsocket are better off 
 than Newport or Cranston. The actual fact appears to be that 
 clinical and nursing services have been provided most freely where 
 the need was most acute, but have not yet been provided anywhere 
 in sufficiently effective concentration to effect a material impression 
 upon the mortality rates. It is also probable that the recognition 
 of tuberculosis is better in the cities and that the death rates would 
 
 14 
 
be higher in the small towns if all deaths really due to tuberculosis 
 were diagnosed as such. 
 
 In general, the variations in tuberculosis mortality correspond 
 closely to general social and economic conditions. Providence is 
 most highly urbanized and industrialized and shows the highest 
 rate. Pawtucket, Central Falls and Woonsocket naturally fall in 
 a second group, while Newport and the rest of the state are perhaps 
 characterized by a more favorable economic status and are relatively 
 free from the unfavorable conditions of urban life. Assuming, as I 
 do, that the basis of the anti-tuberculosis movement is funda- 
 mentally a sound one, two conclusions would seem warranted. 
 
 15 
 
FIG. II. 
 Tuberculosis Death Rates (per 100,000) Principal Cities. 
 Providence Pawtucket Woonsocket Newport Cranston Central Falls Rest of State 
 199 
 
 194 
 
 176 
 
 145 
 
 170 
 
 133 
 
 131 
 
 lOO 
 
 93 
 
 165, 'QS 
 
 141 
 
 133 
 
 1910 1915 
 
 1910 1915 
 
 1910 1915 
 
 1910 1915 
 
 1910 1915 
 
 1910 1915 
 
 1910 1915 
 
 to to 
 
 to to 
 
 to to 
 
 to to 
 
 to to 
 
 to to 
 
 to to 
 
 1914 1919 
 
 1914 1919 
 
 1914 1919 
 
 1914 1919 
 
 1914 1919 
 
 1914 1919 
 
 1914 1919 
 
 i6 
 
First, the four largest cities which are now carrying out organized 
 anti-tuberculosis work must increase its volume, and improve its 
 efficiency, if they are to cope with the peculiarly difficult problems 
 created by urban and industrial conditions. I know of no funda- 
 mental reason why Providence should suffer from a higher rate than 
 other eastern cities of similar size. Table V and Fig. 3 show the 
 quinquennial averages for New York City and for Providence, New 
 Haven, Rochester and Syracuse, cities of the same general class. 
 Providence stood second to New York only, in 1910 to 1914 and has 
 increased its rate from 1915 to 1919, while New York shows a sub- 
 stantial decrease. All the other three cities were well below Provi- 
 dence in 1910 to 1914 and exhibit definite reductions from 1915 to 
 1919. 
 
 TABLE V. 
 Comparison of Tuberculosis Mortality (all forms) in Providence and 
 
 IN certain other eastern cities. 
 City New York 
 
 Death rate City Provid&nce New Haven Rochester Syracuse 
 
 1910-1914 200 194 149 127 116 
 
 1915-1919 172 199 134 111 105 
 
 »7 
 
FIG. III. 
 Tuberculosis Death Rates (per 100,000) 
 
 New York New Haven Rochester, Syracuse Providence 
 
 N.Y. 
 
 194 
 
 116 
 
 105 
 
 1910 1915 1910 1915 1910 1915 1910 1915 1910 1915 
 
 to to to to to to to to to to 
 
 1914 1919 1914 1919 1914 1919 1914 1919 1914 1919 
 
Secondly, the tuberculosis death rate in Newport and in the small 
 towns of the state, while lower than that for the four large industrial 
 centers, is still high enough to constitute a serious health problem. 
 Even in these relatively favored sections more than one person in 
 every thousand dies every year of tuberculosis and conditions by 
 no means warrant the almost complete neglect of administrative 
 machinery for the control of this disease. 
 
 III. ADMINISTRATIVE MACHINERY FOR THE CON- 
 TROL OF TUBERCULOSIS IN RHODE ISLAND. 
 
 While tuberculosis is a communicable disease, it is clear that it 
 differs widely from the more acute contagia in the relative import- 
 ance of the parts played, respectively, by the invading microbe and 
 the vital resistance of the human body. The tubercle bacillus is so 
 widely distributed that extreme rigor in administrative control 
 would be as ineffective as it would be unwise. Two measures of 
 control are, however, essential in dealing intelligently with this dis- 
 ease, — a law requiring the reporting of all known cases and a law 
 permitting the isolation of any individual w^ho is known to be a dis- 
 seminator of tubercle bacilli and who wilfully and habitually refuses 
 to observe the simple precautions necessary to protect his neighbors 
 from the danger of infection. Rhode Island has both these laws 
 upon its statute books, although their enforcement leaves much to 
 be desired. 
 
 Tuberculosis was made a reportable disease in the city of Provi- 
 dence by a rule of the Board of Aldermen in 1905. In 1909, how- 
 ever, a state law was passed requiring the reporting of this disease 
 directly to the State Board of Health (Ch. 386). The state law 
 also requ'res the reporting of tuberculosis, along with other com- 
 municable diseases, to the local health officers throughout the state 
 (Ch. 110). In Providence, at least, it has seemed unwise to the 
 local health authorities to require a double reporting of tuberculosis 
 and, since 1909, reports to the city health officer have been allowed 
 to lapse. 
 
 Since the control of tuberculosis must be largely a local matter 
 it would be most unfortunate if city and town health officers re- 
 mained without knowledge of the existence of cases of this disease 
 within their respective jurisdictions. This was at first an unfor- 
 
 19 
 
tunate effect of the law of 1909. Lately, however, transcripts of all 
 reports of cases of tuberculosis made to the State Department of 
 Health have been promptly forwarded to local health officers. So 
 long as this is done, and if the reporting law is effectively enforced, 
 there would seem to be no insuperable disadvantages, and for rural 
 districts certain positive advantages, in a state reporting law. 
 
 The general principle that reports should be made to the office 
 which is to exercise control is, however, a sound one. In the smaller 
 towns direct control will have to be exercised by the state, if it is 
 exercised at all. In Providence this is not the case. Without 
 change in the existing law it would be feasible for the State Board of 
 Health to make the City Health Officer its deputy for the collection 
 of reports in Providence. This would give the local office the direct 
 contact with reporting which Dr. Chapin feels to be essential for 
 effective control and after transcription the reports could be for- 
 warded to the State House. I would strongly urge that the State 
 Board of Health make an arrangement of this kind. 
 
 That the present reporting law is not being taken at all seriously 
 by the physicians of the state is, however, clearly indicated by the 
 figures for reported cases presented in Table VI. These data, 
 courteously furnished by Dr. B. U. Richards, Secretary of the State 
 Board of Health, when compared with the mortality returns in 
 Table II, show that the reported case rate for nine years averages 
 only 1.40 cases per 1000 population, as compared with a death rate 
 for the same period of 1.66 per 1000. In other words, for each 100 
 cases reported there were 118 deaths. An idea of what may be ex- 
 pected from a reasonably good enforcement of reporting laws may 
 be gained from the data in Table VII, from the Report of the Massa- 
 chusetts State Board of Health for 1915. The reporting even here 
 is of course incomplete; but it is more than twice as good as that 
 attained in Rhode Island. The careful studies conducted in Fram- 
 ingham, Mass., by the Framingham Community Health and Tu- 
 berculosis Demonstration indicate that as a matter of fact the 
 ratio of existing cases in a given community is about 9 cases to 1 
 death, and the actual normal case rate about 10 per 1000 population. 
 
 That this estimate is applicable to Rhode Island, is indicated by 
 the survey of post-influenza cases conducted l)y the District Nursing 
 Association after the epidemic of 1918. Out of 1805 persons vis- 
 ited 27, or 15 per 1000, were tuberculous, and since post-influenza 
 
 20 
 
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 21 
 
Fatal 
 
 ity Rate. 
 
 
 Deaths per 
 
 100 
 
 cases 
 
 
 148 
 
 .4 
 
 
 
 105 
 
 .1 
 
 
 
 74 
 
 .9 
 
 
 
 54 
 
 .4 
 
 
 909, 
 
 added to 
 
 year 
 
 
 57 
 
 3 
 
 
 
 62 
 
 .8 
 
 
 
 56 
 
 
 
 
 
 56 
 
 4 
 
 
 
 58 
 
 .4 
 
 
 TABLE VII. 
 
 Cases and Deaths from Pulmonary Tuberculosis in Massachusetts. 
 
 Case Rate Death Rate 
 
 Year per 100,000 per 100,000 
 
 1906 100.4 149.1 
 
 1907 143.6 150.6 
 
 1908 183.6 137.4 
 
 1909 244.7 132.7 
 
 1909 (Dec.) (Case rate and fatality rate for December, 
 
 1909) 
 
 1910 232.6 133 1 
 
 1911 204 1 128.0 
 
 1912 214.2 119 9 
 
 1913 207.6 117.0 
 
 1914 196.2 114.1 
 
 1915 217.0 113.2 52 2 
 
 (Report, State Department of Health, Massachusetts, 1915, p. 613) 
 
 cases would probably show a tuberculosis incidence somewhat 
 higher than normal, the results may be considered as closely check- 
 ing the Framingham conclusions. We may assume that about 
 6000 cases of tuberculosis actually exist in Rhode Island, of which 
 about 1000 are now reported. 
 
 In order to gain an idea as to the relative incompleteness of the 
 reporting in various areas we have prepared Table VIII for the 
 years 1911 to 1919. There are several points which should be taken 
 into consideration in interpreting these figures. The death sta- 
 tistics have all been corrected by distributing the deaths occurring 
 in tuberculosis hospitals and sanatoria to the cities and towns of 
 actual residence, but the case rates have not been corrected in this 
 manner. This factor would tend to decrease the ratio of deaths to 
 cases in Providence and in the "rest of the State" (the latter in- 
 cluding Cranston and Wallum Lake). On the other hand the 
 deaths which occur in general hospitals would tend to increase un- 
 duly the fatality rates in the larger cities. On the whole it seems 
 probable that the data presented indicated particularly lax report- 
 ing in Newport and in the "rest of the State," which is exactly 
 what we should expect from the fact that these areas are lacking in 
 organized clinic facilities. 
 
 22 
 
TABLE VII. 
 Incompleteness of Reporting of Tuberculosis in Various Areas. 
 
 1911-1919 
 
 
 Average Number 
 
 Average Number 
 
 Apparent Fatality 
 
 
 Cases per year 
 
 Deaths per year 
 
 . Rate. 
 
 Deaths per 
 
 
 
 
 
 100 Cases. 
 
 Providence 
 
 412 
 
 466 
 
 
 
 113 
 
 Pawtucket 
 
 88 
 
 87 
 
 
 
 98 
 
 Woonsocket 
 
 58 
 
 68 
 
 
 
 117 
 
 Central Falls 
 
 40 
 
 39 
 
 
 
 97 
 
 Newport 
 
 20 
 
 37 
 
 
 
 185 
 
 Rest of State 
 
 208 
 
 269 
 
 
 
 129 
 
 With regard to the machinery available for the control of the 
 occasional wilfully careless consumptive, Chapter 110 of the General 
 Laws provides that cases of tuberculosis shall be "suitably quaran- 
 tined" and the term is defined as meaning "the isolation of the per- 
 son or persons having the disease or distemper, and of such other 
 persons as may by contact or association with the affected person 
 become, in the judgment of the state board of health, carriers of con- 
 tagion. The period of time, the manner of such isolation and the 
 method of cleansing and disinfection shall be in accordance with 
 the rules and regulations made from time to time by said Board." 
 
 The State Board of Health appears to have made no specific rules 
 and regulations under this act, certain earlier regulations having 
 been presumably superseded by a set of "Rules Governing Control 
 of Contagious Diseases," issued in 1919. The latter document is 
 essentially a transcript of a report on the control of communicable 
 diseases by a committee of the American Public Health Association. 
 This report laid down the general scientific principles underlying 
 the control of such diseases but was not designed in any sense to 
 serve the purpose of a legally enforceable draft of rules and regula- 
 tions. I am informed that the City Solicitor of Providence holds it 
 necessary for the State Board of Health to make a specific individual 
 ruling in regard to each particular case of tuberculosis to be isolated 
 under Chapter 110, — a procedure which would certainly be intol- 
 erable in dealing with more acute disorders but which may perhaps 
 serve for the rare instances in which forced isolation of tuberculosis 
 is desirable. 
 
 A third very desirable legal provision is found in Chapter 576 of 
 the Public Laws which prohibits tuberculous persons from handling 
 food products. 
 
 23 
 
Aside from forcible legal control it is essential that the public 
 authorities should offer facilities for the laboratory diagnosis of 
 tuberculosis and this is done by the State Board of Health. Dr. 
 L. A. Round, Director of the Laboratory' of the State Depart- 
 ment of Health, has courteously furnished us with the data pre- 
 sented in Table IX in regard to the scope and extent of this work 
 for the past six years. 
 
 TABLE IX. 
 Work of the State Laboratory in the Diagnosis of Tuberculosis. 
 Number of Speciments Examined. 
 Year Positive 
 
 1915 
 
 501 
 
 1916 
 
 533 
 
 1917 
 
 493 
 
 1918 
 
 348 
 
 1919 
 
 417 
 
 1920 (to Sept. 1) 
 
 249 
 
 egative 
 
 Total 
 
 1705 
 
 2266 
 
 1921 
 
 2454 
 
 1967 
 
 2460 
 
 1752 
 
 2100 
 
 1731 
 
 2148 
 
 933 
 
 1182 
 
 Totals 2541 10069 12610 
 
 The state law (Chapter 386) requires that the State Board of 
 Health shall keep a register of all reported cases of tuberculosis and 
 this is done. The physicians of the state are provided with report 
 bkmks of the form indicated below. A minor point of friction could 
 be eliminated by combining this report blank with the blank which 
 must accompany a sample of sputum sent to the State Laboratory. 
 At present the physician must fill out one form to go with the speci- 
 men and later make out the full report blank below which involves 
 apparently unnecessary duplication. 
 
 Keport of a Case of Tuberculosis to the R. I. State Board of Health. 
 
 R. 1 19 
 
 Name 
 
 [Married 
 
 Age Se.\« Color <{ Single 
 
 [Widower 
 
 Street City. . 
 
 Residence No i _, , t, 
 
 I Road Town 
 
 Occupation, trade, profession or particular kind of work 
 
 General nature of industry, business or establishment in which employed 
 Working in what Shop or Mill, etc., for how long previous to date? 
 
 24 
 
Form of Disease: Pulmonary, Laryngeal, Local or General 
 
 How long has patient had the disease? 
 
 Any exposure to another case? 
 
 Have there been any other cases in the same family? ' 
 
 Have there been any other cases in the same house? 
 
 How recently? 
 
 Would you deem it desirable that a member of the District Nursing Association 
 
 call upon this patient to give advice or render assistance? 
 
 If an infant is it fed on cow's milk? 
 
 If so, is the name of the milk dealer known? 
 
 Reported by 
 
 M. D. 
 
 Upon receipt of this report additional blanks and stamped addressed en- 
 velopes will be forwarded for report of any new cases. 
 
 The report blanks are kept on file in the State House, a transcript 
 being forwarded to the local health officer, as indicated above. 
 When the physician's report specifically calls for the services of a 
 public health nurse the State Board notifies the district nursing 
 association of the town. The form of the question on the report 
 blank, however, puts the responsibility of a definite appeal for 
 nursing aid upon the physician; and unless he makes such an appeal 
 no supervision is attempted. 
 
 In addition to the keeping of the tuberculosis register and the 
 provision of laboratory facilities, the State Board of Health dis- 
 tributes an excellent circular, "Advice to Patients having Tubercu- 
 losis of the Lungs" and provides sputum cups and paper napkins 
 free of charge. This is the sum and substance of the part played by 
 the State Board of Health in the campaign against the most preva- 
 lent and most deadly, of all preventable diseases. 
 
 Dr. Richards and Dr. Round, in the Bulletin of the State Board 
 for February, 1919, called special attention to the danger of the dis- 
 semination of tuberculosis by raw milk and urged the enactment of 
 legislation providing for the supervision of the production, transpor- 
 tation and sale of milk. Dr. Round states that five out of seven 
 samples of "Baby's milk" collected in Providence contained tubercle 
 bacilli and adds, "What are we doing about it? Nothing!" Not 
 more than 60 per cent of the milk supply of Providence is at present 
 rendered safe by pasteurization. 
 
 Municipal health authorities appear to be even less interested in 
 the problems of tuberculosis. Outside of Providence our canvass 
 of the situation has revealed no special health department activities 
 
 25 
 
along this line; and even in Providence the official machinery for 
 dealing with tuberculosis is extremely tenuous. A vigorous and 
 well planned anti-tuberculosis program was initiated by the Provi- 
 dence Health Department in 1905, but when the new^ state report- 
 ing law went into force in 1909 this program was permitted to lapse. 
 Even the municipal laboratory diagnosis was finally discontinued, as 
 a result of misguided parsimony on the part of the civic authorities. 
 Lately, however, the more cooperative attitude of the State Board 
 of Health has made possible the very desirable resumption of local 
 activities. Two years ago a nurse was employed by the city health 
 department to prepare a card index of known cases of tuberculosis 
 in Providence, based on the reports transmitted by the State Board 
 of Health, and on data obtained from the District Nursing Associa- 
 tion and other agencies. Thus there is available an up-to-date local 
 register of tuberculosis which has grown from 102 7 frank cases and 173 
 suspicious cases in August, 1919, to 1170 frank cases and 325 suspi- 
 cious cases in August, 1920. Of the 1170 frank cases, 1037, were of 
 pulmonary tuberculosis and 133 of other forms. The laboratory 
 diagnosis of local cases of tuberculosis was also resumed in Febru- 
 ary, 1920 (after the closing of the city laboratory for a year); and 
 during the ten months, December, 1919, through September, 1920, 
 322 specimens were examined in the city laboratory. 
 
