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Industrial Medical
s
Women and Industry
CKildren and Industry
Part Seven
Cleveland Hospital and
Health Survey
Industrial Medical
Service
Women and Industry
Ckildren and Industry
Part Seven
Cleveland Hospital and
Health Survey
Pref
^'he Hospital and Health Survey of Cleveland was made at the request .
le Cleveland Hospital Council.
^'he Survey Committee appointed to be directly responsible for the
: and through whose hands this report has been received for publica-
consisted of the following:
Malcolm L. McBride, Chairman;
Mrs. Alfred A. Brewster,
Thomas Coughlin,
Richard F. GraKt,
Samuel H. Halle,
Otto Miller,
Dr. H. L. Rockwood,
Howell Wright, Secretary
The staff responsible for the work were:
Haven Emerson, M, D., Director,
and the following collaborators:
Gertrude E. Sturges, M. D., Assistant Director;
Michael M. Davis, Jr., Ph. D., Director of the Hospital and
Dispensary Survey;
Josephine Goldmark, B. A., Director of the Nursing Survey;
Wade Wright, M. D., Director of the Industrial Hygiene Survey;
Donald JB. Armstrong, M. D., Director of Tuberculosis Survey;
S. Josephine Baker, M. D., D. P. H., Director of the Infant
and Maternity Survey;
T. W. Salmon, M. D., Director of the Mental Hygiene Survey;
W. F. Snow, M. D., Director of the Venereal Disease Survey;
Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey.
The expenses of the Survey and of the publication of the report have
met by appropriations received from the Community Chest, through
Welfare Federation, of which the Hospital Council is a member.
^he report as a whole, or by sections, can be obtained from the Cleveland
)ital Council. A list of the parts will be found in the back of this volume,
ther with prices.
I
*
8o:>^4^
Copyright. 19i0
by
Thk Clkvkland Hospital Cchncil
ricvolaml, Ohio
rubliiheil by
The Cleveland Hospital Council
308 AnisBeld Hldg.
• Cleveland - Ohio
I • •• •
• • •
. • ' • - •
• • *
• • • • ?
•_ . • ••
• - m m • *w ••
Pref
The Hospital and Health Survey of Cleveland was made at the request .
the Cleveland Hospital Council.
The Survey Committee appointed to be directly responsible for the
3rk and through whose hands this report has been received for publica-
)n consisted of the following:
Malcolm L. McBride, Chairman;
Mrs. Alfred A. Brewster,
Thomas Coughlin,
Richard F. Grant,
Samuel H. Halle,
Otto Miller,
Dr. H. L. Rockwood,
Howell Wright, Secretary
The staff responsible for the work were:
Haven Emerson, 1^1. D., Director,
and the following collaborators :
Gertrude E. Sturges, M. D., Assistant Director;
Michael M. Davis, Jr., Ph. D., Director of the Hospital and
Dispenifory Survey;
Josephine Goldmark, B. A., Director of the Nursing Survey;
Wade Wright, M. D., Director of the Industrial Hygiene Survey;
Donald -B. Armstrong, M. D., Director of Tuberculosis Survey;
S. Josephine Baker, M. D., D. P. H., Director of the Infant
and Maternity Survey;
T. W. Salmon, M. D., Director of the Mental Hygiene Survey;
W. F. Snow, M. D., Director of the Venereal Disease Survey;
Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey.
The expenses of the Survey and of the publication of the report have
en met by appropriations received from the Community Chest, through
e Welfare Federation, of which tlie Hospital Council is a member.
The report as a whole, or by sections, can be obtained from the Cleveland
)spital Council. A list of the parts will be found in the back of this volume,
Kether with prices.
TABLE OF CONTENTS
Industrial Medical Service Page
Introduction 525
The Industries of Cleveland 525
Medical Service in Industry
Industrial Physicians - 526
Industrial Nursing 529
Visiting Nursing.. 531
Clerical Personnel 532
Dispensary Equipment 533
Cost of Service 533
Administrative Relations 534
Medical Service in Non-industrial Establishments 535
Medical Service Beyond the Plant 536
Industrial Medical Records 537
Absenteeism Due to Sickness 541
Physical Examinations 542
Special Services
Industrial Psychiatry 544
Industrial Dental Service 545
Industrial Ocular Service 545
Tuberculosis 546
Venereal Diseases ., 547
Rehabilitation of Industrial Cripples 547
The Small Establishment 550
Industrial Hospitals - u 552
The Training of Industrial Physicians and Nurses... 552
Public Health Authorities and Industrial Hygiene... 553
Recommendations 554
Women and Industry
Introduction 557
Conditions in Various Occupations Employing Women
Industrial Establishments
TheMet^ Trades 559
Textile and Knitting Mills 561
The Garment Trades 561
Candy Factories 562
Miscellaneous Industrial Establishments 562
General Observations
Hours of Work 563
Earnings 564
TABLE OF CONTENTS— r««<i«M«/ Page
•
Additional Benefits 564
Recreation • , . 564
Vacations 565
Supervision 565
Physical Conditions of Work 567
Mercantile Establishments 568
Public Service Organizations
Laundries 569
Hotels 570
Restaurants 571
Public UtUities 571
General Discussion
Night Work 571
Homework 573
Day Nurseries 574
Mothers' Pensions . 575
Recommendations .. 575
Community Interest 576
III. Children and Industry
Introductory 579 '
Legal Provisions for Children 15-18 Going to Work .581
Statistics for Children in Industry in Cleveland. 1919 583
Where Children Work
Occui>ations Employing Children 588
Manufacture of Confectionery .. 590
Manufacture of Hosiery and Knit Goods 590
The Metal Trades 591
Printing and Publishing . ^ 592
Retail and Wholesale Trade 592
Telephone and Telegraph Work . 593
Street Trades 597
Agricultural Work and Domestic Service . 602
Health of Children at Work
Medical Examinations of Children for Work Permits 603
Suggested Content of Ohio Law re Health Certificate 607
Subnormal Children in Industry 608
Summary of Standards of Physical Fitness for Children Enter-
ing Employment. 610
Education's Responsibility 613
Junior Vocation Departments 615
Suggested Plan of Organization for a Vocational Guidance Bureau 617
Summary of Recommendations 619
Appendix
Tables 622
REPORT OF THE INDUSTRIAL DIVISION
PREFACE
111 an industrial city such as Cleveland it is not i>ossible to make a com-
prehensive study of the health of the community without consideration of
the relations of health and industry. Ortain of these relations are the
matter of this report.
The Industrial Division of the Hospital and Health Survey has been
concerned with three fields of industrial activity: medical, surgical and
nursing service in industry; the employment of w^omen and the employ-
ment of children. These three subjects are discussed separately.
All recommendations and for the most part the discussion of various
topics relate specifically to conditions as observed in Cleveland, though it
is true that many other industrial cities present similar problems.
The Survey is indebted to the Committee for the Study of Public Health
Nursing Education for designating Mrs. Anna M. Staebler to aid in the
study of industrial nursing and to the Consumers' League of Ohio which
contributed the services of Miss Florence V. Ball who has conducted the
study of children and industry'.
The Survey wishes also to acknowledge its appreciation of the coopera-
tion and assistance offered by the industrial organizations of Cleveland and
by numerous individuals and agencies in the city and state which have
freely aided in these studies.
HealtK and Industry
Industrial Medical Service
By Wade Wright, M. I).
INTRODUCTION
IN undertaking to study existing measures for the safeguarding of the
health of industrial workers it was fully realized that detailed consideration
of working conditions, of sanitation, of accident hazards and of industrial
health, was not possible in the course of a brief survey. It has been the
purpose of those conducting this inquiry to obtain certain essential data
regarding the medical organization which various industrial and mercantile
establishments have developed for the care of the health of their employes,
to estimate as accurately as might be, the probable efficacy of such organiza-
tion and to present in this report the findings of such an inquiry together with
an expression of opinion regarding the merits of certain features observed,
and ways and means for the remedying of the more outstanding defects.
It is to be remembered that the Survey was without legal authority to
enter and insi>ect industrial or other establishments and that this study has
been made possible only through the courtesy and cooperation of the em-
ployers of the city.
The information here presented was obtained by questionnaire, by visit
and by conference. It was not practicable to visit all of the large industrial
establishments, but the great majority of plants employing over five hun-
dred persons in which medical service is rendered, were visited by one of
the four members of the staff of the Industrial Division.
In all, about one hundred organizations of various sizes were carefully
studied and information secured in some detail regarding many more.
For the purpose of this report certain observations relating to industry
will be separated from those concerning mercantile establishments, the con-
struction trades and the public utilities.
THE INDUSTRIES OF CLEVELAND
The statistical studies of the number and size of industrial plants were
based upon the "Directory of Ohio Manufacturers" issued by the Indus-
trial Commission of Ohio in 1918. The information there published has been
crorrected by data more recently obtained, and though the resulting figures
are not accurate they are probably a fair approximation of the facts.
In Table I., published in the appendix, is shown the divfsion of 1,521
industrial organizations into several size-groups, together with the group-
total number of employes, the average number of employes per establish-
ment and the percentages of establishments and employes in each group.
Approximately 74 per cent of the city's industrial wrorkers are engaged in
establishments employing 200 or more, organizations of this size constituting
526 Hospital, and Health Sitrvey
only 12 per cent of the total nuinl)er of industrial organizations. 57 per cent of
the employes are engaged in establishments employing 50i) or more, 5.3 |>er
cent of the organizations; and 43 i)er cent of the employes work in establish-
ments employing 1,000 or more, 2.6 per cent of all organizations.
It is evident, with so great a i>ortion of all industrial operatives employed
in a relatively small number of large establishments, that medical service
would reach a very considerable number of workers if it were rendered in
the larger plants.
MEDIC AL SERVICE IN INDUSTRY
Table II. presents the findings relating to medical service in industrial
establishments of various sizes. It was perhaps inevitable that in certain
instances the information obtained from organizations was inexact. This
was true of some statements regarding the place of the medical department
in the scheme of administration and its relation to the rest of the industrial
organism and regarding the status of physicians employed part time and on
call. It has been necessary in consequence that the staff rather freely in-
terpret some of these statements.
In estimating the number of firms furnishing medical service a rough
standard of adequacy has been accepted. The presence iii a plant of a
first-aid cabinet which might be supplemented in the event of a serious
emergency by the attention of a neighborhood physician has not been reck-
oned as "medical service." Those plants employing trained nurses for dis-
pensary work have been rated as furnishing medical service even though
physicians were seldom called in.
The quality of medical service rendered in the establishments which
have been considered as furnishing service undoubtedly ranges between
widely separated extremes. In comparatively few instances has it been
found to be of a high order, judged by the best standards of industrial medi-
cine and surgery as practiced in this country.
It is noteworthy and most creditable, however, that about one-half of
the industrial workers of the city are upon o<*casion receiving some sort of
medical attention in industrial plants.
The dressing of industrial injuries of course demands immediate atten-
tion and it is true and to be expected that there is a conc*ent ration of person-
nel and service to meet this first need. A relatively small amount of time
and service is devoted to other than surgical work. No t^ffort has been made
by the Survey to appraise the quality of surgical work done by industrial
surgeons in the city, but there is much evidence that Cleveland is fortunate
in having a group of interested, conscientious and able surgeons giving their
time especially to industrial cases.
Industrial Phyhicians
In Table III. are tabulated data concerning the medical department
personnel of establishments rendering medical service. .
Health AND Industry ^ ^ 527
,j7^j/J^/?-/.uy'vK'y '
i
The Survey has knowledge of but seven physicians employed upon a full-
time basis in the industries of Cleveland. There is a much larger group',
numbering over twenty, who are identified almost exclusively with indus-
trial practice, including a number of surgeons who are each engaged on a
part-time or visit basis by several firms.
There has been an interesting and important development of medical
partnerships which purpose to render comprehensive service to their clients,
including dispensary administration and health supervision as well as indus-
trial medicine and surgery. There is much to be hoped of this type of organ-
ization, especially in connection with small establishments, with contracting
and construction work and those firms not in a position to command the full
service of an industrial physician as the administrative officer of a medical
department.
Industrial medical service as at present conceived is comparatively new,
crudely developed and far from being standardized. Industries have drawn
into their medical departments a variety of types of physicians.
In Cleveland there are a few highly skilled industrial physicians, trained
to consider the intricate inter-relations of medicine and industry, possessed
of wide technical knowledge of their special field.
There is another group of physicians doing little but casualty surgery,
some of them eminently capable and many of them less so. As a rule these
men are frankly interested in nothing but surgical conditions, but many will
consent nevertheless to submit opinions upon any matters relating to health
and sanitation, including obscure poisonings or involved questions of indus-
trial hygiene.
A third class includes men who have been drawn into industry from gen-
eral practice, not infrequently in a sense, against their desire. Often the
basis of selection of such physicians was curious. They were in many in-
stances the attending family physician of plant executives. They are apply-
ing in industry methods very similar to those which they formerly employed
in private practice, with probably the same degree of conscientiousness and
scientific honesty which characterized their work previously. Many of
them become capable executives and well qualified industrial physicians.
They are, however, strikingly indicative of the lack of comprehension among
those directing industrial establishments .of the importance of selecting for
plant physicians, men technically equipped to render a technical service and
who are possessed of proper personality and ability to develop with and be-
yond assigned tasks.
Another group, happily diminishing, is made up of incapables, men who
have not succeeded in general practice, who have drifted near financial rocks
and who eagerly welcome even the small salaries or fees which they may
secure in establishments administered by those who still are of the impression
that any doctor is a good doctor, and if secured cheaply, a better one for
their purposes.
There was a time, not long ago, when industry diligently sought for the
.struggling young physician and, finding him, offered him employment.
528 Hospital and Health Survei
Usually the salary was very small, but the collateral inducements glowing.
The young man was informed that despite the low salary he would be able
to secure a splendid income by the simple means of developing a private
practice among the company's employes.
The glowing prophecy has been fulfilled and the physician, perhaps no
longer young and struggling, has a splendid income, practising among the
employes.
The public views with alarm and suspicion and reads editorials about
public officials who personally benefit through their positions, but industry
has sought and welcomed the physician who comes to advise and remains
to operate. Industry does not aim to employ superintendents or treasurers
upon such a basis of remuneration, why physicians?
Cleveland is not without numerous industrial physicians whose incomes
are very appreciably augmented from the personal practice worked up in
industrial dispensaries. The cough which takes a laborer to his plant dis-
pensary may carry him rather unexpectedly still farther to the company
doctor's down-town office and a tonsillectomy operation, and beyond that
into a dashed state of financial stringency. Or by a particularly fortuitous
arrangement, one involving many thousands of operatives in Cleveland, the
company physician or surgeon may collect within the company dispensary'
his i>ersonal fee for professional services rendered.
It is not dishonest or unethical practice, any more than is that of the
concessionaire who sells pie by the plant gate, and there are honorable and
able men engaged in it. But it is of questionable value to any employer
with whom the health of his employes is a matter of real concern. Indus-
trial physicians should be employed to render specific services. If it is the
feeling of the management of an industrial establishment that they do not
wish to undertake the care of disabilities other than those arising out of
industrial injuries, the services of physicians in their employ should be
restricted to such cases. Under no circumstances should physicians be
permitted to recruit private patients under the guise of their official posi-
tions as company servants. Such employes as need care beyond that fur-
nished by the company should be referred to competent practitioners not
on the company's medical staflf. The situation of an industrial physician in
an industrial dispensary is quite analogous to that of a physician on the
visiting stafiF of one of the many reputable hospitals which forbid staff physi-
cians to rieceive dispensary or hospital cases as private patients except under
very special circumstances.
The temptation to enlarge a personal practice in this manner is compli-
cated by other obvious evils, such as unnecessary treatment or operations,
intrusions upon the practices of fellow physicians and inevitable exploitation
of workers.
Health and Industry 529
The Survey recoDimends that industrial physicians be selected with regard
for their professional and executive abilities and that only the well qualified
be chosen; that they be remunerated upon a basis commensurate with the
amount and character of services expected of them; that they be not permitted
to combine with their official duties personal practice among the company
personnel.
Industrial Nursing
Industrial nursing is perhaps less standardized than industrial medicine,
for the duties assigned to plant nurses vary with plant physicians, ty]>es of
industries and of employes and the purposes and fancies of plant executives.
Of these several factors the last is probably the most potent. Rarely is a
capable nurse selected and encouraged to develop and extend her field of
usefulness. She is frequently added to the payroll in much the same spirit
with which such employes as doorkeei>ers or telephone operators are added.
The great majority of industrial nurses in Cleveland are registered trained
nurses. Most of them have entered industry' after a period of private duty
nursing, others directly from hospital training schools. It is of course to
be expected, as in the case of physicians, that the degree of excellence of
training varies. Again, as with physicians, some are well qualified to do
industrial work and are intensely interested in the progress of the new pro-
fession; some have sought the short hours and freedom of the industrial
world, rather than the strain and uncertainty of private duty nursing; and
others among the least capable of the nursing profession have drifted in.
A small portion of industrial nurses in the city are not registered nurses
and are not graduates of hospital training schools. A number have had
short courses in first-aid, others gained their knowledge of emergency surgery
as dressing assistants. Some of them are very able and others obviously
masquerading in nurses' uniforms and are probably more of a liability than
an asset to the firms employing them. One may safely venture the assertion
that in certain instances executives employing untrained nurses are not aware
of their real professional status.
There is undoubtedly a place in industrial medical service for practical
nurses or nurses' assistants, serving with and under the direction of compe-
tent medical or nursing authority. At present practical nurses are found in
almo.st every instance in charge of their own departments.
In establishments where there is no organized medical service certain
duties ordinarily assigned to a nurse are assumed by matrons or by members
of the clerical forces. Such an arrangement is warranted only in a small
organization.
The progress of industrial hygiene has been due in large measure to the
contributions of industrial nurses. The truth of this may be readily evi-
denced if one endeavors to withdraw from the fabric of industrial organiza-
tions the threads representative of the services, the influence and the person-
alities of able industrial nurses. It is the industrial nurse in many instances
580 Hospital and Health Sirvey
who stands in the minds of employes as the most kindly, most wholesome
human element in a nig industrial machine. Her achievement, however,
nmst dei)end in great degree upon the intelligent su])port and guidance of
the plant administration.
It is to be cx|KH'tcd that the |)ersonality, abilities and ambitions of indus-
trial nurses should in general be in keeping with the types of industrial
organizations which employ them and the purposes for which they are em-
ployed. It is as idle to criticize many an industrial nurse for failure to real-
ize fully her oj)port unities for constructive health work as it is to condemn
the surviving old tyjK* contract surgeon who is comT>etent simply to bask on
the sunny side of the payroll as *'a doctor/' (piitc as content as his employ-
ers are to have him there.
Not infrc(|uently the nurse gives far niore service than is exi)ected of her,
little though that service may be. She finds slight stimulus to better effort.
If she writes a poor report, it serves as well as a good one, for it doubtless
receives but a casual glance from an uninterested front office extx'utive.
Perhaps, as in one plant, she finds no official who con.siders it his duty to
review that report, s<i she submits none. She may attempt to extend her
usefulness, as in another Cleveland establishment, but the employes make
such increased use of her department that she is n*tired to her own reserva-
tion, instructed to renuiin there. If the professional advice she offers is
unsound, there is no oih» the wiser, certainly not the reci|)ient of the advice.
«
If she has had fairly good training, is reasonably decorative, has a ready
suggestion for the relief of the general manager's indigestion and the em-
ployes like her, she may be an eminent success as an industrial nurse in almost
any one of the large group of plants where physicians are employed part
time or on call.
The employment of nurses with littU* or no medical supervision has led
in Cleveland to a lowering of accepted standards of nursing and medical
practice regarding medication. With the exception of instances so rare as
to be practicably negligible the industrial nurses of the city are freely ad-
ministering drugs for the relief of minor ailments without individual or
standing orders of physicians. There is constant and free use made of
various sedatives for the relief of headaches, coughs and divers pains and of
cc)caine for the removal of foreign bodies in the eye. Though it is not to bo
(juestioned that many or most nurses are (jualified to use these drugs with
discretion, the fact remains that indiscriminate medication of this kind is
not in accordance with modern standards of medical treatment and unauthor-
ized, as in these instances, it is in direct violation of the medical practice
act of the state.
Isolated, as most industrial inirses are, from professional associations,
confined to their duties for the entire weekly working period, they naturally
tend to become .somewhat limited in conception of their duties and their
opportunities. They are pioneers in their respective establishments often.
H K A L T n AND INDUSTRY 531
each one endeavoring to work out her own problems, a difficult task when
no precedents are at hand and no competent advice readily available.
There is urgent necessity in Cleveland, as in other cities, for some means
of carrying to industrial nurses the counsel and technical assistance which
most need and many desire. The present Industrial Nurses' Club is presum-
ably of real value in this connection but its services are quite inadequate. It
would be much to the advantage of organizations employing industrial
nurses to contribute to a common fund devoted to the maintenance of a
<'enter for gatherings of industrial nurses; of a good library on industrial
hygiene, including related i)criodicals; of a series of conferences and of one
or more well salaried counseling industrial nurses. Such a counsellor, wisely
chosen, rendering an expert technical consultation service, could be of unques-
tioned assistance to industrial nurses and plant executives and would in no
sense conflict with established relations of authority and responsibility.
VlSITINC; Xl'RSINd
It has l>eeii difficult to determine with any exactness the number of
firms whose nurses make visits to £he homes of employes. In a small num-
l>er of establishments visiting nursing is an acce|)ted part of the medical
department routine, in others, visits to the homes of sick workers are made
infrecjuently. A total of 22 firms are recorded as providing at least occa-
sional visiting nursing services; 18 of these firms employing 1,000 or more;
7 firms employing .500 to 1,000, and 2 firms from 20() to 500 employes. In
no instance does a visiting industrial nurse do bedside nursing, at its best
the purpose of her visit being rather to determine whether or not the sick
or injured worker is receiving proper care.
Industry has made occasional use of nurses furnished by the Visiting
Nursing Association. A more extended utilization of such an established
service might be advantageous.
In Cleveland a considerable number of nurses em[>loyed in industry for
vi.siting do not report to the medical department but are responsible to
employment officials. Their task is to visit the homes of absentees to de-
termine the cause of absence and to exert such influence as they may to
induce the delinquent to return to work.
Such service, valuable though it may be, is not visiting nursing, is not a
part of medical care or supervision and the employment of nurses for this
work is frequently a transparent subterfuge of employment departments
used to mask the real purpose of such visiting. It rarely fails to discredit
the organization responsible for the activity and to lower the respect of
employes for the plant nurses. With good reason employes resent the com-
ing to their homes unasked of women who wear the uniform of nurses but
who in purpose and in fact belong to the company espionage service and
not to its health department.
532 Hospital and Health Survey
It is obvious that absence follow-up can best be done by visitors who are
qualified to discern illness when it exists, but nurses are so few and absentee-
ism so prevalent that it is of doubtful wisdom to assign nurses to routine
absence follow-up instead of to visiting of the known or suspected sick. In
any event, visiting nurses should be considered as medical department per-
sonnel and their reports should be part of the medical department records.
RECOMMENDA TIONS
The survey recommends that:
Industrial nurses be graduate, registered nurses. That they be employed
in the practice of nursing or in the maintenance of the physical welfare of
establishment personnel.
That industrial nurses be carefully chosen for professional fitness and
for such qualities of personality and character as will enable them to fulfill their
many responsibilities.
That practical, untrained nurses be employed only under competent
medical or nursing supervision.
That industrial nurses in establishments where they are directly and
wholly responsible to executive officers rather than to industrial physicians be
granted such authority and receive such support as may be necessary for
the development of their fullest usefulness. That industrial physicians re-
member that the industrial nurse must be more than a handmaiden of the
medical profession.
That medication without the individual or standing orders of a physi-
cian should be prohibited in industrial establishments as it is in law.
That encouragement and assistance be offered by industry to industrial
nurses in their efforts to maintain contact with progressive movements in
their rapidly developing profession.
That visiting nursing be considered as a normal function of industrial
medical service to be exercised as required or desirable.
That industrial visiting nurses be rated as medical department personnel.
That they visit the known or suspected sick and ht not employed for routine
absence follow-up from employment departments.
Clerical Personnel
Clerical personnel of medical departments in Cleveland is limited. It is
about as rare and found in about the same places as ade(|uate dispensary'
records. Seven firms employ a total of fourteen clerks in connection with
industrial dis])ensaries. Efficient health administration is as dependent
upon proper dispensary records as efficient ])roducti(>n and sales methods
upon proper cost accounting.
In all industrial dispensaries there is need of some clerical work. Nurses
and physicians are trained for medical service. If clerical work is exc»essive
^it should be |>erformed by clerks and not by the medical or nursing staff.
h^a:lth and industry 533
. . Dispensary Equipment
No detailed consideration of the equipment of industrial dispensaries is
included in this report. Excellent work can be done with meager equip-
ment and worthless work in the midst of much white enamel.
It has been a matter of some interest that with a few exceptions the
medical departments rendering the best service in the city are in poor quar-
ters and possessed of inferior dispensary fittings. The equipment of many
of the most elaborately furnished suites has apparently exhausted the inter-
est and thought of those responsible for medical administration.
It is certain that an efficient staflF will be aided by adequate and convenient
equipment as well as by quarters which are accessible and sufficiently large
for the number of cases to be handled.
Most of the industrial X-Ray work in the city is done by hospitals or
firms specializing in this service. A small number of firms have installed
apparatus for such purposes as radiographing teeth or minor injuries. Sev-
eral establishments have apparatus enabling them to do practically all grades
of X-Ray work.
Few dispensaries ha^e even limited clinical laboratory facilities. There
are probably not more than five such laboratories in use.
One private ambulance has been ordered by a large industrial organiza-
tion. The inadequacy of ambulance service in the city is not infrequently a
source of annoyance and even danger in the transfer of injured workmen to
hospitals. Especially apparent is the need of trained ambulance attendants.
There is much reason for believing that th6 industries of Cleveland could be
served much more satisfactorily than at present by a centralized ambulance
call system, the cars of such a system to be operated by a single agency or
controlled jointly by the hospitals of the city.
Cost of Service
Though many of the results of industrial medical service must be reck-
oned as intangible, there are ways in which the quality of service which is
rendered may be checked, as well as certain effects upon employment and
insurance costs to be noted. Through these means may be obtained an
approximate estimate of what the service is worth.
It is more simple to secure accurate figures regarding the cost of
service. There are several plants in Cleveland efficiently applying cost
accounting to medical departments and it is in these few plants alone that
there is definite knowledge of the total outlay for medical work. Other
firms may roughly calculate the cost by guessing at the value of medical
supplies purchased or on hand and adding to that amount the salaries of
personnel. In most establishments there is the greatest vagueness regard-
ing costs of service, occasionally combined with a fanciful exactness regard-
ing the benefits derived.
534 HOBPTTAL AND HeALTH SuBYEI
A number of firms stated the cost to be in the neighborhood of five dol
lars a year per employe* but this amount, it is interesting to note, is lela
tively constant, independent of the size of the plants, nature of products
types of workers or the extent and quality of service rendered. In om
large establishment the cost is $10.92 a year per employe and in anothe
$11.23. Such amounts are probably not excessive at the present time i
the service secured is comprehensive and of a high order.
Administrative Relations
The ultimate utility of a medical department is certainly to some extep
determined by the place which the department occupies in the industria
organization, though it must be recognized that all plants are not conductec
along the lines prescribed in the schematic plan of administration. If i
medical department is to develop and render more than relatively inugnifi
cant service it must have at its head a responsible executive in whom i
vested suitable authority.
As it is the function of this executive to conduct operations relating U
the maintenance of a healthy staff of employes, it would seem reasonable t
select for the office a properly qualified physician. Not infrequently medica
departments are administered by laymen who direct the activities of subordi
nate physicians, a practice which may be compared to the employment o
a good foundryman to superintend a draughting room or of a capable pip
fitter to direct the tuning of a piano.
If it is not feasible in any particular industrial organization to mak
the medical head of a medical department directly responsible to a genera
executive, he should at least have authority to control the policies aw
methods within his own field.
In Table IV. are shown tlie administrative relations of a number o
industrial medical departments in Cleveland. Reasonably accurate infoi
mation regarding fifty-six organizations has been tabulated. In certai)
establishments the duties of executives are not well defined and it has bee
necessary to determine rather arbitrarily the classification of the adminis
trative relations of a few medical departments.
Under ** Administration" are included medical departments responsibl
to general administrative bodies as executive boards and to general manager:
''Production" is inclusive of factory managers and superintendents. "Em
ployment" includes welfare departments, service departments, employmen
and industrial relations managers. "Claims" includes pension and ace
dent departments.
Almost half of the medical departments classified are responsible to som
form of employment service, 78 per cent are responsible to either such en
ploy men t service or to general administrative officers, while only 17 per cei
are responsible to production. In an extensive study of industrial medic
•vice by C. D. Selby in 1919, 41 per cent of a group of medical departmen
Health and Industry 535
were found to be responsible to production, 16 per cent to labor relations
and 18 per cent to administration.
Thou^ conditions within individual organizations must in great measure
determine the relation <^ medical departments to various executives, it has
appeared that the best developed medical services have been in departments
headed by full-time physicians directly responsible to general administrative
officers. It is to be accepted that such departments must cooperate closely
and harmoniously with related plant activities. If no full-time physician
is employed the medical department may well come under the supervision
of the company officer or executive charged with labor relations.
The heads of two medical departments are also in charge of the
service departments of their respective establishments. Such an arrange-
ment may be successful, as in these instances, under favorable circumstances
and when the chief surgeon and service head is an able executive, but it is
not one to be commended as generally applicable or desirable.
MEDICAL SERVICE IN NON-INDUSTRIAL ESTABLISHMENTS
Certain mercantile establishments of the city and a number of public
utilities have developed medical services which are so similar to those found
in industry that they may be considered as within the scope of this survey.
In Table V. of the appendix is set forth a summary of the statistical find-
ings covering these groups. Contrary to the condition prevalent in manu-
facturing establishments, mercantile medical service is concerned more with
the health of employes than with accidents. It affords an excellent oppor-
tunity for a demonstration of the value and possibilities of medical service
as distinguished from that essentially surgical.
Medical departments have not to this time been developed in the con-
struction trades though the health and accident hazards are notable. A
b^inning has been made in Cleveland, though not, however, by a Cleveland
construction firm.
There are in Cleveland about twenty thousand workers in the construc-
tion trades. For many of these the work is arduous and hazardous and
demands continued exposure to inclement weather. Both health and safety
of construction labor are frequently imperiled. Small injuries are numerous
and serious accidents common. Extensive construction enterprises involve
the housing of workmen and necessarily si>ecial problems of sanitation.
'Wages in the construction trades are high and the time lost by injured
workers is a costly factor. The loss incident to the absence of men from
their jobs, sent away for the dressing of small injuries is alone great. To
this must be added the cost of turnover from more serious accidents and from
ill health, and the burden of numerous fatalities.
586 HosPTTAir AND Health Subvby
There could be developed on construction jobs medical service somewluit
similar to that of the army in the field. Portable dispensaries could be in-
stalled where needed, suitable light equipment provided and medical and
surgical care thus made available for sick or injured workmen. It is a matter
of great concern to individual workers, to construction firms and to puWic
health authorities.
MEDICAL SERVICE BEYOND THE PLANT
Industrial medical departments are in most instances established and
manned to furnish surgical care for industrial injuries. As previously indi-
cated, there has been relatively slight development of service purjjosed to
care for the health of operatives. There has been in Cleveland almost no
consideration of the health of employes beyond the confines of plant prop-
erty except through the ministrations of a few visiting nurses.
It is of course difficult to determine the limits of the social orbit of an
employe, an orbit touching many interests, work, home, church and recrea-
tion. •
In this connection it is of interest to consider the curious philosophy of
many employers who rather belligerently assert that they have not con-
cerned themselves with the health of their employes because that is a private
affair; that if the men received good working conditions and good wages
they receive enough; and that besides there are in the city men who have
secured training for the medical profession, implying that in consequence
the community is in duty bound to support these physicians regardless of
their merits. Yet the same employers turn to show proudly their company
cooperative stores where food and clothing are sold at cost, or at a trifling
profit, food for the worker and for his family. The implications in this case
are probably that food and clothing are not to be regarded as private affairs
and that the community does not owe storekeepers a living.
The employer who has joined with his employes to enhance the purchas-
ing value of wages by sharing in the operation of a cooperative store has but
few mental steps to tread till he faces an opportunity to secure for his em-
ployes that which is as necessary in their lives as socks and canned tomatoes
— a fair chance for health and for competent medical care at a reasonable
cost.
It should be possible for employers and employes together to arrange for
the establishment of industrial dispensaries, for the securing of medical and
nursing personnel and for the conduct of such dispensaries upon a mutually
satisfactory basis. A dispensarj'^ of this nature might be limited to the
full medical care of employes or might increase its resources to include the
care of employes' families. The extent of medical and nursing service
and the apportionment of cost are details which any representative fair-
minded body could readily determine.
There are in Cleveland at least two mutual benefit associations which
Participate in the administration of plant medical service. One is, in its
\l a A LTHAND INDUSTRY 537
>lan, but little above the level of the old-time lodge practice, the other is the
nost promising industrial medical service in the city. One of these mutual
>enefit associations employs a physician whose oflBce is provided by the com-
>any and who for a small annual sum contributed by each member renders
«rvice to members of the association, services necessarily limited. Em-
>layes who are not members of the mdtual benefit association may consult
his physician, but upon a fee basis.
In the other organization cited, the plan is to render comprehensive
nedical service of the highest type, employing physicians and nurses in such
lumbers as .'may be required to insure adequate and prompt treatment of
employes. It is contemplated that later, service shall be available for the
nembers of employes' families.
INDUSTRIAL MEDICAL RECORDS
There is such a thing as accumulating useless statistical material, of
Qultiplying indices and cross indices, just as there is the considering of prob-
ems by guess work when they are considered at all. There is also such a
hing as keeping an accurate record of important facts and of summarizing
he data so made available in such a manner as to render them possible of
ntelligent interpretation. It is a safe assumption that the industries of
Cleveland have not attained their present eminent position by the universal
ipplication of the sort of administrative methods which are generally foun.d
n their medical departments.
There are several establishments in Cleveland in which essential data
egarding injuries and illness incurred by employes are recorded and the
Indings so tabulated as to be of significance and great value. There are
lumerous establishments with thousands of records so inadequate, confused
md inaccessible that they are practically worthless; and there are others which
:eep no records worthy of mention, yet expend a total of many thousands of
iollars for the purpose of safeguarding the physical welfare of employes.
The conditions in various plants, such as the type of industry, of organ-
zation, of personnel and of medical service, all enter into the consideration
>f dispensary records and forms for records. It is probably futile and not
lesirable to hope for general adoption of any uniform record system, but
here are a few minimum standards for good industrial medical practice
ust as there are for good hospital practice. Industrial medical records
hould indicate the recognition of such standards.
It is not within the province of this report to set forth dogmatically a list
>f standards for industrial medical records, but several suggestions may,
lowever, be submitted.
Records concerning individuals should be so filed as to be readily acces-
ible. This may entail a cross index by name if records ^\^ ^^^ ^y c«^
lumber or shop number. Individuals may well be identified by name,
lumber, department, nationality and address. It is very desirable to state
be actual process upon which an employe is engaged.
588 Hospital and Health Survey
Dates of injury, illness, treatment and discharge should be set down.
Adequate, though possibly brief statements should be made regarding
treatment, such as dressings or medication. Progress notes are valuable.
Accurate diagnosis, by standard nomenclature, should be required.
"Deferred" and "provisional" diagnoses should be supplemented by more
accurate opinions. Condition of the case at discharge should be stated.
Whether the record form be a card filed separately or in a folder or a
sheet bound loose-leaf fashion or filed folded or flat is a matter for each
organization to consider. Good records are kept in any one of these ways.
There is much to be gained by filing all of the data relating to an indi-
vidual in one place. A fairly preva.*ent custom is to make out a new form
for each new accident or illness without reference to the previous history of
the individual concerned. In many instances the custom can be well justi-
fied but in general it is not good practice, especially in regard to medical
cases, to ignore an available case history.
Ample evidence warrants a gentle caution against indiscriminate '^eUmi-
nation of paper work." A certain amount of paper work is a good thing;
it saves other kinds of more arduous work.
*
Industrial medical department forms are of practically unlimited variety
as to shape, filing system, purpose, content and degree of usefulness. The
forms collected in Cleveland in connection with this survey may be roughly
classified into several groups.
(a) Forms used to get injured or ill workers from the plant to the dis-
pensary. They include passes from timekeepers and foremen, with or with-
out provision for record of time elapsed in transit. Some include space
for description of the accident incurred. In large plants it may be found
very desirable to have some sort of a check on the time consumed by employes
in coming to the dispensary and in returning to work. An ingenious shirker
can occupy several hours in negotiating the short distance between his de-
partment and the plant dispensary. It is to be remembered, however, that
as little difficulty as possible should be thrown in the way of patients which
might deter them from making free and prompt use of the dispensary. In-
fections and prolonged disabilities are the penalties. Official statements re-
garding the percentage of industrial injuries in Ohio which have become
infected and regarding the influence of infection on the production of perma-
nent disability offer matter for serious and thoughtful attention. A bulletin
of the Industrial Commission of Ohio published March 1, 1917, stated that
of 73,525 industrial accidents for which awards were made by the Com-
mission for the year ending June 30, 1915, infection was reported in connec-
tion with 7,073 cases, approximately one-tenth of all accidents. Of these
7,073 cases 39 resulted fatally, 161 in permanent partial disability and
,873 in prolonged temporary disability.
Health and Industry 539
(b) Fonns used for follow-up to insure the return of cases needing
continued dressings or treatment. These include hospital passes and cards
patterned after the conventional time card, used in racks, one for a case,
and *' pulled" by the dispensary nurse when a patient has received his ap-
pointed treatment.
(c) Forms for case records, medical, surgical, dental, ocular or for spe-
cial studies. They range from simple cards to elaborate forms upon which
positive findings may be indicated by signs.
(d) Forms for physical examinations. Such forms vary with the pur-
pose for which physical examinations are performed. They also vary with
the training and the professional hobbies of their medical authors.
(e) Forms for preliminary and final reports on cases. Usually for the
purpose of informing compensation departments regarding the nature of
injuries and the progress or termination of cases. Occasionally include a
statement of professional fees.
(f) Forms for periodic reports to executive departments. They, for the
most part, present a somewhat curious selection of data and, as with the
case of many other forms, are of unknown executive origin.
Industrial accidents and disease, as well as non-industrial accidents and
illness, are important and costly matters concerning employes and their
employers, affecting as they do not only the well being and income of indi-
viduals but also operating costs through lowered morale, absenteeism, in-
creased turnover, lowered production, faulty goods, medical care and insur-
ance rates. It would appear to be a subject of genuine interest to progres-
sive employers, but the supposition is not borne out in the records of many
industrial medical establishments. Even though ample material may be at
hand in the files of the medical departments it is seldom summarized and
tabulated in monthly or other periodic reports in such fashion as to furnish
responsible executives with sound bases for comparative judgments.
For example, there is rarely careful discrimination between numbers of
individuals, numbers of cases and numbers of dressings, treatments and
visits. There is rarely a comparative statement of accident and illness inci-
dence based upon some common factor, such as a hundred or a thousand
full-time workers. A relatively small department of a plant showing ap-
pai^ently a low accident incidence may in fact have a very high accident rate.
There is rarely in periodic reports a differentiation between trifling and seri-
ous accidents, yet more important than the frequency rate is the severity
rate indicating the time lost. This may be illustrated by the machine trades
in which the number of accidents causing an immediate loss of time of less
than one day is much greater than the number of serious accidents, perhaps
ninety to ninety-five per cent of the total. Though an important group of
injuries, these trivial cases are not reportable to the Industrial Commission
and do not figure in an estimation of the severity rate. Thus the machine
trades, having a fairly high accident severity rate, have a still higher accident
frequency rate because of numerous accidents, each causing disability for a
short period.
540 Hospital and Health Survey
These more accurate reports of medical department data do not demand
the attention of skilled statisticians. They can be very satisfactorily com-
piled by industrial nurses or clinic clerks with possibly occasional supervision
or assistance.
There is much to be gained from the general adoption of some uniform
basis of reckoning for accident and sickness statistics, and at the present time
there appear no more authoritative standards than those employed by the
Bureau of Labor Statistics of the United States Department of Labor. These
include the standards of the Committee on Statistics of the International
Association of Industrial Accident Boards and Commissions regarding
tabulable accidents, diseases and injuries; what shall constitute a full-time
worker; the computation of the number of man-hours worked in an estabUsh-
ment and a scale of time losses for weighting various industrial accidents.
According to these standards the accident frequency rate expresses the
number of tabulable accidents incurred i)er 1,000 full-time workers, a fuD-
time worker being one who works ten .hours a day, three hundred days a
year. The accident severity rate expresses the number of days lost through
tabulable accidents for each full-time worker per year.
The utilization of this method of tabulating accidents and illness would
enable executives to estimate accurately the losses from these sources by
departments, by j)rocesses, by various time periods, by day and night shifts,
by nationalities, or in other ways; would enable them to compare their losses
with other simihir establishments or with other industries.
Complete and recent reports of accidents in Cleveland have not been
available, but a bulletin published by the Industrial Commission of Ohio in
1915 presents an analysis of reportable industrial accidents occurring in
Cuyahoga County front July to December, 1914. Computations based
upon the figures of this report indicate an accident frequency rate of 93.7
accidents per 1,000 workers per year, and an accident severity rate of 4.53
days lost per worker per year. (Table VI., Appendix.)
Through the courtesy of the Industrial Commission advance figures
have been received indicating the number of reportable accidents occurring
in several groups of plants located within selected important industrial
areas of the city during the period of June 1, 1919, to November 30, 1919.
The industries represented were quite diversified, though for the most part
they were engaged in the manufacture of metal products. These figures,
which are presented in Table VII. of the appendix, indicate for a total of
54,091 employes, an accident frequency rate of 201.7 accidents per thousand
workers per year, and an accident severity rate of 2.6 days lost per worker
per year.
Detailed information regarding the computation off accident and illness
frequency rates and severity rates may be obtained from the Bureau of Labor
Statistics in Washington.
Health and Industry 541
ABSENTEEISM DUE TO SICKNESS
There is little question in the minds of those deeply concerned with
problems of industrial health that the greatest present need in this field is
for the accumulation of accurate and extensive data regarding absenteeism
due to sickness and non-industrial accidents. It is not always easy to obtain.
In one Cleveland {}lant unusually satisfactory reports of illness are obtained
by conditioning a portion of an attendance bonus upon the prompt report-
ing of cause of absence, with' a penalty for false reporting. In another
establishment all absentees are questioned by the employment department
upon their return to work regarding illness or other cause of absence.
0
In another organization all employes absent over a certain period return
through the medical department. Numerous plants obtain much valuable
information regarding absenteeism due to sickness through follow-up person-
nel, either nurses or visitors working from the employment offices. It is
necessary that there be close coordination of the medical and employment
departments, and of importance that all facts secured be recorded and in-
corporated with the records of individuals in the medical department.
The subject is one which has been rather studiously neglected by employ-
ers who customarily state that non-industrial sickness is not of their concern
and, like the medical care of such illness, is wholly a private affair of employes.
This is questionable.
In recent years there have been numerous careful investigations into the
incidence and duration of absence due to non-industrial accidents and illness
of industrial workers. These studies have shown that there is an average
time loss per worker usually ranging upward from six days per year. Seven
days of lost time a year is probably a conservative estimate for all industries.
One set of authoritative figures, based upon consideration of over half a
million workers, places the time loss at nearly nine days per year per worker.
These are averages. In certain trades and among certain nationalities
the loss may be less or greater.
If to a time loss of seven days for non-industrial accidents and illness
there be added an estimated loss of four days for industrial accidents, there
is a total loss among the industries of Cleveland of approximately two and
a fifth million days a year. When to the two hundred thousand industrial
workers are added the many thousands employed in the public utilities, in
mercantile and commercial establishments, in the construction trades and
in transportation, there is a most impressive total of time loss, w^th its
attendant economic loss to employes, employers and the community as a
whole. This loss is not of wages and j)roduction alone for to it must be added
the burden of medical and social care placed upon numerous individuals,
physicians, nurses, hospitals and other institutions.
Estimates of actual time lost must be supplemented by consideration of
the intangible but noteworthy losses due to non -disabling poor health and
54£ Hospital and Health Survey
physical and mental defects. The findings of the examiners of dralt regis-
trants in 1917 and 1918» indicating 468 men per thousand with important
physical or mental defects, are significant.
It is reasonable to believe that these evidences of sickness and accidents
could be materially reduced by applying intelligent and simple preventive
measures and by providing a better mechanism than now exists for the care
of ill health. Even were the burden so evenly distributed that the ardent
champion of the rights of the individual might justly argue that each citizen
bore only his proper share and so should be responsible as an individual,
there would still be ample reason for developing health and safety education
and better means of providing medical and nursing care.
The burden is not evenly distributed. An illustration may be found
in Table VIII. of the appendix where are compared the accident incidence
of the construction trades and that of the metal trades in Cuyahoga County,
as published by the Industrial Commission. This comparison indicates ata
accident frequency rate in the construction trades over twice that of the
metal trades, and a severity rate four to eight times as great, the variation
being dependent upon various assumptions as to the length of the working
day for workers in the construction trades.
It may be pointed out that industry presents an unparalleled opportunity,
for the detection and remedy of defects, for the observation of disease in
its earliest recognizable stages and for the institution of measures for the
treatment of such disease. In no other way than at work are so many
persons brought frequently together in groups, each group constituted of
individuals living much the same sort of life under similar conditions.
It is recommended by the Survey that industrial, mercantile and other
establishments proceed to collect data regarding the incidence and nature
of sickness and accidents among employes causing absence from work. This
information may later be analyzed witii great profit by individual organiza-
tions, and the findings of individual establishments may be available for
consolidation and study by such groups as associations of employment man-
agers, industrial physicians and other interested agencies.
PHYSICAL EXAMINATIONS
It is essential for efficient public health control that there be knowledge
of the community's physical constitution, of its defects, of menaces to the
public health. So does efficient control of the health of the individual rest
upon knowledge of the physical condition of the individual. It is of course
possible without this knowledge to maintain certain general safeguards, but
they are of necessity inadequate and probably frequently misdirected.
If men and women, and especially children, are to labor under conditions
which do not work undue detriment to their health it is of the greatest im-
portance that there be such continued observation of their physical state as
will lead to the prompt institution of corrective measures following detection
Health and Industry 543
of ill effects. This can no more be done without initial physical examina-
tions than can the running time for a race be recorded when the moment of
starting is not noted.
There has been much opposition to compulsory physical examinations
exerted by organized labor» usually the expression of feeling that the exami-
nations might be made an instrument for discriminative action against indi-
viduals considered by employers to be undesirable. Without doubt physical
examinations have been at times the occasion of injustices, but there are now
thoughtful men in the labor group who have affirmed their belief in the value
of physical examinations when fairly conducted and not instituted for the
elimination of defectives.
Ohio manufacturers are unusually strengthened in their position of being
able to accept practically all labor applicants, by the operation of the Work-
men *s Compensation Act which does not penalize the employer of a defec-
tive workman who incurs by accident a loss to a single remaining paired
member, by charging against that employer's compensation account a
claim for the total, double loss.
The findings of the Survey are that eleven industrial organizations in
Cleveland conduct compulsory physical examinations. A small additional
number offer optional examinations. It is of importance that in practically
every instance the only bases of rejection were of the following nature:
. (a) Communicable disease.
(b) Conditions which would render the applicant, if employed, liable to per-
sonal injury or harm.
(c) Conditions which would render the applicant, if employed, a menace to
the health or safety of fellow workmen.
(d) Unreasonable lack of personal cleanliness.
The second and third reasons for rejection have not been frequently
operative, partly because of the labor shortage and partly because in large
establishments there can be found suitable work for almost any defective.
There are in the files of the Survey the names of scores of firms employing
cripples and persons handicapped by orthopedic conditions, deaf and dumb,
partially and totally blind and even pronounced and recognized mental defec-
tives. Selective placement is not always made with desirable precision, but
it is in a general way the purpose of numerous large establishments.
Ohio law requires that **no person suffering from or afflicted with tuber-
culosis, a venereal or a contagious disease, shall be employed in or about
any part of a restaurant or its kitchen or handle foodstuffs or products used
therein."
In the course of this study but one establishment among the leading
hotels and restaurants of the city has been found in which physical examina-
.544 Hospital and Health Survey
tions are conducted, and that a department store restaurant. Various
managers evinced genuine interest in examinations, but found their labor
so highly mobile and scarce as to deter them from pursuing the matter.
There are, however, many deaths reported from tuberculosis among
cooks, bakers, stewards and waiters, a sufficient number to suggest that
existing active cases are widely distributed among the members of these
occupational groups. One large group of food handlers, apparently recog-
nizing that many of its members were suffering from or afflicted with com-
municable disease, app)ealed for the cooperation of the Survey in an effort
** looking to a clearing up of the situation."
It would appear to be a wide field of endeavor for the department of the
State Fire Marshal, to which department the Legislature in its wisdom has
committed the administration of these matters pertaining to the public
health. It is recommended that the responsibility for the maintenance of
health among food handlers in restaurants be transferred to the State De-
partment of Health.
Many persons are daily imperiled because of defective vision or other
disability, physical or mental, in those who operate taxicabs or other motor
cars, trucks, cranes and elevators. Few of such operators are examined.
The safety of that portion of the public which boards street cars and rides
therein or has occasion to cross tracks is daily entrusted to a large corps of
men, none of whom are examined to determine their freedom from infirma-
ties which might disqualify them for certain types of work.
The municipal government of Cleveland is the largest single employer of
labor in the city, having on its payroll approximately 10,000 men and women.
As such its responsibility in connection with the maintenance of health among
working people is not only a great one but very immediate. It is also grossly
neglected. It is a responsibility shared by each tax-paying citizen.
The Survey recommends that the City, through its Division of Health,
provide for its employes an initial and subsequent periodic physical examina-
tion with such medical and surgical care from time to time as may be deemed
necessary and advisable.
It is wholly reasonable to expect of the city government a service for its
workers comparable with the best medical services provided by large indus-
trial organizations.