 No follow-up work of reported cases is attempted, however, al- 
 though a visit is made following each reported death from tubercu- 
 losis. 
 
 Both the State Board of Health and the City Department of 
 Health, therefore, practically limit their activities in regard to tu- 
 berculosis to the provision of laboratory diagnosis and the keeping 
 of a register of known cases of the disease. Such a condition is by 
 no means unusual; for curiously enough the task of combating tu- 
 berculosis has very commonly been left to the initiative of private 
 organizations. Such organizations have striven earnestly and effec- 
 tively, in Rhode Island as elsewhere, to meet the responsibilities 
 which have been placed upon them; and they will always have an 
 important function to perform in supplementing the work of public 
 agencies. A complete program of tuberculosis control must, how- 
 ever, center about the inspiring leadership of the constituted health 
 authorities; and it is more than time that legislatures and municipal 
 councils should be awakened to their responsibility in regard to 
 this grave health problem. 
 
 26 
 
For the effective control of tuberculosis in Rhode Island I believe 
 it to be, first of all, essential that the State Board of Health should 
 promulgate hew and specific regulations in regard to the control 
 of this disease which shall ensure the adequate supervision of each 
 reported case, a supervision which at present is practically non- 
 existent. The proper policy is, I believe, embodied in the tuber- 
 culosis law of New York State. This law requires the reporting of 
 every case of tuberculosis within twenty-four hours. It makes it 
 obligatory upon the local health officer to call this provision to the 
 attention of any physician signing a death certificate for tuberculo- 
 sis who has not previously reported the disease, and in case of re- 
 peated violations the health officer sliall report such violations to 
 the local health authorities who shall cause such steps to be taken 
 as may be necessary to enforce the penalty for such violation. 
 Whenever a case of tuberuclosis is reported, the local health officer 
 must transmit to the physician "a printed statement and report in 
 a form approved by the state commissioner of health, naming such 
 procedure and precautions as in the opinion of said commisisoner 
 are necessary or desirable to be taken on the premises of a tuber- 
 culosis patient." Upon receipt of this statement the physician 
 must s'gn and date the report, agree to carry out such precautions or 
 if unwilling to do so he must so state upon the report, whenthe duties 
 prescribed devolve upon the local health ofificer. The health officer 
 has the authority to cause all reported cases of tuberculosis in his 
 jurisdiction to be visited from time to time by a public hea'th nurse. 
 Whenever a complaint shall be made by a physician to a health 
 officer that a patient suffering from tuberculosis is unable or unwill- 
 ing to conduct himself and to live in such a manner as not to expose 
 members of his family or household or other persons to infection, 
 the health officer should investigate the circumstances and, if he 
 finds ground for so doing, he shall lodge a complaint with the magis- 
 trate upon which the offending patient can be brought before the 
 magistrate and committed to a county hospital for tuberculosis or 
 to any state hospital or institution which cares for this disease. 
 
 The same principles are embodied in the Sanitary Code of the 
 State of Connecticut, Regulations 35 and 36 of which read as follows: 
 
 Regulation 35. Method of control of tuberculosis. 
 
 "When a licensed physician or hospital superintendent reports a 
 case of tuberculosis and agrees to assume the responsibility for the 
 proper instruction of the patient and the taking of measures neces- 
 
 27 
 
sary for the protection of others, the health officer need not take 
 action other than prescribed by Chapter 79, PubHc Acts, 1909. 
 
 "Every physician thus assuming the control of a case of tubercu- 
 losis shall repori to the local health officer on or before the first 
 day of each month, stating whether or not such case is still under 
 his care, and if such report is not made, the health officer shall in- 
 vestigate and take such measures as he deems necessary for the 
 protection of public health. 
 
 "When a physician or hospital superintendent declines to assume 
 such responsibility, it shall be the duty of the health officer to supply 
 the afflicted person with printed instructions and take such other 
 action as may be necessary and proper for the protection of public 
 health." 
 
 Regulation 36. Control of refractory persons affected with 
 tuberculosis. 
 
 "When it comes to the attention of a health officer that a person 
 is affected with tuberculosis and is a menace to the public health or 
 is liable to jeopardize the health of any person or persons in or on 
 the premises occupied or frequented by the afTected person, he shall 
 immediately investigate and take proper measures to prevent the 
 spread of such disease for the protection of public health, and if 
 necessary may cause the removal of such person to an isolation hos- 
 pital or other proper place, there to be received and kept until he 
 shall no longer be a menace to the public health." 
 
 It would seem that under Section 13 of Chapter 110 of the Gen- 
 eral Laws the State Board of Health of Rhode Island has ample 
 powers to formulate regulations along essentially similar lines to 
 those laid down in the New York and Connecticut law. 
 
 Outside of Providence it might be necessary to make special pro- 
 vision for the care of the few refractory cases which require forcible 
 detention. In Providence the City Hospital could be used for this 
 purpose. 
 
 Ordinances requiring the pasteurization of all milk not of certified 
 grade are eminently desirable; but such ordinances are preferably 
 issued by local authorities. I would recommend that an earnest 
 elifort be made to secure such ordinances in Providence, Pawtucket, 
 Woonsocket, and other large communities. Newport already has 
 an ordinance of this kind. 
 
 Even more important than legislation, is the provision of a proper 
 expert personnel for dealing with the broader tuberculosis prob- 
 
 28 
 
lems of the state. The whole campaign, at least in that part of the 
 state outside, of the city of Providence, should be planned and di- 
 rected by a single competent leader who can, month by month, watch 
 its progress, fill in gaps as they are manifest and recommend to the 
 State Board of Health such steps as may be necessary for obtaining 
 from time to time a more effective control of this disease. Such a 
 leader should be a physician trained in the diagnosis of tuberculosis, 
 for this branch of medicine is a complex and dif^cult specialty, al- 
 most unrepresented in Rhode Island outside of the city of Provi- 
 dence except by the staff of the State Hospital at Wallum Lake. 
 He should also, if possible, have had training and experience in pub- 
 lic health work. A Director of a Division of Tuberculosis under 
 the State Board of Health, if properly qualified, could not only plan 
 the general anti-tuberculosis campaign for the state as a whole but 
 could also supervise existing clinics, organize and, where necessary, 
 serve new clinics, furnish itinerant clinic service for the rural dis- 
 tricts and act as a consultant to assist private physicians in the 
 diagnosis of respiratory disorders. The appointment of such a 
 Director is perhaps the most important single step to be taken in 
 the development of anti-tuberculosis work in Rhode Island. 
 
 It might be well, as suggested above, for such a State Director of 
 Tuberculosis work to devote his energies chiefiy to the portion of 
 the state outside the city of Providence. Providence is a com- 
 munity of sufficient size to occupy the full service of a specialist of 
 this type. Clinic facilities and nursing service are more ful y de- 
 veloped in Providence than elsewhere but they are imperfectly co- 
 ordinated and experience has shown that no agency short of that 
 which represents the community as a whole can hope to effect har- 
 mony between conflicting interests. The City Department of 
 Health should, therefore, also be provided with a Division of Tu- 
 berculosis under a competent medical specialist, whose duty should 
 be to see that all cases of tuberculosis on the register are so cared for 
 as not to be a menace to others and that each case has every pos- 
 sible opportunity to receive the medical and nursing care or sana- 
 torium treatment necessary for his own welfare. His powers should 
 of course be exercised only where no private physician has under- 
 taken or will undertake to assume the responsibility for the conduct 
 of the case. 
 
 Si Arthur Newsholme has well said that when "the medical 
 officer of health or the tuberculosis officer takes little, if any, useful 
 
 29 
 
action after notifications have been received, the practitioner has an 
 excuse for not notifying subsequent cases. He can argue with some 
 cogency that notification has no value per se; its utility depends on 
 the action which follows on notification. Unless useful action fol- 
 lows on notification, default in notification has little practical im- 
 portance." 
 
 The principles which should underly the official control of tuber- 
 culosis may be stated very simply, although the application is by 
 no means easy of realization. Every case of tuberculosis, for which 
 a physician does not assume direct responsibility, should be fol- 
 lowed up to see (a) that the exposure of other persons to infection is 
 minimized, and (b) that the individual affected is brought in con- 
 tact with facilities for medical, nursing and hospital treatment and 
 given the fullest opportunity to avail himself of the curative pos- 
 sibilities which they ofTei. In order that machinery may be built 
 up for these ends it is essential that an official director of anti- 
 tuberculosis work in the city of Providence and another to serve the 
 remainder of the state should be appointed under the auspices, 
 respectively, of the city and state departments of health. 
 
 IV. CLINIC SERVICE FOR THE DIAGNOSIS AND TREAT- 
 MENT OF TUBERCULOSIS IN RHODE ISLAND. 
 
 The tuberculosis clinic serves a double purpose as an instrument, 
 on the one hand for the early diagnosis of the disease, and on the 
 other for the systematic treatment of such known cases as may 
 properly be cared for outside the sanatorium. In view of its im- 
 portance as a diagnostic agent the clinic deserves first place in a re- 
 view of available machinery for the control of tuberculosis. 
 
 In the city of Providence there are at present eight different tu- 
 berculosis clinics each week, four at the Rhode Island Hospital (one 
 for children), two (one opened very lecently) at the City Hospital 
 and one each at Lyra Brown Nickerson House and at Federal Hill, 
 House (both the latter being under the direction of the medical 
 staff of the City Hospital). Outside of Providence five clinics are 
 held each week, two in Pawtucket, and one each in Woonsocket, 
 Riverpoint and East Providence. 
 
 The four clinics directed by the Rhode Island Hospital are op- 
 erated under particularly advantageous circumstances. The Dis- 
 
 30 
 
pensary Building at the City Hospital plant itself and the two settle- 
 ment houses (Lyra Brown Nickerson and Federal Hill), where these 
 clinics meet, are convenient and attractive. Furthermore Dr. 
 D. L. Richardson, superintendent of the City Hospital, is keenly 
 interested in the development of his tuberculosis clinics and pur- 
 poses in the future to have a member of his full-time stafT in attend- 
 ance at each clinic to ensure continuity and harmony of service. 
 This is the greatest need in clinic service at the present time, in 
 Rhode Island, as everywhere else. It is hard to say too much in 
 praise of the busy physicians who in the past have given so gener- 
 ously of their time and energy in clinic service; but it is unfair to 
 demand, and unreasonable to expect, that unpaid assistance can 
 ever fulfill the highest ideals of clinic service. The nursing or- 
 ganization of the Providence clinics on the other hand is admirable, 
 all of them being served by the tuberculosis nurses of the District 
 Nursing Association. Adequate clerical service is supplied by the 
 hospitals and settlement houses where the clinics are held. 
 
 The volume of work accomplished by these clinics is indicated 
 in Table X below. It is apparent that the City Hospital clinics are 
 all growing rapidly, while the Rhode Island Hospital clinics suffered a 
 material decline in numbers during the first half of the present year. 
 
 TABLE X. 
 
 Volume of Work Done bv Providence Clinics. 
 
 Period Clinics Number of Number of visits by patients. 
 
 clinics held Old patients New patients Total 
 
 R. I. Hospital 
 
 141 
 
 915 
 
 341 
 
 1256 
 
 (3 clinics for adults) 
 
 
 
 
 
 " children's clinic 
 
 34 
 
 148 
 
 73 
 
 221 
 
 1918 City Hospital 
 
 50 
 
 237 
 
 120 
 
 357 
 
 Nickerson House 
 
 39 
 
 119 
 
 48 
 
 167 
 
 Total for year 
 
 264 
 
 151 
 
 1419 
 1025 
 
 582 
 365 
 
 2001 
 
 R. I. Hospital 
 
 1390 
 
 (3 clinics for adultsj 
 
 
 
 
 
 1919 " children's clinic 
 
 40 
 
 50 
 
 23 
 
 73 
 
 City Hospital 
 
 50 
 
 441 
 
 197 
 
 638 
 
 Nickerson House 
 
 48 
 
 176 
 
 94 
 
 270 
 
 Federal Hill House 
 
 16 
 
 88 
 
 50 
 
 138 
 
 Total for year 
 
 305 
 
 1780 
 
 729 
 
 2509 
 
 31 
 

 R. I. Hospital 
 
 
 75 
 
 327 
 
 123 
 
 450 
 
 Jan. 
 
 (3 clinics for adu 
 
 ;lts) 
 
 
 
 
 
 to 
 
 " children's clinic 
 
 
 22 
 
 91 
 
 31 
 
 122 
 
 June, 
 
 City Hospital 
 
 
 25 
 
 309 
 
 105 
 
 414 
 
 1920 
 
 Xickerson House 
 
 
 24 
 
 135 
 
 62 
 
 197 
 
 
 Federal Hill House 
 
 
 23 
 
 131 
 
 60 
 
 191 
 
 Total for six months 169 993 381 1374 
 
 Outside of Providence, there are three well-estabhshed chnics, at 
 Pawtucket, Woonsocket and Riverpoint, and a new one just opened 
 at East Providence which received twenty-two visits from eighteen 
 patients during the month of September. Tuberculosis cases may 
 be cared for in an emergency at the Newport Hospital but there is 
 no regularly organized clinic. 
 
 The Pawtucket clinics are held twice a week at the Memorial 
 Hospital in that city and they serve Central Falls as well as Paw- 
 tucket. During the four months previous to my visit (April-July, 
 1920), thirty-two clinics had been held and eighty-nine new patients 
 and seventy old patients had received treatment. 
 
 The clinic at Riverpoint is held every Saturday afternoon and 
 serves the Pawtuxet Valley district in the towns of Coventry and 
 West Warwick. It meets in a commodious and attractive Health 
 Center building, and is fortunate in the keen interest of prominent 
 local physicians, and in the service of an unusually able and devoted 
 nurse. During the twelve months from September, 1919, to Au- 
 gust, 1920, fifty-three clinics were held, with fifty-three new pa- 
 tients and one hundred and eighty-seven old patients. 
 
 The clinic at Woonsocket has operated under considerable diffi- 
 culties. It is maintained chiefly by the earnest efforts of the dis- 
 trict nursing association. The local medical society appoints six 
 different physicians during the year to serve for two months apiece, 
 an arrangement which does not make either for continuity of policy 
 or skilled specialist service. The clinic is held once a week and 
 during the eleven months, October, 1919, to August, 1920, seventy 
 new patients and seventy-three old patients received treatment. 
 
 Some conception of the quantitative adequacy of clinic service 
 may be gained from Table XI. 
 
 32 
 
TABLE XI. 
 
 Amount of Clinic Service in Various Areas. 
 
 Clinic Visits per month Visits per month per 
 
 100,000 population 
 
 
 o 
 
 Eh 
 
 
 "3 
 
 (2 
 
 o 
 
 
 Providence 
 
 
 
 
 
 
 Rhode Island Hospital (adults) 75 
 
 
 
 
 
 
 " (Children) 20 
 
 ► 226 
 
 63 
 
 237,595 
 
 91 
 
 26 
 
 City Hospital 66 
 
 
 
 
 
 
 Federal Hill 32 
 
 
 
 
 
 
 Lyra Brown Nickerson 33 
 
 
 
 
 
 
 Pawtucket and Central Falls 40 
 
 
 22 
 
 88,422 
 
 45 
 
 25 
 
 Woonsocket 13 
 
 
 6 
 
 43,496 
 
 30 
 
 14 
 
 Pawtuxet Valley (Coventry and 
 
 
 
 
 
 
 West Warwick) 20 
 
 
 4 
 
 21,131 
 
 95 
 
 19 
 
 East Providence 22 
 
 
 18 
 
 21,793 
 
 101 
 
 83 
 
 It is evident that from the standpoint of new patients per unit of 
 population both Providence and Pawtucket are fairly well served. 
 (The figures for East Providence are of course abnormal since they 
 refer to the first month of operation of this clinic.) The ratio of new 
 patients admitted to all tuberculosis clinics in New York City for 
 the twelve months, October, 1919 to September, 1920, was 29 per 
 month per 100,000 population. On the basis of total visits per 
 month per 100,000 population, however, both Pawtucket and Woon- 
 socket show up very badly. Even in Providence and at Riverpoint 
 the ratios of 91 and 95 visits per month per 100,000 population, 
 while it compares favorably with the ratio existing in many com- 
 munities (the corresponding figure for New Haven is 97), falls far 
 short of the standard set in New York City where the admirable 
 system of clinic statistics shows an average of 173 visits per month 
 per 100,000 population for the twelve months, October, 1919 to 
 September, 1920. Evidently the existing Rhode Island clinics are 
 getting the patients, but are failing to hold them; and nearly a third 
 of the state population, outside the cities listed in the table, is en- 
 tirely without local tuberculosis clinic facilities. 
 
 The measurement of the quality, as distinguished from the 
 quantity, of clinic work is an exceedingly difficult task. In New 
 York the Association of Tuberculosis clinics requires all its members 
 to prepare a monthly report which includes a classification of dis- 
 
 33 
 
charged cases according to duration of treatment, reason for dis- 
 charge and condition at time of discharge. No such data are pre- 
 pared by the Providence cHnics. The ratio of new to old cases 
 treated gives us a rough measure, however, of the efficiency 
 with which the cHnic holds its patients. 
 
 Variations in the type of patients treated will of course affect 
 this ratio and it is evident that even a single visit may be wholly 
 adequate if it leads to prompt admission to a sanatorium. On the 
 whole, however, in a large clinic this ratio varies pretty closely with 
 efficiency of service and furnishes one of the objective criteria, so 
 much to be desired in measuring the quality of public health agen- 
 cies. In New Haven, for example, the clinic at the New Haven 
 Dispensary shows a ratio of 3.3 visits per new patient while the City 
 Clinic, which has been more or less disorganized by unavoidable 
 changes in medical personnel, shows a ratio of 1.7 visits per new 
 .patient. The well organized clinics of New York City show a ratio 
 for the past twelve months of 6.0 visits for each new patient ad- 
 mitted. On the basis of this ratio, it appears from Table XH that 
 
 TABLE XII. 
 