SPECIAL SERVICES
Industrial Psychiatry
As one of the outgrowths of careful study of the causes of industrial unrest
there has come new knowledge of psychology' as applied to industry and even
more recently the beginnings of industrial psychiatry'. Psych ologj*^ and
psychiatry are terms often used somewhat carelessly and it is of importance
that they be differentiated. Psychology may be defined as the study of
H*>A.LTH AND INDUSTRY 545
states of consciousness, but is ordinarily limited to consideration of normal
processes. Most psychologists are not physicians. Psychiatry is the
st«dy of abnormal, pathological mental processes and conditions. Most
psy<jiiatrists have been trained as physicians.
Military surgeons during the war found that men whose mental equip-
ment was not such as to permit them to withstand military discipline and
routine had not infrequently checkered industrial histories, having held many
jobs and no job for a long while. Carefully studied, in many instances these
individuals proved to be of psychopi^thic type. In industry they had prob-
ably been called unruly, inefficient or lazy.
When upon deficient mentality are thrown the burdens of fatigue, of
unhealthful working conditions, of real or fancied injustices and of economic
unoertainties, it is rather to be expected that unrest results.
In a realm of science so beset with difficulties as is psychiatry, complicated
in an industrial environment by many different factors, progress will likely
be slow, but the development of this field warrants earnest consideration by
industry. It is not a subject to be approached by the inadequately trained
or by the casual enthusiast.
There have been in Cleveland at least two employers who have made
extended use of psychometric tests and over such a period of time as to
justify, apparently, the continued use of these aids to employment and place-
ment. In neither organization have the tests been considered as other than
one of several gauges of the fitness of applicants.
Industrial Dental Sf:rvice
The public in recent years has come to realize in some degree tlie impor-
tance to health and self-respect of good teeth and high standards of mouth
hygiene. This interest has been reflected in the development in industry of
dental clinics and in the importance which is attached in many establish-
ments to the care of the teeth of employes. While a casual inspection of the
teeth is a part of every reasonably thorough physical examination, several
firms have installed dental diairs and employ capable dental surgeons to
in.spect the teeth of all recent employes. Four manufacturing and one mer-
cantile establishment in the city maintain dental service. The amount and
kinds of work performed vary with the establishment but are in every in-
stance limited to nothing more costly than amalgam fillings. The cost is
borne either entirely by the employing company or shared by the employes
who pay a moderate sum for materials used.
It is a service which is generally enthusiastically endorsed by the organiza-
tions which have installed it and it is one which merits wide adoption.
Industrlvl Ocular Service
Several industries in which fine work demands good vision have found it
sound practice to secure for their employes the services of competent oculists,
not only to determine the grade of vision at the time of employment, but also
546 Hospital and Health Subvet
to re-examine workers from time to time to secure by glasses proper correc-
tion of refractive errors. Five firms maintain oculists for work of thb
nature* but many more make use of oculists as consultants or refer to them
serious eye injuries. In far too few instances are these serious eye cases
promptly referred. Inquiry recently made indicates that a large portion of
industrial eye injuries referred to ophthalmologists had been previously
mishandled. Industrial Coqunission figures for the state at large have
shown that eye injuries made up ^^ per cent of the cases of permanent total
disability, 8.9 per cent of cases of permanent partial disability and 10.9 per
cent of the cases of temporary partial disability. In a study of the influence
of infection upon disability, it was found that 18 per cent of the cases of total
or partial loss of vision were due to infection.
The neglect of vision begins early in many industrial plants. The SneUen
diart as generally used is one of a number of false gods before which a suc-
cession of company officials reverently bow. If the chart is veiled in dim
obscurity, the almost superstitious regard for its subtle values is the greater.
Snellen diarts hang in sunny offices or in half -lighted basements; some
illuminated at the top, some at the side; some by glaring light, some by
moribund filaments.
There are in Cleveland a number of able oculists who are greatly interested
in industrial eye injuries and a number in the safeguarding of the vision of
industrial workers. More use should be made of them.
There is no hospital in the city devoting a special service to the care of
eye cases, though such cases are occasionally received in seven general hos-
pitals. One hospital only regards certain b^ds as belonging to the eye serv-
ice, holding four beds in a surgical ward for this purpose. Five hospitab
have magnets for the removal of metallic foreign bodies.
Cleveland is greatly in need of an eye hospital and the almost unanimous
and generally emphatic statements of the oculists of the city regarding the
desirability of such an institution warrant a favorable response from the
community.
Tuberculosis
In an industrial population as large as that of Cleveland it is certain that
there are a considerable number of cases of tuberculosis, yet in the establish-
ments conducting physical examinations the number of cases observed is
almost negligible. They have presumably been overlooked either because
the examinations have been made too casually and hastily or because they
have been made by physicians ill qualified to examine for pulmonary disease.
Reports of the municipal Division of Health offer evidence that large
numbers of industrial workers are dying of tuberculosis. As no data are
available regarding the numbers of reported cases for occupational groups or
detailed information concerning the numbers of various types of workers in
the city, no fatality or mortality rates can be given.
HbalthandIndustry 547
It is to the interest of those afflicted as well as their companions at work
that reasonalble measures be taken to identify persons with this disease and
to assist them in securing proper care. The incipient cases must be sought
with special diligence* for in such cases there may be slight evidence of ill-
ness to attract the attention of foremen or fellow workers.
The physician who conducts examinations ^ust have sound knowledge
of chest conditions or the examinations will be more or less futile. Not all
physicians have this knowledge and while it is in a sense unfair to general-
ize, it is safe to say that a very large portion of the surgical group of the pro-
fession and a somewhat smaller portion of the medical group know little
about the diagnosis of pulmonary tuberculosis, except possibly in its well
advanced stages.
«
It should be wholly practicable, however, for industry to make frequent
use of expert consultants who might review groups of doubtful cases selected
by plant physicians.
The opportunity of industrial medical services to cooperate in the reduc-
tion of tuberculosis is a very valuable one. In Cleveland littl^ utilization
has been made of it. There is awakening doubt of the blissfulness of igno-
rance in regard to this preventable disease which is alone the cause of a
fifth to a quarter of all the deaths occurring in the working-age groups.
Venereal Disease
The activity during the war, of the United States Public Health Service,
in connection with its extensive program for the combating of venereal dis-
ease unfortunately did not stimulate a sustained interest in the subject
among employers. There are probably not more than two or three establish-
ments in Cleveland in which venereal disease is of more than trifling concern.
Yet Cleveland is not a community distinguished for its freedom from venereal
disease and from the conditions which foster it. Nor is venereal disease
without influence upon the efficiency of working people and upon iabsentee-
ism. Like defective vision, and tuberculous lungs, venereal disease has been
considered a personal affair of the worker, another inviolable right of the
individual.
Though much of the traditional prejudice against frank and honest care
of venereal disease has fortunately passed, it is still in practice difficult
either to secure reporting or to conduct the treatment of cases in industrial
dispensaries. There are, however, no insurmountable difficulties in the way
of tactful and straightforward educational work with advice regarding the
accessibility of centers for diagnosis and treatment. This is a reasonable
function of industrial medical service.
The Rehabilitation' of Industrial Cripples
The analogy of industrial casualties to those of war has frequently been
pointed out. Though this has long been a matter of comment and there
. 1- ]?'
550 Hospital and Health Survey
has been a lively interest in the care of military cripples, govermental agen-
cies have been slow to evince any realization of the economic and social
folly of scrapping the cripples produced in industry.
There has been scant development in Cleveland of methods for the treat-
ment of industrial injuries calculated to restore the injured to the fullest
possible function in the shortest period of time compatible with good surgical
practice. There has been limited application of the knowledge gained else-
where in recent years of rehabilitative methods and devices. There has been
in the community and in its leading medical centers an unfortunate neglect
of orthopedic surgery with consequent loss to the community of services of
a special nature which the community has reason to expect. Medical cen-
ters, teaching and others, hold a public trust.
THE SMALL ESTABLISHMENT
The employer of less than two or three hundred workers seldom feels justi-
fied in making the ex|)enditures necessary for a plant dispensary installation
and for the maintenance of the needed personnel, even though he realizes
that his employes are exposed to certain hazards, and when ill or injured do
not receive proper care, (considerations of economy may lead him to aban-
don his desire to have physical examinations of applicants for employment,
suitable placement of the less fit, prompt and efficient medical and surgical
attention, visiting nursing service and health supervision in his plant.
Ninety-four per cent of the industrial organizations in the city employ
less than five hundred workers each, a total of 83,711. (Table I., Appendix.)
Eighty-eight per cent employ less than 200 each, a total of 51,682.
Eighty percent employ less than 100 each, a total of 41,000.
The need of great; numbers of these smaller organizations for medical
service of a high order could be met by the establishment of industrial dis-
p)ensaries at various points in industrial districts, carefully selected with
regard for accessibility from the plants which each dispensary^ would sen-e.
The greatest agglomeration of small industrial establishments in Cleve-
land is in the heart of the city. Within a radius of a mile of the Public Square
there are 536 establishments of various sizes, employing a total of 34,131
workers. Of these plants, 459 employ less than 100 each; 505 shops employ
less than 200 each, 94.2 per cent of all establishments in the area, 53 per cent
of the employes, an average of 36 workers per establishment.
Basing an estimate upon Industrial Commission figures for accidents
occurring in plants of this group, there is an annual time loss for industrial
operatives from reportable industrial accidents of approximately 16,000 days*
an annual total of 22,400 accidents of all grades; and a time loss from all
accidents and illness of over 250,000 days. Plant medical service now
reaches less than 8,000 of the operatives in this area through eight dispen-
saries employing a total of ten industrial nurses, two full-time and four
part-time physicians.
Health and Industry 551
Quite comparable for density of industrial population with this central
area of the city is the region about Forty-fifth Street and St. Clair Avenue.
Within a radius of half a mile of this point are employed a total of 21,100
operatives in 114 establishments. Of these plants, 71 employ less than 100
workers; 89 employ less than 200, being 77 per cent of all the shops in the
zone, employing 22 per cent of the employes, an average of 53 in each plant.
The estimated annual time loss for industrial operatives from reportable
industrial accidents occurring in this area is 38,845 days. There is an esti-
mated annual total of accidents of all grades of 53,340, with a time loss from
all accidents and illness of 186,000 days. Plant medical service now reaches
a little over 7,000 employes in this region, through eight plant dispensaries
and the services of four industrial nurses and eight part-time physicians.
The area of density of industrial population extends southward from this
region about Forty-fifth Street for a depth of three or four miles from the
lake front. Statistics similar to those presented might be furnished for other
circumscribed areas within this belt.
Though there are many physicians practising within this large zone and
in other parts of the city which are thickly set with industrial plants, there
is at present no industrial dispensary conducted upon an essentially coopera-
tive basis.
It would be the reconmiendation of the Survey that the general adminis-
tration of such a cooperative dispensary as has been suggested, or of such
dispensaries, be in the hands of a conmiercially disinterested body associated
wiUi a controlling board representing employers, employes, physicians and
the administrative organization. The administration might be the respon-
sibility of a general hospital or of any one of several recognized and trusted
public agencies of which the local chapter of Ihe American Red Cross may
be considered an example.
Such a dispensary should be self-supporting, and though paying salaries
and fees sufficient to conunand the services of able personnel, should not be
conducted for profit in the customary sense. It should have such profes-
sional supervision as would assure the rendering of efficient service.
The first requirement of the dispensary would be the care of industrial
injuries, with surgeons and nurses in attendance in such numbers and at
such times as mi^t be needed. It would be wholly feasible, however, to
extend the service to include, if desired, physical examination of applicants
for employment or of employes, mental examinations, medical care of indus-
trial and non-industrial sickness, dental service, ocular service and visiting
nursing.
The cost of installation and maintenance should be guaranteed by the
industrial estabhshments participating, but it would in part be returned by
the Industrial Conmiission in payments for service rendered under the Work-
men's Compensation Act.
55^ Hospital and Health Survey
If established for a group of two thousand employes the cost of main-
tenance would be approximately that of medical service in a single plant
employing a similar number of workers, between five and ten dollars a year
per employe, though of course the amount would vary with the range <rf
ser\'ices offered.
INDUSTRL\L HOSPITALS
Cleveland is at present greatly in need of additional hospital beds. With
the consequent demand, it is wholly to be expected that serious industrial
accident cases are frequently peddled about the hospitals until a vacancy is
found. As the larger part of such cases come within the provisions of the
Workmen's Compensation Act, enabling the Industrial Commission to pay
for certain surgical and hospital ser\4ces, and as the amount customarily paid
by the Conmiission approximates, in most instances, half or less than half
of the actual cost of maintenance in hospital, it naturally follows that a
financially pressed institution offers the injured workman its minimum
services which may or may not be adequate.
Not all industrial surgeons hold staff positions in the hospitals of the city
and some who do not have experienced difficulties in performing the services
for which they are employed because of the necessity of relinquishing their
responsibilities to the hospitals with which their patients are placed.
Inquiry made by the Survey has confirmed an impression that there is a
field in Cleveland for one or more hospitals to be established and maintained
for the care of industrial cases exclusively. It is 3uggested that such a hos-
pital could best be administered either by some present existing hospital
organization in which there is general confidence or by a board of control
of representative character. It is of importance that the professional stand-
ards of such an institution be high for the medical, nursing and laboratory
services, and that the hospital be open to all qualified industrial physicians
who are willing and able to practise according to the established standards.
Conducted for industrial cases, staffed and visited by skilled industrial
physicians and surgeons, such an institution should make available a type of
service needed but not at present found in the city. The opportunities
which would be presented for attention to such matters as ambulance service,
the use of interpreters, the treatment of industrial eye injuries, of severe
bums, the development of physiotherapy and other rehabilitative measures,
would alone commend the project to many p)ersons who have had occasion
to follow the progress of cases of industrial injurj- under existing hospital
conditions.
THE TRAINING OF INDUSTRIAL PHYSICIANS AND NURSES
It has been evident, perhaps, that industry makes certain special demands
upon the physicians and nurses who serve therein, demands wnth which most
physicians and nurses not in industry are unfamiliar and which they are not
trained to meet.
Health and Industry 553
There is a rapidly growing need for the services of industrial hygienists,
men who have studied the toxic effects of various poisonous substances such
as are now used in many industries; men who are competent to consider such
problems as those of the effects of dusts and fumes, of ventilation, of illumi-
nation» of fatigue and of factory sanitation. These are matters which most
industrial physicians are not qualified to handle intelligently and thoroughly
though they may from experience be able to express a valuable common sense
opinion.
While the nurses who are graduates of good hospital training schools
may quickly become proficient as dispensary nurses they are by no means
prepared to assume readily the duties and to comprehend the many respon-
sibilities which are now properly those of a well equipped industrial nurse.
Special instruction is required for the rapid training of industrial physi-
cians, hygienists and nurses, and it is to be hoped that the existing facilities
of the Western Reserve Medical School may be expanded and supplemented
to permit of such instruction to graduate physicians and nurses within the
coming year. Certain portions of the instruction offered to physicians might
be made available to nurses in addition to courses arranged to meet their
special requirements.
The industriesi of the Cleveland district would unquestionably profit
greatly by the estabUshment of such a school of industrial hygiene, not only
through the services of the skilled physicians and nurses which it would pre-
pare for their employ, but through the development of research facilities
which would be at their ready disposal. It is an undertaking deserving of
their deepest interest and of their support and cooperation.
As a part of the reorganized hospital and dispensary service of the city
there is contemplated a clinic centrally located to receive emergency cases
and to offer facilities for consultation. In connection with such a consulta-
tion clinic it is the beUef of the Survey that there should be established an
industrial clinic where ailments of industrial origin might be thoroughly
studied, to which plant dispensaries might refer doubtful cases for diagnosis
and to which workers in the various industries and trades might go for
authoritative medical advice.
It would be of advantage to associate this clinic closely with the prospec-
tive school of industrial hygiene in order that each might profit by the re-
sources of the other.
PUBUC HEALTH AUTHORITIES AND INDUSTRIAL HYGIENE
The Industrial Commission of Ohio is vested with broad powers to safe-
guard the health and safety of working men and women. It possesses con-
siderable police authority. The Division of Industrial Hygiene of the State
Department of Health is endowed with certain powers of inquiry but is unable
to institute obligatory corrective measures. The activities of this division
are unfortunately not closely correlated with those of the Industrial Commis-
554 Hospital and Health Subvet
sion whose inspectors are especially concerned with questions of safety and
conditions of employment other than those relating to the health of opera-
tives.
Adequate as are the powers of state authorities to make inquiries and
issue orders regarding matters pertaining to the safety and health of indus-
trial workers, there would be much gained to the industries and to the work-
ingmen and women of Cleveland through the establishment of a Bureau of
Industrial Hygiene w^ithin the municipal Division of Health. It could
serve in an advisory and consultant capacity, aiding in the planning of fac-
tories and work rooms and in the solution of problems concerning industrial
hygiene. Such a division might well be charged with the conduct of medical
service for the municipal employes such as was reconmiended in the section
of this report relating to physical examinations. It in no sense need conflict
with or duplicate with the activities of the state authorities.
Cleveland is an industrial conmiunity; the greatest common interest of
her people is in her industries and those of her people who labor therein are
the life of the city.
The future of Cleveland depends upon the well being and the happiness
of her industrial workers and to secure and safeguard their health is the vital
task of industrial medical service.
SUMMARY OF RECOMMENDATIONS
It is the recommendation of the Survey —
That industrial physicians be selected with regard for their professional and execu-
tive abilities; that they be remunerated upon a basis commensurate with the amount
and character of service expected of them; that they be not permitted to combine with
their official duties a private practice among the company personnel.
That industrial nurses be chosen for professional fitness and such qualities of person-
ality and character as will enable them to fulfill their many responsibilities.
That untrained nurses be employed only under competent medical or nursing super-
vision.
That industrial nurses be granted such authority and receive such support as may
be necessary for the development of their fullest usefulness. That medication by nurses
without the individual or standing orders of a physician be prohibited. That encourage-
ment and assistance be offered industrial nurses in their efforts to maintain contact with
progressive movements in industrial medicine. That visiting nursing be considered a
normal function of industrial nurses. That industrial nurses be rated as medical person-
nel. That they visit sick or suspected sick and be not employed for routine absence
follow-up from employment departments.
That sufficient clerical personnel be employed in industrial medical departments to
free physicians and nurses for professional service.
That industrial dispensaries be furnished with adequate and convenient equipment
which need not be elaborate.
Health and Industry 555
That some municipal or cooperative industrial service be undertaken providing
efficient ambulance transportation of sick and injured to the hospital from industrial
establishments.
That there be applied to industrial medical departments efficient cost-accounting
^rstems.
That administrative relations of industrial physicians permit of free and direct ac-
cess to general executives; that wherever possible physicians and not laymen direct the
activities of the health service in industrial plants.
That employers and employes together arrange for the establishment and maintenance
of cooperative industrial dispensaries.
That industrial medical records conform to recognized standards of adequacy and that
they be filed in such manner and so summarized as to make possible their intelligent in-
terpretation. That there be a general adoption of some uniform system of reckoning for
accident and sickness statistics.
That there be study of absenteeism due to sickness and non-industrial accidents,
among the employes of industry.
That physical examinations be generally adopted as prerequisite to employment, not
for the purpose of the elimination of those not physically fit, but for guidance in the proper
placement of labor applicants; that the conditions found in such examinations be followed
up by subsequent periodic examinations.
That responsibility for the maintenance of health among food-handlers in restaurants
be transferred from the department of the State Fire Marshal to the State Department of
Health, or preferably, if possible, to the Division of Health of the City of Cleveland.
That there be compulsory physical examination of all applicants for positions as oper-
ators of public conveyances.
That the municipal government maintain within the Division of Health, for the serv-
ice of all its employes, an adequate health service or bureau which shall be charged with
the conduct of physical examinations of applicants for civil service positions, with annual
periodic medical examination of all city employes, and such further medical service as
may be deemed necessary.
That there be a study of the problem of abnormal mentality among industrial workers,
particularly in its relations to vocational guidance and unemployment.
That there be an extension and development of industrial dental service.
That there be more extended use made of the services of skilled oculists, both in the
care of industrial injuries and in the conservation of the sight of industrial workers.
That there be more extended use made of able consultant diagnosticians in connec-
tion with suspected cases of tuberculosis.
That there be a revival of interest in educational work directed against venereal
556
Hospital and Health Survey
That there be proper consideration devoted to cases of permanent disability resulting
from industrial injuries with particular regard to the development of methods for functional
rehabilitation.
That there be developed among groups of small industrial establishments some form
of cooperative dispensary to operate under the joint direction of employers and emplpytt
and some commercially disinterested organization. That there be established one or more
industrial hospitals exclusively for the care of industrial cases, such a hospital to permit
to practice any industrial physician able and willing to meet the requirements, which should
be of high standard.
That there be developed within the Western Reserve University Medical School fac-
ilities for the training of industrial physicians and nurses. That there be established in
connection with some central dispensary a consultation diagnostic industrial clinic.
That there be established within the municipal division of health a bureau of
industrial hygiene.
Health and Industry 557
Women and Industry
By Marie Wright
INDUSTRY has become interested in the health of employes. The con-
crete expression of this interest takes diflFerent form in almost every
establishment. One executive enthuses over rest periods, another shows
every visitor the immaculate new dispensary, still another expatiates upon
the benefits to be derived from hot food at noon. Any or all of these features
may contribute to the well-being of the working force. They are represen-
tative of various activities which are reasonably those of industry, not to
be considered mildly extravagant novelties, but essential equipment and
services giving to the workers the opportunity to lead a healthful life at work
as well as away from it.
There is a tendency to attribute much of the ill-health of working people
to conditions under which they live when not at work. Important as is the
relation of the home life of workers to their health, it must be remembered
that the character of the home life is largely the result of influences growing
out of their work. Home life and working life are closely inter-related. The
hours of work determine the amount of leisure for improvement and appre-
ciation of the home. Wages determine to a large extent the choice of neigh-
borhood, of building, and often of furnishings and food. Visitors to the
homes of working people are at times dismayed by their clutter and apparent
lack of cleanliness, but these conditions are not necessarily productive of
disease. No matter what the home of an employe may be, his employer
has the responsibility of providing a work place reasonably clean, well venti-
lated, and with suitable conveniences. The work should, if possible, be
^without special hazard, but where there is danger of accident or illness as
a result of any process, the employe should be informed of the risk and
encouraged to guard against it in every way.
The relative susceptibility of men and women to fatigue and special
hazards is a matter of opinion at present only partially substantiated by fact,
but the employment of women should be safeguarded at least as well as
that of men. Because of the important relation of women to present and
future generations, it is generally considered that they should have especially
favorable surroundings where possible. Another reason that the working
environment of women should be wholesome and their occupations health-
ful is that they are less likely than men to spend their margin of leisure time
^ healthful recreation. Many girls do their washing and ironing and make
^^ mend their clothes in the evenings. Married women and widows often
^^I'k harder at housework than they do during the day.
Since in so far as employers endeavor to promote the health of employes
^^y are promoting the public health, and since work under adverse circum-
^^nces is one of the greatest detriments to health, especially for women, a
^udy of the work which women are doing in Cleveland and its probable
^Ution to their health has been included in the general survey of the health
^Huation of the city.
558 Hospital and Health Survey
In order to learn the nature of the various occupations in which women
are engaged, visits were made to most of the firms known to employ women
in considerable numbers. Realizing that, in general, conditions in small
shops are not as good as in large ones, it was nevertheless considered advis-
able to study conditions affecting the major part of the working women.
As has been pointed out, in Cleveland seventy-nine per cent of all industrial
operatives are in establishments each employing over one hundred persons.
The remaining twenty-one per cent are distributed throughout a large
number of small shops averaging about thirty-three employes each.
(Table I, Appendix.) This condition is even more apparent among mer-
cantile establishments.
During February, March, and April, 1920, visits were made to seventy-
nine establishments employing a total of 22,906 women. While the study
was primarily concerned with the industrial field, other types of organiza-
tions employing women were found to have problems so similar that a
number of them were included. Of the employes in the establishments
visited, 12,613 were in industrial plants, 6,730 in mercantile establishments,
1,458 in organizations of public service and 2,105 in public utilities.
There are no recent figures available as to the number of women gain-
fully employed in Cleveland except those in the Directory of Ohio Manu-
facturers (Industrial Commission of Ohio, 1918), and as the employment
of women has fluctuated since this report was issued, its figures were not
found accurate in all cases. Consequently no totals can be given for the
numbers of women in various occupations for comparison with the figures
from the establishments visited in the course of the Survey.
Information was obtained by means of interviews with managers, super-
intendents, or other executives in touch with personnel problems, and was
usually supplemented by a visit of inspection through the plants. \STiile
information so obtained is general and often not exact, the collection of
repeated impressions by an impartial observer is so far almost the only
means of judging the subtle factors which enter into the making of a good
place to work. While the attitude of executives varied, there was in general
a manifest interest in the well-being of employes and an appreciation of
the fact that knowledge of methods for maintaining and improving the
health of workers should, by the interchange of ideas and experiences, be
made available for all industry. The value of health is appreciated at a
time when labor is scarce.
INDUSTRIAL ESTABLISHMENTS
It is not a new thing for women to be in industry. The war focussed so
much attention upon women who were doing the work of men in factories
that it is frequently forgotten that women have had a place in Cleveland's
nut and bolt shops and other plants making small metal products since
those concerns were first established — a matter of thirty to forty years. In
the textile and knitting, garment and candy trades, women have always
been a predominant labor element.