 Frequency of Attendance on the Part of the Individual Patient. 
 Clinic Ratio of Total Visits to New Patients* 
 
 Providence 
 
 Rhode Island Hospital (adults) 3 .7 
 
 (children) 3.9 
 
 City Hospital 3 .9 
 
 Federal Hill 3 .2 
 
 Lyra Brown Nickerson 3 .2 
 
 Pawtucket and Central Falls 1 .8 
 
 Woonsocket 2,0 
 
 Pawtuxet Valley 4.5 
 
 the Riverpoint (Pawtuxet Valley) clinic is attaining good results, 
 the City Hospital and Rhode Island clinics are doing fairly well, 
 the Federal Hill and Lyra Brown Nickerson clinics less well and the 
 Pawtucket and Woonsocket clinics very poorly. It is probable 
 that the failure to hold patients in the last two instances is chiefly 
 due to the lack of continuous medical service by specialists; but the 
 nursing service in these two cities is also perhaps not up to the 
 
 *Note that this ratio is higher than the ratio of visits par patient in Table XIII, since it is 
 computed from the total visits and the new patients. 
 
 34 
 
standard set in Providence and at Riverpoint. Conditions at the 
 Pawtucket clinic are being materially improved through the active 
 interest of Dr. James Wheaton. 
 
 In order to gain a somewhat clearer conception of the actual na- 
 ture of the clinic work Mr. Chandler analyzed the individual rec- 
 ords of 209 patients from the Rhode Island clinic and of 172 pa- 
 tients from the City Hospital clinic, the cases being taken at ran- 
 dom, among those admitted prior to July 1, 1919, so that all should 
 have been under care for at least one year. The results are pre- 
 sented in Table XIII. Aside from the fact that a larger propor- 
 tion of cases are recorded as definitely non-tuberculous at the City 
 Hospital the results at the two clinics are fairly comparable. The 
 Rhode Island Hospital clinic is somewhat more successful in secur- 
 ing' institutional treatment, although both records in this respect 
 are very good. Excluding cases found to be non-tuberculous, the 
 Rhode Island Hospital placed 36 per cent of its cases in hospitals 
 or sanatoria, the City Hospital, 30 per cent. Exactly the same pro- 
 portion of cases in each instance was kept under observation with 
 deferred diagnosis and 11 per cent of the cases were kept under 
 observation with a definite diagnosis at the Rhode Island against 
 18 per cent at the City Hospital (percentage computed after ex- 
 cluding cases definitely pronounced non-tuberculous). The small 
 proportion of cases reported as lost is, in both cases, most gratifying. 
 
 TABLE XIII. 
 Analysis of a Random Series of Clinic Cases. 
 
 Rhode 
 
 Island Hospital 
 
 
 City Hospital 
 
 
 
 
 
 Visits 
 
 
 
 Visits 
 
 Classification 
 
 
 Per 
 
 per 
 
 
 Per 
 
 per 
 
 
 No. 
 
 Cent 
 
 patient 
 
 No. 
 
 Cent 
 
 patient 
 
 Found non-tuberculous 
 
 52 
 
 25 
 
 2.3 
 
 80 
 
 46 
 
 2.1 
 
 Admitted to sanatorium or hos- 
 
 
 
 
 
 
 pital 
 
 57 
 
 27 
 
 2.8 
 
 28 
 
 16 
 
 2.8 
 
 Kept under observation. 
 
 Tu- 
 
 
 
 
 
 
 berculous. 
 
 17 
 
 8 
 
 3.1 
 
 17 
 
 10 
 
 3 4 
 
 Kept under observation. 
 
 Di- 
 
 
 
 
 
 
 agnosis deferred. 
 
 56 
 
 27 
 
 2.3 
 
 29 
 
 16 
 
 2 5 
 
 Moved from city 
 
 9 
 
 4 
 
 3.9 
 
 3 
 
 2 
 
 2.3 
 
 Lost 
 
 8 
 
 4 
 
 1.0 
 
 4 
 
 2 
 
 1.5 
 
 Dead 
 
 10 
 
 5 
 
 1.3 
 
 9 
 
 5 
 
 3.4 
 
 Discharged to physicians 
 
 
 
 
 2 
 
 1 
 
 2.5 
 
 Total 209 100 2.5 172 2.5 
 
 35 
 
It will be noted that the number of visits to the cHnic per patient 
 is over three for the cases definitely diagnosed as tuberculous and 
 kept under observation at home, just under three for the group finally 
 placed in institutions, 2.3 to 2.5 for the group kept under observa- 
 tion with deferred diagnosis and 2.1 to 2.3 for the patients definitely 
 pronounced non-tuberculous. 
 
 The results of this analysis indicate that our comparison of the 
 ratio of clinic visits to new patients in New York and in Rhode 
 Island is not seriously vitiated by differences between the type of 
 patients handled. The proportion of cases found non-tuberculous 
 was 25 per cent at the Rhode Island and 46 per cent at the City 
 Hospital, against 40 per cent for the New York clinics, in 1919. 
 If anything the Rhode Island Hospital clinic should require a higher 
 average of visits per case. The disadvantages under which 'the 
 Rhode Island Hospital clinic would appear to labor on the face of 
 these figures is however in great measure counterbalanced by the 
 very large group of cases with deferred diagnosis (27 per cent). 
 
 There is a real difference, on the other hand, between the Provi- 
 dence and New York clinics in regard to the utilization of sana- 
 torium treatment. The Rhode Island clinic shows 27 per cent of 
 its cases admitted to a sanatorium or discharged to other medical 
 care, and the City Hospital, 17 per cent; while the corresponding 
 figure for the New York City clinics in 1919 was only 9 per cent. 
 This contrast may help to account for the lower ratio of visits in 
 Providence; but its influence cannot obviously be important, since 
 Table XIII shows that the visits per patient in the Providence clinics 
 were actually higher in the case of the cases admitted to sanatoria 
 than for the general average of all patients treated. 
 
 Somewhat in contrast to the Providence figures are the data ob- 
 tained from a study of 70 consecutive cases admitted to the Woon- 
 socket clinic which showed 23 cases {33 per cent) pronounced non- 
 tuberculous and only 8 (11 per cent) admitted to hospitals or sana- 
 toria. The average visits per patient in this series was only 1.7. 
 
 The conclusions which may be drawn from a review of the tuber- 
 culosis clinic situation in Rhode Island may be summarized as fol- 
 lows: 
 
 In Providence the clinics are fairly adequate in the amount of 
 service rendered and are on the whole operating with success. 
 Through the efforts of the District Nursing Association it is possible 
 to keep in some sort of contact with 90 per cent of all patients who 
 
 36 
 
once visit a clinic and the fact that, of all patients not definitely pro- 
 nounced non-tuberculous one-third are actually admitted to hos- 
 pitals or sanatoria is most gratifying, although the ratio of visits 
 per patient is as usual regrettably low. An obvious deficiency is to 
 be found in the inadequacy of the system of records in use. The 
 records kept by the nurses are excellent so far as they go, but it is 
 most important, in order that the efficiency of the clinics may be 
 properly appraised, to institute a system of medical records which 
 shall show clearly, at monthly intervals, how many patients have 
 been admitted and at what stage of the disease process, how many 
 have been discharged, for what reasons, and in what condition, how 
 many patients remain under care and to what grades of disease they 
 belong; and which shall make it possible to compute the true ratio 
 of visits per patient and the average length of time for which various 
 classes of patients remain under care. 
 
 As a general principle it seems clear that the fullest development 
 of clinic service in the future will demand the payment of the physi- 
 cians who attend the clinics. The City Hospital is fortunate in 
 having a full-time staff which can be utilized so as to secure adequate 
 medical supervision of its clinic service, and the extension of the 
 plan of paid medical service must be given serious consideration in 
 the future for all clinics of this type. 
 
 Finally it must be recognized that there is a certain proportion 
 of dispensary cases of tuberculosis in which domiciliary visits by a 
 physician are essential to adequate control of the disease. Such 
 domiciliary visits should not be made on an eleemosynary basis 
 but as a part of the duty which the community owes to its citizens 
 in the protection of the public health. The working out of detailed 
 plans for the attainment of these three desiderata, the standardiza- 
 tion and extension of clinic records, the reorganization of clinic 
 medical service on a proper financial basis, and the provision of oc- 
 casional medical service for domiciliary cases is beyond the scope of 
 the present survey. They should form the first duties of the Di- 
 rector of Tuberculosis, whose appointment as an officer of the muni- 
 cipal health department has been recommended above. 
 
 Outside the city of Providence, conditions in regard to clinic fa- 
 cilities are far less satisfactory. The Pawtuxet Valley is admirably 
 served by the Riverpoint clinic. The Pawtucket and Woonsocket 
 clinics on the other hand are by no means on a satisfactory basis. 
 The attendance per 100,000 population has been low and the ratio 
 
 37 
 
of two visits or less per new patient indicates a waste of resources 
 and a failure to serve effectively even the small clientele which is 
 reached. Outside of the cities of Providence, Pawtucket, and 
 Woonsocket and the towns of West Warwick and Coventry there 
 is no regular clinic service at all. The entire southern half of the 
 state, the northwestern quarter of the state and the Newport 
 region are without clinical facilities, including nearly one third of 
 the population of Rhode Island. 
 
 The first duty of the Director of Tuberculosis of the State Board 
 of Health should be to stimulate the development of the Pawtucket 
 and Woonsocket clinics on the most effective basis, to secure the 
 establishment of new clinics in Newport and perhaps in Cranston, 
 Warwick and Bristol, and to provide in some way for occasional 
 clinic service in the smaller rural communities. The latter object 
 might be attained through visits to be made by the Director to 
 rural communities where prospective patients had been located 
 through the activity of visiting or industrial nurses; and in any of 
 the larger centers where specialists equipped to diagnose tuberculo- 
 sis are not available, the State Director might well arrange to con- 
 duct a weekly clinic in person. The well equipped staff of the 
 State Sanatorium at Wallum Lake could well be called upon to 
 assist in this work. 
 
 Finally, a word should be said in regard to the importance of de- 
 veloping the general medical service, available for the community 
 at large, to the highest possible level in respect to the problem of 
 tuberculosis. The diagnosis of this disease is a task of exceeding 
 difficulty and for its successful performance requires a detailed 
 knowledge and a special experience which the average general prac- 
 titioner cannot be expected to possess. The great value of an ex- 
 pert consultation service in the diagnosis of tuberculosis has been 
 amply demonstrated at Framingham and elsewhere ; and Dr. Elliott 
 Washburn, Executive Secretary of the Providence Tuberculosis 
 League, has just inaugurated a consultation service of this kind for 
 physicians in the city of Providence. This is a most admirable 
 step and the consultation service, as continued and extended, should 
 prove one of the most valuable instruments in the anti-tuberculosis 
 campaign. A very useful function of the state director of tubercu- 
 losis, whose appointment is recommended in this report, would be 
 to offer such a consultation service to physicians of the state outside 
 of the city of Providence. 
 
 38 
 
V. PROVISION FOR HOSPITAL AND SANATORIUM 
 CARE OF TUBERCULOSIS IN RHODE ISLAND. 
 
 Provision for the hospital and sanatorium treatment of pulmonary 
 tuberculosis in Rhode Island is made by the following institutions: 
 
 A. State Hospital and Sanatorium at Wallum Lake. Total of 
 363 beds (sanatorium cases, 170 beds, advanced cases, 153 beds, 
 children, 40 beds). 
 
 B. Providence City Hospital, 60 beds (for advanced cases). 
 
 C. St. Joseph's Hospital Annex, Hillsgrove, 70 beds (for ad- 
 vanced cases). 
 
 D. Tuberculosis wards, State Almshouse Hospital, Howard 
 (46 beds). 
 
 There are also a certain number of cases of tuberculosis cared 
 for in the State Hospital for Mental Diseases at Howard, 19 in num- 
 ber on July 1, 1920. 
 
 In addition to the institutions designed for the care of active 
 cases of pulmonary tuberculosis, there is a Preventorium at Hoxsie, 
 conducted by the Providence Tuberculosis League and a hospital 
 for bone and joint cases (Crawford Allen Branch of the Rhode 
 Island Hospital), at East Greenwich. The Preventorium has win- 
 ter accommodations for about 40 children and in summer can re- 
 ceive about 50. During the year ending October 1, 1920, 153 chil- 
 dren were given 9359 days' care in this institution; while in addi- 
 tion convalescent and summer outing provision was made for 618 
 women and children (7845 days' care). 
 
 The Crawford Allen Branch has 45 beds and is open only in the 
 summer season, the patients returning to their homes or to general 
 hospitals for the winter. 
 
 Returning to the institutions designed primarily for the institu- 
 tional care of active cases of tuberculosis we find provided a total 
 of approximately 540 beds, 170 for early cases, 283 for advanced 
 cases, 46 for either type (at the State Hospital) and 40 for children 
 (at Wallum Lake). The total provision amounts to 1 bed for every 
 1100 population or 1 bed for every 1.6 annual deaths from tuber- 
 culosis. On the theoretical basis which calls for at least 1 bed for 
 every annual death the hospital provisions of the state would seem 
 to be still inadequate. Rhode Island is much better off than most 
 states, however. In New York State (outside of New York City) 
 
 39 
 
the corresponding ratios are 1 bed for 1600 population or 1 bed for 
 every 1.9 deaths from tuberculosis. Furthermore, the hospital 
 beds now provided are by no means fully occupied.* At Hillsgrove 
 the 70 beds have been regularly filled to capacity and at one time 
 20 additional cots were in use. At the State Almshouse two pa- 
 vilions containing 46 beds are usually filled. At the Providence 
 City Hospital, however, there have generally been extra beds avail- 
 able and the Wallum Lake wards have of late been only two-thirds 
 filled, as indicated by Table XIV below. 
 
 Prior to 1917 the beds at these two institutions were fairly well 
 utilized but during the past three years there has been a falling off 
 in cases at the City Hospital, and no increase at Wallum Lake to 
 correspond with the opening of the new building for advanced cases 
 in 1918. 
 
 Empty beds have been common in many sanatoria as a result of 
 the decrease in tuberculosis during the last two years and of the 
 high wages which tempt patients to stay at work when they should 
 
 TABLE XIV. 
 
 
 Utiliz 
 
 ATIOX OF H 
 
 OSPITAL AND SANATORIUM 
 
 Facil 
 
 ITIES 
 
 
 
 
 
 Wallum La 
 
 ke 
 
 
 Ci 
 
 ity Ho£ 
 
 ipital 
 
 
 Year 
 
 Beds 
 
 i available 
 
 Bed 
 
 s occupied 
 
 Beds 
 
 avail 
 
 lable 
 
 Bed! 
 
 3 OC 
 
 1910 
 
 
 
 130 
 
 
 123 
 
 
 35 
 
 
 
 29 
 
 1911 
 
 
 
 140 
 
 
 127 
 
 
 35 
 
 
 
 33 
 
 1912 
 
 
 
 140 
 
 
 134 
 
 
 60 
 
 
 
 41 
 
 1913 
 
 
 
 140 
 
 
 115 
 
 
 60 
 
 
 
 52 
 
 1914 
 
 
 
 140 
 
 
 119 
 
 
 60 
 
 
 
 54 
 
 1915 
 
 
 
 157 
 
 
 146 
 
 
 60 
 
 
 
 60 
 
 1916 
 
 
 
 208 
 
 
 180 
 
 
 60 
 
 
 
 61 
 
 1917 
 
 
 
 216 
 
 
 201 
 
 
 60 
 
 
 
 45 
 
 1918 
 
 
 
 360 
 
 
 222 
 
 
 60 
 
 
 
 44 
 
 1919 
 
 
 
 360 
 
 
 232 
 
 
 60 
 
 
 
 55 
 
 be in the hospital. Nine New York county hospitals for which I 
 have obtained data show from 5 per cent to 40 per cent of empty 
 beds in 1919, with an average of 23 per cent. Only one of the nine, 
 however, shows as high a ratio as Wallum Lake (36 per cent vacant 
 beds). 
 
 In the best sanatoria, treatment is still in as great demand as 
 ever. At the Gaylord Farm Sanatorium in Connecticut 97 per 
 
 *The intensive work carried out at Framinjham has indicated that an ideal provision would 
 be two beds for each annual death. 
 
 40 
 
cent of the beds were occupied on the average during both 1918 and 
 1919, in spite of an increased capacity of 14 beds during the latter 
 year. In Dutchess County, New York, the Samuel Bowne Me- 
 morial Hospital reports 99 per cent utilization of facilities. 
 
 In order to obtain a better idea of the actual degree of hospitaliza- 
 tion accomplished from time to time, in the state as a whole, and in 
 its various areas, Mr. Chandler has prepared Tables XV and XVI, 
 which give the admission rate at Wallum Lake and Hillsgrove, 
 respectively, from each city or tovvn in the state for each year from 
 1910 to 1919. Similar data for the Providence City Hospital are 
 combined with the yearly averages for all admissions at Wallum 
 Lake and Hillsgrove for the various years in Table XVII. 
 
 41 
 
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TABLE XVII. 
 Admission Rate to Tuberculosis Hospitals and Sanatoria. 
 
 Admissions per 100,000 Population. 
 
 Ten 
 Year 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 Years 
 Rate 92 97 100 102 117 115 125 137 153 133 117 
 
 The admission rates show a practically steady increase from 1910 
 to 1918, with a large increment in 1918, when the new pavilion at 
 Wallum Lake was opened. In 1919 there was a falling off, coinci- 
 dent with the decreased incidence of tuberculosis indicated by the 
 mortality rates previously cited. This decrease in the incidence 
 of tuberculosis characteristic of the year 1919 (and apparently con- 
 tinuing in 1920) is presumably due to the combined influences of 
 prosperity, prohibition and military training. It would naturally 
 lead to a decrease in sanatorium treatment, other things being 
 equal, but since we know that in the best of times a very large num- 
 ber of cases of tuberculosis which would benefit by institutional 
 care fail to receive it, the present situation should merely serve as 
 an opportunity for developing the use of hospital and sanatorium 
 facilities by classes of cases which have failed to avail themselves 
 of such advantages in the past. 
 
 The general situation with regard to the hospitalization of tu- 
 berculosis in Rhode Island is, however, extraordinarily good as 
 compared with other states. Connecticut in 1918 had a total tu- 
 berculosis admission rate of only 78 per 100,000 population; and 18 
 counties of New York State for which we obtained the 1919 records 
 had an average admission rate of only 109 per 100,000 population. 
 The Rhode Island figures give 91 admissions per 100 annual deaths, 
 the New York figures 80 and the Connecticut figures only 53, a 
 splendid showing for Rhode Island. 
 
 Turning to the variations in degrees of hospitalization apparent 
 in different areas within the state we have prepared in Table XVIII 
 comparative figures for the larger cities and for the rest of the state. 
 In all these tabulations the cases cared for at the state institution 
 of Cranston are omitted, but the totals would be too small to affect 
 our ratios in material degree. 
 
 It appears from Table XVIII that hospitalization of tuberculosis 
 cases, in proportion to the incidence of the disease (ratio of annual 
 admissions per 100 annual deaths), is most complete in Providence, 
 with Woonsocket, Central Falls, Pawtucket and Newport follow- 
 
 44 
 
ing in the order named, while Cranston and the rural districts lag 
 notably behind. This is exactly what would be expected from the 
 fact that clinic and nursing services are most highly developed in 
 Providence and are almost lacking in Cranston and in the other 
 rural districts. 
 
 In general we may conclude, in regard to the quantitative ade- 
 quacy of institutional facilities, that while the number of hospital 
 and sanatorium beds provided is not sufficient for the care of all 
 the patients who ought ideally to receive institutional treatment, 
 there are today more beds available than are being utilized. The 
 immediate problem is therefore the development of machinery 
 v,'hich will get more patients into the hospitals and sanatoria, an 
 end which can best be attained by the impro\'ements in clinic ser- 
 vice which have been suggested above; for the clinic if properly 
 organized should be the primary feeder of the sanatorium. 
 
 TABLE XVIII. 
 
 Admission Rate to Tuberculosis Hospitals and Sanatoria. 
 
 Average 1910-1919 
 
 O 'S t s ^ ^ " ° 
 
 o 5 o " 2 i; ^ 
 
 Ah P-i > ^ (U o 
 
 Admission rate per 
 
 100,000 population 135 89 111 74 44 105 69 
 
 Admission rate per 
 
 100 annual deaths 69 56 64 56 46 64 50 
 
 The main service which the hospital for advanced cases of tuber- 
 culosis renders is the removal of dangerous open cases from the 
 proximity of other persons, and particularly of children, who might 
 be endangered by their presence in the community at large. The 
 object of sanatorium treatment on the other hand is the restora- 
 tion of the health of the patient; and the attainment of this end de- 
 pends on the beginning of treatment at a sufficiently early stage in 
 the treatment of the disease. The next point in which we are in- 
 terested is, therefore, the condition of the patients admitted, par- 
 ticularly at W'allum Lake, since the Providence City Hospital and 
 the St. Joseph's Annex are primarily designed for the hospitaliza- 
 tion of advanced cases. 
 
 The admirable statistics of the State Sanatorium at Wallum 
 Lake give the following classification of cases admitted, in ikt- 
 centages of total admissions for each year: 
 
 4.S 
 

 1915 
 
 1916 
 
 1917 
 
 Incipient cases 
 
 7 
 
 4 
 
 1 
 
 Moderately advanced cases 
 
 80 
 
 82 
 
 83 
 
 Far advanced cases 
 
 13 
 
 13 
 
 15 
 
 The average duration of disease before admission was estimated 
 at 21.8 months and 24.5 months for the years 1916 and 1917, 
 respectively. 
 
 For the past two years the patients have been classified accord- 
 ing to the newer terminology as follows: 
 
 Condition on Admission 1918 1919 
 
 I A 38 33 
 B 34 45 
 C 4 3 
 
 II A 42 35 
 B 211 190 
 C 32 24 
 
 III A 5 4 
 B 61 72 
 C 110 91 
 
 Other 29 55 
 
 The data for 1915, 1916 and 1917 are most important for our pur- 
 poses, since they include only sanatorium cases, the new ward for 
 advanced cases having been opened in 1918. They are distinctly 
 discouraging from the standpoint of curability of the patients ad- 
 mitted, since only from 1 to 7 per cent of the cases fall in the in- 
 cipient class. Statistics from many institutions show that of in- 
 cipient cases 75 per cent or over may be expected to show improve- 
 ment under proper sanatorium treatment, while with moderately 
 advanced cases the proportion falls to 50 to 60 per cent, and with far 
 advanced cases to 40 per cent or less. It is unfortunately true that 
 tuberculosis cases reach all our sanatoria at a deplorably late stage, 
 but conditions are not usually as bad as in Rhode Island. At the 
 Gaylord Farm Sanatorium in Connecticut the figures for 1917, 
 1918 and 1919 show, respectively, 19 per cent, 14 per cent and 11 
 per cent of the cases admitted to be incipient, 67 per cent, 69 per 
 cent and 74 per cent moderately advanced and 14 per cent, 17 per 
 cent and 14 per cent, respectively, to be far advanced. Even the 
 four state sanatoria of Connecticut, which admit all types of cases, 
 report for 1918, 7 per cent of incipient cases, although the propor- 
 tion of far advanced cases (52 per cent) is also much higher than 
 at Wallum Lake. 
 
 46 
 
At the Providence City Hospital conditions are naturally even 
 less encouraging than at Wallum Lake. For the three years 1917 
 to 1919 between 1 per cent and 3 per cent of the patients admitted 
 have been incipient cases, between 10 per cent and 22 per cent 
 moderately advanced cases and between 77 per cent and 87 per 
 cent far advanced cases. This is naturally to be expected, since 
 the City Hospital tuberculosis pavilion is primarily intended for 
 isolation rather than for curative treatment. 
 
 The next criterion which may properly be applied in estimating 
 the efficiency of sanatorium and hospital treatment is the length of 
 stay in the institution ; for it may be assumed under present condi- 
 tions of sanatorium management that an average of six months' 
 residence will be necessary in order to effect a reasonable proportion 
 of successful treatments. 
 
 At the Providence City Hospital and at Hillsgrove the average 
 period of residence is of course short, since the cases received are 
 mostly in an advanced stage; and at Wallum Lake the opening of 
 the ward for advanced cases in 1918 was followed by a sharp fall in 
 the average for the institution as a whole. Incidentally it may be 
 remarked that it would be helpful to keep and tabulate separately 
 the. statistics for the sanatorium and hospital wards at Wallum 
 Lake, since the aims of the two types of treatment and the criteria 
 by which they may be judged are so distinct, although Dr. Barnes 
 feels that certain practical considerations make such a sharp separa- 
 tion undesirable. If we exclude 1918 and 1919 from consideration, 
 however, the average period of residence for the years 1910-1917 at 
 Wallum Lake is still only 156 days. 
 
 This period of residence is too short to permit of the maximum 
 benefit from sanatorium treatment; but it is a record no worse than 
 is reported from many instifutions of similar type. Recent sta- 
 tistics have shown an average residence of 129 days at Wildwood 
 Sanatorium, 158 days at the New Jersey Sanatorium and 160 days 
 at Hebron, Maine. On the other hand, New Hampshire reports 
 175 days, Suffolk County, New York, 204 days, Monroe County, 
 New York, 214 days. North Reading, 213 days, Rutland, 269 days. 
 At Gaylord Farm the average stay for all patients was 182 days in 
 1917, 200 days in 1918 and 194 days in 1919. It is clear that the 
 short period of residence at Wallum Lake is a distinct handicap to 
 the efficiency of the institution; and this conclusion is emphasized 
 by the fact that of the total patients discharged 41 per cent in 1915, 
 
 47 
 
54 per cent in 1916, and 53 per cent in 1917, left against advice. 
 The period of residence at Wallum Lake is also however affected 
 by the fact that patients who are definitely failing are frequently 
 forced to go to Hillsgrove or the Providence City Hospital to make 
 room for more favorable cases. During the years 1908-1912, in- 
 clusive, 16 per cent of the discharged patients were forced out in 
 this way. 
 
 Considering the fact that so many of the patients at Wallum 
 Lake are admitted too late in the course of the disease and leave too 
 .soon for a cure to be effected, the immediate results of the treatment 
 are surprisingly favorable. For simplicity we have arranged the dis- 
 charged cases at Wallum Lake (and also at the two hospitals for 
 advanced cases) under three main headings: (a) improved (including 
 arrested and apparently cured and quiescent cases), (b) dead, and 
 (c) all other groupings (including a few cases which were non- 
 tuberculous or doubtful in nature). The results expressed in per- 
 centages are given in Table XX. 
 
 At the Providence City Hospital and at Hillsgrove a little more 
 than half the patients die and less than a quarter show improve- 
 ment, a result which is about what might be expected from the type 
 of cases admitted. At Wallum Lake the opening of the ward for 
 advanced cases in 1918 naturally led to a marked decrease in the 
 proportion of improved cases. Again the importance of keeping 
 distinct the statistics of sanatorium and hospital cases at Wallum 
 Lake is made apparent. The only fair basis of judgment as re- 
 gards sanatorium treatment is to consider the statistics for Wallum 
 
 TABLE XIX. 
 Average Length of Stay in Sanatoria and Hospitals. 
 
 
 Wallum 
 
 Lake 
 
 Hillsgrove 
 
 Providence C 
 
 ity Hospital 
 
 1910 
 
 153 days 
 
 50 days 
 
 36 days 
 
 1911 
 
 151 
 
 
 81 " 
 
 82 ' 
 
 
 1912 
 
 149 
 
 
 85 " 
 
 131 ' 
 
 
 1913 
 
 155 
 
 
 113 " 
 
 109 ' 
 
 
 1914 
 
 138 
 
 
 79 " 
 
 94 ' 
 
 
 1915 
 
 169 
 
 
 134 " 
 
 117 ' 
 
 
 1916 
 
 154 
 
 
 109 " 
 
 99 ' 
 
 
 1917 
 
 179 
 
 
 111 " 
 
 92 ' 
 
 
 1918 
 
 138 
 
 
 221 " 
 
 90 ' 
 
 
 1919 
 
 139 
 
 
 151 " 
 
 71 ' 
 
 
 Average 
 
 152 
 
 
 113 " 
 
 92 ' 
 
 
 48 
 
TABLE XX. 
 
 Condition of Patients Discharged from Hospitals and Sanatoria. 
 
 (Percentages of Total). 
 
 
 Wallum Lake 
 
 
 
 Providence City 
 
 Hospital 
 
 
 Hillsgrc 
 
 ve 
 
 Year 
 
 Improved 
 
 Dead 
 
 Others 
 
 Improved Dead 
 
 Others 
 
 Improved 
 
 Dead 
 
 Others 
 
 1910 
 
 74 
 
 2 
 
 24 
 
 25 
 
 60 
 
 15 
 
 50 
 
 50 
 
 
 
 1911 
 
 70 
 
 1 
 
 28 
 
 25 
 
 61 
 
 13 
 
 23 
 
 58 
 
 19 
 
 1912 
 
 73 
 
 3 
 
 25 
 
 28 
 
 55 
 
 17 
 
 16 
 
 55 
 
 29 
 
 1913 
 
 65 
 
 1 
 
 34 
 
 23 
 
 54 
 
 23 
 
 14 
 
 47 
 
 39 
 
 1914 
 
 61 
 
 1 
 
 37 
 
 21 
 
 48 
 
 31 
 
 9 
 
 53 
 
 38 
 
 1915 
 
 62 
 
 4 
 
 34 
 
 27 
 
 54 
 
 19 
 
 15 
 
 52 
 
 33 
 
 1916 
 
 63 
 
 4 
 
 32 
 
 21 
 
 58 
 
 20 
 
 16 
 
 49 
 
 35 
 
 1917 
 
 61 
 
 5 
 
 34 
 
 25 
 
 53 
 
 22 
 
 14 
 
 61 
 
 25 
 
 1918 
 
 46 
 
 26 
 
 28 
 
 18 
 
 53 
 
 29 
 
 22 
 
 52 
 
 26 
 
 1919 
 
 42 
 
 26 
 
 32 
 
 19 
 
 54 
 
 27 
 
 32 
 
 40 
 
 28 
 
 Ten years 
 
 62 
 
 7 
 
 31 
 
 23 
 
 55 
 
 22 
 
 21 
 
 52 
 
 27 
 
 Lake prior to 1918. The averages for 1910-1917 are as follows: 
 improved, 66 per cent; dead, 3 per cent; all others, 31 per cent. 
 
 The heading "improved" as used in Table XX is of course a very- 
 vague term and the Wallum Lake cases of this type have been fur- 
 ther subdivided in Table XXL It appears from this tabulation 
 that only 3 per cent of the sanatorium cases treated between 1910 
 and 1917 were definitely considered as cured and only 17 per cent 
 as apparently arrested, 12 per cent being quiescent and 34 per cent 
 merely improved. 
 
 At the Gaylord Farm Sanatorium, the average results for the 
 three years 1917 to 1919 were as follows: cases apparently arrested, 
 8 per cent; quiescent, 39 per cent; improved, 32 per cent; dead, 2 
 per cent; all others, 19 per cent. 
 
 The success of sanatorium treatment can not, however, be 
 judged solely by the somewhat arbitrary classification of the con- 
 dition of the patients on discharge. The real' test is the fate of the 
 patients when they return to the conditions of community life out- 
 side. Dr. Barnes, the superintendent of the State Sanatorium, has 
 conducted most valuable studies of the condition of his patients 
 after discharge, which were published in the reports of the Trustees 
 of the Sanatorium up to 1917. The discontinuance of these full 
 statistical reports since 1917 (due to misguided parsimony on the 
 part of the state authorities) is a real misfortune since they con- 
 stituted a real contribution to this important subject and were much 
 to the credit of the state of Rhode Island. 
 
 In Table XXII we have summari/.ed the data presented in Dr. 
 Barnes' report for 1917, covering a total of 3088 cases admitted be- 
 tween January 1, 1906, and January 1, 1917, showing the condition 
 
 49 
 
TABLE XXI. 
 Condition of Patients Discharged from 
 (Percentage of Total) 
 Year Apparently Cured Apparently Arrested Quiescent 
 
 35 
 30 
 27 
 11 
 
 6 
 
 5 
 10 
 13 
 
 1910 
 
 7 
 
 1911 
 
 9 
 
 1912 
 
 7 
 
 1913 
 
 
 1914 
 
 
 1915 
 
 
 1916 
 
 
 1917 
 
 
 1918 
 
 
 1919 
 
 
 Ten years 
 
 2 
 
 Eight years 
 
 
 1910-1917 
 
 3 
 
 3 
 15 
 
 17 
 
 18 
 17 
 23 
 23 
 18 
 14 
 14 
 13 
 
 12 
 
 Wallum Lake. 
 
 Improved Dead Others* 
 
 32 
 31 
 40 
 36 
 38 
 35 
 31 
 30 
 24 
 25 
 32 
 
 34 
 
 2 
 1 
 3 
 1 
 1 
 4 
 4 
 5 
 26 
 26 
 7 
 
 24 
 28 
 25 
 34 
 37 
 34 
 32 
 34 
 28 
 32 
 31 
 
 31 
 
 *Chiefly "unimproved." 
 
 TABLE XXIL 
 
 Results of Sanatorium Treatment at Wallum Lake. 
 
 3088 Patients Admitted 1906-1916. 
 
 Percentages for each Admission Group. 
 
 Condition on 
 
 Condition on 
 
 Condition Jan. 1, 1918. 
 
 
 
 Admission Discharge 
 
 Well 
 
 Living and 
 
 Living, not 
 
 
 Un- 
 
 
 
 Working 
 
 Working 
 
 Dead 
 
 known 
 
 f Apparently cured 
 
 15 
 
 4 
 
 
 
 4 
 
 3 
 
 . . Apparently arrested 
 
 14 
 
 3 
 
 3 
 
 6 
 
 3 
 
 "T'"\ Quiescent 
 
 3 
 
 1 
 
 2 
 
 1 
 
 1 
 
 (227 cases) 1 i.,,p,,,,d 
 
 15 
 
 4 
 
 4 
 
 5 
 
 4 
 
 Unimproved 
 
 2 
 
 4 
 
 
 
 3 
 
 
 
 f Apparently cured 
 
 2 
 
 1 
 
 
 
 
 
 
 
 Moderately Apparently arrested 
 
 7 
 
 3 
 
 2 
 
 10 
 
 2 
 
 Advanced < Quiescent 
 
 2 
 
 2 
 
 2 
 
 3 
 
 
 
 (2558 cases)] Improved 
 
 4 
 
 4 
 
 4 
 
 23 
 
 2 
 
 [ Unimproved 
 
 1 
 
 1 
 
 2 
 
 22 
 
 1 
 
 
 Apparently cured 
 
 
 
 
 
 
 
 
 
 
 
 
 Apparently arrested 
 
 1 
 
 
 
 
 
 3 
 
 
 
 Far Advanced , 
 (303 cases) 
 
 Quiescent 
 
 
 
 
 
 
 
 1 
 
 
 
 Improved 
 
 
 
 
 
 1 
 
 17 
 
 1 
 
 
 , Unimproved 
 
 
 
 
 
 
 
 73 
 
 1 
 
 of these patients on admission, on discharge and on January 1, 
 1918, — five years on the average since they began treatment. We 
 have reduced all these figures to a percentage basis, considering 
 each of the three main groups admitted as 100 per cent. 
 