Health and Industry 559
During the war more women went into factories than had ever done so
before. Increased demand for the regular products of essential industries
enabled manufacturers in those branches to hold and increase their forces,
while wom^ for the making of munitions were usually recruited from the
"non-essential industries'* or from that large body of women who had not
worked before but whose patriotism enabled them to undertake successfully
the new and often heavy work. Most of these women left the factories upon
the completion of government orders and have not returned. The "non-
essential industries" have reclaimed many of their former employes, and
by now readjustment iSf about complete.
There are a few factories which, as a result of their war exi)erience, have
continued to employ women although they had not done so before. In the
six factories where it was learned that this was the case, six hundred
women are employed. Two of these factories have continued to
employ the women who started to work there during the war, but as they
drop out men are hired in their places, and consequently the number of
women is dwindling. In another plant there are very few women com-
pared with the number employed during the war, and the women are giving
up machine work for bench work of a light type.
Within the past two years there have been established four new factories,
employing a total of 698 women. Neither the retention of women in plants
which had not formerly employed them, nor their employment in new fac-
tories, is sufficient to account for the present shortage of female labor. The
checking of immigration and the return of many foreign workers to Europe,
is a partial cause of a general shortage of both men and women. The fact
that wages for men are higher than ever before means that many women
do not have to w^ork now as they did formerly, and in many cases this new
independence has apparently resulted in an unfortunate attitude toward
work, with a greater absenteeism and a tendency to float from job to job.
In the face of this labor shortage the cry for increased production has
aroused feverish efforts on the part of employers to get help in one way or
another. The alluring advertisements of "Help Wanted" contribute to the
prevailing unrest, and the readiness to try a new job upon the slightest dis-
satisfaction with the old. Applicants from such sources do not prove satis-
factory. Instead of advertising, several firms are now paying a bonus to
employes who bring in friends who will continue to work for a certain
period of time, recognizing the principle that a satisfied employe is the
best advertisement in the labor market.
The Metal Trades
The largest group of industrial establishments studied was in the so-
called metal trades, where the product varies from a small piece of machined
steel to an assembled oil stove or an electric lamp. 3,691 women were
employed in the twenty-three plants visited. The operations included bench
work and assembly, as well as operating such machines as drill presses, punch
presses, screw machines, lathes, and a variety of machines adapted for special
560 Hospital and Health Survey
Most of the work is not heavy, and the girls are instructed to lift not
over ten to fifteen pounds, although they not infrequently disobey this
rule. Where girls are on machines requiring gear shifts, special efforts have
been made to favor ease of operation. However, there is considerable efiPort
in the running of any screw machine or lathe, and in general it has seemed
better practice for men to do that work.
Punch presses and drills are usually guarded, and relatively few acci-
dents to women have been reported. Although no data are available as to
the carefulness of women in operating machines compared with men, there is a
prevalent impression that they are more careful than male operatives and
that, freely accepting risks of operation, they make little complaint when
injured. Nineteen of these twenty-three establishments provide medical
service.
Bloomer uniforms are required in five plants and are optional in several
others. The uniform has fallen into disfavor since the war, and effort is needed
to enforce its use at machine work and to maintain any degree of uniformity
and safety by the avoidance of jewelry, fluffy collars and ties. High-heeled
shoes for standing work should also be opposed where possible by making it
easy for the women to get sensible working shoes reasonably priced. Indi\ddual
steel lockers are provided in twelve plants and hooks in dressing rooms in
most of the others. The increased feeling of well-being and self-respect of
the worker who changes from street clothes to working clothes and back
again is worth emphasizing by employment or service departments.
Although several of the plants have physical examination for men, only
one organization was found to give to girls anything which might properly
be called a physical examination. There seems to be little realization of the
impossibility of judging by appearance as to a girl's fitness for fatiguing work.
yVith a high degree of conscientiousness, several employment departments
have taken a timid attitude in this matter. The fear that girls will object
to physical examinations properly conducted is with slight foundation, as
they are in general use in similar establishments elsewhere, ahd where used
in Cleveland meet with little or no opposition. If physical examinations
are conducted on a reasonable basis of rejection and if their purpose is
frankly explained, it is, as a rule, only the undesirable worker who will raise
any objection.
The dirt and grease of machine shops, which in the minds of many people
render them unsuitable places for the employment of women, are in fact
not objectionable if there are provided proper washing facilities and oppor-
tunity to use them. Such facilities must include hot water.
The noise and vibration from different kinds of machinery are of rela-
tively greater importance.
There is about many machine shops a wholesome attitude toward work
which is very appealing to the sturdy, independent type of girl, frequentily
encountered in this industry. Many girls who worked in munitions factories
testified that they had never been so happy before.
EAL.TH AND INDUSTRY 561
I
Tables XI and XII of the appendix present the findings regarding hours
id starting rates for the various industries studied. The usual working day
»r women in the metal trades is from seven to half past four. Although
«ce-work is prevalent, a certain minimum daily wage is guaranteed in
:teen plants, while three others pay a guaranteed minimum wage for the
aming period. There is little or no seasonal variation, but the supply of
ork frequently varies with orders.
Some factories employ American girls almost exclusively, others only
reign bom or those of foreign parentage. Usually all nationalities are
presented, but for heavy, dirty work the foreign women of peasant type
•e in greatest demand. Colored women are employed in two plants in con-
derable numbers.
Textile and Knitting Mills
The female operatives of the textile and knitting trades constitute an
iportant group of working women, numbering 4,642 in the eleven estab-
shments visited. The knitting mills seem in almost every case to be work-
g beyond normal capacity. In a number of instances mills were working
ider great pressure upon goods for delivery a year hence. Supposedly/as
result of the increased activity, work-rooms were cluttered with piles* of
ifinished work, and there were evidences of poor factory housekeeping.
The numerous exposed overhead belts furnishing power to circular
litting machines seem to be an unnecessary accident hazard for the opera-
ves who are constantly obliged to move about under them.
The brightly colored fluff from the yarn is everywhere on the machines,
id at times adheres noticeably to the faces, arms, and hair of the girls,
ccasionally they develop sore hands or arms, said to be caused by the
res. In one plant mention was made of the numerous sore throats, but they
ere attributed to 'Mate hours and dances." As only four plants in this
oup have medical service, and only one employs a physician, there has
^n little definite study of health problems within this industry.
The working hours are forty-nine and one-half or fifty in all but two
tablishments, as may be seen in Table XI. The working day is usually
ven-thirty to five or five-fifteen. Most of the women employed are either
reign-bom or are of Hungarian, German, Austrian, or Polish parentage.
Ithough most of them are between twenty and thirty years of age, they are
a mature type, appearing much older.
The Garment Trades
In the seven garment factories visited, 2,700 women are employed.
[uch of the work is power-machine operating, with the usual varieties^of
lishing work. The great problem of the garment trades is the regulariza-
>n of employment, or elimination of seasonal variations in production.
5 a result of the attention which has been given to this problem, three
562 Hospital and Health Survey
firms reported that they had work steadily throughout the year. One re-
ported work for at least forty-eight weeks. Two large establislunents operate
through a fifty-week year, and of the remaining two weeks, one week is
**layoflF " and one may be vacation with pay. Another firm has a fifty-one-week
year, and the whole factory closes for one week of vacation. As is shown in
Table XI, weekly hours are forty-four or forty-three and three-quarters, in
all but two shops, where they are forty-seven. One plant uses an allotment
system — workers going home when the day's task is completed, and seldom
working even the possible forty-four hours. Two firms work an eight and
three-quarter-hour day five days a week, with a full holiday Saturday.
Another firm, after trying the same plan, is strongly in favor of the eight-
hour day and a half-holiday on Saturday.
In the ladies' garment trade the wages are usually set by the union wage
scale agreement, under which the minimum is $14 per week. Comparative
starting rates may be found in Table XII.
Bohemians, Italians and Hungarians are the leading nationalities in each
of several factories visited, with various Slav peoples also represented. In
several factories there are more than one-third or one-half American bom.
Two factories will hire no one who does not speak English.
The use of routing systems and time study has made the modern garment
factory a very different place from the old-style tailor shop.
Candy Factories.
Candy factories are as a rule relatively small establishments. The six
visited had a total of 371 women employes. The demand for candy is
seasonal, and there seems to be no way to regularize its manufacture, since
it should be sold within a short time after it is made, unless stored under
most favorable conditions. Two firms reported that they never laid off
any help, as their forces automatically decreased in slack seasons when workers
who left were not replaced. Most of the girls were American bom, and
as a group were young, although older women are used for sorting and other
work since girls have become .scarce. As little skill is required, except that
natural to young fingers, there are many floaters who find in the busy seasons
of the candy trade the brief employment which satisfies them. Such workers
are apt to be careless about their work, and their persons, and require care-
ful supervision, especially in the making of a food product. This supe^
vision was generally found, but several establishments could well improve
their standards of cleanliness as well as their equipment for the comfort of
employes.
Miscellaneous Industrial Establishments
Of those establishments listed as miscellaneous, some of the paper-box
factories are small but quite progressive in policy.
Two tobacco factories revealed an interesting general situation. The
tobacco industry of Cleveland finds itself on the decline largely because of
Health and Industry 563
scarcity of skilled labor. In Cleveland no American girls and very few young
foreign girls will work on cigars. As a result the workers are practically
all foreign bom and mostly foreign-speaking, and with the realization of
their dwindling numbers have become very independent. One executive
said that his plant is kept open fifty hours a week for the convenience of his
employes, but none of them work so long, as they come and go at their
pleasure. Several firms which began business in Cleveland have found it
necessary to take most of their work elsewhere, and now have large tobacco
factories in New York, Pennsylvania and Texas. These are said to be
model factories as the workers speak English and appreciate the good work-
ing conditions provided. The firms apparently realize that the Cleveland
factories could be made both more attractive and more healthful. Learning
to make cigars requires several weeks, during which time most of the material
handled is waste and cannot be reclaimed. The cost of teaching a new maker
is said to be $350, even at the starting rate of $12 a week. When $15 and
$16 a week is offered to an unskilled girl in other industries, there is little
incentive for her to learn a difficult trade, even with the promise of high
piece-work earnings later.
General Obsf:rvation8 on Industrial Establishments.
Hours of Work
Reference has already been made to the weekly hours in several trades.
(Table XI.) In the course of the Survey, little overtime work was reported.
Only ten firms admitted that they had any overtime for women, and that
was said to be only occasional or optional. It seems probable that over-
time is more frequent in clerical work than in industry.
While, to the knowledge of the Survey, regular rest periods are arranged
for in only one factory, there are four establishments in which women are
allowed fifteen minutes about nine o'clock in the morning for the purpose
of eating part of their lunch. This is an interesting acceptance of the custom
of many women who go to work with little or no breakfast, and consequently
feel the need of food before the regular lunch hour. Another establishment
has two five-minute rest periods which are optional, and consequently not
extensively used. One firm had discontinued rest periods duringlthe day
but dismissed all employes twenty minutes before the accustomed closing
hour, granting pay for the full day. Rest periods may be of additional value
as a means of improving ventilation by open windows. Many workers
object to fresh air if it must be admitted near them. Few people fail to
appreciate a room full of fresh air replacing what has been vitiated, especially
when there are present fumes or odors incident to an industrial process.
It is probable that in many factories where the work is monotonous and
exacting, much might be gained by instituting rest periods. Both before and
after the introduction of such a measure, it is important that careful obser-
vation be made of the physical condition of workers as well as of production
rates.
564 Hospital and Health Survey
Earnings
It was hoped at first that figures might be received from payrolls show-
ing actual earnings of a group of workers over a suitable period in order to
obtain a fair conception of the relation of earnings to the cost of living and
the opportunity for health. This was not found practicable, however. Wage
rates are misleading, and as some are by the day and others by the hour or
piece, comparison is difficult and often unfair. The starting rates reported
have been tabulated in Table XH. Some establishments raise the rate at
the end of the first week, some after two weeks or a month, and in many
cases the rate stands until the piece-work earnings are higher, which may
be in a few days or a matter of months. Estimated averages for the various
establishments and their maximums are obviously so inaccurate in most
cases that they have not been presented in this report. In several cases
where averages of actual earnings have been made and analyzed, the results
have been at variance with previous estimates — additional evidence of the
futility of accepting approximate figures regarding actual earnings even from
persons familiar with establishment pay-rolls.
Additional Benefits — Cafeteria
Practically all industrial establishments provide either a cafeteria or a
lunch-room. The cafeteria may serve a full meal approximately at cost or
may provide food to supplement the lunch brought by workers. Most
plants arrange that coffee or other hot drinks may be secured free or at slight
expense. In six plants the employes eat in work-rooms, in certain instances
the company providing coffee. Several of these establishments have rooms
which are called lunch-rooms, probably in the hope that they may thus
fulfill the requirements of the law. The benefit of a change of environment
together with good food at meal-time, is generally recognized, and many
factories are planning better equipment in new buildings which they have
in pros])ect.
Cooperative buying is another way of increasing the purchasing power
of wages, which has been undertaken in several Cleveland factories with
much success. Group life insurance carried by the company is an advantage
offered by many firms. Only eight industrial establishments reported benefit
associations or some form of sickness insurance for women employes.
Several other firms have benefit associations but women are excluded from
membership, the reasons not always being clear.
Recreation
In twenty-one establishments there was found some sort of group recrea-
tion instituted and supported by the employes, with or without the co-
operation of employers. In certain establishments this is merely an informal
banding into social clubs. In others there are carefully managed parties
and entertainments for the employes and their families. A number of
organizations have bow^ling clubs, baseball or basket-ball teams. Some
firms have employed recreation leaders who direct setting-up exercises and
BA1L.TH AND InDUSTBT 5K
mes at noon. Where this is done, at the request or with the sympathy of
e workers, excellent results have been obtained, but no person wishes to
: coerced into play. The field of recreation oflFers an- excellent opportunity
r the development of employes' organizations upon a sound basis. The
perience gained in deciding upon the form and direction of such activities
excellent preparation for consideration of more serious issues which may
infront employes in their industrial relations.
The value of group meetings is realized by many establishments as a
suit of their liberty loan rallies. Feelings of comradeship and friendship
nong employes are incentives to contentment in labor, and so become
le modem equivalent of the spirit of craftsmanship. Group activities
hich foster these friendly relations and promote the feeling of solidarity
nong employes are to be encouraged.
Vacations
Many firms have a definite vacation policy. Four factories in the metal
'ades closed last year for two weeks during July or August. In one instance
ages were paid for one week; in another plant, diu'ing a shut-down of four
eeks, payment was made of two weeks' wa^es. Another firm oflFers one
eek of vacation with pay as a bonus to any employe who has not been
bsent diu'ing the year, except with a physician's certificate of illness. Several
stablishments reward old employes with vacations. One knitting mill has
dopted the policy of one week of vacation with pay after one year of service,
mother closes ten days during the year without pay. The garment fac-
ories generally give one week with pay after one year, although in one
rase days of paid vacation are reckoned by periods of service completed.
31 the candy factories, two give one week with pay after one year, one gives
ten days and another two weeks with pay. Other establishments recog-
nize the desirability of vacations and permit leave of absence for the purpose.
Only two establishments were found in which Saturday was not at least
a half holiday; two garment factories have no regular work on Saturday.
Supervision
•
There is no uniformity as to methods of employment in the various plants,
^^t in many places the modern principle of having all applicants pass through
^^e oflSce has been adopted. This oflSce is responsible for definitely hiring
Workers for all departments, and with the advice of foremen usually decides
questions of adjustment, discipline and discharge.
For the purpose of the Survey an establishment has been considered as
^ving centralized employment when the authority to hire or reject all
applicants is vested in one person or oflBce. (Table XIV.) In eighteen of
|ke plants visited women were in charge of hiring women employes, and
^n some cases men also. The plants of Cleveland are recognizing more
^ more the value of having women in a supervisory capacity where
^omen are employed.
566 Hospital and Health Subvet
The number and size of plants having supervisory women appear in
Table XV which under this term includes: employment managers, welfare
directors, and those who are in some measure responsible for conditions
affecting the work of women in factories. Nurses have not been included
unless when concerned primarily with such responsibilities rather than
nursing. Foreladies^ have been omitted as their sphere is usually limited to
direction of the performance of manufacturing operations. When there is
no other woman in supervision, a forelady often successfully handles social
problems and acts as intermediary between the girls and the management
As the duties of supervisory women are often not clearly defined, it has been
necessary to make rather arbitrary classifications in some instances for the
purpose of tabulation. In each of three establishments work of this natuie
is so extensive that there is a well-organized department staffed by a number
of women, each with well-recognized duties. There is clearly an important
place in industry for the woman who has by training adapted her common
sense and personality to seeing fairly the problems of human relations and
interjireting them in the everyday adjustments of factory life.
The question of health supervision for women includes a special problem
discussed here rather than in connection with general healtii supervision.
In almost e\ery case where plant nurse, employment manager or other
executive was asked about the policy in regard to the employment of preg-
nant women, the reply was that each case was decided upon its individual
merits. There is need, however, of a certain well-defined standard of pro-
cedure, for if left to themselves, many women work longer than they should,
and in their eagerness to conceal their condition may do themselves harm.
Usually the executive in charge of personnel is eager to have any woman who
is pregnant leave work as soon as or before her condition becomes notice-
able. This is often desirable where numbers of girls and men are employed
in the same departments, for comment cannot be avoided and is frequently
unwholesome. Several cases were noted where special effort had been made
to place favorably, pregnant women who were badly in need of money so
that they might continue to work until about the seventh or eighth month
under supervision of the factory nurse. It was generally believed that ordi-
narily a woman should not continue factory work after the sixth month.
None of the executives interviewed wished women to return to work within
six months or a year after childbirth, and except with foreign women it is
seldom that any worker endeavors to return so soon. In plants where foreign
w^omen are employed without careful questioning or an effort to learn of
home conditions, it may not infrequently ha])pen that mothers of small
children will be at work when they should be at home. Although it is not
feasible to generalize for all processes and industries regarding the limita-
tions which should be placed upon the einplo>nnent of pregnant women,
because of variations in the hazard of continued employment, thoughtful
consideration should be given to the problems presented in individual cases,
and in no event should pregnant women knowingly be permitted to work
within two weeks before, or four weeks after childbirth.
Health and Industry 567
Physical Conditions of Work
Light, air, and to some extent sanitation vary largely with the age of
the plant equipment. Many Cleveland firms are planning to build new
factories with model installations and feel that they should not be judged
on present facilities meanwhile. Cleanliness is more difficult to maintain
in an old plant than in a new one, but it can always be achieved by dint of
special appUcation to the problem and is important for its moral effect as
well as for physical comfort. Toilet facilities were usually found to be ade-
quate and in compliance with the legal requirements, but in several cases
were not entirely partitioned oflF from the main work-room, which is a very
undesirable arrangement. Washing facilities varied greatly, but on the
whole were adequate except for a somewhat too limited supply of hot water.
Drinking water was usually provided by bubble fountains, or water coolers.
Several common drinking cups were seen, as will always be the case when the
workers must provide their own.
Facilities for the seating of workers were found to be of great
variety, ranging from a barrel top or a box to the most modern steel chairs,
adjustable for height of seat and back. The law requires that individual
estabUshments ''shall provide a suitable seat for the use of each female em-
ploye and shall permit the use of such seat when such female employes
are not necessarily engaged in the active duties for which they are employed,
and when the use thereof will not actually and necessarily interfere with
the proper discharge of the duties of such .employes, constructed where
practicable with an automatic back support." In practice, while chairs are
generally provided for at least occasional use, the phrase ''interfere with the
proper discharge of their duties" may be broadly interpreted to prevent
the use of chairs at any operation, and has not resulted in the general realiza-
tion that chairs can now be designed for use in connection with almost any
type of work.
The law also provides that, "No female under the age of twenty-one
years shall be engaged or permitted to work at an employment which com-
pels her to remain standing constantly while on duty." Knitting, weaving
and spinning are not considered standing work because the operator walks
about her machine. As it is difficult to judge the ages of girls eighteen to
twenty-one, this law is all but impossible of enforcement. A campaign for
education concerning better seating and its use is needed for both employers
and employes. It is true that employes often will not choose to sit at their
work, and old employes frequently object to new types of chairs with backs.
Operatives can usually be won over to acceptance of an appliance which
is really to their advantage by a patient and persistent demonstration of
its merits.
Lockers are another institution which often cause the employer to weary
of well-doing, for keys are lost and many workers will not use locks when they
are furnished. Twenty-five establishments reported that they had lockers,
usually of steel, one for each person. Other firms use racks in a dressing-
room. Only two cases were found where clothing was hanging in the work-
room.
568 Hospital and Health Subvet
Couches were provided for women employes in thirty-two establishments.
This might mean a single couch in a room crowded with wraps, or a com-
fortable bed in a silence-room or dispensary. Many plants have, in addi-
tion to a dispensary bed, a room with several couches to be used for rest when
needed. The plant which has no cot available for an emergency is not properly
equipped to care for women employes.
MERCANTILE ESTABLISHMENTS
In the seven mercantile establishments visited, 6,730 women are em-
ployed.
Department stores have uniform closing hours, giving them forty-eight
hours per week, except a few that remain open an extra half-hour on Satur-
day. During July and August a number of the stores are closed all day
either Satiu-day or Monday. The vacation policy varies slightly, but all
stores grant a week with pay after a certain period of service, which may be
three, six, nine, or twelve months, and usually two weeks with pay is given
after a longer service.
Department stores have developed a special service for employes in
their educational departments. It is helpful to a new employe to have
the necessary information as to store policy and department relations pre-
sented in definite fashion. Through careful observation, the ability of the
individual may be directed into the most fruitful channels. There is in
many mercantile establishments opportunity for advancement, and effort
is encouraged by the knowledge that many buyers and executives have
worked their way up through the store. Classes in salesmanship give added
zest to selling as well as increased earning in commissions.
Efficient employment is an important preliminary to the work of the
educational department, and the health of employes as well should be
carefully considered. Several of the stores are now giving attention to the
development of adequate health departments.
Starting rates vary with the age and ability of the worker. For the stock,
cashier and inspection departments, two stores have a minimum of $10 per
week, while others do not give less than $12 or $13. For selling on a com-
mission basis, the usual minimum is $15 per week.
Several stores have women elevator operators who are said to be more
satisfactory than the men wlio are obtainable. Where doors are arrangtti
to open easily, little physical effort is required, but adequate opportunity
for rest should be provided to relieve the nervous strain of constant atten-
tion to an important duty, while at the same time treating passengers with
courtesy and answering questions. Rest periods are provided in practicdly
all establishments by the use of a relief operator. Except in one-way ele-
vators standing is usually constant in busy hours, but suitable seats should
be available for use upon occasion.
Health and Industry 509
Women also operate elevators in several hotels and public buildings.
This is another kind of work on which colored women are frequently employed.
$14 per week is the lowest of the wage rates reported for elevator operators.
PUBLICSERMCE ORGANIZATIONS
Laundries
It is unfortunate that conditions for workers in laundries at present
seem to be in some ways poorer than in the past. The services of a woman
supervisor have been given up in one place, use of lockers, cafeteria and
recreation in another. Labor cost is fifty per cent of the cost of laundering,
and as the public resents increased prices, it is difficult for laundries to raise
their wage rates to a point of competition with factories. Consequently
the scarcity of female labor is severely felt in laundries. Some plants were
so short-handed that managers and executives had to take the places of
absent workers. Porter service was most inadequate and often the laundry
housekeeping was poorly done.
The attitude of laundry men toward their workers varied greatly. iSome
were indifferent to the objectionable features of the work. Others maintained
that standing was not harmful, that high humidity was beneficial, and that
marking soiled clothes was a particularly healthful occupation. In one
laundry there was an effort made to seat all employes so far as possible. New
machines, often designed so that the worker could be seated, were being
installed beside old ones, showing the advances in this direction and suggest-
ing further improvements that should follow if the comfort of workers is
to receive the same consideration in laundries that it does in most factories.
Ventilating devices were generally used, although often they were ineffec-
tive. It would seem that much of the steam could be kept from the general
work-room by partitioning off the section used for washing, and mangles
could also be installed in separate rooms, although there is no excuse for a
noticeable escape of steam from mangles when excellent exhausts are avail-
able.
The nature of laundry work makes it particularly desirable that em-
ployes' wraps should not be left in the work-room, that separate lunch-
rooms should be provided, that toilet and washing facilities should be ade-
quate, but this^was not always the case.
It is interesting that even the less progressive laundry men speak of the
laundry as a type of public service, and feel a responsibility to serve their
customers faithfully, especially when there is much general sickness as was
the case this winter. One manager considered that the importance of getting
the work done outweighed the importance of good working conditions for
laundry workers so long as there was no violation of the law. Often the
law's minimum is considered the only reasonable maximum.
The scarcity of labor has resulted in the use of colored girls in three of
the commercial laundries visited, and three of the hotel laundries. Separate
coat rooms, toilets and eating facilities were usually provided. The colored
570 Hospital and Health Subyet
workers were generally considered less efficient, and much slower to learn
the work — which was given as the reason for their lower wage. Colored
girls started at $10 where white beginners received $13. In two laundries
white girls received $14 for a starting rate, in another, $12. The average
for laundry workers seemed to be about $17.
The variation of busy and slack days has been largely eliminated from
laundries by daily collections of clothes from patrons. Tliere is said to be
no overtime for women. Two plants work fifty hoiirs, one forty-nine, and
two, forty-seven hours.