 50 
 
It is apparent from this very interesting table that, of the incipient 
 cases admitted, two-thirds of those who could be located were found 
 to be well or alive and at work, a very encouraging record. On the 
 other hand, of the moderately advanced cases, over 60 per cent of 
 those that could be traced were dead and only 28 per cent were well 
 or living and working; while of the far advanced cases 63 per cent 
 were dead and 28 per cent were well or at least alive and at work. 
 
 From another standpoint we may conveniently divide the whole 
 series into nine main groups, first on the basis of condition on ad- 
 mission and second on the basis of condition on discharge, group- 
 ing apparently cured, arrested and apparently arrested cases to- 
 gether as presumably favorable, — grouping quiescent and improved 
 cases as doubtful, and considering unimproved cases as clearly un- 
 favorable. 
 
 TABLE XXIII. 
 Efficienxy of Sanatorium Treatment at Wallum Lake 
 3088 patients admitted 1906-1916 
 Percentages of Total Group. 
 
 Condition on Condition on • Condition Jan. 1, 1918 
 
 Admission Discharge Per cent Per cent 
 
 well or living living, not Per cent 
 and at work working dead 
 2 1 
 
 2 
 
 Incipient 
 
 Moderately 
 Advanced 
 
 Far Advanced 
 
 Favorable 
 
 Doubtful 
 
 Unfavorable 
 
 Favorable 
 
 Doubtful 
 
 Unfavorable 
 
 Favorable 
 
 Doubtful 
 
 Unfavorable 
 
 Total all cases: 
 
 10 
 
 10 
 
 1 
 
 25 
 
 9 
 21 
 19 
 
 2 
 
 7 
 
 59 
 
 Per cent 
 unknown 
 
 Table XXIII indicates that of the patients discharged from 
 Wallum Lake during the period 1906-16, only 5 per cent were in- 
 cipient cases at the time of admission. Four per cent, out of this 
 5 per cent, were living and at work after an average of five years. 
 Nine per cent were far advanced cases at the time of admission and 
 practically all were dead after an average of five years. The great 
 bulk of the cases (84 per cent) were moderately advanced cases; of 
 these 23 per cent were in a favorable condition on discharge, and 10 
 
 51 
 
per cent remained alive and able to work; 39 per cent were in a 
 doubtful condition (quiescent or improved) on discharge and 10 
 per cent remained alive and able to work; 22 per cent were unim- 
 proved on discharge and only 1 per cent remained alive and able 
 to work after an average of five years. Taking all groups together 
 it appears that sanatorium treatment effected a fairly permanent 
 cure in 25 per cent of the cases discharged, that 59 per cent of all 
 cases discharged were dead after an average of five years, while 8 
 per cent were alive but not able to work, and 6 per cent were lost. 
 The actual result of institutional treatment in this case is, there- 
 fore, to save about one quarter of the cases discharged. 
 
 These results are disappointing; and it is evident that the reasons 
 for the failure to effect a larger percentage of cures is a twofold one. 
 First, of the 3088 patients covered in Table XXIII, only 5 per cent 
 were incipient cases on admission; and second, only 26 per cent re- 
 mained in the institution until the disease was apparently cured or 
 arrested. 
 
 Where sanatorium treatment is secured early and continued for 
 a sufficient period very different results are obtained. Dr. F. B. 
 Trudeau reports (American Review of Tuberculosis, 4, 518) that of 
 979 consecutive cases discharged from Saranac Lake between 1907 
 and 1913, 64 per cent were well in 1918, 13 per cent living, 21 per 
 cent dead and 1 per cent lost. 
 
 Table XXIV presents the results of treatment at Gaylord Farm 
 in a form comparable to Table XXIII. Arrested cases have been 
 called "favorable," improved cases "doubtful," and progressive 
 cases "unfavorable," in estimating the condition on discharge. In 
 the classification of the cases five years or more (5-12 years) after 
 discharge the "still arrested" group corresponds fairly well with the 
 "living and at work" group in Table XXIII. The "improved or 
 progressive" group may be compared with the "living but not work- 
 ing" group in Table XXIII. On this basis Gaylord Farm appears 
 to effect a permanent cure for 44 per cent of its patients against 25 
 per cent at Wallum Lake, and this result is made possible, not be- 
 cause the actual treatment given is superior to that at Wallum Lake, 
 but primarily because 22 per cent of the Gaylord Farm patients 
 were incipient at entrance against 5 per cent at Wallum Lake. 
 It is the type of patient treated that makes the primary difference, 
 Wallum Lake, like nine out of ten sanatoria the country over is deal- 
 ing with patients most of whom are so far advanced as to be hope- 
 
 52 
 
less, while specially favored institutions like Saranac Lake and Gay- 
 lord Farm show what can be done by sanatoria which really treat 
 tuberculosis in its incipient stage. 
 
 It is also certain that the type of patients treated at Saranac and 
 at Gaylord Farm go back to much more favroable home conditions 
 than the average of those treated at Wallum Lake. 
 
 TABLE XXIV. 
 
 Efficien'CY of Sanatorium Tre.\tment at Gaylord Farm 
 
 817 Cases admitted prior to 1912. 
 
 Percentage of total group. 
 
 Condition Condition Condition May 1, 1917 
 
 on admission on discharge Percentage Percentage Per- Per- 
 
 still improved or centage centage 
 
 arrested progressive dead unknown 
 
 Favorable 11 1 1 
 
 Incipient Doubtful 7 ;... 1 1 
 
 Unfavorable 
 
 Moderately Favorable 17 1 8. . ..-. 1 
 
 Advanced Doubtful 8 1 12 1 
 
 Unfavorable 1 8 
 
 Far Advanced Favorable 2 
 
 Doubtful 6. 
 
 Unfavorable 9 
 
 44 2 47 4 
 
 The State Sanatorium at Wallum Lake is an admirable institu- 
 tion. It was constructed on an unusual and economical plan. It 
 is ably and efficiently administered, and the scientific quality of the 
 work done by Dr. Barnes and his assistants is of the highest order. 
 Doctors Pinckney and Hamblet, who come into most direct contact 
 with the patients, are untiring in their devotion. Yet, in the case 
 of more than three fourths of the patients admitted, this institution 
 fails of attaining satisfactory results. The remedy for this situa- 
 tion can only be found by securing the treatment of patients at an 
 earlier stage in the development of the disease and by continuing 
 that treatment until the disease is definitely arrested. The earlier 
 beginning of treatment must lie chiefly with agencies outside the 
 sanatorium itself, with the state and municipal health authorities, 
 with the clinics and public health nursing associations and with the 
 voluntary anti-tuberculosis organizations of the State. The task 
 
 53 
 
of holding patients until they are cured is largely the problem of 
 the sanatorium itself (although the success attained will naturally 
 be affected by economic conditions and by the intelligence of the 
 patients) ; and any improvements in psychological atmosphere which 
 will keep old patients happy will indirectly make it easier to per- 
 suade new patients to enter the institution. 
 
 In the past, far too little attention has been paid to the problem 
 of the mental attitude of the sanatorium inmate, as a man or a 
 woman, rather than a patient. The experience of the social 
 workers of the Red Cross in the hospitals maintained for tuber- 
 culous soldiers has shown how much may be accomplished by 
 specialists in the social service field. The busy physicians respon- 
 sible for the medical work of a large sanatorium cannot find the 
 time, even if they have the special gifts and the special knowledge, 
 to write letters, to clear up financial and family problems, to give 
 personal cheer and counsel. I am inclined to believe that nothing 
 would contribute more to the success of the State Sanatorium than 
 the appointment of a medical social worker to care for the personal 
 life of the patients and to make it easy and pleasant for them to re- 
 main at Wallum Lake until their cure is completed. Ultimately 
 such an officer should form a part of the regular official staff of the 
 institution; but until the worth of the position has been conclusively 
 demonstrated I would recommend that the Rhode Island Tubercu- 
 losis Association pay the salary of a medical social worker to serve 
 at the State Sanatorium for the purposes outlined. 
 
 There is one peculiar handicap under which the sanatorium at 
 Wallum Lake suffers; and that is its distance from the centers of 
 population and the consequent difficulty of access for the families 
 and friends of patients. Even from Providence a trip to Wallum 
 Lake consumes an entire day, with existing train service, and for 
 residents of other parts of the state two days and one or two nights 
 would be required. The opening of some regular means of com- 
 munication would make it easy for patients to receive visits and 
 would greatly assist in securing earlier and longer treatment. 
 Again there seems a distinct field for the Rhode Island Tuberculosis 
 Association; and I would urge that this organization give serious 
 consideration to the possibility of arranging for daily automobile 
 service to and from Wallum Lake. 
 
 Prior to the effective establishment of such transportation ser- 
 vice, it is necessary, however, to provide for substantial improve- 
 
 54 
 
ment in the highways leading to the sanatorium. I am informed 
 that the road from Pascoag to Wallum Lake is almost impassable 
 for four to six months of the year ; and it would seem proper to urge 
 upon the Legislature the pressing need for such repairs as shall put 
 this highway into proper condition. 
 
 Finally it should be pointed out that there is still another prob- 
 lem to be considered in connection with sanatorium treatment,— 
 the after care of patients who have been discharged. In Provi- 
 dence and the other large cities of Rhode Island discharged cases 
 are well followed up by the public health nursing organizations; 
 but experience teaches us that of the patients discharged as ar-^ 
 rested, quiescent or improved there is a certain, fairly large, pro- 
 portion who will continue in good health while living under ideal 
 sanitary hygienic conditions, but who will go steadily down under 
 the ordinary conditions of urban and industrial life. For such 
 cases salvation lies, not in any temporary treatment, but in a per- 
 manent change in the conditions of their daily life. Long con- 
 tinued sanatorium treatment for such patients is neither necessary 
 nor desirable. What they need is the opportunity for normal family 
 life and for the maximum of self-support, under environmental and 
 industrial and social conditions which make it possible for them to 
 retain their new-found health. It is now generally recognized that 
 the solution of this problem lies in the establishment of industrial 
 colonies, such as Dr. Pattison has so admirably projected in the 
 American Review of Tuberculosis for July, 1919, or in the provision 
 of special industrial facilities, like those furnished by the Com- 
 mittee for the Relief of the Jewish Tuberculous in New York City, 
 or of special housing facilities, like those established by the Associa- 
 tion for Improving the Condition of the Poor, also in New York 
 City. Such projects must be worked out for the future with much 
 thought and discrimination. I would suggest that those who are 
 interested in the furtherance of anti-tuberculosis work in Rhode 
 Island could render a most important service by undertaking a 
 study of the problem of the provision of proper conditions for the 
 family and industrial life of arrested and quiescent cases of tuber- 
 culosis in Rhode Island, with a view to formulating a definite 
 plan of action at a later date. 
 
 55 
 
VI. PUBLIC HEALTH NURSING IN RHODE ISLAND AND 
 
 ITS RELATION TO THE ANTI-TUBERCULOSIS 
 
 CAMPAIGN. 
 
 Next to the clinic and the sanatorium the pubHc health nurse is 
 the most vital factor in the anti-tuberculosis campaign. Her work 
 is essential in the discovery of new cases and in bringing them in 
 contact with the clinic and the sanatorium, in the active follow-up 
 and bedside care of cases under the charge of the clinic, and in the 
 after care and continued instruction of discharged arrested cases. 
 A general review of the public health nursing facilities of the state 
 is therefore an essential part of our survey. 
 
 So far as we have been able to learn, — chiefly from the very ac- 
 curate information in the hands of the Providence District Nursing 
 Association, — there are at present 112 public health nurses in the 
 state of Rhode Island, exclusive of the industrial nurses, who will 
 be considered separately. They are distributed in proportion to 
 population as indicated in Table XXV. 
 
 Wherever the development of public health nursing has been 
 attempted on an intensive scale, as in selected Health Center Dis- 
 tricts of Boston, New York and New Haven, it has been found that 
 a group of 1500 to 2000 persons is the largest that can be cared for 
 in a really adequate manner. The supply of nurses is everywhere, 
 however, deplorably short of the need, and as matters stand today 
 any community which has one public health nurse for every 4000 
 to 5000 population is relatively well served. Providence, the Paw- 
 
 TABLE XXV. 
 Public Health Nursing Service in Rhode Island. 
 
 Number Nurses Population per Nurse 
 
 Providence 66 3600 
 
 Pawtucket, Central Falls, and 
 
 Cumberland 
 Woonsocket 
 Pawtuxet Valley 
 East Providence 
 Newport 
 Cranston 
 Westerly 
 
 Fourteen other towns* 
 Rest of state 
 
 State Health Department 
 
 Total 112 5400 
 
 *Barrington, Bristol, Burrillville, East Greenwich, Johnston, Little Compton, Middletown, 
 North Kingstown, North Providence, Smithfield, South Kingstown, Tiverton, Warren, and 
 Warwick. 
 
 56 
 
 9 
 
 10900 
 
 6 
 
 7200 
 
 4 
 
 5200 
 
 3 
 
 7100 
 
 4 
 
 7500 
 
 2 
 
 14500 
 
 2 
 
 5000 
 
 14 
 
 5800 
 
 
 
 20000 persons with no 
 
 
 public health nurse 
 
 2 
 
 
tuxet Valley (Coventr\- and West Warwick) and Westerly are, 
 therefore, ia reasonably good condition, so far as public health 
 nursing service is concerned, while the population per nurse is 
 woefully high in Pawtucket and Central Falls and in Cranston. 
 There is no community of 2000 population which would not bene- 
 fit by the service of a trained public health nurse and which does 
 not need such a nurse in order that preventable disease may be 
 avoided and needless suffering saved. 
 
 In the first communities listed in Table XXV the care of tubercu- 
 losis cases is entrusted to special nurses who devote all, or most, of 
 their time to this task. We may therefore consider the work of 
 these tuberculosis nurses first of all, returning later to the anti- 
 tuberculosis work carried out by the generalized nurses working in 
 Cranston, Westerly and the smaller communities. 
 
 Taking up, first of all, the city of Providence, sixteen of the nurses 
 included in Table XXV are school nurses and contagious disease 
 nurses in the employ of the Department of Health while fifty are 
 employed by the Providence District Nursing Association. Of these 
 fifty nurses, seven devote themselves wholly to tuberculosis.* 
 They are well trained women working under the systematic guidance 
 of a thoroughly qualified and able supervisor. Miss Edgecomb, and 
 the full records which are kept furnish evidence of admirable 
 accomplishment. The nurses of the D. N. A. furnish service to all 
 the clinics of the city and problems of social service are considered 
 in a weekly conference with representatives of the Society for Or- 
 ganizing Charity. 
 
 Through the courtesy of Miss Edgecomb it has been possible to 
 obtain very full data in regard to the work of the D. N. A. The 
 chief figures so far as admission and disposition of cases is concerned 
 are presented in Table XXVI. They indicate that each nurse 
 cared for approximately 225 patients during 1919; and that 6.6 
 persons per 1000 total p(;pulation came under the care of the tuber- 
 culosis nurses. The tuberculosis nurses of the New Haven V. N. A. 
 care for almost exactly the same proportion of the population (6.8 
 per 1000); but each nurse has an average of only 159 cases under 
 her care. In New Haven, however, the tuberculosis nurses care 
 for the severely ill cases, which they do not do in Providence. 
 
 ♦These nurses do not give bedside care to cases which are severely ill, such cases taking up 
 about half the time of one additional nurse. 
 
 57 
 
TABLE XXVI. 
 General Summary of the Tuberculosis Nursing Service of the Provi- 
 dence DisTRisT Nursing Association. 
 Admission 
 1917 1918 1919 
 
 Under care, Jan. 1 755 869 1022 
 
 Admitted during year 419 494 551 
 
 Total 1174 1363 1573 
 
 1917 1918 1919 
 
 Under care, Dec. 31* 742 909 1049 
 
 In sanatoria Dec. 31t 127 113 162 
 
 Discharged non-tuberculous 32 45 54 
 
 Dead 177 217 222 
 
 Left city or lost 96 79 86 
 
 Total 1174 1363 1573 
 
 *Exclusive of cases in sanatoria and hospitals. 
 
 tTotal eases in sanatoria and hospitals during year: 1917, 237; 1918, 281; 1919, 348. Total 
 
 cases which had at some time received hospital and sanatorium care: 1917, 418; 1918, 629; 
 
 1919, 577. 
 
 The type of cases cared for is indicated in a general way in Table 
 XXVII. 
 
 TABLE XXVII. 
 
 Classification of Cases. 
 
 1917 1918 1919 
 
 Positive cases 631 708 830 
 
 Contact cases 296 349 375 
 
 Suspicious cases 165 209 223 
 
 Non-pulmonary cases 82 97 145 
 
 Total 1174 1363 1573 
 
 The source from which the District Nursing Association cases 
 were obtained during the year 1919 are indicated in Table XXVIII. 
 
 
 TABLE XXVIII. 
 
 
 
 
 Source of Cases, 
 
 1919.* 
 
 
 
 
 Positive cases 
 
 Contact 
 
 suspicious cases 
 
 Physicians 
 
 163 
 
 
 
 72 
 
 Clinics 
 
 198 
 
 
 
 140 
 
 Sanatoria or Hospitals 
 
 245 
 
 
 
 
 Other agencies 
 
 108 
 
 
 
 91 
 
 Found by nurses 
 
 116 
 
 
 
 295 
 
 Total 
 
 830 
 
 
 
 598 
 
 *Pulmonary cases only. 
 