Hotels
In spite of the inclusion of the word ** hotel'* in the Industrial Com-
mission's definition of ** shops and factories," there seems to be doubt as
to whether hotels do come under the supervision of the Industrial Com-
mission, especially since enforcement of ** Laws Providing for Inspection and
Licensing of Hotels and Restaurants" has recently been entrusted to the
department of the State Fire Marshal, although with no mention of kinds
of work or hours for employes. The hotel department heads were of the
impression that some restrictions existed but were vague as to their nature.
Hotel and restaurant workers are said to be confirmed floaters. Some of
the women live in hotel dormitories, with board in addition to their monthly
wage; some live outside, receiving two meals daily besides a weekly wage;
and others live outside and carry their own meals. Earnings depend in
part upon tips and cannot be accurately estimated. They are often Inigsr
potentially than in reality, especially for chamber-maids. The stated
sum paid for similar work in different places varied, and in general there
seemed to be little opportunity for increases based on efficiency or length
of service, although one hotel has group insurance and a bonus as incentives
to continued employment.
The decentralization of responsibility in hotels rather surprises the
inquirer who must go from department to department to learn of the various
types of workers and the conditions of their employment. The hotel manager
has two problems — serving the public and maintaining a staff of employes
to render that service. As catering to the public is the fundamental pur-
pose of a hotel, it receives most of the manager's attention, and the demands
of the public are so varied that a great amount of detail is involved. The
problems incident to maintaining a staff of employes are left to those in
charge of the several departments, which are conducted quite independently
of each other. The effectiveness of such an arrangement depends, of course,
upon the efficiency of department heads. As stewards and hotel house-
keepers are somewhat temperamental, and invariably complain of the un-
reasonableness of their employes who stay only a short time, it seems pos-
sible that the present method of hiring and dealing with employes in hoteb
might be replaced to advantage by an organized central employment service
similar to that used in industries, in many of which the requirements fw
different types of employes are as varied as in hotels.
Health and Industry 571
Restaurants
Waitresses are one of the few groups of women strongly unionized in
Cleveland. Their wage scale of $12 to $18 per week in addition to meals
and tips, prevails in the city. They work eight hours for six days per week,
but often the day is broken in two parts with the afternoon hours free. These
cannot be well utilized, and the union is about to campaign for all straight
watches of eight continuous hours. By using the shift system some managers
have practically all of their waitresses working continuous hours.
While restaurants and cafeterias in many cases seem slow to provide
facilities for the comfort of employes, some progressive managers have
taken these matters into cbnsideration, and are also planning centralized
employment, employes' organizations, and medical service for workers.
PUBLIC UTILITIES
The diflBculties of poor telephone service are well known to the public,
but the reasons back of it require special study. Operators are scarce,
special urging is often needed to induce girls to enter this field, and many
of them stay for but a short time. The low wages paid have been one very
evident reason. Changes have recently been effected in Cleveland, but
comparison with most industrial work is still unfavorable. The nervous
tension under which the work must be performed is trying to many tem-
peraments. This has been recognized to a degree by the provision of a
fifteen-minute rest period in each three and one-half or four hour period of
duty. Whether this is sulSScient for relaxation from such work is something
that should be carefully studied and every effort made to preserve the routine
so that no matter what the pressure of tralSSc may be, the rests need never
be omitted. Rather than deny the nervous strain of telephone work, it
would seem that companies might well devote themselves to special study
of methods for lessening the strain on operators. The public should be
better informed as to the conditions under which operators work, in order th^t
they may cooperate with telephone companies to improve service by properly
signalling operators, carefully giving numbers, and displaying a reasonable
patience.
The telegraph companies employ several hundred girls as telegraph
operators. Others are in the telephone department. All of this work
requires a keen mind and a combination of speed and exactness in opera-
tion that would seem to deserve better pay than is generally given.
GENERAL DISCUSSION
Night Work
The diflBculty of securing an adequate supply of female labor has already
been discussed. One of the results of this labor scarcity has been to cause
several manufacturers, under pressure of unfilled orders, to see in night
work the simplest solution of their problem. There are women eager to
572 Hospital and Health Survey
work at night, and many firms report that women are turned away from
the night shift though they cannot be secured for work by day. These women
have families of small children for which they must care during the 'day.
At night their husbands come home and assume the responsibiUty of family
care so that the mothers may go to the factory. Here they may work from
five o'clock to ten, or more likely from three to eleven, five to twelve, or
six to two, and in one plant from six to half past four in the morning.
It is hard to believe that after a day's housework and the care of smaU
children a woman is in any condition to be a good factory operative, but
many employers seem to feel that night work is very satisfactory. As most
of the night shifts have begun in the past six months, the effect of a woman's
holding two jobs has not become apparent in the quality of her work. The
result will be sooner evident in her home, for even a sturdy woman of the
European peasant type cannot long stand such double duty without impair-
ing her physical condition, the first effect of which will be upon her children.
A hard-working mother with insufficient sleep is apt to be irritable, and
even if she is conscientious enough to feed and clothe her children properly,
their tempers are apt to reflect her own. Of real home life there can be none
when father and mother scarcely see each other, and the inculcation of
American ideals under such circumstances is a barren hope.
The Survey has a record of 980 women who were working on night shifts
in fifteen Cleveland factories on April 15th. Of these 652 were employed
in the textile and knitting mills and 3£8 in the metal trades.
Aside from the effect upon home life, and the street dangers at ni^t, the
night work in the factory itself is not so pleasant as it is by day. Factoiy
illumination generally is none too good. At night with only artificial light-
ing it is usually worse. Other parts of the building are dark, and there is
a sense of the uncanny about being at work when naturally one should be
asleep. In factories where there are cafeterias and dispensaries for the use
of the day force, these facilities are seldom available at night. Often there
is no definite pause for eating, even in a seven or eight-hour shift. There is
almost never the same supervision at night that there is during the day,
and where both men and women are employed there is even more reason
for it.
Night work is possibly but a temporary measure. The exi)erience of
England during the war and, before that, the feeling that led six European
countries to agree to prohibit night work for women, should make our people
consider the institution carefully before we sanction its use even in an emer-
gency threatening the life of the nation — and such an emergency does not
now exist. So long as there is no hindrance to the establishment of night
shifts for women, there will be temptation to meet orders by this means
rather than by improved management, routing and planning of work. It
would be well for Ohio to record on its statute books its opposition to the
employment of women at night. At present there is not even an avenue for
learning the full extent of night work, as there is no requirement for reporting
night shifts to the Industrial Commission and no method for its control exc^t
through chance visits of state inspectors.
Health AND Industry 573
The telephone and telegraph companies employ a few women at night,
and there is an occasional small restaurant with night waitresses. Girl
ushers are used in several of the theatres and moving-picture houses, but
in small numbers. Aside from factories the largest number of women who
work at night are those who clean oflBce buildings. They usually work
eight hours, and it may be at any time of the night or early morning, although
the shift from five to twelve o'clock is most popular, leaving, as it does, a
little of the night for sleeping. The women are usually hired by the fore-
lady in charge, and are in large proportion foreign. They frequently bring
neighbors to work with them to avoid the journey home alone. These
women speak their native languages, and enjoy the informality of the work,
though there is no question about the fatigue in connection with scrubbing
and carrying heavy pails of water, frequently with no elevator service. In
April a night cleaning woman was killed while on the way to her home inja
Cleveland suburb and robbed of her pay.
Home Work
A means of adding to the day's output utiUzed by a number of factories
is home work. Parts of sweaters are frequently joined by a stitch done by
hand, and use of factory space for this work is avoided in many cases by
sending the work to the homes of women who have spent a few days in the
factory learning the work. It is estimated that at least 225 women work
on sweaters and other knit goods in their homes. Except for the delivery
and collection of material by some of the firms, there is no overhead expense
in connection with home work, so that it is difilcult to understand why rates
for this work should be so low.
A number of factories have established small branch factories, occasion-
ally located in connection with a dwelling, but under the law considered work-
shops only when they are the assembly place for workers other than those
living in such a dwelling. Between this type of workshop and the service
rendered by women sewing by hand in their own homes, there is another
type of industrial service performed by the women in whose homes a com-
pany has installed a power machine. While the Industrial Commission
inspects the main factories and the smaller branch shops, it is not practicable
for inspectors to maintain adequate supervision of the conditions under
which work is performed in the homes of individual workers.
There is a variety of home work. An occasional garment factory sends
out cuflfs to be turned. The carding of snaps and fasteners employs about
one hundred women. This work is done entirely in the homes, and the
workers must carry supplies back and forth to the factory. The earnings
seem very little for the time required, but the work is light and many women
have probably been able to earn in this way who would otherwise not have
been able to do so. Stringing of sales tags is another type of home work
done mostly by children, some of whom object to the low rates of pay. In
season there is also the home trimming of tailored hats, which are delivered
by the case. A few women work on brushes at home.
574 Hospital and Health Subvet
While the advantages of home work for crippled or convalescent patients
has given interest to its possibilities in special cases, the general increase of
home work, due to current high prices on the one hand and the demands
of employers for labor on the other, must be carefully watched. The repeti-
tion^ of such abuses of home work as were revealed by studies of conditions
in New York should be avoided.
Not only in this country but abroad has it been observed that more
unfavorable conditions for the children are created where their mothers do
industrial work in their homes, than result from other forms of work under-
taken by married women. Carmagnano, inPediairia (March, 1920, XXVIII,
No. 5), beUeves that we should go so far as to provide legal measures to
protect prospective and nursing mothers who are engaged in wage-earning
or piece-work at home, as we protect them in factory work.
Day Nurseries
In almost every establishment visited, more married women were em-
ployed than ever before. Many of these were young women with few home
responsibilities, for it was frequently said that in these days working girls
return to the factory or store a few days after they are married. Many,
however, are women with families who find even the fairly good wages (rf
their husbands insufiicient for the family needs, or those who wish to pro-
vide for the future by laying something aside now that wages are high, or
others who are helping to pay for a home or sending money to suffering
relatives in Europe.
Many complaints come from the schools that children of school age are
kept at home to care for the younger members of the family, or in other
cases that mothers are either leaving the children to run the streets or lock-
ing them in their houses while the mothers are at work. More than one
child left in this way has been burned to death.
Whether mothers of small children should be permitted to work is a
difficult social problem. They cannot be legislated into their homes, nor
should they be encouraged to evade responsibilities by day-nursery facilities.
On the other hand the children cannot be permitted to be neglected. Day
nurseries have provided care for some children whose mothers are obliged
to work. 337 such children were cared for by the Day Nursery and Free
Kindergarten Association last year. The day nursery, however, is an expen-
sive institution, and we have little information from which to judge its net
social worth.
If working women were to be charged one dollar per day per child, which
is the approximate cost of nursery care, probably few women would use
day nurseries. Should the community then contribute to the support of the
families of those mothers by supplying nursery care for a slight fee, encourag-
ing the mothers to work outside their homes and leave their children for
the group care of the nursery.^ If such is to be the case the community
[balth and Industry 575
lust insist that this care be of the best and that preventive health measures
3r the young child be used to ward off later illnesses and defects so far as
ossible, in order that the eventual economic cost to the community may
ot be too high.
Mothers are working at the present time. The care that should be given
o their children is a community health problem with economic and social
dpects so important that each community should give careful study to
ts own situation.
Mothers' Pensions
The provision of mothers' pensions has been a partial approach to the
ame problem, but is applicable only in cases of widows who are mentally
.nd morally sound and whose legal residence is established. . Even where
ttothers' pensions can be granted, they are most inadequate. $15 per month
or the first child and $7 for each additional child, is the maximum per-
aitted. This maximum is always granted in Cuyahoga County, but is
o inadequate that in numbers of cases the pension must be supplemented
>y the Associated Charities.
In some counties, however, no pensions are given, and in others the
imount is very small, so that great effort will be required to arouse sufficient
mblic opinion through the state to secure legislative increase of the maxi-
num.
The court takes the stand that no mother may receive a pension if she
vorks more than three days a week, which means that a widow with four
children is faced with the alternatives of receiving a pension of $36 per
nonth or of earning a living for the family.
RECOMMENDA TIONS
It is the recommendation of the Survey —
That industrial and other establishments bring to the attention of
employes the health value of suitable working clothing, with special regard
for the advantages of proi>er footwear for women who are much upon their
feet, and for the safety of women in machine trades.
That in establishments where there is routine physical examination of
men, women employes be admitted to an examination of similar natxire.
That uncertainty of the adequacy of piece-work earnings be obviated
by a guaranteed minimum wage-rate when practicable.
That the industries of Cleveland devote special consideration to the
elimination of hazards of accident and illness where women are employed.
That various industries endeavor to eliminate seasonal variations in
employment through regularization of work.
576
Hospital and Health Survet
That special effort be made to interest both employers and employes
in the use of seating suitable for different operations, and that where possible
chairs be adjustable for height of seat and back.
That every establishment employing women provide one or more
couches for the use of such employes.
That the municipal department of health maintain careful supervision of
laundries with special reference to the comfort and health of employes.
That the public be more adequately informed regarding the technical
difficulties incident to maintenance of a telephone service, to the end that
its cooperation be secured in a reduction of the hazard of nerve strain for
telephone operators, and a consequent improvement of a service which at
present is essentially dependent upon the high efficiency of a human factor.
That night work of women be prohibited by law, except in essential
public utilities.
That greater publicity be given to provisions of the laws of the State
of Ohio governing conditions of employment.
That the number of women inspectors of the Industrial Commission
assigned to the Cleveland district be increased' in order that the conditions
attending the employment of women and children in individual establish-
ments may be observed more frequently than at the yearly intervals at
present prevailing.
INTEREST OF THE COMMUNITY
The hope of solution of the various problems in connection with the
employment of women lies in the interest of the community. The Young
Women's Christian Association has, through its Industrial Extension De-
partment and more recently through the Industrial Women's Club, taken
an active part in recreation for working girls, and has also attempted, by
educational means, to prepare these girls to think out their problems for
themselves.
The Vacation Savings Club has been eflFective in the encouragement of
thrift among working people, especially women.
The (lirls' City Club has been recently established by the League of
Women Workers, with the aid of secretaries of the Vacation Savings Club,
and affords a downtowTi social club for girls, with a variety of recreation
and classes.
The local branch of the Consumers' League has taken an active interest
in the various aspects of the work of women, and is cooperating with other
agencies in an effort to learn actual conditions of work in relation to present
and proposed legislation, and to learn the opinions of thinking working
women concerning their own problems.
Health and Industry 577
The State-City Free Employment Buieau is interested in the work of
women from the practical point of view of placement. The worth of such a
central agency for employment has been demonstrated in many places, and
its usefulness grows as it is used.
Where working women play so important a part in the industrial life of
a city as they do in Cleveland, there is reason to hope and believe that the
people of the city will consider and protect their interests.
When a Feller Needs a Friend
MWRATON Of OEPENDENCf
l^tSfAveA That childhood 15
aeoiKi .with certain inherent and
iMlienaDK rigrt5 amorg wtiich ari2
frc«(ta' fiwi toil for daily bread,
Ide right to play and to drrani -
the rght to Hif normal i\ee\i or
the night reason ; the right to
an cduoatioji that lue may houe
equality of opportunity (ordeuclop-
irg oil that Inere is m us of
mind and. hfort" wf/fp/^^
~^j^grte-"aT^-:-~
L.TH AND Industry 579
Cliilclren and Industry
By Florence V. Ball
INTRODUCTORY
STUDY of children and industry is included in the report of the Hos-
pital and Health Survey because the health of the large portion of the
city's population who are going to be its industrial workers depends largely
what provisions are made for their welfare during the period when
are 15-18 years old. The years from 15-18 are the adolescent years,
[children of this age face especial health problems which must have care-
ttention. Out of the children who go to work are developed the future
strial workers and citizens of the city. If only a few of the children in
"onununity were going to work it might not be important from a health
ipoint to consider their interests so carefully. But at 17 years of age
of the children of Cleveland are already at work, and many of them have
at work for two or three years previously. They are no longer under
direct care of school medical authorities. Neither are their especial
s studied and provided for in industrial medical service. Unless special
rvision is provided for children of these years, their passage into industry
[guarded and unguided, and irreparable damage may be done to their
:al and physical well-being, which will have serious results both in their
future and in that of the community.
lor is the sound health of this group of children assured by considera-
of their physical wants alone. Their problem is a psychological as well
physiological one. The degree of adjustment between children and
first jobs, the success of their transition from school into industry,
amount of preparation which they have had for industrial life, are all
)rs of great power in determining their development from childhood into
d maturity.
L study of children and industry from a health standpoint involves three
ral considerations: first, measures taken to protect the health of chil-
upon entrance into industry, by the adoption of requisite health stand-
; second, regulation of their industrial careers until they reach matur-
which means a study of legal restrictions of children's work as well as a
y of present conditions under which they work; and, third, the niore
ect but no less important relation between educational preparation,
stment with the job and sound health.
nder what circumstances are children going to work? What measures
been taken to develop their bodies and make them physicially fit to
• industrial Ufe.'^ What kind of work are children doing and what kind
chance does it oflFer them for future industrial competency? What hap-
to children at work who are not normal, mentally or physically? What
ucation has prepared children for the shift from school to eight hours of
daily, at work quite different from the sort of activity which has char-
580 Hospital and Health Suhvet
acterized their school Ufe? What is going to be the effect of such a radical
change on growing boys and girls, whose physical and mental instability at
this time is marked?
Childhood naturally falls into several distinct periods, the prenatal period,
infancy, the pre-school period, the school period and the adolescent period.
Each of these periods is important in the welfare of children. To those
interested in one particular stage of a child's development, that one may
seem of paramount importance. Probably not until all periods are equally
emphasized will children have a full chance for development. However, the
successive needs of childhood may be viewed, no one will deny the need for
careful instruction and guidance during the adolescent years. All of the
care which has been given to children's health in earlier years will prove to
have been futile if they are allowed to go free from guidance and protection
in these later years before they are competent to take care of themselves.
The physical and moral difBculties which approaching maturity thrusts on
them, require for children assistance and advice and often medical care, in
order to safeguard their health, as well as to complete the training and prep-
aration which have been the work of society for the 14 or 15 preceding years.
These are the years of transition from supervised childhood to indepen-
dent maturity. Opinion is divided as to the advisability of allowing chil-
dren to go to work during this period. One point of view sees always the
child in the developing boy and girl and desires for the child the maximum
of care and protection. This protective care can go too far and, in extreme,
smothers the springs of initiative and self-reUance needed in the man. The
other point of view, more hard-headed, believes that participation in the
work of the world cannot begin too soon for sturdy development. In its
interest in independent character it tends to lose sight of the fact that too
early work stunts a child's development and that a soimd mind should
be combined with a healthy body in order to realize its greatest powers.
Another point of view, the commercial one, of the dollar value of child labor,
should not be seriously considered. Obviously the industry of this country
does not have to depend on the work of children for its income, although it
is chiefly to combat the commercially-minded that it is necessary to make
such strictly defined child-labor laws. Otherwise, it would be possible to
make laws elastic, in order to meet more easily the individual needs of chil-
dren.
It is our belief that the efforts made on behalf of children of adolescent
years, regarding their passage from schooj to work, should be directed
towards individual adjustments. In concern for the child, the man in the
developing l)oy should not be overlooked, neither should the child be
allowed to enter the adult's world of work too soon. There is great variation
here in individual children. Some children mature much sooner than others
and are ready sooner to make the transition from school to work. Methods
must be developed by which allowance can be made for individual variation.
althandIndustry 581
Lsiderabie antagonism is aroused towards the present regulation of children's
k, by the hardship caused in individual cases. Even though hardship in
vidual cases is ho argument for the abolition of restrictions on the age of
dren going to work, it should be possible to originate some methods
making distinctions in individual cases, which will not be loopholes for
crupulous and destructive evasion of the laws designed to protect the
1th and best interests of children. Such distinctions can be worked out on
basis of the physical ability of the individual child, determined after
sful medical and mental examinations. It is purposed to bring out the
sibilities of such a method in the following sections.
This study is a survey of the present relation between children and in-
try in Cleveland, presenting information not so much comprehensive, as
resentative of the situation. The regulations limiting children's work
eh are at present in force are considered first, and next, the information
ch has been available regarding the number of children at work, both
lily and illegally. Discussion, in some detail, of the kinds of work in
ch children are found employed follow. The questions of their health and
measures taken to safeguard it are considered separately. There is included
rief report on the mentally subnormal children known to be at work.
; section of the report considers the relation between industrial training,
cational preparation, vocational guidance, and health and efficiency. The
elusions reached at the end of the study and the recommendations made
summarized in the last section.
The study was made during the spring of 1920. It had been the inten-
I of the Consumers' League of Ohio to make some such research into
Ith in the industrial field in Cleveland. Upon hearing the comprehensive
as contemplated for the Hospital and Health Survey, the Consumers'
Lgue decided to support the services of a special worker who would be under
direction of the Survey, rather than to carry on an independent research.
ih an arrangement was eflFected for the present study, which has been
ie by a member of the staff of the Industrial Division of the Hospital
I Health Survey, the subject of Children and Industry being especially
^ropriate to the long continued interest of the Consumers' Ix^ague in work-
children.
GAL PROVISIONS FOR CHILDREN 15 TO 18 GOINC; TO WORK
In order to understand the situation as it is in Cleveland for children of
•king age, a review of the existing legislation relating to children of this
is essential. Who are children.^ When does a boy become a man, and
iri a woman.'' The Ohio Child Labor Law says that a girl is an adult
m she is 18, and may work the same hours and under the same circum-
ices as any woman, save that she cannot work at night until she is 21.
lording to the Child Labor Law a boy of 16 may work longer hours than
adult woman may work. After he is 18 this law considers him a man
jvcry respect, able to work any number of hours, day or night, and under
same conditions as govern men's work.
582 Hospital and Health Survet
Researrh has shown that boys mature more slowly than girls, but the
Child Labor Law says that a boy may go to work a year earlier than a girl,
and that he may have a year's less schooling than a girl.
On the other hand, the common law of the state does not consider a boy
a man until he is 21, when he may for the first time exercise property rights
and the right of franchise, and get a marriage license without {permission oi
his parents or guardian.
Following is a summary of the essential provisions of the Child Labor Law
of Ohio, and of other laws relating to children of 15 to 18 years going to
work.
Age Requirements
Employment of boys under 15 and girls under 16 years of age is strictly
forbidden. Age and schooling certificates are required for all boys under 16
and all girls under 18 years of age.
Boys under 16 and girls under 18 years of age may not legally be emdelrpo
more than eight hours daily, 48 hours weekly, before 7 in the morning, not
after 6 in the evening, nor more than six days in any week.
Boys under 18 years of age may not legally be employed more than 10
hours daily, 54 hours weekly, before 6 in the morning or after 10 at night
nor more than six days in any week.
Girls between 18 and 21 years of age may not legally be employed more
than nine hours daily (except Saturday in mercantile establishments, when
10 hours is the limit), 50 hours weekly, before 6 in the morning and after 10
at night, nor more than six days in any week.
Certain occupations involving physical and moral hazard are prohibited
for all women, (iirls under 21 cannot work at employment involving con-
stant standing. No boy or girl under 18 can be employed at extremely
dangerous occupations to health and morals, eighteen such occupations being
specified in the law. No boy under 15 years of age and no girl under 16 yeaR
of age can be employed at all, save in agricultural work or in domestic service
No boy 15 to 16 can be employed at dangerous machinery or where his healtk
may be injured and his morals depraved, or at the tobacco trades. Thirty-
two other occupations are prohibited to boys in the law.
Educational Requirements
I. The age and schooling certificates required for all boys 15 to 16 yetfs
of age, and all girls 16 to 18 years of age must show that every boy h>*
passed a sixth grade test, and that every girl has passed a seventh grade test
If upon examination and by school record a child proves to be below the n<»^
mal in mental development and unable to pass this test, he may receive t
school certificate at the discretion of the issuing officer.
EALTH AND INDUSTRY 583
^. Every boy 15 to 16 years of age must return to school if he ceases
ork and does not find other work. No provision is made requiring girls
5 to 18 to return to school if not at work.
■
Health Requirements
A certificate is required from the school physician or some properly quai-
led physician showing that a child is physically fit to be employed in any of
le occupations permitted by law for a child between 15 and 16 years of age,
rovided that if the records of the school physician show such child to have
een previously sound in health, no further physician's certificate need be
H^uired.
Special Vacation Certificate
Boys 15 to 16 years of age and girls 16 to 18 years of age may have vaca-
lon certificates to be employed in occupations not forbidden by law, even
liough they have not passed the required school grade, provided all other
jquirements for a certificate are complied with.
Street Trades
No provision is made in the Ohio State Law which covers street trades,
.^here is a city ordinance, not enforced, regulating this kind of work. This
nil be further discussed in a section of the report on newsboys.
Juvenile Court
Provision is made through the Juvenile Court and probation system for
iealing with delinquent young people of all ages who can be classed as juve-
liles. The oflFending street trader, or truant from school, here receives less
severe handling than in regular law courts, and is dealt with by persuasion
rather than by punishment.
Enforcement of Present Laws
This comes under the School Attendance department of the city schools and
he department of Factory Inspection of the State Industrial Commission.
rhese two agencies cooperate to keep track of all children of the ages in
luestion. The adequacy of their working force and their success in enforcing
hese regulations will be discussed at the end of the next section.