 58 
 
From this table it appears that the tuberculosis nurses are doing 
 excellent work in the discovery of new cases of frank or suspicious 
 tuberculosis. They have themselves discovered almost exactly 
 half of all the contact and suspicious cases for which they care, and 
 14 per cent of the definitely positive cases, against 20 per cent re- 
 ferred to them by physicians, 24 per cent by clinics, and 30 per cent 
 by sanatoria and hospitals. This showing is really better than it 
 seems, since the sanatorium and hospital group of cases did not 
 really originate with those institutions, but in most cases were sent 
 there by physicians, clinics or public health nurses. 
 
 It will be noted from Table XXVII that out of the 1428 pul- 
 monary cases cared for in 1919, 830 were positive cases and 598 
 contact, or suspicious cases. Of the 830, 301 were classed as in- 
 cipient, 415 as moderately advanced, and 114 as far advanced, in- 
 dicating that on the whole the material with which the nurses deal 
 is fairly promising. Conditions here, however, might well be im- 
 proved. In New Haven, out of 266 new cases admitted by the 
 V. N. A. in 1919, 119 were incipient cases, 97 moderately advanced 
 and only 50 far advanced. 
 
 The next problem in which we are interested is the nature of the 
 care which is given to the patients under the District Nursing Asso- 
 ciation. Our first criterion is, of course, the number of visits paid; 
 and data in regard to this point are presented in Table XXIX for 
 the three years 1917-1919. 
 
 
 
 TABLE XXIX. 
 
 
 
 Statistics of 
 
 VISITS 
 
 PAID BY 
 
 Providence 
 
 Tuberculosis 
 
 Nurses. 
 
 Visits per Patient 
 
 
 
 1917 
 
 1918 
 
 1919 
 
 No visit paid 
 
 
 
 4 
 
 7 
 
 5 
 
 1-2 
 
 
 
 158 
 
 233 
 
 297 
 
 3-4 
 
 
 
 166 
 
 257 
 
 273 
 
 5-6 
 
 
 
 196 
 
 247 
 
 239 
 
 7-9 
 
 
 
 210 
 
 218 
 
 270 
 
 10-12 
 
 
 
 164 
 
 183 
 
 214 
 
 13-18 
 
 
 
 178 
 
 158 
 
 174 
 
 19-24 
 
 
 
 49 
 
 31 
 
 42 
 
 25-35 
 
 
 
 34 
 
 20 
 
 41 
 
 Over 35 
 
 
 
 15 
 
 9 
 
 18 
 
 Total cases 
 
 1174 
 
 1363 
 
 1573 
 
 Total visits 
 
 
 
 11944 
 
 11128 
 
 15359 
 
 Average visits per case 
 
 
 10 
 
 8 
 
 10 
 
 59 
 
The visits per patient indicated in this table appear to be some- 
 what low. In New Haven, the Visiting Nurse Association makes 
 17 visits per patient on the average. In New Haven, however, as 
 pointed out above, each nurse has only 159 patients to care for and 
 severely ill bed cases are nursed; but the visits made per year by 
 each nurse average a little better at New Haven, 2452, as against 
 2194 in Providence. 
 
 The results of treatment are a little less satisfactory than at New 
 Haven, 14 per cent of the 1919 patients being dead at the end of the 
 year as against 9 per cent in New Haven. This is no doubt a re- 
 sult of the fact that 14 per cent of the patients nursed in New Haven 
 were far advanced cases against 19 per cent in Providence. Every- 
 where the results of the treatment of tuberculosis vary directly 
 with the stage at which treatment is commenced. 
 
 In order to obtain a more direct measure of the actual results ob- 
 tained by District Nursing Association, I obtained through the 
 courtesy of Miss Edgecomb the data presented in Table XXX. 
 The object of a tuberculosis nursing service, so far as the known 
 case is concerned, is either to get the patient into a sanatorium or 
 to keep the patient in touch with a clinic and to render such home 
 nursing care and give such instruction as may enable him to recover 
 in the home. In Table XXX are presented the results of an analysis 
 of 448 random cases of positive pulmonary tuberculosis, under ob- 
 servation for at least one year, classified according to the type of 
 treatment given and its results. 
 
 TABLE XXX. 
 
 Analysis of Disposition and Results in 448 Random Cases of Pulmonary 
 
 Tuberculosis under care by the District Nursing Association. 
 
 Prior to July 1, 1919. 
 
 (Percentages) 
 
 Cured or 
 
 Improved Unimproved Dead Total 
 
 A. Admitted to hospital or sanato- 
 
 rium and kept there for a rea- 
 sonably satisfactory period. 53 19 11 83 
 
 B. Cared for at home under ade- 
 
 quate sanitary and hygienic 
 
 conditions. 9 2 1 12 
 
 C. Kept at home without adequate 
 
 care. 2 2 2 6 
 
 Total 64 23 14 101 
 
 The showing made by the District Nursing Association in this 
 table is a remarkable one. Eighty-three per cent of this group of 
 
 6o 
 
cases were placed in sanatoria or hospitals and 12 per cent were 
 adequately cared for in the home; in only 6 per cent of the 488 cases 
 was there a failure to secure satisfactory treatment in one way or 
 another. The result is that but 14 per cent of the group are dead 
 and 64 per cent are classed as cured or improved. The Providence 
 District Nursing Association is handling a large group of cases for 
 the size of its staff; it is detecting many new cases in the early stages 
 of the disease. It is giving adequate and intensive nursing care, 
 and it is achieving marked success in securing sanatorium treatment 
 for its patients. How effectively the organization works is well 
 indicated by the fact that of 889 patients referred to the District 
 Nursing Association for follow-up work, on discharge from Wallum 
 Lake or Providence City Hospital, during the three years 1917- 
 1919, only 37 cases were not found; 114 were at once admitted to 
 another institution than the one they had left; and 638 cases were 
 found at home and given nursing care. 
 
 The onh- thing one could wish would be an enlargement of the 
 staff of tuberculosis nurses, so that the volume of work could be 
 multiplied. From what we know of the actual amount of uncared 
 for tuberculosis in every community it is certain that fifteen tuber- 
 culosis nurses could profitably be employed in Providence instead 
 of seven; in New Haven, wuth a population of a little over 160,000, 
 seven nurses under the Visiting Nurse Association and two nurses 
 under the Health Department devote their whole time to tuberculo- 
 sis cases. It must be remembered, however, that even under 
 present conditions Providence is far better off than the rest of the 
 state, — or than most American cities. 
 
 In the Pawtucket and Central Falls district one of the nine nurses 
 employed by the Visiting Nurse Association devotes herself 
 entirely to tuberculosis work, the population served being nearly 
 100,000. During the year, April 1, 1919 to April 1, 1920, 305 cases 
 were cared for and 3029 visits made, an enormous amount of work 
 accomplished by one nurse, but far too heavy a load to be carried 
 effectively. It is not surprising that 67, or 22 per cent, of these 305 
 patients died during the year as compared with 14 per cent of the 
 patients cared for in Providence. One nurse working in a popula- 
 tion of 100,000 people can only give care to the most advanced cases 
 and cannot possibly find time for the more fruitful work of discover- 
 ing the early and favorable cases. Seventy-nine per cent of the 
 patients under care in Pawtucket on May 28 were positive cases, 
 
 6i 
 
against 53 per cent during the year 1919 in Providence. There is 
 obviously a very great need for several more tuberculosis nurses in 
 this district. 
 
 In Woonsocket one of the six nurses of the Public Health Nursing 
 Association has devoted herself entirely to tuberculosis since Sep- 
 tember 1, 1919; prior to that time tuberculosis cases were cared for 
 on the generalized nursing plan. Again the population of over 
 40,000 is much too large for a single nurse, though the discrepancy 
 is not nearly so large as at Pawtucket. During the year 1919, 229 
 tuberculosis patients were treated, of whom 107 remained under 
 care on December 31, 53 were discharged to hospital or sanatorium 
 care, 29 were dead, 24 were discharged well or improved and 16 
 were discharged for other causes. Eighteen hundred and sixty- 
 three visits were paid. This is too low a ratio, but in general the 
 statistics indicate successful results. Only 13 per cent of the pa- 
 tients treated died during the year; a remarkably fortunate result 
 in view of the fact that of 106 cases under care in September, 1920, 
 67 per cent were positive cases. The Woonsocket nursing staff 
 deserves very special success for its efforts to keep the tuberculosis 
 clinic in operation in the face of disheartening difficulties. 
 
 The only other nurse who gives full time to tuberculosis work is 
 the nurse at the Pawtuxet Valley (Riverpoint) Clinic, who serves 
 chiefiy the town of West Warwick and Coventry, with a contribu- 
 tory population of between 20,000 and 30,000 persons. Here we 
 have the nearest approach to an adequate service, outside of Provi- 
 dence. The very capable nurse at this center cared for 169 cases 
 during the year ending July 1, 1920, and made 1775 visits, an ex- 
 cellent ratio for a rural district. Of these 169 cases, 96 were still 
 under care July 1, 1920, 10 were in sanatoria or hospitals, 35 had 
 been discharged and 28 were dead. 
 
 In East Providence one nurse divides her time between tuber- 
 culosis and school work. During the year ending July 1, 1920, she 
 cared for 70 tuberculosis cases and made 420 visits, far too low a 
 ratio. Of these, 36 were still under care on July 1,12 were in sana- 
 toria, 14 had died, 6 had moved away and 2 had been lost. The 
 death rate, 20 per cent, is high and it seems clear that more intensive 
 tuberculosis work is needed in this community. 
 
 The situation as regards tuberculosis nursing in Newport is most 
 unusual. The city has a school nurse and an infant welfare nurse 
 and a Metropolitan Life Insurance nurse; and externe home nursing 
 service is rendered by two pujiil nurses from the hospital under the 
 
 62 
 
(direction of a supervisor. This supervisor under an arrangement 
 with the city herself gives nursing care to advanced indigent cases of 
 tuberculosis but has had only one such patient in the last six months. 
 The general task of detecting and supervising early cases, which is 
 the normal function of a public health nurse, is in Newport under- 
 taken by the Secretary of the local Anti-Tuberculosis Association, 
 Miss Mary K. Akerley. Miss Akerley is accomplishing much 
 valuable work but the most efifectiv'e instructive work in the home 
 can only be done by a fully-trained public health nurse. The lack 
 of a clinic and the lack of tuberculosis nursing service are no doubt 
 important factors in the meagre reporting of tuberculosis and in the 
 relatively low hospitalization for the city of Newport. 
 
 The rest of the anti-tuberculosis nursing work of the state is done 
 as part of the generalized public health nursing service in the cities 
 and towns of Harrington, Bristol, Burrillville, Cranston, East Green- 
 wich, Johnston, Little Compton, Middletown, North Kingstown, 
 North Providence, Smithfield, South Kingstown, Tiverton, War- 
 ren, Warwick, and Westerly. A circular letter was sent to the pub- 
 lic health nurses of these towns asking for certain data in regard 
 to their tuberculosis work during the past calendar year and in 
 every case the information was most courteously and promptly 
 furnished ; and the results are presented in Table XXXI below. 
 
 TABLE XXXI. 
 
 Cases Cared for by Generalized Nurses in 
 
 Sixteen Rhode Island Towns. 
 
 
 
 
 03 u 
 
 
 o a 
 
 -. ^.^ O 
 
 c 
 
 •B 
 
 
 
 6 
 
 > 
 
 CS >> 
 
 Q 
 
 OS Ms- 
 
 o 
 
 3 
 
 5 
 
 s 
 
 1-1 
 
 Barrington 
 
 14 
 
 219 
 
 7 
 
 2 
 
 1 
 
 3 
 
 1 
 
 
 
 Bristol 
 
 29 
 
 354 
 
 7 
 
 6 
 
 6 
 
 2 
 
 8 
 
 
 
 Burrillville 
 
 13 
 
 476 
 
 6 
 
 5 
 
 1 
 
 1 
 
 
 
 
 
 Cranston 
 
 30 
 
 211 
 
 11 
 
 8 
 
 3 
 
 6 
 
 2 
 
 
 
 East Greenwich 
 
 5 
 
 146 
 
 3 
 
 
 
 2 
 
 
 
 
 
 
 
 Johnston 
 
 16 
 
 178 
 
 13 
 
 
 
 
 
 3 
 
 
 
 
 
 Little Compton 
 
 3 
 
 15 
 
 1 
 
 1 
 
 
 
 1 
 
 
 
 
 
 Middletown 
 
 3 
 
 39 
 
 2 
 
 
 
 1 
 
 
 
 
 
 
 
 North Kingstown 
 
 2 
 
 75 
 
 
 
 
 
 1 
 
 
 
 1 
 
 
 
 North Providence 
 
 22 
 
 490 
 
 6 
 
 9 
 
 5 
 
 2 
 
 
 
 
 
 Smithfield 
 
 9 
 
 164 
 
 6 
 
 2 
 
 
 
 1 
 
 
 
 
 
 South Kingstown 
 
 11 
 
 450 
 
 4 
 
 4 
 
 
 
 1 
 
 2 
 
 
 
 Tiverton 
 
 3 
 
 186 
 
 2 
 
 1 
 
 
 
 
 
 
 
 
 
 Warren 
 
 9 
 
 91 
 
 1 
 
 5 
 
 3 
 
 
 
 
 
 
 
 Warwick 
 
 18 
 
 56 
 
 2 
 
 5 
 
 1 
 
 1 
 
 1 
 
 8 
 
 Westerly- 
 
 6 
 
 13 
 
 2 
 
 2 
 
 2 
 
 
 
 
 
 
 
 Total 
 
 193 3163 
 
 73 
 
 50 
 
 26 
 
 21 
 
 15 
 
 63 
 
The death rate for this group of cases as a whole is high (25 per 
 cent) and the wide variations between the ratio of visits per case 
 indicate startHng divergence of practise. It can hardly be that 
 tuberculosis cases in North Kingstown and South Kingstown really 
 require 40 visits a year; and those in Warwick and Westerly must 
 certainly need more than the two or three visits they receive. 
 
 As a matter of fact these data simply indicate that in some towns 
 the nurses are overworked while in others they have free time on 
 their hands. The work of the public health nurse in a small com- 
 munity would benefit greatly by expert supervision; and the plan 
 of the State Board of Health to obtain appropriations for a Division 
 of Public Health Nursing is a most commendable one. A qualified 
 Director of Public Health Nursing, such as many states now pos- 
 sess, would be of the greatest service in developing and standardiz- 
 ing public health nursing in Rhode Island. The project deserves the 
 earnest support of all who are interested in the tuberculosis problem. 
 
 Aside from the aberrancies manifested in a few of the smaller 
 towns the quality of the service rendered by the public health 
 nurses of Rhode Island seems to be admirable. It is in quantity 
 that it is deficient; and the particular weak points are brought out 
 by the statistics presented in Table XXXII. 
 
 It is apparent that the Pawtuxet Valley region is better served 
 than any other section of the state. The figures are a little more 
 favorable than they should be, for we have used only the popula- 
 tions of West Warwick and Coventry in computing our ratios and 
 the nurse at Riverpoint cares for a few cases in adjoining parts of 
 Scituate and Cranston. Providence comes next, with 65 nursing 
 visits to tuberculosis cases per 1000 population per year. Woon- 
 socket stands next, while Pawtucket, East Providence and the small 
 towns served by generalized nurse service are notably deficient. 
 
 TABLE XXXII. 
 Relative Extent of Tuberculosis Nursing Service for Various Areas 
 
 IN Rhode Island. 
 Tuberculosis Patients 
 
 
 Given Nursing 
 
 Care 
 
 Visits to Tuberculosis 
 
 Visits 
 
 
 per 
 
 1000 Popul 
 
 ation 
 
 Patients 
 
 i per 
 
 1000 
 
 Per 
 
 
 
 per 
 
 Year 
 
 
 Population per year 
 
 Case 
 
 Providence 
 
 
 
 7 
 
 
 
 65 
 
 
 10 
 
 Pawtuciiet, Central Falls, 
 
 
 
 
 
 
 
 
 
 Cumberland 
 
 
 
 3 
 
 
 
 30 
 
 
 10 
 
 Woonsocket 
 
 
 
 5 
 
 
 
 43 
 
 
 8 
 
 West Warwick, Coventry 
 
 
 
 8 
 
 
 
 85 
 
 
 11 
 
 East Providence 
 
 
 
 3 
 
 
 
 19 
 
 
 6 
 
 Generalized Nurses in 16 
 
 
 
 
 
 
 
 
 
 small towns 
 
 
 
 2 
 
 
 
 26 
 
 
 16 
 
 State as a whole 
 
 
 
 4 
 
 
 
 42 
 
 
 10 
 
 64 
 
In Xew Haven the nine tuberculosis nurses (seven under the 
 Visiting Nurse Association and two under the Board of Health) 
 care for eight patients and make 127 visits per year per 1000 popu- 
 lation, an average of 16 visits per case. Rhode Island needs more 
 tuberculosis nursing all along the line; and, particularly, it is clear 
 that the State Board of Health, the Rhode Island Tuberculosis 
 Association and other agencies should do everything possible to 
 stimulate the development of public health nursing in Newport, in 
 Cranston (where only 7 nursing visits to tuberculosis cases are 
 made per 1000 population), in East Providence, and in the Paw- 
 tucket region. 
 