STATISTICS FOR CHILDREN IN INDUSTRY IN CLEVELAND, 1919
There are three sources of information from which to ascertain how
aany children there are in Cleveland, of what age and of what sex, how
tlany of them are working and how many are in school.
1. The school census, taken every spring by the Census Bureau of the
toard of Education, enumerates each child in the city from 6 to 20 years of
fije, whether he is in school, out of school or at work.
584 Hosp^AL AND Health Survey
2. The Industrial Commission of Ohio obtains annually from all employ-
ers records of the occupations and wages of all boys and girls under 18 whom
they employ.
3. The work certificate office, at the Board of Education, keeps on file
the name, age and sex of every child who, after complying with certain re-
quirements, secures from the office an age and schooling certificate, which
entitles him to go to work.
It was possible to obtain information from these three sources for the
same period of time, the year of 1919. The school census of May, 1919, was
analyzed so as to obtain information for boys and girls separately, the records
of the work certificate office for the school year, September, 1918, to June,
1919, were secured and, through the courtesy of the Industrial Commission,
their statistics for 1919, which are not yet published, were obtained and
.analyzed.
The information collected in this way for the number of children at work
is somewhat surprising to compare. Following is the summary of results.
The full tables for this information may be found in the Appendix, Table?
XVI. to XVIII.
TABLE XIX.
Comparison of Three Tables for Number of Children at Work in
Cleveland in 1919.
Boys Girls Total
School Census, 15-18 ytars of age 9,068 (15-18) 6,778 (16-18) 15.846
Industrial Commission of Ohio, 15-18 years of
age 2,957(15-18) 2,072(16-18) 5,029
Work Certificates Issued, 15-16, 16-18 years of
age 1,444(15-16) 2.057(16-18) 3.501
Of the three records probably the records of the School Census more
nearly approximate the truth as to the number of children actually in indus-
try. Their figures were obtained in a house to house canvass of the whole
city and were then checked up with the existing school records at the Census
Bureau of the Board of Education, where a school child's card contains as
well, a record of the whole family of children, whether of school age or not.
The figures of the Industrial Commission were obtained from employers,
and it may well be that they recorded only the certificated children whose
permits were on file in their oflBce, which would be boys 15 to 16 and girls
16 to 18 years of age. The boys 16 to 18 employed are only estimated in
many cases. Not all employers keep age records of their employes. Fur-
thermore, the Industrial C^ommission records are not complete, as a number
of employers have not yet made their reports to the Commission for 1919.
The work certificate office figures included only tho.se children who went to
work through the legal channels.
Health and Industry 585
4. Illegal Child Labor and Law Enforcement.
Comparison of these sets of figures shows the great extent of unlicensed
labor on the part of girls 16 to 18 years of age. Almost 5,000 girls are at
work in Cleveland with no check on them in any way to see that the health
and educational standards considered essential for them are maintained. In
addition, these figures take no account of the extent of work among children
who are under the legal age for employment. Reports have come in on all
sides as to the number of under age children who are at work regularly, as
well as at work part time after school and on Saturdays.
It has been exceedingly difficult to verify these reports, save for scattered
individual cases. There is undoubtedly truth in the prevailing opinion.
The school census bureau is freely used by a number of employers to verify
the ages of young children applying for work. Records were kept by the
school census bureau office for several weeks of such calls f!*om employers,
and disclosed actually at work, or applying for work, 168 boys and girls who
were under the legal age for employment.
Ages and Number of Children Applying for Work
Age Boys Girls
11 1
12 5
13 25 13
14 34 41
15 1 48
Total, 66 102—168
4£ of the boys and 73 of the girls were regularly at work, the remaining num-
ber, 23 boys and 28 girls, had applied for work. 22 employers were repre-
sented in this Ust. One department store was responsible for 60 of the viola-
tions, the majority of which were for girls, and one manufacturer of metal
products was responsible for 18 violations, most of them for boys. The
facility with which these figures were collected is an indication of the extent
of illegal employment of children. In addition must be reckoned those chil-
dren working after school and on Saturdays without permits.
Some of these children had been out of school for months, two or three
as long as two years. One boy had been injured and his case brought into
court. Another boy of 15 was working with a paper company without a
permit. An accident brought this case to the notice of the school authori-
ties. The boy's hand was crushed in a machine. His school record showed
him to be defective, of a mental age of 9 years according to the test. If this
boy had gone to work through the work permit office where his physical and
586 Hospital and Health Survey
mental condition would have been determined, his employer would have
been notified of his mental disability, and the boy protected from an accident
hazard.
The Child Labor Law of Ohio is often cited for its excellence. If the law
is not enforced, its excellence is without virtue.
One explanation of this illegal employment is to be found in the depart-
ments of School Attendance and of Factory Inspection. For it is their joint
responsibility to see that the school and child labor regulations are enforced.
Both these agencies work at a disadvantage. One truant oflScer must keep
track of 10,000 children. Boston requires one attendance officer for ever}*
6,000 children. Obviously, one officer cannot cover all of the cases of irregu-
lar attendance which occur among 10,000 children. As it is now, the truant
officers devote only a small part of their time to following up children of
working ages. * If a child has come into the office and obtained a permit for
a job, but has left that job, the permit then coming back to the office from
* the employer, he should return to school. This is not followed up. No one
knows what becomes of the child. A list of such children was once started
but the list grew so rapidly that it was impossible for the attendance officers
to keep up with it, so the matter was dropped. This means that either the
children are not working and are not in school, or they are w^orking illegally
without a permit.
There is no question of the efficiency of the present force. Sc*hool prin-
cipals and others interested have spoken most highly of the work of the
attendance department, saying that the officers are untiring in their effort-s
and most coofjerative. With such a small force something has to be neg-
lected and the children of working age have been ready to take advantage
of the light authority imposed on them.
This situation is true also for the State Department of Factory Inspection
of the Industrial Commission. There arc for the 88 counties of Ohio eight
women visitors to see to the enforcement of the child labor law and others.
The several counties surrounding and including (^leveland have the full
services of two ins])ectors, who do splendid work, but who, obviously, could
not be expected to be responsible for full enforcement of the law. Cleveland
industry alone employs tens of thousands of women and young people and
needs the supervision of several inspectors in order that industrial ])lants
may be visited more than once annually.
Undoubtedly one source of illegal child labor is the tremendous labor
shortage whidi has prevailed tliroughout the present year. This shortage was
mentioned almost without cxce[)tion by every employer visited. **We
can't get help. Ordinarily our rule is never to employ anyone, boy or girl
under 18. But we have been forced to make exceptions to this rule l>ecau.se
we can't get enough helj) otherwise."'
The attitude of foreign parents is antagonistic also. They wish their
children to go to work as soon as possible and will resort to any subterfuge
HEALTH AND INDUSTRY 587
in order to evade the law. It should be pointed out that economic necessity
is by no means always the explanation of their attitude. Foreigners have a
different attitude toward their children from that of most Americans. Chil-
dren represent so much potential earning power which must be utilized for
the family income at the earliest possible time. The sense for property,
owning a home, is strongly developed in European peasant people, and they
will make every sacrifice of themselves and even of their children, in order
to acquire a little land and a house, having no thought for the possible physi-
cal harm they are bringing on themselves. The strong constitution which is
the inheritance of the European p>easant does not always endure for
his children. Life in an American city offers less opportunity for the de-
velopment of a rugged physique able to withstand heavy toil as well as the
high power, top-speed existence characteristic of city life.
Extension of school hygiene and general health education will in time
eliminate this attitude on the part of parents towards their children. But
meanwhile the laws designed to conserve the health and welfare of children
are the only defense available to protect them from their own ignorance and
the ignorance or short-sightedness of their parents or employers.
But one of the principaF causes of so much illegal employment of children
is the fact that the children know they **can get away with it.'* Otherwise
there would never be so many applications for work from such young chil-
dren. Inadequate supervision on the part of the truant officers on one band
and of the Factory Inspection Department on the other, leaves too many
loopholes for children to slip through.
If it is impossible to enforce these laws with the present organization
and personnel of the school and state departments, then their methods should
be improved and their j)ersonnel increased to cover the city adequately.
No city of the size and importance of Cleveland can afford to allow large
numbers of its children of the ages of 12 to 16 years to enter industry, unre-
stricted and undirected, their physical fitness to perform the tasks which
they pick out for themselves, in no way ascertained, nor their capacity to
stand up imder continued years of industrial life assured in any degree.
More supervision must be provided both by the school authorities and
by the State Industrial Commission, in order to check up on this illegal
employment. This is vital. No prerequisite health standards for children
at work can be established and maintained until it is certain that every
child going to work goes through the work permit office, where he is medi-
cally examined and must show physical fitness })efore he can obtain a permit
for employment.
It is recommended that at least three more women inspectors be assigned
to the Cleveland district by the State Industrial ('ommission and that the
number of attendance officers in the School Attendance Department be in-
crea.sed from 13, the present number, to at least 20.
588 Hospital and Health Survey
WHERE CHILDREN WORK
1. Occupations Employing Children
Boys and girls are employed in greatest numbers in manufacturing, retail
and wholesale trade, and in telephone and telegraph work. Table XX. in the
Appendix shows the distribution of boys and girls in the various trades, as'
shown in the Industrial Commission's report. As before stated, the statistics
of the Industrial Commission are not numerically complete, but they are
sufficiently extensive to be representative of trades employing children in
Cleveland. The information obtained through personal visits to 50 different
establishments employing children in some numbers, corroborates in even-
instance the evidence of the Industrial Commission's figures.
The last published report of employment by the Industrial Commission
of Ohio for Cleveland is for the year of 1915. A total of 3,299 children under
18 were employed in that year, as against 5,029 employed in 1919, showing
an increase of about 1,800 in four years, or 35%. Table XXI. in the Appendix
shows the distribution of children in the various trades for these two years,
1915 and 1919. There are several noteworthy changes. Telephone and tele-
graph work in 1919 used 463 girls under 18. In 1915, 35 girls were so employed.
On the other hand, the employment of young girls has fallen off considerably
in the manufacture of clothing, hosiery and knit goods, and woolen and
worsted goods. The employment of boys has increased, mainly, in the
manufacture of electrical machinery, foundry and machine shop products
and sewing machines. Their employment has decreased in steel works and
rolling mills. Both boys and girls are employed in greater numbers now in
the retail and wholesale trade than in 1915.
The largest numbers of both boys and girls are employed in manufactur-
ing, in round numbers 3,000 boys and 900 girls. The majority of these are
wage eamers, as distinguished from clerical workers. This is true of all
employment for children. The classification of the Industrial Commission
includes three groups of employes: clerical workers, wage earners and sales
l)eople. ^3.7% of all children accounted for are clerical workers, 72.8% are
wage earners and 3.5% are sales people.
Boys and girls are scattered throughout the manufacturing trades, being
found in greatest numbers engaged in the manufacture of men's and women's
clothing, hosiery and knit goods, the metal trades and printing and publish-
ing. 39 manufacturing establishments were visited. In all, 50 establish-
ments employing young peo])le were visited and information collected re-
garding hours, wages, nature of work, opportimity for advancement, educa-
tional requirement, medical service and general conditions of work. The
opinion of each employer was obtained as to the cni]>loyment of junior help.
Medical ser\'ice is descril>ed in detail in the first section of the Industrial
Survey report, and conditions of work in the second section, therefore, no further
discussion will be made of these two subjects in this reiK)rt. In all places
where girls are found at work women are employed as well, and conditions
Health and Industry 589
of work are identical for both. This does not apply equally to boys. It
must be remembered, as pointed out earlier in the report, that boys do not
work under the same supervised conditions of work which the law insists upon
for women and girls. Boys must use those toilet and dressing room facilities
which are provided for the men, and must eat their lunch under the same
circumstances that men do. This often means a cold lunch. While many
factories provide a cafeteria where girls and women may obtain a hot lunch,
not all of them provide the same service for boys and men.
A .. Hours of Work
The law limits the hours of work of boys 15 to 16 and girls 16 to 18 years
of age, to 8 daily and 48 weekly. So far as it was possible to ascertain the
facts on this point, the law is observed. Employers who wish to use the
.services of children, find no difficulty in arranging their schedule of hours to
accommodate an eight-hour shift for the children. Employers who can get
along without the services of children state that they employ no one under
18, because of the difficulty of arranging a separate 8-hour shift.
B, Wages
Table XXII. in the Appendix shows the rates of wages paid to children in
all occupations. 2,635 of 5,029 children listed by the Industrial Commission
report receive from $10 to $15 weekly. 648 children receive less than $10
weekly. Figures obtained by visits in the spring of 1920 run very slightly
higher, 22 establishments pay between $13 and $15 weekly, 18 establishments
pay $15 or more weekly and 15, establishments pay less than $13 weekly. In
all cases where employers were questioned as to wages, the beginning rate
has been quoted, as the character of the information for regular wage rates
varies greatly. Some employers use hourly rates, others weekly, some esti-
mate wages on a piece work basis, and others use a straight time rate. Even
a payroll would not give exact figures, for the result of the labor scarcity of
the past few months has been to make labor very independent, working only
a few days in one place, or at one time. As one employer said when inter-
viewed, "The girls come and go as they please. I don't dare say anything,
or they put on their hats and leave. All I do is to carry the key."
•
Wage rates are slightly lower in retail and wholesale trades, and very
definitely so in telephone and telegraph work, where the rate is $10 to $12
weekly. Manufacturing pays more, especially to boys. More boys receive
from $15 to $21 per week than from $10 to $15 per week. Wages for boys
are generally higher than for girls. This is true of all occupations. The
present wages paid to boys in the various shops classed under metal trades
work have been so high as to make boys a scarcity in all other kinds of work
open to them. On the whole wage rates for children are high, due to the
fact that many children are doing adults' work because of the labor shortage.
590 Hospital and Health Survey'
C. Nature of Work and Opportunity for Advancement
These vary in almost every trade for boys and girls. In the industrial
field proper the manufacture of men's and women's clothing offers to girls
good opportunity to learn a trade and advance to higher positions. Boys
in this trade run errands, or work in the shipping room. Their greatest
chance for a job with some future is to become an apprentice to a cutter. In
the six establishments visited, girls learn the trade in a school maintained
in the factory or from instructors, and require from two to eight weeks in
which to learn. They may start in at once on power machine operating or
begin by examining or packing the finished product. One instructor states
that young girls are not strong enough to do machine work and so are started
in on hand work. The sewing trades offer a very good opportunity to girls.
Girls should be carefully watched, however, against undue eyestrain. One
factory has the eyes of girls regularly examined by an oculist, and insists on
glasses being obtained if prescribed. The physical condition of each girl
should be determined before she is allowed to begin power machine operat-
ing. This could be done by the company physician or by the examining
physician at the office where she obtains her permit to work, and a recom-
mendation put on her permit as to her physical ability to essay heavy work.
The Manufacture of Confectionery
This is a seasonal industry and attracts girls of the floater tyire who never
stay very long anywhere, or w^ho wish to work only occasionally and do not
wish to work where they have to spend time learning a trade. Chocolate
dipping is the only operation fot women in this trade requiring any skill,
and very few of the younger girls are foimd at chocolate dipping. The em-
ployment of boys in this trade is negligible.
The Manufacture of Hosiery and Knit Goods
This industry emi>loys boys and girls in about ccjual numbers. In most
instances it is no longer a seasonal industry. The work is easy to learn and in-
struction is given by other workers or by foreladies. Some of the boys and girls
w^ork on knitting machines, but most of them handle the finished product in the
stock room, doing inspecting, folding and packing. In addition, boys are em-
ployed to run errands. There is little or no opportunity for advancement in this
kind of work. An increase in wages is the most that can be hoped for.
Considerable standing is necessary'. The law states that no girl under i\
shall be employed at an occupation recjuiring her to stand constantly, and
that seats nuist be provided for every girl and woman employed. Seats
are usually i)rovided and sometimes made use of. The average girl needs
instruction in health education. Some standing is necessary in all occupa-
tions, but many employes stand constantly, even though their work does
not require it. On the other hand, many ta^ks are done standing which
could be done seated, if emj)loyers would devote a little thought to the mat-
ter. Numerous machines are now operated from seats, which formerly re-
quired a standing position. It is very essential to the health of young girls
BALTH AND INDUSTRY 591
at they be not subjected to the strain of continued standing. No small
action of the medical service m industrial plants should be the instruction
employes, especially the younger ones, in the application of common sense
their daily living, in such matters as alternate sitting and standing at
>rk, changing of posture while at work, the wearing of practical working
>thes which will give freedom of movement and the maximum of comfort,
e necessity for nourishing diet, plenty of sleep, fresh air, and other related
bjects.
lie Mmiai Trades
Of the 23 metal trades establishments visited, nine employed boys and a
w, girls. 294 boys and 9 girls under 18 were found at work. The girls
ere for the most part engaged in packing and sorting parts and in making
tiall pasteboard boxes. In no case was their work difficult and in every
ise they were seated at benches. For boys the metal trades offer exception -
ly good opportunities for learning a skilled trade. In eight of the nine
ants they were found working in machine shops under the supervision of
lilled workmen, making good pay and having everj' chance to apply them-
Ives and get ahead. Very few of these boys, however, were imder 16 years
age. Employers almost universally stated that it was their rule to employ
> l>oys under 16. "They are a nuisance.*' Much of the machinery involves
►o great an accident hazard for such young boys, and there is nothing much
ley can do but run errands. Even boys from 16 to 18 years of age are looked
3on with disfavor. Whatever the explanation may be, it is true that the
s.satisf action of employers with boys of this age is general. **They are
ird to get and no good." A number of firms were visited which had been
lown to employ boys of this age, but no longer do so, having made a strict
lie to employ no one under 18, boys or girls, because tliey had proved to be
ich imsatisfactory help. As a group, the metal trades seem to be above
le average in plant organization for the welfare of employes. Medical
Tvice is provided, equipment is good, hot food may be obtained at noon,
id some recreation is provided.- This is well worth noting because of the
rge number of boys it affects. 1,119 of the 2,090 boys employed in indus-
y proper in Cleveland are in the metal trades.
In the plants visited 115 of the boys were employed as apprentices. This
leans that they were systematically learning a machinist's trade and in addi-
on were occupied part of each week in study and class work, either at East
echnical High School or in classes conducted in the plant. The superi-
rity of this method of inducting boys into industry cannot be emphasized
>o strongly. It will be discussed in more detail in a later section.
There are only a few shops in Cleveland where a modem or in fact any
r.stem of apprenticeship is now made use of. A number of employers stated
lat they have plans for it in mind, but that with the present scarcity of
3ys, it is not possible to establish such a system now. In the two plants
here an apprenticeship system is well established, great satisfaction was
[pressed as to the results obtained.
592 Hospital and Health Survey
Printing and PubiiMhing
This is a trade which is largely unionized in all its branches, even in the
binderies, which make use of girls and women. For girls, in practically all
work .done by them outside of the binderies, there is no job with a future.
Feeding presses is the commonest sort of a job. This is easy work, is safe,
is done sitting, but is very monotonous. Employers frankly say that it b
blind alley work and it is very difficult to hold girls at it any length of time.
Boys have always the chance to learn the printer's trade or to become
pressmen. This work they may leam through the apprenticeship system
which is directed by union rules. Union rules require four years' time
spent as an apprentice before a boy is able to qualify as a skilled woriLer.
Non-union shops claim that the work can be learned in a year and a half.
Union rules require, in the case of pressmen, that there can be only one
apprentice to every five pressmen in a shop. The employer in this trade
states that there should be an allowance of one apprentice to every three
pressmen in a shop. As the union rule works out, it is difficult for a boy to
become an apprentice, as there are few openings. No relation is made be-
tween school and shop. No part of the boy's time is spent in class work.
Working conditions in the printing trades are fair. There are definite
lead hazards in most branches of the trade, and as yet union organization
has not recognized this hazard in relation to young boys who are especially
susceptible to lead j>oisoning. Xo provisions are made to protect boys from
a lead hazard. In European countries boys are not permitted to work in
occupations which expose them to lead fumes or dust. Boys in American
shops have been found doing the dustiest kind of work, cleaning and brushing
linotype machines and gathering up lead scraps. Under section 133D74
of the State Child Labor Law the State Board of Health has power to forbid
the employment of boys under 18 at any process injurious to their health.
This authority should be used to exclude boys from employment on those
processes in the printing trades involving a lead hazard.
Retail and Whoie»aie Trade
Seven large department stores were visited. In this group 105 boys and
466 girls under 18 are at work. They are apparently employed in about
equal numbers. Here again opportunity differs for boys and girls. Boys
are employed in the stock room as messengers and as ** jumpers" and wagon
boys in the delivery department. Many boys who are still in school engage
in this kind of work after school and on Saturdays. This is not difficult
work for an active boy. It is done in good surroundings, for the most part.
The modern department store* of which there are a number in Cleveland,
serves hot meals and uses care and thought in arranging for the welfare of
its employes. The chief ol)jections to this kind of work for boys are that it
does not get anywhere in giving training for a trade, and the law regulating
the hours of work for young boys is often disregarded in the delivery service.
It is common experience to have a package thrust in a house door late in the
evening by a small hoy, especially on Saturdays and in a holiday season.
[kalth and Industry 593
Girls are welcomed into department store organization very readily. One
mployer says, '*We cannot get along without our junior help." Another
Btys, **We give careful attention to the young girls coming to work for us,
>r in them we look for our future material for salesmanship." At least four
f the stores visited have an educational department, where girls receive a
ertain amount of class instruction as training for store work. Girls under
8 rarely start in as saleswomen. They are employed as branch cashiers,
s wrappers and in inspecting merchandise. In time they may graduate
ato salesmanship work, where there is greater opportunity both iji salary'
,nd for responsible positions. The New York State Factory Investigating
l^ommission considers there is a definite health hazard for young girls in
luch of department store work. "The nervous tension of the work of parcel
rrappers and of floor cashiers has been found to he of a serious character."
"(mtmphonm and Telegraph Work
jelephone Work.
About 400 girls imder 18 are employed in telephone work. This is a
narked increase over the number in 1915, when only 35 girls were listed for
joth telephone and telegraph work. The telephone companies have in the
»ast endeavored to limit employment to girls over 18, but their inability to
)et suflicient operators, with the resulting unsatisfactory telephone service,
las led them to seek younger girls.
No report of the trade of telephone operating can be made without careful
onsideration of the nature of the work. Telephone officials stoutly insist
hat there is no nervous strain in operating, that it is pleasant and healthful
Fork. Some of them base this statement on their own experience of years
n the service. And in appearance these women justify their contention,
lowever, in comparison with other types of work open to girls there is con-
iderable difference. Girls work in "tricks" of four hours; having during
bat time one 15-minute relief period, when they can leave the switchboard.
This 15-minute relief period is a regular part of the routine. However,
irhen a supervisor is short of workers it is not infrequently impossible for
ler to arrange this relief period. The rest of the four-hour period operators
must sit steadily in one position before the switchboard. There is no op-
portunity for them to move around and change their physical position, as is
he case in most other occupations. During this period girls are sitting with
heir arms stretched out before them or reaching upward, and their eyes
tiust be continually on the switchboard. White and colored lights are con-
inually winking on this board in front of them. In addition, operators
lUst listen and talk against the constant buzz and noise created by a large
umber of people talking in one room, even though the noise from talking
as been scientifically reduced to a minimum by the construction of the
mtchboard mechanism. While the noise in the operating room of all
Kchanges does not compare with the roar in the average machine shop, the
ifficulty is that in a telephone exchange almost continuous conversation is
ecessary with subscribers, requiring close and sustained attention from
594 Hospital and Health Survey
operators. It is often difficult for a subscriber to retain his poise and calm
during a fifteen minute period of telephone communication. How much
more exacting it is to expect the same of an operator for four hours at a time.
Telephone work is learned in a training school, requiring attendance from
two weeks upwards, part of which time is spent in the class room, and part
at the switchboard. A salary is paid to the student while attending school.
The same excellent lunch and rest room facilities are provided for students
as for regular operators.
There is good opportunity for advancement to supervisory positions for
a girl who likes telephone work and will continue in it. There is also con-
siderable opportunity in the commercial field for private branch exchange
operators. This kind of work pays well and often leads to other opportuni-
ties.
The average duration of service of telephone workers is not long. Sta-
tistics for Cleveland are not available on this point, l)eyond the statement of
ofikials that their labor turnover is high. However, in the report on tele-
phone work just made public by the New York State Industrial Commission,
it is stated that of every three applicants registered for telephone training
one does not finish training, one stays less than one year, and one stays more
than one year. As a girl is an expense to the company until she has been
employed one year, this means that the loss on operators is high. The
telephone companies make every effort to cut down the high labor turnover
by means of careful selection of operators, improved conditions of work
and well developed welfare features. That the rapidly shifting working
force may be due to the exacting nature of telephone operating seems not
to have been so carefully considered. While medical service is provided for
all plants of the companies, it is not adequate. The facilities of the medical
department should be expanded to give operators a |)eriodical as well as an
initial physical examination, and complete medical records should lie main-
tained, in order to obtain reliable information as to the degree of nervous
strain experienced, and its effect on the health and efficiency of operators.