 In order to complete the picture of public health nursing in Rhode 
 Island brief mention must be made of the activities of nurses em- 
 ployed by the larger industrial plants of the state. The names of 
 19 such nurses were courteously furnished to us by the officers of 
 the Providence District Nursing Association and a letter was writ- 
 ten to each nurse to ask if she did any work in the homes of tuber- 
 culosis patients, either nursing care or social service. Sixteen replies 
 were received to this letter. In eleven cases it was stated that no 
 nursing care was given in the home, although in most instances the 
 writer made clear that cases of tuberculosis occurring in the factory 
 are followed up to some extent and placed in the hands of com- 
 munity nursing or social service agencies. Of the eleven plants 
 which give no home nursing service seven are located in Providence 
 and three in Pawtucket. On the other hand one firm in Providence, 
 one in Bristol, one in Lincoln, one in Cumberland and one in Coven- 
 try, report that home nursing care is given to cases of tuberculosis, 
 a highly commendable practice for an industry located in a rural 
 section. Four of these five nurses report a total of nine cases of 
 tuberculosis cared for during the past year; so that the influence 
 of this factor upon the general statistics cited above is not an im- 
 portant one. In passing it may be noted that the work of the in- 
 dustrial nurses in Rhode Island would be far more effective if cor- 
 related with adequate medical service. I am informed that there is 
 not a single full-time industrial physician in the state of Rhode 
 Island and that in many instances the factory nurses for lack of 
 medical direction are tempted to assume responsibilities which 
 properly belong to the medical profession alone. The pro\ision, 
 
 .65 
 
in connection with the larger industries, of plant hospitals, wherever 
 possible with full-time medical service, would prove a powerful 
 weapon in the anti-tuberculosis campaign. 
 
 VII. THE PART PLAYED BY VOLUNTARY ASSOCIA- 
 TIONS IN THE ANTI-TUBERCULOSIS CAMPAIGN. 
 
 The view has been emphasized throughout this report that more 
 definite and vigorous participation of official health organizations 
 is the greatest need of the anti-tuberculosis movement at the present 
 time. On the other hand, it is equally true that there are many 
 things which can best be accomplished by private initiative: and 
 the volunatry anti-tuberculosis association must always play an 
 important and essential part in this campaign. Rhode Island is 
 fortunate in possessing a number of organizations of this type, and 
 particularly a strong state association and a strong tuberculosis 
 league for the city of Providence. 
 
 The Rhode Island Tuberculosis Association, under whose au- 
 spices this survey has been conducted, has been in operation for over 
 thirteen years. It has an excellent constitution, providing for full 
 representation in its directorate of various public and semi-public 
 agencies, such as the State Board of Health, the State Sanatorium, 
 the various hospitals, the local health department, and anti-tuber- 
 culosis and district nursing associations, — with fifteen members at 
 large. The Executive Committee is, however, a rather small one, 
 including only three members, besides the President, First Vice- 
 President and Secretary. It would seem best to add at least two 
 more members to this committee and, in particular, to place upon 
 it one or more public spirited and influential women, in order that 
 the potential influence of the newly enfranchised half of the popu- 
 lation may be fully utilized. The budget of the association during 
 the past year amounted to $7100, derived chiefly from the sale of 
 Red Cross seals. The success of the association is in large measure 
 due to the devoted and effective service of its Executive Secretary, 
 Mr. Willis E. Chandler. 
 
 The activ^ities of an organization of this type may conveniently 
 be classed under the five heads of Research, Education, Legislative 
 Propaganda, Organization and Direct Service. The present re- 
 port is the most recent evidence of the interest of the Association 
 
 66 
 
along the first of these Hnes; and the Association Hke the Providence 
 League has made important contributions in the past to the study 
 of the problems of housing, which bear so directly upon those of 
 tuberculosis. Mr. Chandler served as secretary of the Committee 
 on Improved Housing in Providence, to which Mr. John Ihlder made 
 his admirable report on The Houses of Providence, in 1916. The 
 attempt to secure the legislation contemplated in this report un- 
 fortunately failed, but should be renewed when economic conditions 
 make its prosecution possible. 
 
 From the standpoint of publicity, the state association has de- 
 voted itself particularly to the advertisement of the value of clinic 
 and sanatorium treatment and to educational work in the schools. 
 A very effective circular has been prepared, describing the facilities 
 at Wallum Lake and information in regard to the Providence clinics 
 is presented through paid advertisements in the leading English 
 and foreign-language newspapers. For reaching the school chil- 
 dren of the state the admirable machinery of the Modern Health 
 Crusade is being effectively utilized. Both these lines of activity 
 are of the greatest value and should be continued and extended. In 
 connection with the Health Crusade it would be well to develop a 
 campaign along the lines laid down by the Child Health Organiza- 
 tion of America for the monthly weighing and measuring of school 
 children, with the development of nutrition clinics, and of effectiv'e 
 general education in dietary hygiene. A beginning of activities 
 along this line was made during the first half of 1920 by Dr. Ellen 
 Stone, Director of Child Hygiene in the City Department of Health, 
 and by one of the school nurses. Similar work was done last year 
 in a primary school by a worker representing the Providence House- 
 \vi\es' League. Much more should, however, be accomplished 
 along these lines in all the cities of the state. Malnutrition is cer- 
 tainly one of the most important contributory causes to tuberculo- 
 sis; and the "scale in every school" movement is perhaps the best 
 method of obtaining a hearing for the lessons of dietary hygiene. 
 
 The state association has, in the past, played an important part 
 in securing the legislation which provided the state sanatorium at 
 Wallum Lak(?, in obtaining the present legislation in regard to the 
 isolation of tuberculosis, and in securing local action by towns and 
 cities in favor of fresh air school rooms. Of the latter, there are 
 now five in operation in Providence, accommodating 100 children 
 in all, and others in Pawtucket and Newport. The most immediate 
 
 67 
 
problems for the association in the legislative field would appear to 
 be the securing of the appointment of a state Director of Tuberculo- 
 sis under the State Board of Health and the obtaining of appropria- 
 tions for improving the road between Pascoag and Wallum Lake. 
 
 In the field of organization, the Rhode Island Tuberculosis Asso- 
 ciation has done yeoman service in the development of local anti- 
 tuberculosis associations and of district nursing service and has 
 made gratifying progress in standardizing nursing records and pro- 
 cedures in the smaller communities. The following 24 different 
 local anti-tuberculosis associations, health leagues or district nurs- 
 ing associations within the State of Rhode Island are at present 
 affiliated with the State Association : 
 
 Harrington District Nursing Association 
 
 Nursing Committee of the Bristol Fortnightly Club 
 
 Burrillville Anti-Tuberculosis Association 
 
 Cranston Anti-Tuberculosis Association 
 
 Visiting Nurse and Anti-Tuberculosis Association of East Green- 
 wich 
 
 East Providence District Nursing Association 
 
 Glocester Anti-Tuberculosis Association 
 
 Johnston District Nursing Association 
 
 Newport Association for the Relief and Prevention of Tubercu- 
 losis 
 
 New Shoreham Anti-Tuberculosis Committee 
 
 Visiting Nurse and Anti-Tuberculosis Association of North Kings- 
 town 
 
 North Providence District Nursing and Anti-Tuberculosis Asso- 
 ciation 
 
 Pawtucket Chapter of the American Red Cross 
 
 Visiting Nurse and Anti-Tuberculosis Association of the Paw- 
 tuxet Valley 
 
 Providence District Nursing Association 
 
 Providence Tuberculosis League 
 
 Smithfield Public Health Association 
 
 South Kingstown Public Health League 
 
 Warren District Nursing Association 
 
 Warwick Health League 
 
 Westerly Committee on the Prevention of Tuberculosis 
 
 Woonsocket Public Health Nursing Association 
 
 68 
 
The need for additional nursing service is still very great and every 
 effort should be devoted to the increase of existing staffs (particu- 
 larly in Cranston and Pawtucket), and to the building up of new- 
 nursing organizations (particularly in Newport County). 
 
 Among other lines of direct service the state association played 
 a large part in the early development of the Preventorium at Hoxsie 
 and during the war did an admirable piece of work in the supervision 
 of drafted men rejected for tuberculosis, and service men invalided 
 for this cause. For the future it would seem, in view of the specially 
 close relation existing between this association and the state sana- 
 torium, that the provision of a social service worker at the sana- 
 torium, and the development of convenient transportation facilities 
 between Providence and Wallum Lake, would be natural and de- 
 sirable activities of the association. 
 
 The second voluntary organization, of major importance, is the 
 Providence Tuberculosis League,* which was organized in 1905 as 
 the Tuberculosis Committee of the Society for Organizing Charity. 
 It is governed by a board of fifteen directors, with an executive com- 
 mittee of seven. As in the case of the state association the ex- 
 ecutive committee of this organization might be strengthened by 
 the inclusion of one or more public spirited lay women. The budget 
 of the league in 1920 amounted to 825,000, derived partly from its 
 quota of the Red Cross Christmas seal sale, and partly from a spe- 
 cial annual appeal for funds for the Preventorium. 
 
 With the appointment of Dr. Elliott Washburn as Executive 
 Secretary, early in the present year, an admirable program of ex- 
 pansion has been planned in the investigative field. The three 
 main projects which are contemplated are (a) an intensive health 
 survey of a selected district in the city of Providence, (b) a study of 
 industrial problems of the city with special reference to the factors 
 tending to produce industrial tuberculosis and to the possibilities 
 of combating tuberculosis through organized industrial medical and 
 nursing service, and (c) a study of the possibilities of occupational 
 therapy, and of the feasibility of developing facilities for the self- 
 support of arrested cases of tuberculosis. The last tw^o of these 
 problems are of supreme importance in the development of our 
 future campaign ; and the League has shown both courage and vision 
 in placing them in the forefront of its program. The relation of 
 
 ♦References to the League in the following discussion includes the work of its precursor, the 
 Tuberculosis Committee of the Providence Society for Organizing Charity. 
 
 69 
 
tuberculosis to industry (and particularly to the hazard of industrial 
 dusts) is one of the most significant and one of the most neglected 
 phases of the etiology of this disease; the betterment of sanitary 
 conditions in the factory and the provision of adequate systems of 
 medical examination for industrial workers should accomplish 
 notable results in the prevention of tuberculosis. For the per- 
 manent cure of those already affected with the disease, the provision 
 of industrial colonies, model factories or model tenements, in which 
 arrested cases can become, so far as possible self-supporting, and 
 yet remain under favorable environmental conditions, is an absolute 
 essential. If the Providence Tuberculosis League can carry these 
 two investigations to a successful conclusion it will render a great 
 service to the cause of public health throughout the country, as 
 well as in Rhode Island. The after care of arrested cases is so large 
 a problem and one of such paramount importance, that it might 
 well be attacked by a joint committee representing both state and 
 city associations. 
 
 In the field of education, the League has followed much the same 
 lines as the State Association, having held numerous local exhibits, and 
 having made a beginning with the Modern Health Crusade move- 
 ment in the schools. The education of the school child in the principles 
 of hygiene is absolutely fundamental to the whole future progress 
 of public work. The Health Crusade activities should be steadily 
 extended; and as suggested above it would be wise to lay particu- 
 lar stress upon the problem of dietary hygiene. The development 
 of the Health Crusade movement in Rhode Island has been un- 
 fortunately hampered by the fact that certain educational officials 
 are not in sympathy with some of its essential features. 
 
 The legislative work of the League has been mainly directed to- 
 ward the securing of open-air schools, the strengthening of the tuber- 
 culosis work of the municipal health departments and the support 
 of the state campaign for isolation legislation and for the main- 
 tenance of the sanatorium at Wallum Lake. If the conclusions of 
 this report are approved, the most immediate political task of the 
 League is the securing of appropriations from the city government 
 for the creation of a Division of Tuberculosis in the municipal de- 
 partment of health. 
 
 In the field of organization, the League has played an indispen- 
 sable part in the development of clinic and nursing service for the 
 city of Providence, as well as in the establishment of the Preven- 
 
 70 
 
torium. The first evening clinic for tuberculosis in the city was 
 organized by the League in 1911 (later transferred to the City Hos- 
 pital) ; and the Fresh Air School, opened on Meeting Street in 1908, 
 was the first fresh air school in America. 
 
 Direct service can not be sharply separated from organization, 
 since several of the Providence clinics, as well as the Day Camp, 
 were actually operated by the League, and from 1907 to 1910 it 
 paid the expenses of the tuberculosis nursing staff. The chief 
 direct work of the League has, however, been the maintenance of 
 the Preventorium, and summer outings which have be^ discussed 
 in an earlier section. 
 
 A new project, of the greatest importance, was initiated on Octo- 
 ber 11, when a letter was sent to 400 physicians of the city offering 
 the free service of the executive secretary as Tuberculosis Con- 
 sultant. Examinations will be made at the office of the League, 
 at the office of the physician or at the home of the patient. Dr. 
 Washburn is admirably qualified for this work and the utilization of 
 this consultation service by the local medical profession will make 
 possible a notable advance in the conduct of the entire campaiga 
 against tuberculosis in Providence. 
 
 VIIL SUMMARY OF CONCLUSIONS AND RECOMMEN- 
 DATIONS. 
 
 The present survey of the tuberculosis situation in Rhode Island 
 has been conducted on the assumption that the mortality from 
 tuberculosis is in large measure controllable, by definite and specific 
 administrative, and medical, and nursing procedures. Both theo- 
 retical knowledge and practical experience indicates that the sever- 
 ity of community infection can be reduced by the pasteurization of 
 milk and the control of open cases among human beings and that 
 the development of the disease process can be prevented or arrested 
 by the building up of individual resistance, the latter line of attack 
 being on the whole the more promising of large results. The rela- 
 tively slow progress which was made in the control of this disease 
 l)etween 1910 and 1918 is more reasonably attributable to the im- 
 perfection of official organization and the slackening of public in- 
 terest in the problem than to any inherent defects in the anti- 
 tuberculosis program itself. The improvement in social and 
 
 71 
 
economic conditions during the past two years has led to gratify- 
 ing reduction, in the tuberculosis death rate throughout the United 
 States; but this fortuitous gain should be only an encouragement 
 to a renewed and purposeful attempt to hold what has been won 
 and to accomplish further victories. 
 
 Tuberculosis still remains one of the two leading causes of death 
 in the state of Rhode Island, heart disease alone claiming an equal 
 number of victims; and each of these causes ordinarily accounts for 
 over 10 per cent of all the deaths which occur within the state. The 
 tuberculosis death rate in Rhode Island is abnormally high, as com- 
 pared with the Registration Area of the United States as a whole 
 or with such a neighboring state as Connecticut; and the excess 
 would amount to about 15 per cent, even if the 1920 census of 
 Rhode Island were assumed to be incorrect and the population of 
 the state were estimated on the basis of the 1910 and 1915 censuses 
 alone. The high death rate is undoubtedly in large part attribut- 
 able to the intensely urban and industrial conditions of the state 
 and to its large foreign population ; but whatever the cause may be, 
 the problem is here. 
 
 A study of the mortality figures for different sections of the state 
 shows that Providence has by far the highest death rate, 196 deaths 
 from tuberculosis of all forms per 100,000 population for the de- 
 cennium 1910-1919. Woonsocket stands next with a rate of 173, 
 Central Falls third with a rate of 165 and Pawtucket fourth with 
 a rate of 158. All these figures are extremely high and, except in 
 the case of Pawtucket, there has been no appreciable improvement 
 in the last half of the decennium as compared with the first. A 
 comparison between the Providence rates and those recorded for 
 other large eastern cities shows that Providence sufTered far more 
 heavily than New Haven, Rochester, or Syracuse in the quinquen- 
 nium 1910-1914, but was exceeded at that time by New York. 
 For the quinquennium 1915-1919, Providence shows no reduction, 
 while all the other cities have materially decreased their rates, that 
 for Syracuse being only 105, and even that for New York being 172, 
 as compared with 199 for Providence. It seems evident that Paw- 
 tucket, Central Falls, Woonsocket, and particularly Providence, 
 face a tuberculosis problem of unusual magnitude, a problem which 
 is not at present in the way of being solved. 
 
 Newport, Cranston and the smaller towns of the state show ma- 
 terially lower tuberculosis death rates, (Newport, 132; Cranston, 96; 
 
 72 
 
small towns, 137). Even here, however, the tuberculosis menace 
 is a very real one since any disease which kills one person out of 
 every thousand every year is a serious problem. The fact that the 
 mortality in these communities is relatively low is due to favor- 
 able economic conditions, not to specific anti-tuberculosis machinery ; 
 for it is precisely in these cities and towns that clinic and nursing 
 service has been least developed. It is natural, but not judicious, 
 to accept the fact that one's neighbors are even worse off, as an ex- 
 cuse for inertia in the betterment of one's own position. 
 
 Turning now to the machinery for the control of tuberculosis in 
 Rhode Island, it appears that here, as in many American com- 
 munities, the official guardians of the public health, — the state and 
 municipal health departments, — have taken but little direct part 
 in the campaign against the most serious of all communicable dis- 
 eases. Reporting of cases of tuberculosis was first required in the city 
 of Providence in 1905 and a state reporting law was passed in 1909. 
 The system of reporting to the State Board of Health would be a 
 most undesirable one if it led, as was at first the case, to a complete 
 cessation of local activity. At present transcripts of all reports are 
 promptly forwarded to local authorities. The enforcement of the 
 reporting law is, however, lamentably defective. The cases re- 
 ported per year amount, for the state as a whole, to about 85 per 
 cent of the actual deaths, while for Pawtucket and Central Falls 
 they rise to 102-103 per cent, and in Newport they fall to 54 per 
 cent of the actual deaths. Massachusetts obtains reports of about 
 two cases for every death and special surveys indicate that in Rhode 
 Island, as elsewhere, there really exist about nine cases to each 
 death. We may fairly assume that some 6000 cases of tuberculosis 
 exist in Rhode Island, of which not much over 1000 arc known to 
 the authorities. A better enforcement of the reporting law is cer- 
 tainly one of the first desiderata in the anti-tuberculosis campaign. 
 
 The prompt reporting of cases of tuberculosis is primarily im- 
 portant so that the affected individuals may be brought into contact 
 with the opportunities for clinic and sanatorium and nursing ser- 
 vice. In the vast majority of cases the danger of infection can be 
 controlled without rigorous measures of isolation. Legal machinery 
 must, however, be provided for restraining the exceptional wilfully 
 careless consumptive. The State Board of Health has the power to 
 promulgate regulations to this end; and it seems important that 
 more definite and specific rules in regard to the isolation of the care- 
 
 73 
 
less consumptive should be formulated, along the general lines laid 
 down in the sanitary codes of Connecticut and New York. 
 