That there is a distinct health hazard in telephone work for younger girls
seems undoubted. Up to the age of 18 years a girl's nervous organism is
none too stable in any case, and it is questionable whether it should be sub-
jected to the peculiar nervous strain of telephone operating in an urban
community. The Ohio Child Labor Law prohibits to girls under 18 crertain
occupations dangerous to their health. It is recommended that a careful
study be made of the effects on the health of young girls of this kind of work,
and that if the results of this study warrant it, telephone operating be included
in the occupations forbidden to girls under 18 years of age. As the tele-
phone companies, in Cleveland as well as elsewhere, are coming to rely
more and more on the services of younger girls, this is a question which should
have immediate attention.
HealthandIndustry 595
Telegraph Work.
As organized in Cleveland at the present time telegraph work has few
places for girls under 18 years of age. The only work open to them is mes-
senger work in the operating room. When a girl becomes 18 years old, how-
ever, she may go the company school and take a several weeks' course in tele-
graph operating. There is in this work a trade with some, if not a consider-
able future, and it involves no great health hazard.
Telegraph business makes use of boys in large numbers, 140 being em-
ployed as messengers by the two companies in Cleveland. Their work is
easily learned, familiarity with the city being about the only requirement.
There is no real opportunity for advancement in messenger work. A boy
might better make his initial contact with the industrial and commercial
world through a job holding out some inducement to buckle down and learn
a trade. Messenger work, like newspaper selling, can be done and is suc-
cessfully in one company, by older men. Employers like the energy and
hustle native to youth, but it is short-sighted to allow that energy to be
dissipated in a job without a real future.
D, Educational Requirement
Throughout the trades there is no educational requirement, save in the
case of apprentice schools, when a boy must have graduated from the 8th
grade. The last group described, including telephone and telegraph work,
endeavors to maintain an 8th grade requirement. Their need for workers
does not always allow them to do so. Possibly the most striking comment
which can be made upon the various tasks at which girls under 18 and boys
ilhder 16 are employed is that the mentally subnormal children found at
work in the city almost without exception are engaged at the same tasks,
upon which normal children are working. Apparently the tasks are so
simple that it is possible for subnormal children to engage in them without
difficulty. The work is easily learned. Few of the jobs upon which the
younger people are now employed require any great skill. From the stand-
point of learning a trade this is not always objectionable. For example,
in department store work there are a variety of tasks for girls to become
familiar with, no one of which requires any great skill for proficiency, but all
contributing to a knowledge which is essential to the higher jobs opening up
to girls later on in the profession. The same may be said of metal trades for
boys. There is considerable preliminary work upon which a boy's time
may be spent, which proyides general training for machine shop work and
which does not waste his time.
From the standpoint of learning a trade, it is objectionable, however, to
employ a boy or girl at work which utilizes youthful energy without yielding
any training for future competency. The messenger work at which so many
boys and some girls are employed in factories merely uses young legs because
they are quicker than old ones, and so long as a man has at his disposala
pair of young legs it is easier to use them than to think up some means of
596 Hospital and Health Survey
getting along without them. The use of messenger and office boys is a
holdover from the older, more inefficient methods of doing business when
work was conducted without thought for the most economical organization
of time and energy. In the labor shortage in Cleveland of the past spring,
the job that was the hardest hit was that of office boy. It was the universal
complaint that it was impossible to get an office boy, even when a largely
increased salary was offered as inducement. When opportunity was open
for other work, boys chose the job of office boy and messenger last of all.
E. Comments of Employers
Opinion differed somewhat as to the merits of boys and girls under 18.
It was almost universally stated that the boy of certificate age, that is,
15 to 16, would be better oflF in school. Many employers thought all children
under 18 were better off in school, but so long as it was possible to do so,
they employed a few. A number stated that they intended to eliminate
the younger help as fast as possible.
F. Conclusions
The trend of the comments of employers strengthens the conclusions
reached after the study of children's employment, a brief summary of which
is recorded in the observations made on the various occupations. These
conclusions are first, that the presence of boys of 15 to 16 years of age in
industry is not necessary and can and should be eliminated; and, second,
that there must be more conscious direction into the industrial field of boys
and girls 16 to 18. The blind way in which the average boy or girl gets his
or her first job is one reason for their employment at casual work, learned
today and forgotten tomorrow. Their work is unsatisfactory and they are
unreliable because there is nothing about their jobs to wake them up to
real effort.^ Their minds are elsewhere.
Blind alley jobs in children's employment have been rei*ognized for some
time, and while not approved have been more or less condoned as unavoid-
able. They are not unavoidable. The labor of children 10 to. 14 years of
age was once thought unavoidable and was condoned. It has been proved
conclusively that such labor is not necessary. So long as children are allowed
to drift about, as fancy dictates, from job to job, instability and unsatisfac-
tory work will result. Methods should be worked out in connection with the
certification of children for work, which will provide that a child's first job
is selected with some care and thought. This selection should be determined
by the inclination of the child as much as possible, but also by his physical
and mental capacity, ascertained through the careful medical examination
made.
Unless especially pointed out in the description of the particular occupa-
tion there is comparatively little health hazard for a normally developed
child, 16 years of age, in the trades where he is found employed in Cleveland,
provided the legal regulations regarding hours and conditions of work are
Health and Industry 597
complied with. There is quite a definite health hazard, however, in the
effect on a child of irregular and promiscuous jobs, or in work uninteresting
in itself and holding no promise of a real vocation in the future. The opinion
of the director of boys' employment of the Public Employment Bureau
in Cleveland is of weight on this point. After several years' experience she
states her conclusions as follows: '*The freshness, interest and alertness of
the boy seeking his first job are so much valued by employers that school
boys seeking vacation work are readily hired, even though their sevices
are temporary. Contrasting strongly with the keen forcefulness of these
school boys are the sullenness and stolid disinterestedness of the boys who
keep changing jobs. Employers have corroborated our observations that
boys are, as a rule, less valuable at the end of one or two years' work than
they were when they began their first job. The chief reason for this unfor-
tunate but common state is that boys leave school anxious to earn money,
and, because they have not thought about a trade or future advancement,
they take the first thing they happen to find. This is usually a 'blind-
alley' job which pays from the start a reasonably high wage. The boy is
at first delighted and applies himself so well that his earnings, if on a piece-
work basis, become higher. If he wishes to speed up and work overtime,
he can ^am more. Because of his high weekly earnings at this rate, if he has
a chance on another job at a higher rate, he leaves to try that. After a year
or so of this, the results noticed in him are definite physical deterioration,
such as nervousness, enervation, drooped shoulders, sluggish bodily move-
ments, and slow mental reactions. Boys who have shown great promise
when their applications were first presented, but who have insisted on this
kind of Work, have been a real disappointment when it is evident what their
work has cost them. The long, confining hours of industry, unless the boy
is buoyed up by the stimulation of a future finished apprenticeship and a
worthy goal of achievement, and the loss of nervous energy in high speed
jobs stamp upon the face, figure and health of that boy the price he has had
to pay."
It is largely from a health consideration that more care is urged in the
selection of jobs for children. Children have a right to work and in many
cases the effect on them of employment is highly beneficial. But they are
not adults and some supervision of their activities in industry is legitimate.
Children are not wholly free agents in the selection of their school studies,
and there is no reason why they should be in the selection of work until they
have reached the age of maturity. Boys and girls of 16 have not reached
the age of maturity. Left to their own direction they think of their health
last, if they think of it at all. If they are directed into work for which they
are physically and mentally qualified, the health hazard involved in allowing
young children to work daily will be greatly diminished.
^. Street Trades
There is no provision iH the Ohio State Child Labor Law relating to
newsboys, and other street traders. There is a Cleveland city ordinance,
not enforced, containing these provisions:
598 Hospital and Health Survey
No boy under 10 and no girl under 18 years of age may work at all on
the city streets.
No boy under 14 years of age may work on the city streets before 5:30
in the morning and after 8 at night.
No boy 10 years of age and over may work on the city streets, without
a permit issued to him in writing by the mayor of Cleveland, or by his author-
ized representative. The permit shall state that the boy is mentally and
physically fit to perform this work. After a i>ermit is secured by a boy
he shall receive a badge, which he nmst wear while at work. This permit
may be revoked if the provisions of this ordinance are violated. Trades
which come under this ordinance are, selling of papers, periodicals, gum,
pencils, candy, perfume and other commodities, in a public place.
The Consumers' League of Ohio has campaigned for some time to eecure
the enforcement of this ordinance. Through interviews with i)ublic officiak
they secured the following promises:
(a) Mayor Davis said that he would authorize someone at the Board of Edu-
cation to issue perinits and badges.
(b) Superintendent Spaulding and Mr. Jones have promised that the Board
of Education would issue the permits and badges, provided money could
be raised to pay for the latter.
(c) Chief of Police Smith has promised that he would instruct his squad in
the enforcement of this ordinance. Judge Addams will cooperate.
The Consumers' league states that the ordinance is not now enforced
because —
1. The newspapers do not wish regulation, claiming they are making efforts
to take care of the trade from within.
2. There is no money in the city license department to pay for badges (esti-
mated cost $300.)
3. There is no money to pay special officers to be detailed to this particular
work.
Boys and a few girls enter these trades as young as six and remain in them
throughout the years while they are in school. The majority of them sell
newspapers. Anyone who will take the trouble to observe, may judge for
himself as to the extent that newspapers are sold on the downtown streets
and busy outlying jjtreet corners by small boys.
Xor is it necessary to point out in any detail the undesirable nature of
this work for children. Common sense alone will indicate the inadvisability
of allowing children from six years of age up to spend time on the downtown
Health and Industry 599
streets, in an atmosphere of great confusion and excitement, getting home
after dark, going to bed late and having irregular and badly chosen meals.
The fact that a progressive city like ('leveland will continue to allow its chil-
dren to hazard their health and safety in this way is puzzling, although it
may be an illustration of the extremes to which American sentiment for
business independence will go. There is a very real appeal made by the
small hustler who thrusts an evening paper at the passerby, which has been
felt by everyone, but it requires only a little thought to realize that this
appeal is not justified by the price which the child must pay in the end.
For the purpose of securing some specific information as to the extent
and general character of the newsboy trade, a census was taken in a downtown
school adjoining the business district, of the boys in that school who vyere
selling newspapers or other articles on the streets. There are about 800
pupils in this school, 400 of whom are boys. One hundred records were
secured from boys and 10 from girls by a canvass made from room to room.
A summary of these records is found in Tables XXIII., A and B, in the Appen-
dix. As many as 20 boys under 10 years of age were found who sold i)apers.
Six of these youngsters sold papers until after 8 at night. Fourteen of them
earned less than 50 cents a day. Twelve of them were classed by their
teachers as not having good health, and eleven of them were classed as
having inferior mental capacity.
According to the ratings of age and grade in use by the public schools,
.39 of the 100 boys who sold papers were retarded in school one, two and three
years. Eight additional boys were in a special "opportunity" class which
was not graded. 17 out of the 100 boys were in open air classes. 34 of the
100 boys had a poor health record and 16 a fair health record, making 50%
of the boys whose health is only fair or poor. All of the boys sold papers on
Saturdays, either for the same afternoon and evening period or all day.
While it would not be justifiable to conclude that the physical and mental
Condition of these boys is due wholly to the fact that they sell newspapers,
as there are probably other contributing factors, such as home conditions,
ignorance of foreign-born parents, and others, the fact should be emphasized
that almost two-thirds of these boys are in no condition, physically or men-
tally to justify their work of selling papers in their spare time after school
and on Saturdays.
Seventeen of the boys were found in open air classes. This means that
they had been diagnosed as suffering from some degree of poor nutrition,
and so were placed in special rooms where a maximum of fresh air is provided
and the children are given the benefit of extra food. The teachers report
that the children improve greatly in health when attending these open air
classes. A number of stories of the newsboys found in these open air rooms
are of interest.
Arthur, age 9, in the third grade, sells papers every afternoon until 8
o'clock and Saturday the same time. Saturday morning he sells boxes
which he picks up around the market. He makes about 50 cents a day.
600 Hospital and Health Survey
He is only a fairly good student. As open air class boys rank, his health is
fair.
Joe, age 10, in the fourth grade, delivers papers from 4:30 until 7 in the
morning. He sells papers after school until 6. On Saturday his hours are
from 4:30 a. m. to 7 a. m. and from 9:30 a. m. to 6 p. m. He makes
about 75 cents a day. Although he was regular in attendance at school, his
physical condition is poor. He was a failure last year in school, and at
present applies himself only fairly well.
John, age 11, in the fifth grade, sells papers after school until 6. He is
badly undernourished, and is only a fair scholar. He expects to get a job
and work this summer.
Peter, age 11, in the fifth grade, sells papers after school until 6 o'ckxi.
He makes a dollar a day. He has been selling papers for a year, is markedly
nervous and jumpy. He has been a truant from school and has to report to
the truant office. He is bright, but he is not able to apply himself, according
to his teacher.
Martin, age 10, in the fourth gra,de, works after school until 6 o'clock,
making 40 cents a day. He was sick and lying on a cot when interviewed.
He is only a fair student.
Amelio, age 11, in the sixth grade, sells papers until 7 every night and
on Saturday from 10 in the morning until 8 at night. He has been selling
papers five years. He is regular in his attendance at school, but not very
strong, and is very nervous. His health has improved greatly since going
into the fresh air class.
Mike, age 7, in the second grade, sells papers until 7 at night, making
19 cents a day. He goes to the office with his brother for the pai^ers. He is
frail looking. His teacher reports that he is not at all well.
Frank, age 8, in the third grade, sells papers from 7 in the morning until
school time, and after school until 8. He makes 95 cents a day, including
tips. His health seems fair. He is very nervous, talks very fast and stut-
ters. He is in a si)ecial class for stutterers, and tries very hard to overcome it.
Billy, age 8, in the second grade, s^lls papers until 10 at night. It
takes him a half hour to get home from the downtown district where he
works. The school nurse and doctor cannot find anything wrong with him,
but they have not been able to understand his sleepiness. The teacher
states that it has been a struggle all the year to keep him going. "He is so
lifeless, bright enough and gets along well enough in his studies, but has no
energy."
Sam, age 11, in the fifth grade, delivers papers from 5 to 7:30 in the morn-
ing and sells after school until 6. He makes a dollar a day. He has been
Health and Industry 601
selling papers two years. He is small, nervous and of a high strung type.
He is bright, a good student, and has been a truant, but not at the present
time.
Joe, age 11, in the fifth grade, sells papers until 7 ^> clock. Then every
night and Sunday he watches tickets in a show until 9 o'clock. He gets 75
cents a week for this. He is undersized and not strong. He is intelligent
and a good student.
Joe, age 12, in the fifth grade, sells papers after school until 7, making
40 cents. He has been selling papers for five years. On Saturday, from 8
in the morning until 4 in the afternoon, he sells boxes which he picks up
around the market, making about $1.50. On Sunday he shines shoes from
8 to 10 in the morning, making 50 cents. He gives the money to his mother.
She usually gives him a dime. He is very anaemic and not in good health.
His scholarship record is poor. He does not apply himself, and his teacher
considers that he has dull mentality.
•
These cases, selected at random, show very clearly the kind of life which
newsboys lead. While the amount of money they make varies in many
cases, it is not worth the time spent making it. It should be noted that in
every case where boys are working later than 6 o'clock their physical condi-
tion shows the effect of their late hours and irregular meals.
Their hours out of school should be occupied in a manner which will not
drain their vitality further. The excitement of street life with its over
stimulation of young nerves and energies requires sound health and strength
to withstand its strain. Boys should not be allowed to engage in newspaper
selling and other street trading unless they can show a clean bill of health
and are up in their school studies. Boys like and enjoy this kind of work,
in most cases. If they are allowed to engage in it only when they can com-
ply w^ith a certain standard of scholarship and physical ability, the desire to
become a newsboy could be utilized as the necessary incentive to master
school studies and develop health habits.
It is recommended that the city ordinance regulating street trades be
enforced, j)ending amendment of the ordinance or inclusion of these trades
in the state law. Permits to boys to engage in this work and badges to be
worn by them while at work, should be issued through the work certificate
office of the Board of Education, where each boy will receive a medical .ex-
amination showing him to be physically fit for this occupation before he can
obtain a permit.
»
Early morning paper delivery should also be regulated by issuance of
certificates based on physical fitness for this work.
Although regulation of this trade does not come under the^'state school
law, the enforcement of the existing city ordinance directly affects pupils
throii^out their school life and unless some effort is madejto^keep watch of
6iH Hospital and Health Survey
the children in these trades, their unguarded pursuit of them will break down
the work of the Board of Education in the medical and truancy departments.
It is logical that children in the school system engaging in these trades
should do so only under the direction of the Board of Ekiucation, so that the
work of the medical and truancy departments may not be nullified by the
extra-school activities of these children.
3. Agricultural Work and Domestic Service
Neither of these groups of work is included in the list of occupatious
employing children which come under the regulation of the State Child Labor
Law. The number of children who are employed at these kinds of work
cannot even be guessed at, as no record is kept of them in any place. Un-
doubtedly some of the 6,778 girls 16 to 18 years of age, listed by the school
census as working, are employed in domestic service.
Agricultural work for children under 18 does not affect any number of
children in Cleveland except in one situation, which is, however, of consider-
able importance. This is the case of children who leave Cleveland in the
early spring and remain until the late fall to work in agricultural fields either
in Ohio or elsewhere. The children are recruited by agents who are paid by
the farmer who employs them so much a head for children recruited. These
agents obtain individual children without their parents, or whole families,
and transport them to the locality where they are to work.
Principals of schools in districts where there is an industrial population
report that every spring about six weeks or two months before the close of
school, or in April sometimes, there is an exodus of children and families
from the district. One school principal reported that 20 families and some
boys had gone from her district, taking about 100 children altogether, the
majority of whom were her school pupils. They went to work in the beet
fields near Flint, Michigan, and were signed up by agents who came into the
district and went directly to the homes of the families. In this school dis-
trict there are Italians, Slavs and Hungarian gypsies. The Italians do not
undertake this kind of work, hut many Slavs and most of the Hungarian
gypsies go.
This happens every spring. These people will return about one month
after school begins. The children miss from two to three months of school
and considerable retardation in school is the result.
All of the children from 6 years of age upward work in the beet fields.
According to the statement of this school principal even the little tots bring
home as much as $150.00 for the season's work. The Uving conditions are
primitive. The people live in shacks and very bad sanitary conditions pre-
vail. The National Child Labor Committee has made considerable research
into this form of work and has found very undesirable situations in every
state visited.
Health and Industry 603
So far as is known practically no boys are employed in domestic service.
As before stated, it is impossible to make any estimate of the number of
girls under 18 years of age so employed. In the canvass made of one school
to obtain information as to the numbers of children working after school
hours at selling papers, it was learned incidentally that quite a number of
girls 14 years of age and under were doing housework after school and on
Saturdays.
Experts in industrial diseases state that housework contains more health
hazards than are found in any other industry. There are no statistics avail-
able to sustain this statement, but it would be wise to make a study of this
occupation and accumulate more accurate information regarding it. It is
questionable whether housework has any beneficial effects on the health of
very young girls who engage in it.
Both of these occupations should have age limitations and some super-
vision of conditions of work, particularly agricultural work. There should
be an age limit of at least 12 for these occupations and a limitation of the
hours of work, similar to the limitations in hours for other occupations. A
health certificate should be required of every child. Regulation of condi-
tions of work may involve some difficulties needing the cooperation of other
agencies, but examinations for a health certificate can be conducted in
the same manner as for other occupations by the existing machinery, with-
out great difficulty. By limiting the age and the hours of work of children
engaging in these occupations and by requiring of them a certificate of
physical fitness for this kind of work, their health will be better safeguarded.
HEALTH OF CHILDREN AT WORK
1. Medical Examination of Children' for Work Permits
"Little has been done up to the present time in the United States to pre-
vent children from going into work for which they are physically unfit, and
practically no study has been made of the effects of early labor on the growth
of the body. Many children who begin work between the ages of 14 and 18
are the children of least resistance in the community. They are in general
the children of the poor, and in consequence are likely to be the ill-nourished,
the undersized and the anaemic. Already handicapped, their growing bodies
can offer no resistance to the exacting demands of industry on muscles and
nerves. During these maturing years they are peculiarly liable to injury
from overstrain and peculiarly sensitive to all sorts of industrial hazards.
"A great deal of the work done by children is, moreover, totally unfit for
them. It often involves too much sitting, or too much standing, the carrying
of weights beyond the child's strength, the over exercising of one set of
muscles at the expense of another, and, in certain occupations, the loss of
sleep. Foreign investigations have shown that the sickness rate among
juvenile laborers is alarming, especially during the second year of working life
when the injurious effects of early labor upon already undeveloped bodies
have' had time to make themselves felt.
6^ Hospital and Health Survey
''*A 'physical minimum* for children entering employment was provided
in the standards adopted by the Children's Bureau Conferences held in
Washington and other large cities in May and June, 1919. This minimum
proposed that *A child shall not be allowed to go to work until he has had a
physical examination by a public school physician or other medical ofiBcer
especially appointed for that purpose by the agency charged with the enforce-
ment of the law, and has been found to be of normal development for a child
of his age and physically fit for the work at which he is to be employed.*
It proposed also that * There shall be an annual physical examination of all
working children who are under 18 years of age.' (For the complete text of
the standards, see pages 3, 4, 5 of Conferences Series 2, Bureau Publication
No. 62 of Children's Bureau of the U. S. Dept. of Labor.)
'*But what constitutes 'normal development' for boys and girls of dif-
ferent ages, and what indicates that a child is 'physically fit' for the employ-
ment which he is about to enter? Only through exact observation and meas-
urements can it be demonstrated that a child is unfit for certain kinds of
work, or that too early and too exacting labor is endangering his physical
development. The standards to be applied constitute a vitally important
part of the problem of child labor."
The above paragraphs are quoted from the statement of the Federal
Children's Bureau made at the time of the appointment of its Committee
on Health Standards for Children Entering Industry. It states very clearly
the necessity for special care for children of these years who are going to
work.
In the descriptions of the various occupations in which children were
found employed in Cleveland an effort has been made to point out the par-
ticular health hazard, if any, present in each. There is, however, some health
hazard in any kind of employment for growing boys and girls, unless their
work is carefully supervised. Their physical and nervous organisms are not
yet stabilized. They have less enduranc*e, and they are more susceptible to
fatigue and bodily strain. Postural strain is most likely to be overlooked
unless a child receives some medical supervision after his initial examination
for a certificate. The bony structure of a child is quite flexible. Children
are peculiarly susceptible to deformities if subjected to unusual and pro-
longed strain on one set of muscles, the use of which is es|)ecially required
by the job at which they are employed.
In the future, probably industry itself will exercise more supervision over
the work engaged in by children in its employ. The attitude of many em-
ployers at the present time is exceedingly intelligent and considerate, in so far
as they have knowledge of the physical needs of children 15 to 18 years old.
As the medical service in industrial plants develops there will be better
facilities for close observation of children at work, and of the effect on them
of different kinds of work. It will be possible to make finer adjustments
between children and the tasks they perform which will definitely affect
their health and efficiencv.
Health and Industry 605
Pending the time when industrial medical service can share this respon-
sibility, the health of children in industry must be guarded by the pubhc
department which has the responsibility of examining the mental and physi-
cal abilities of children applying for working certificates.
In Cleveland this work is done in connection with the Department of
Medical Insp)ection in Schools of the Board of Education. The present
requirement in the Ohio School Law of a health certificate for every child going
to work has been only superficially observed until the past year. The present
director of the work has been at work since last June. Records have been
in use only since September, 1919. Therefore, there are no data available for
a longer period than one school year.
Children are examined carefully as to eyesight, hearing, teeth, throat,
lungs and heart, and are looked over for bodily defects, fallen arches, evidences
of malnutrition. All children are measured and weighed. They are
questioned on their previous health history and for any diseases from
which they have suffered, such as epilepsy, rheumatism, contagious diseases,
influenza, etc. This is quite a casual inquiry of the whole group being ex-
amined. On the occasion when the procedure was observed 15 girls were
being examined, and as the room is small there was some confusion. The
girls took a personal interest in each individual examined, crowding around
her until ordered back.
The information obtained is recorded on each child's health record and
filed. Separate files are arranged for records of children with serious physical
defects, of children requiring correction of defects, and of children who are to
be re-examined at a later period. The last named usually have conditional
certificates. The medical oflScer spends about three hours daily in the oflSce
and a daily report is made up which is kept in the school medical inspection
oflSce. These records show the total number of boys and girls examined,
the number considered defective and those who were relatively sound, the
different defects found and the number of corrections effected during the 8
months from September to May.
In the 8 months from September, 1919 to May, 1920, there were examined
2,S48 children, 1,001 boys and 1,347 girls. 492 of the boys and 19 of the
girls, or 1,111 of the children, had one or more physical defects. The com-
plete figures from these records will be found in Tables XXIV. and XXV.
in the Appendix.
The defects from which children were suffering in largest immbers were
carious teeth, defective vision and poor nutrition. 623 children had defec-
tive teeth, of which number 367 were later reported corrected. 199 children
were handicapped by defective vision, of which number 109 were later re-
ported as having corrections made. 403 children were suffering from some
degree of poor nutrition. There was no record of treatment recommended
or received in these cases. 27 children were diagnosed as suspicious or
positive tubercular cases.