 Aside from the provision of laboratory diagnosis, and the keep- 
 ing of a register of cases, by the State Board of Health and by the 
 City Health Department of Providence, neither state nor local au- 
 thorities are at present taking any active part in the anti-tuberculo- 
 sis campaign. The most important step which can be taken in 
 developing this campaign would seem to be the organization, under 
 the State Board of Health, and under the Providence Health De- 
 partment, of Divisions of Tuberculosis, each under the charge of a 
 medical director, expert in the diagnosis and control of this disease. 
 Properly qualified men in these positions could serve as the respon- 
 sible leaders of the anti-tuberculosis movement, in the state outside 
 of Providence and in Providence itself, securing the enforcement of 
 legislation for reporting and isolation, developing, supervising, and 
 when necessary serving local clinics, co-ordinating nursing and social 
 service, and, outside the city of Providence, aiding local physicians 
 through a consultation service. Steps for securing the appoint- 
 ment of such official leaders of anti-tuberculosis work in state and 
 city are strongly recommended for the consideration of all who are 
 interested in the campaign against tuberculosis. It is also highly de- 
 sirable that ordinances, requiring the pasteurization of all milk not 
 of certified grade should be passed in the leading cities of the state. 
 
 In the everyday conduct of anti-tuberculosis work the clinic for 
 diagnosis and the treatment of ambulant cases is a primary essen- 
 tial. Rhode Island has at present thirteen weekly clinics of this 
 type, eight in Providence, two in Pawtucket, and one each in Woon- 
 socket, Riverpoint and East Providence. The best measure of the 
 quantitative adequacy of clinic service is perhaps the number of 
 visits paid to clinics per month per 100,000 population. From this 
 standpoint Providence and the Pawtuxet Valley district (River- 
 point clinic) make the best showing, with 91 and 95 visits per month 
 per 100,000 population. Even this ratio is low compared with the 
 corresponding figure for New York City (173); while Pawtucket 
 and Woonsocket show up very badly, with figures of 45 and 30, 
 respectively. Of the cases treated at the Providence clinics (ex- 
 cluding those pronounced non-tuberculous) about one-third are 
 placed in sanatoria against only one-sixth at Woonsocket. It ap- 
 pears that the number of new patients coming to the clinics is fairly 
 satisfactory but that the clinics fail to hold them. In New York 
 
 74 
 
City we find an average of 6.0 visits for each new clinic patient, while 
 the best of the Providence clinics show less than 4.0 and the Paw- 
 tucket and Woonsocket clinics fall, respectively, to 1.8 and 2.0 
 visits per new patient. A record such as those last cited indicates 
 that the clinic organization is functioning most inefficiently; and the 
 obvious reason is to be found in a more or less half-hearted voluntary 
 medical service on the part of busy practitioners who are not special- 
 ists in tuberculosis. The clinic at Riverpoint is admirable and 
 those in Providence are well organized, although susceptible of con- 
 siderable improvement. In the other large cities, the service ren- 
 dered can not possibly be considered adequate. The entire southern 
 half of the state, the northwestern quarter of the state and the 
 county of Newport, including nearly a third of the population of 
 the state, are without organized tuberculosis clinic facilities of any 
 kind. 
 
 It seems clear that the opportunity for service on the part of a 
 State Director of Tuberculosis would be an almost unlimited one in 
 this particular field. A tactful leader could secure the reorganiza- 
 tion of the Pawtucket and Woonsocket clinics on an effective basis, 
 could develop new clinics in Newport and perhaps in Cranston, 
 Warwick and Bristol, and coulcj provide periodic clinic service in 
 the smaller rural communities. 
 
 Even in Providence, itself, it seems probable that the highest 
 efficiency of tuberculosis clinics can only be realized in the long run 
 by the gradual development of a paid medical clinic staff, for which 
 the City Hospital administration offers promising facilities. The 
 records at all the clinics should be reorganized on the plan used in 
 New York City so that it may be possible to determine at the end 
 of each month how many patients have been admitted and at what 
 stage in the disease process, how many have been discharged and 
 for what reasons and in what condition. The provision of domicil- 
 iary visits for those cases which require it should also form a part 
 of a comprehensive plan of tuberculosis control. 
 
 Passing to the problem of institutional treatment, Rhode Island 
 is fortunate in possessing a well equipped and well managed state 
 sanatorium at Wallum Lake with 170 beds for sanatorium cases, 
 153 for advanced cases and 40 for children. In addition the Provi- 
 dence City Hospital provides beds for 60 patients, St. Joseph's Hos- 
 pital Annex at Hillsgrove for 70 patients and the tuberculosis wards 
 at the State Almshouse and Hospital in Cranston for 46 patients, — 
 
 75 
 
all these last institutions dealing with advanced cases. The Pre- 
 ventorium at Hoxsie (maintained by the Providence Tuberculosis 
 League) accommodates 40 children in winter and 50 in summer, 
 while the Crawford Allen Branch of the Rhode Island Hospital 
 cares for 45 bone and joint cases during the summer months. 
 
 The facilities for the care of active cases of tuberculosis amount 
 in the aggregate to the provision of 1 bed for every 1100 persons in 
 the general population or 1 bed for 1.6 annual deaths from tubercu- 
 losis. This ratio is below that to be recommended as ideal; but it 
 is high as compared with conditions in most other states and at 
 present the actual supply of patients is below the facilities for treat- 
 ment, over a third of the beds at Wallum Lake having been empty 
 during the past two years. This condition is in part due to the 
 real decrease in tuberculosis incidence since 1917, but it is quite 
 certain that there remain in Rhode Lsland tuberculosis patients 
 needing sanatorium treatment more than sufficient to fill Wallum 
 Lake twice over, if the medical and nursing machinery of the state 
 were sufficiently developed to get them there. 
 
 The admission rate to hospitals and sanatoria rose for the state 
 as a whole from 92 per 100,000 population in 1910 to 153 in 1918 
 and fell again to 133 in 1919, which is an exceedingly good figure as 
 compared with other states. Comparing different districts within 
 the state, it appears that Providence has the highest admission 
 rate (135), while the rate for Cranston falls to 44. A better measure 
 of the degree of success in hospitalization is the ratio of admissions 
 per 100 annual deaths. This figure too is highest in Providence 
 (69), with Woonsocket and Central Falls next (each 64), Pawtucket 
 and Newport next (each 56), the smaller towns next (50), and Crans- 
 ton last (46), the degree of hospitalization effected varying di- 
 rectly with the general efficiency of clinic and nursing service. 
 
 The first serious obstacle to success in sanatorium treatment is 
 the relatively late stage of the disease at which patients are ad- 
 mitted. We may hope for a cure in 75 per cent of the incipient cases 
 admitted, in 50 to 60 per cent of the moderately advanced and in 
 less than 40 per cent of the far advanced cases. The fact that only 
 from 1 to 7 per cent of the cases admitted at Wallum Lake fall in 
 the incipient class is the first handicap with which this institution 
 (in common with most others of its class) must deal. A second 
 handicap is the short time for which patients will continue treat- 
 ment. The average period of residence for sanatorium cases be- 
 
 76, 
 
tween 1910 and 1917 was 156 days, while the most successful sana- 
 toria keep their patients for an average of six months or more. 
 About one half of the patients at Wallum Lake leave against advice. 
 
 In spite of these handicaps two-thirds of the patients leave 
 Wallum Lake with definitely improved health; but when they re- 
 turn to the unhygienic condition of home life many of them quickly 
 relapse. The admirable statistics published by Dr. Barnes in the 
 reports of the State Sanatorium up to 1917 make possible an un- 
 usually full survey of the ultimate fate of the discharged patients. 
 It appears that about 25 per cent of all cases discharged make a 
 fairly permanent cure, being alive and at work after an average 
 period of five years from the time they leave the institution. Fifty- 
 nine per cent are dead, 8 per cent alive but not able to work and 6 
 per cent have been lost. 
 
 This somewhat disappointing showing is by no means unusual, 
 although the results accomplished at Saranac Lake and at the Gay- 
 lord Farm Sanatorium in Connecticut indicate that under the most 
 favorable conditions half or two-thirds of a series of sanatorium 
 cases can be saved instead of one-quarter. 
 
 If sanatorium treatment, in Rhode Island or elsewhere, is to be 
 made really effective three things are necessary. The disease must 
 be detected promptly and patients admitted to the sanatorium in 
 an early and curable stage. They must be kept in the institution 
 until the disease process is definitely arrested. And after discharge 
 they must be kept under supervision and provided with living and 
 working conditions, under which a maximum of self-support may 
 be achieved, with the possibility of maintaining a reasonably favor- 
 able hygienic regimen. The first of these ends must be attained 
 chiefly by the building up of more effective clinic and public health 
 nursing service and by the education of the practising physicians of 
 the state in the diagnosis of tuberculosis. It is essential, however, 
 both in getting patients to a sanatorium and in keeping them there, 
 that the institution be made as attractive as possible from a psycho- 
 logical standpoint and that every facility should be provided for 
 the contact with family and friends which alone makes exile from 
 home bearable for the tuberculous patient. In this connection it 
 is suggested that the Rhode Island Tuberculosis Association, which 
 has always felt a deep interest in the State Sanatorium, could ren- 
 der an unusually important service by supporting a medical social 
 worker at Wallum Lake to care for the personal side of the life of the 
 
 77 
 
patients and by developing some means of transportation service 
 which would make it possible for the friends of patients to visit 
 them conveniently at Wallum Lake. As a prerequisite to the full 
 development of this later service it would be necessary to secure 
 from the state legislature funds for the improvement of the high- 
 way between Pascoag and Wallum Lake which is almost impassable 
 for four to six months of the year. 
 
 The public health nurse is the third essential factor in the scheme 
 of tuberculosis control; and here too Rhode Island is reasonably 
 well off as compared with other states, though falling far short of a 
 desirable ideal. There are 105 public health nurses in the state, 
 a ratio of one nurse to 5800 persons. It requires one nurse to 1500 
 or 2000 persons to give really adequate service. Providence has 1 
 nurse for every 3600 persons, being far ahead of any other com- 
 munity. Westerly and the Pawtuxet Valley stand next with about 
 5000 persons per nurse. Woonsocket and East Providence have 
 about 7000 persons per nurse, Pawtucket and Central Falls about 
 11,000 and Cranston over 14,000; while Newport County and other 
 districts embracing a population of 57,000 have no organized public 
 health nursing service. 
 
 In Providence, Pawtucket, Woonsocket, the Pawtuxet Valley 
 and East Providence tuberculosis cases are cared for by special 
 tuberculosis nurses while in the other communities the generalized 
 district plan of nursing prevails. The seven tuberculosis nurses of 
 the Providence District Nursing Association are doing admirable 
 work. Their records are unusually complete and reveal evidence of 
 service of a high order. They have themselves discovered about 
 half of all the contact and suspicious cases for which they care, as 
 well as 14 per cent of the positive cases. Each nurse cares for ap- 
 proximately 225 cases in a year and makes an average of about 10 
 visits per case. The latter figure is too low, as must be expected 
 with so small a nursing force. A special study of 500 consecutive 
 positive cases to indicate the nature of the actual results achieved 
 shows that 83 per cent of the patients were placed in a sanatorium 
 or hospital and kept there for a reasonably satisfactory period and 
 that 12 per cent were cared for at home under adequate sanitary 
 and hygienic conditions. Sixty-four per cent of these 500 patients" 
 were definitely improved in condition at the end of a year and only 
 14 per cent were dead. 
 
 78 
 
In comparing the adequacy of tuberculosis nursing service, the 
 best criterion is perhaps the ratio of visits to tuberculosis patients 
 per year per 1000 population. On this basis the Pawtuxet Valley 
 district (West Warwick and Coventry) shows up best, with 85 
 visits per 1000 population; and the work of the nurse at Riverpoint 
 is in every way deserving of the highest praise. Both clinic and 
 nursing service at this little health center are models of their kind. 
 
 Providence comes next with 65 visits per 1000 population; Woon- 
 socket next with 43; Pawtucket next with about 30; twelve small 
 towns which employ generalized nurses next with 24; and East 
 Providence last with 19. In New Haven, nine nurses, serving a 
 population of 164,000, make 127 visits to tuberculosis cases per 
 1000 population. 
 
 In regard to the quality of the tuberculosis nursing service in 
 Rhode Island there is no legitimate criticism to be made, except in 
 the case of certain of the small towns where the generalized nurses 
 do not appear to have grasped the essentials of the problem. In 
 general however, it is quantity, not quality, which is deficient; the 
 nurse at Pawtucket with 305 cases to care for is, for instance, under- 
 taking a clearly impossible task. It is no wonder that 79 per cent 
 of the cases cared for by this nurse were positive cases and that 22 
 per cent of them died (as compared with 53 per cent positive cases 
 and 14 per cent deaths in Providence) ; for in a population of 100,000 
 a single tuberculosis nurse can only attend to the most critical and 
 advanced cases. The State Board of Health, the Rhode Island 
 Tuberculosis Association and other interested agencies should do 
 everything in their power to aid in the development of public health 
 nursing where it is now wholly lacking or notably deficient in amount, 
 — notably in Pawtucket and Central Falls, in East Providence, in 
 Cranston (where only 7 visits are made per 1000 population) and 
 in Newport County (where there is no tuberculosis nursing service 
 at all). The organization of a Division of Public Health Nursing 
 under the State Board of Health should prove of the greatest value 
 in stimulating and co-ordinating the nursing service of the state. 
 
 ■ Finally, there remains to be considered the part played in the 
 anti-tuberculosis campaign by voluntary associations, and particu- 
 larly by the Rhode Island Tuberculosis Association and the Provi- 
 dence Tuberculosis League. Both these organizations have ren- 
 dered splendid service to the cause and their work is full of promise 
 for the future. Past achievements of these organizations along the 
 
 79 
 
lines of research, of education, of legislative propaganda, of or- 
 ganization and of direct service, have been discussed above; it re- 
 mains only to consider certain of the more important lines of future 
 activity. Both the Association and the League will obviously con- 
 tinue their admirable service in the stimulation of clinic and nursing 
 organization and in the education of school children through the 
 Health Crusade movement. In addition, however, there are spe- 
 cial new phases of the tuberculosis program which offer a call for 
 unusual service to both organizations. 
 
 For the Rhode Island Tuberculosis Association the three most 
 important tasks would appear to be the following: 
 
 A. The organization of a legislative campaign to secure the crea- 
 tion of Divisions of Tuberculosis and of Public Health Nursing 
 under the State Board of Health with adequate funds for their sup- 
 port (at least $15,000 a year each), and to obtain an appropriation 
 for improving the road to Wallum Lake. 
 
 B. The systematic attempt to develop and improve clinic and 
 nursing facilities throughout the state, particularly in Pawtucket, 
 Woonsocket, Cranston and Newport County. This work should be 
 vigorously pushed, without waiting for the appointment of the 
 State Director, and later carried forward in co-operation with him. 
 The ideal of 1-2 clinic visits and 5-10 nursing visits per month 
 per 1000 population might be set as a fair standard of reasonably 
 adequate service. 
 
 C. The support of a medical social worker at Wallum Lake and 
 the provision of special transportation service which will facilitate 
 the visiting of patients by their families and friends. The officers 
 of the association should not consider their duty done until all the 
 beds at Wallum Lake are filled, and until the average period of 
 residence is over six months. 
 
 For the Providence Tuberculosis League there are four oppor- 
 tunities which seem to offer rich possibilities: 
 
 A. The organization of a vigorous campaign for the establish- 
 ment of a Division of Tuberculosis in the municipal health depart- 
 ment of Providence, with a Medical Director whose duty shall be 
 to coordinate clinic and nursing services, and to maintain super- 
 vision over all cases of tuberculosis within the city limits. 
 
 B. To offer to the private physicians of Providence the far- 
 reaching advantages of a medical consultation service. 
 
 8o 
 
C. To conduct a survey of industrial conditions in their relation 
 to tuberculosis and to formulate a program of industrial medical 
 and nursing service to combat this disease. 
 
 D. To conduct (perhaps with the cooperation of the Rhode 
 Island Tuberculosis Association) a study of the problems of occu- 
 pational therapy and to consider the possibility of establishing in- 
 dustrial colonies, supervised workshops or model housing plans 
 which will make it possible for the arrested case to maintain the 
 ground that has been gained after discharge from the sanatorium. 
 
 The last three of these suggestions are all prominently included in 
 Dr. Washburn's plans for the development of the League; and the 
 vision which has been shown in formulating these plans is deserving 
 of the highest praise. 
 
 The neglect of tuberculosis by public authorities is a phenomenon 
 of general occurrence. There are fashions in public health as in 
 other things. Tuberculosis work began with great vigor twenty 
 years ago and has slackened its activities during the past decade. 
 The health officer, the physician and the public must be reawakened, 
 — reconvinced that tuberculosis is a terrible, and largely a pre- 
 ventable, disease. 
 
 The attention of public health workers throughout the country is 
 focused with the keenest interest upon the little town of Framing- 
 ham, where a small-scale demonstration of tuberculosis control is 
 being conducted with such marked success. Rhode Island has the 
 opportunity of conducting a similar demonstration in a whole state, 
 yet a state compact enough to make possible easy and complete con- 
 trol. The essential elements of sanatorium facilities, clinics and nurs- 
 ing service are in existence and could be expanded and coordinated 
 to form a machine of power and effectiveness; and the present exces- 
 sive tuberculosis death rate which lays such a heavy burden on 
 the state is a definite challenge to action. If this death rate could 
 be reduced twenty points per 100,000 (to the level of the correspond- 
 ing death-rate in Connecticut) it would mean the saving, each year, 
 of 120 lives, worth to the community over $600,000. Such a reduc- 
 tion is possible and practicable. Is the undertaking not worth a 
 serious attempt? 
 
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