606 Hospital and Hel^lth Survey
The records of the large number of children suffering from decayed teeth,
in many cases so bad that repair was impossible, from defective vision and
from poor nutrition, indicate that the work of school medical inspection Ls
not adequate. Children should not be allowed to reach the ages of 15 and
16 with such uncared-for teeth that many must be extracted. Poor nutri-
tion may be due to a number of causes. More study of the subject of nutri-
tion is necessary. The school medical department is already conducting
experiments and classes in nutrition which it is hoped will lead to the diminu-
tion of the undernourishment which handicaps so many school children. In
some cities a minimum standard of nutrition is set, determined according to
the height, weight and age of the child, as requisite for a health certificate.
•
It is not within the functions of this department to do other than examine
children and prescribe treatment for physical defects discovered. No medical
or dental work is done. The child is sent back to his own physician for treat-
ment. In case it is understood that the parents of the child are unable to
pay for such care, the child is referred to one of the public dispensaries.
In order to obtain prompt action on the part of parents in having the
prescribed corrections made, certificates are usually refused until the work
has been done or until the child can show evidence that the corrections are
under way. A conditional certificate valid for a short period of time is often
given to a child who is under medical or dental treatment for some remediable
defect. At the end of the period for which the conditional certificate has
been given the child must return to the office and show evidence that the
defect has been corrected before he can obtain a i)ermanent certificate.
While this department has been organized less than a year, it is already
fairly well established, and its work is proving its value. The officers are
much interested in its development and the outlook is promising for an
organization having a splendid influence on the health problems of
children going to work. The department needs to be considerably expanded
and its working force increased. Health standards for children going into
industry should be formulated, patterned after those soon to be issued by
the Federal Children's Bureau Committee already mentioned. A sunmiar}'
of the conmiittee's preliminary report on standards is included at the end of
this section. One of the functions of the department still to be developed
should be sufficient contact with the industrial field to assure familiarity
with the jobs in which children are employed, in order that the examining
physicians may be able to decide intelligently as to the desirability of dif-
ferent kinds of work for the various children examined.
It is to be regretted that there are no health records available for a longer
Ijeriod of time than one year. It is not possible to learn from the records of
one year only, the physical effects of employment on children, data which it
is important to collect before conclusive statements can be made as to the
desirability of this or that occupation for children. A prominent activity of
this department should be the study of the various occupations which chil-
dren enter, and the accumulation of evidence of the development of children
after a period of months and years in these occupations. This information
Health and Industry 607
can only be obtained by means of periodic medical examinations of children
after employment has begun. The Ohio law relating to health certificates
for work permits should be amended to require such periodic medical exami-
nations. The law should be amended also to assure a medical examination
in every case before a certificate is issued for a specific job. The pledge of
the employer required in the present law should be amended to specify the
exact nature of the work a child is to do, as otherwise a child may be trans-
ferred to work, other than that for which he received his work certificate,
which may be injurious to his health. The amendments to the present law
can be made as in the suggested form of the law, which follows:
i. Suggested Content of Ohio Law re Health Certificate for
Child Applying for a Work Certificate.
Section 7764-1 (4) Health Certificate. A certificate from the school
physician, or if there be none, from the board of health, and if there be no
board of health within the school district in question, from a licensed physi-
cian appointed by the board of education, showing after a thorough medical
examination that the child is physically fit to be employed at the specific
occupation for which the child makes application for a permit, such occupation
to be one not prohibited by law for a child under 18 years of age.
Periodical examination of children who have been granted one health
certificate shall be provided for by limiting the period of time for which
certificates may be issued to two periods of six months each and one period
of one year siuccessively. A thorough medical examination showing the
child to be physically fit for the employment in which he is to engage or is
engaged shall be necessary in every case, before a certificate may be issued.
Certificates may be granted for shorter periods of time than six months or
one 3rear, successively, if the physical condition of the child warrants more
frequent examination, or if the child is allowed to work while receiving medi-
cal treatment for correction of remediable physical defects.
A new certificate shall be required upon every change of employment.
An adequate force of qualified physicians and others shall be provided
for the work of examination and follow-up which may be necessary.
(Pledge of Employer) (1) A pledge or promise signed by the employer
or by an authorixed manager or superintendent, specifying the exact nature
of the work which the cWld is required or permitted to do, the number of
hours per day during which the child is to be regularly employed, and the
name and address of the employer, in which pledge or promise the employer
agrees to employ the child in accordance with the provisions of this act, and
to return to the superintendent of schools or to the person authorized by
him to issue such certificates, the age, schooling and health certificate of the
child within two days from the date of the child's withdrawal or dismissal
from the employer, giving the reasons for such withdrawal or dismissal.
608 Hospital and Health Survey
3. Subnormal Children in Industry
There are at present no means of ascertaining the mental capacities of all
children wishing to go to work, other than the school record, which is too
brief to furnish any information except the fact that the child has completed
a specific school grade. Completion of the sixth grade is required of all boys
and of the seventh grade of all girls. If it is decided that the mental capacity
of a child is such that he cannot pass the required grade, that child may obtain
a special permit to go to work, other requirements being complied with.
School children who are suspected of being mentally deficient are tested by
the examiner of subnormal children of the Department of Medical Inspection
of the Board of Education. Only a small number of the subnormal children
in the city are so examined. Such of those known deficient children as apply
at the attendance department for a certificate to work, have on their school
record the fact of their deficiency, and that fact is taken into consideration
when the children are medically examined for a certificate. This information
is invaluable in directing a child into the sort of work for which he is most
suited because of his mental disability. A 15 year old boy went into the
attendance department one day to obtain a permit to drive a truck for a
construction company. He proved to be physically sound and during the
time while he was Keing examined seemed normal. His school record showed
that he was mentally deficient, having tested to a mental age of eight. The
doctor promptly refused to grant him a permit for that job, as it did not
seem wise to allow a boy of eight year old mentality to drive a truck about
the city streets.
■
There has been some discussion in the department as to the advisability
of putting the statement of a child's mental deficiency on. his school record,
which goes to the work certificate oflSce. Some officials felt that it was
unfair to handicap the child in this way in finding employment. It is true
that such a statement may not give a fair representation of the child's ca-
pacity. The circumstances under which mental tests are given to a child
may be such as to upset a not too well balanced mentality; that is, to a
child in any degree uncertain of himself, it would be very upsetting to have to
answer questions by strange people in the presence of his teacher and others
who are strangers or of whom he is afraid. In such cases no child woidd
give a very good account of his faculties. Furthermore, intelligence tests are
still in the field of research, and not yet completely developed. It should
not be so difficult to ascertain the mental capacity of an adult whose
faculties have become somewhat crystallized, but it is questionable whether
one group of tests as now used can set a value on the faculties of a growing
child some of whose abilities are still latent. One employer, who has con-
siderable sympathy for handicapped children, stated that he took three
certificate boys who were mentally subnormal and put them to w^ork in the
machine shop. That was a year or so ago. Two of the boys were still there
this spring, and one of them, his employer states, is making one of the best
machinists in the shop and is an assistant foreman. It was his opinion that
the tests which classed these boys as subnormal were too narrow in their
scope, giving no indication of the fact that their ability might be entirely
along a mechanical line.
HealthandIndustry 609
Whatever the facts may be as to the adequacy of the tests as now given,
their usefuhiess is undeniable and those in charge of them are exerting earnest
effort to make the tests used complete, reliable and in step with the latest
findings in this field of research. While more efficient tests may be worked
out, those already in use are of great assistance in indicating, even if crudely,
differences in mental capacities.
Any knowledge of a deficiency in mentality of a child wishing to go to
work should be communicated to his employer, as a protection both* to the
child and to the employer. In the visits to industrial establishments made
during the course of this study, employers were questioned as to this point
and the answer was invariably the same. "This information should be on
the certificate of the child. It is of great assistance to us in deciding just
what the child shall do, and it protects us both from the chance of an accident."
A study was made of all the records of the subnormal children applying
at the work certificate office for working papers from September, 1919, to
March, 1920. Of the 2,323 health records on file in the office for that period
148 were those of children whose mentality was deficient. According to
these records 6.4% of all children having work permits are subnormal.
This does not represent the total number. It represents only those
children whose subnormality had been ascertained while they were in
school. In close connection with the medical examination for work certifi-
cates there should be facilities for determining more accurately the mental
capacities of all children wishing to go to work. The data available from
such examinations will be an exceedingly valuable contribution to the studies
of employment for children which are now being made.
A careful study was made of the 148 records of children of subnormal
mentality. The work which these children were doing was analyzed, their
physical defects tabulated and mental age recorded. In Table XXVI. in
the Appendix the information thus obtained is shown in detail.
•
There was more deficiency among the boys than among the girls, as the
subnormal boys were 8.6% of the total number of boys who had obtained
work certificates and the subnormal girls were 4.8% of the total number of girls.
Twenty-seven of the boys and twenty-two of the girls had no physical
defects. Poor nutrition and bad teeth were the chief sources of trouble for
both boys and girls. In many cases the two went together. While the
number of cases of defective vision was not great, it should be noted that
what is described as mental deficiency in children is not infrequently retarded
mental development due to bad vision. 13 girls and 8 boys who had tested
subnormal in school came to the work certificate office with defects m eye-
sight which should have been corrected before, in view of the fact that the
children were thought to be defective and had proved to be so upon being
tested.
Not all of the children who had applied for work certificates were at work.
Between a third and a hal£ of the certificate had been returned to the office.
010 Hospital and Health Survey
showing that the children had left their original jobs. As the oflSce has not
followed up such cases, it is not known whether these children got other jobs
and are working illegally or whether they are staying out of school at home.
The jobs for which the children had certificates could be classified in
three general groups, machine work, hand work and errand work. Almost
half of the boys were doing errand work as messengers, wagon boys, etc.
The machine work was of a simple sort, such as is done in a large knitting
mill. Under hand work was grouped a large number of jobs in sorting and
packing products, all of which require practically no skill and involve the
repetition many times of one simple operation. Employers seem to have
no objection to this group of workers. In many cases the work is very little
different from that required of normal children. As before stated, the kind
of work which many young children are doing is exceedingly simple, is easily
learned and involves little or no mental effort.
A question which requires study and which must be settled regarding
such children, is whether or not they should continue in special schools where
they can receive more training, or whether they should be more carefully
inducted into industry where they can Ik* under the stabilizing influen<*e of
regular work.
Opinion differs on this point. Some teachers of backward children regret
very much that they leave before 16 years of age, saying that it takes several
years of special work to get any results with the children. Others believe
that they are better off at work than in school and that the law requiring
their attendance in school should be more flexible than it is, in order that
such individuals may get to work as soon as possible. Such children can re-
reive their industrial training to better advantage in a shop than they can
in a special class in school, where only meagre industrial equipment is pos-
sible.
In Cincinnati a special committee supervises the industrial careres of all
such children. In Baltimore unusual boys are taken from school and put
to work under the direction of a department having this special responsi-
bility. The effect of carefully directed work on the character development
of these boys has been noteworthy. An experiment of this kind is well
worth trying. Too little is known of the possibilities which lie in the right
kind of work for backward and unusual children. It is suggested that a
special arrangement should be made in the work certificate offices w^hereby
children of this groiij) will be carefully studied and directed into employment
nnd followed up after they arc at work.
k SiMMAuv OF Standards of Nohmal Development axd Physical
Fitness for Working Children
(Tentative report of the committee appointed by the U. S. Children's
Bureau to formulate standards for the use of physicians in examining chil-
dren entering employment and children at work.)
Health and Industry 611
A. GENERAL RECOMMENDATIONS
J. Age Minimum for Entrance into Induntry,
Should be not less than 16 years. It is important to protect a child from the physical
and nervous strains of industry because of his general instability during the pubescent
period.
2. Physical Minimum for Entrance into industry.
No child imder 18 years should be permitted to go to work who is not normally de-
veloped for his age, of sound health and physically fit for the work at which he is to be
employed.
3. Physical Examinations for Children Entering industry.
A thorough medical examination for entrance into industry should be required and
must show that a child is physically fit for industry. Before the examination is made the
child must bring a promise of employment from his prospective employer stating the
specific occupation in which he is to be employed.
4. Re-examinations for Children Changing Occupations,
With each change of employer another examination should be made before the child
is again permitted to work, likewise when a child is transferred in the same place to work
differing in its physical demands and hazards from that for which a permit is issued.
5. Peri€>dical Re 'examinations for All Working Children,
Yearly medical examinations should be required of all children at work up to the age
of 18 years, or more frequently if judged desirable. These examinations shall take place
either in the certificate issuing office or in the place where the child is employed.
6. Need of study by local administrative and medical officers of occupations in
which children are employed and of their effect upon health,
CXxupations employing children should be especially studied by the examining physi-
cian, who should also be required to familiarize himself with conditions of employment and
the various health hazards of industry.
7. Need of authoritative scientific investigation.
Considerable further study of the effects of different kinds of work upon the physique
of the adolescent child is necessary, and especially with reference to:
(a) Comparison of the rate of growth of children employed in different occupa-
tions with that of children not in industry.
(b) Comparison of morbidity among children employed in different occup>a-
tions with that of children not in industry.
612 Hospital and Health Survey
(c) Compariaon of mortality among children employed in different occupa-
tions with that of children not in industry.
(d) Fatigue in children employed in different occupations and industries.
(e) Effect of employment in specific occupations at different stages of physio-
logical development upon the growth and health of (1) normal children,
and (2) children with certain physical defects.
(f ) Effect of employment in specific occupations upon the special functions
and organs of adolescent girls and young women.
(g) Types of work desirable for: (1) children with some mental defect, and
(2) children who are suffering from some physical handicap.
Considerable material for these studies could be obtained from public
school medical records and records of examinations made for work certificates.
All such records should be standardized so as to be statistically comparable.
8. Certain tentative minimum standards obtainable from results of ccienfdic
research already available.
Although further study is necessary, there are sufficient data already on hand to
justify the recommendation now of certain tentative minimum standards, which ^will
materially safeguard the welfare of children entering industry while still immature.
B. MINIMUM STANDARDS OF PHYSICAL FITNESS FOR CHILDREN
ENTERING AND WORKING IN INDUSTRY
i. Standards of normal development.
(a) Certificates should be refused to children who do not cpme up to the fol-
lowing minimum standards of height and weight for specified ages, based
on the most reliable present-day experience.
Age Weight (in clothing) Height
14 80 lbs. 58 inches
15 85 lbs. 58 inches
16 90 lbs. 59 inches
Exceptions may be made if other circumstances in the child's case,
such as racial characteristics, warrant it.
(b) Certificates should be refused to children who do not show certain unmis-
takable signs of adolescence.
2. Standards of health and physical fitness for specific employment.
(a) Certificates should be refused permanently to all children who have cer-
tain specified defects. All such children should be referred to the appro-
priate agency for whatever assistance may be necessary.
EIealth and Industry 618
(b) Certificates should be refused to all children pending correction of all
serious remediable defects. Such children should be referred to the ap-
propriate medical agency for the necessary medical treatment.
(c) All children who, for any reason, show a tendency to weakness or disease
of any organ should be excluded from occupations which tend to aggravate
that tendency.
C. POINTS TO BE COVERED AND METHODS TO BE EMPLO YED
IN PHYSICAL EXAMINATIONS
\ iimnia for Inquiry.
(a) First examination should include a record of sex, race and nationality, age,
Qtcnded employer (name and address), intended occupation and industry, school grade
iOfnpleted, family history of father, mother, brothers and sisters, previous illness and phys-
cal examination. The physical examination should include the following:
Nasopharynx
Glands
Chest, heart, lungs
Abdomen
Nervous system
Summary of defects, as correctable and nco-correctable.
should be (a) recommended after first examination, or (b) refused, either per-
manently or temporarily, pending correction of specified defect, or (c) recommended after
re-examination (that is, after correction of defect).
(b) In re-examinations the same points should be covered as in the first
examination, and any changes noted in detail.
2- Record card and inMtructiona for use of examining phynician.
The use of a uniform record card is recommended in order that uniformity may be
^^btained in administration and in statistical analysis. Such a record form is included in
^be report of the committee. (These standards in full may be obtained from the Federal
Children's Bureau, Washington, D. C, upon application.)
EDUCATION'S RESPONSIBILITY
More educational preparation for the transition from school to industry
is necessary. Upon the training provided in public education depends in a
great measure the success with which children are guided out of the school
))eriod of semi-dependence into the industrial period of greater freedom and
6nal independence when they must rely wholly on their own efforts.
Height
Maturity
Weight
Sldn
Physical condition
Eyes
Nutrition
Ears
Anaemia
Mouth
614 Hospital and Health Survet
It is generally agreed that education's prime function is that of training
for citizenship in the complete sense. That this education must contain
more elements which will connect it with industrial life is also generally
agreed. When 75% of the children leave school shortly before the comple-
tion of the elementary grades to go to work, it is necessary to plan a course
of education which will supply the essentials within these grades. Indus-
trial experts believe that vocational training should not be included in ele-
mentary education except in the broadest sense, that schools supported by
general taxation should not be expected to supply specific training for par-
ticular jobs, that being the responsibility of industry. But the schools are
not alive to their responsibility in getting children siEifely to work. Their
influence should not cease as soon as the child goes through the school door.
Authorities agree that partial supervision of the child should continue until
the child is 18. His public school education should continue at least as long
as that in some form.
The problem of incorporating into the school program a sufficient amount
of preparation for industrial life, of the right sort, is one of the most pressing
and fundamental of the many questions which educators must face. (X the
various experiments already being tried out none has as yet proved itself of
sufficient value to justify its general use. The problem has many angles
and requires considerable study and experimentation. The endeavor of
the National Association of Corporation Schools to gather data on the
subject and to develop experimentation in industrial training as well as
in general education is a noteworthy instance of the many earnest efforts
being made to throw light on a perplexing but inte^'esting problem, interest-
ing because it is of recent growth and is an index of the changing attitude of
society towards industry. It has taken a long time for general thought to
recognize that cultural education may include knowledge of the industrial
world as well as of the world of letters and of science.
This problem cannot be solved easily. It is not within the province of
a health survey to make specific recommendations as to how it shall be done,
whether by more vocational training of a general nature in the school cur-
riculum, whether trade apprenticeship in industry, or by the exten-
sion of the estabhshment of continuation schools. The Smith-Hughes Act,
passed by the United States Congress in 1917, has been a great incentive to
the organization of some sort of vocational education in all of the states of
the country. The local Board of Education or the Ohio state educational
authorities should give this subject careful consideration in the near future
and make more adequate provision for industrial training in the school pro-
gram than exists at the present time.
One element of training for industrial life which should be mentioned
here is that of health education. Education for physical develd^ment and
health maintenance cannot begin too soon. Knowledge of the elements of
hygiene and sanitation should be thoroughly taught. For the child entering
industry it is important that he shaU laiow not only the value of physical
and nervous energy' and its conservation, but also the particular health
hazards which he will encounter in industry. Trained to take into account
Health and Industry 615
health considerations just as he takes into account wages and hours of work,
in determining the relative merits of possible jobs he will have learned a
valuable lesson, and a most useful one. As reported in the section on Child
Health Work (Part III.) there is no systematic instruction in hygiene and
sanitation offered to the school children of Cleveland at present. A study
of the subject brings out the necessity for such instruction for children who
are going into the greater freedom of the industrial world, while they are
still children. Every possible measure which can be taken to teach them
to take care of themselves contributes towards their dievelopment into
healthy adults. The Board of Education should provide at once for syste-
matic and thorough health instruction throughout the grammar grades.
JUNIOR VOCATION DEPARTMENTS
Nor is there space in the scope of a health survey to do more than indi-
cate the problem of actual industrial placement of children going to work
at an early age. Sufficient industrial training before leaving school and care-
ful selection of the first jobs in industry are both factors of influence in
assuring the establishment of sound health in children of this formative age.
Not only must a child be adequately prepared and physically qualified to
go into industry; he must also get into the right place where his individual
abilities have a chance for expansion. As pointed out previously a child
cannot be expected to do this unaided. Many do and eventuaUy make a
success of their work, but it is not reasonable to expect that every child can
do SO9 nor to assume that it is anything more than chance when a child does
l^ accident, marked inclination, or repeated trials, land in a job which suits
hun and offers opportunity for development. Provision should be made for
continuance during the early years of his employed life of the supervision
by which a child is guided through school life. Some advice and individual
consideration for each child going to work, given by a person familiar with
the various fields of work open to children and having sympathy with and
anderstanding of their desires and inclinations, can be of great service in
effecting an early adjustment for the child with industrial life. Vocational
S 'dance is still in the stage of experimentation, being one of the many prob-
LS concerning children of working age which have only recently received
attention.
The whole problem of inducting children from school into industry, which
has been considered in this study in its relation to the establishment of sound
health in youth, can be met by the organization of Junior Employment
Departments. England as long ago as 1910 saw the possibilities of central-
isation, and made provision for it in the Education (Choice of Employment)
Act. For the past five years even more care has been given to working
children than provided for in this act. Children going to work have the
benefit of individual advice regarding work, of consideration of their physical
^rell-beingy of educational opportunity to train for a vocation either before or
after th^ begin work. It is considered to the nation's interest "that all
duldien receive a good chance of health and satisfactory employment." In
Ki^and the juvenile labor exchange is under the direction of the school.
616 Hospital and Health Surtxt
Junior employment departments or vocational guidance bureatis are
developing in this country, and it has been found likewise advantageous to
have the department closely connected with the school. When the activities
for children of this age are closely related it is possible to unify the efforts of
all and to be sure that all children are kept track of, and aU information re-
garding individual children made use of. There are numerous reasons which
make advisable such centralization of activities.
In Cleveland a free public employment bureau has been in existence for
some years under the joint control of the state and city authorities. This
bureau has conducted employment work for boys and girls for some time.
The boys' work is in a separate department. The girls' and women's work
has been combined in one department although previously separate. Careful
investigation of the work in which young people are employed and of the
establishments where they are to be sent has been a prominent feature of the
junior employment work.
The work of this department could probably be more effectively carried
on in direct connection with the Board of Education department which has
supervision of aU children going to work. By such a central organization
the process of guiding children from school to work would be a continuous
one, under unified control and direction, making contradiction of purpose
impossible. Free interchange of opinion and advice between those ascer-
taining by examination the abilities qf children and those directing them
into industry would be possible and of great value. All of the data available,
relating to the various phases of the employment of children, would be ac-
cumulated in one place and their value for research and action be unequaled.
Until such time as it is possible to eflFect a consolidation between the two
departments it is recommended that their relations be made as close and
direct as possible in order that the opinion of those examining the child who
wishes to go to work, may direct the eflForts of the employment bureau in
finding the child suitable employment. Employment suited to a child's
physical and mental abiUties is essential. The degree of harmony attained
between a child and his first job has no smaU influence in determining whether
he will settle down and develop desirable work habits leading to a well ori-
ented character or whether he is going to be dissatisfied in a short time and
try another job, drifting about until his work habits become unsettled and
his character unstable.
An outline for such a Vocational Guidance Department is appended. It
contains in the plan of organization the essential activities involved in deal-
ing with the children of working age, all of which are properly included in a
department functioning under the Board of Education in any city. Some
features included have proved their value in similar departments already
organized in this country and abroad. A plan of this duuracter is appropri-
ately a part of this report as it emphasizes ou opinion that the proUem
of the child going into industry is fundamentally one of health, and
in order to protect his health adequately there must be a central bureau
Health and Industry 617
which will serve as a bridge for his safe conduct from school into the industrial
world. IVoper consideration of a child's physical abilities comes first. This
fact recognized and coupled with the other factors which must be considered,
there is no reason why children should not benefit by their early industrial
experience, rather than be permanently handicapped if not wasted to society
by their ill-advised efforts at work, before they are equal to it or for which
they are unfitted. A careful organization of the procedure of letting and
getting children to work will give the health questions the important place
which they should have, and will provide adequate machinery for continuing
the task of supervision of children until they reach maturity.
Suggested Plan of Organization for a Junior Vocational Bureau
OF THE Board of Education of Cleveland
To include boys 15 to 18 and girls 16 to 18 years of age. This period of years is sug-
gested rather than 15 to 21 years, because it is the division made by the State Child Labor
Law between children and adults. Also it simplifies the division of children's and adults'
emplQsrment into two offices, which offices can then be physically as well as officially
This organization will include all steps in the procedure of letting and getting a child
to work, from the time when he is still in school and thinking of going to work, to the time
when he is well established in suitable employment.
/• Sch€H>i Connectiona,
1. Continuous record cards to be used, containing the medical, mental, scholastic
and social (including family) history of the child, beginning with his first year in school
and foOowing him through the grades to the office where he makes application for a work
certificate. Such records have been used with great success in other cities.
2. Scholarship fund for children who otherwise would be obliged to go to work be-
cause of economic necessity.
3. Vocational talks to children who are thinking of leaving school, emphasizing the
importance of longer schooling, but also giving introductory information regarding indus-
txial life.
4. Published leaflets on occupations open to children, to contain specific informa-
tioo relative to various occupations for the benefit of children making, ready to leave
acfacx)! for work.
//• Schoot Attendance and illegal Employment
The school attendance and illegal employment of children of working age must be
doaeiy checked up in order to make certain that every child going to work does so legally
b^ floinC through the work certificate office where he must undergo a medical examination
bdbie receiving a work certificate.
618 Hospital and Health Sxtbvet
In order that all information relative to children 15 to 18 yean of age may be utiliied,
the school census records should be available at this office.
Special duties of one Or more of the regular school attendance officers would be to
follow up the school attendance of children of this age, to keep in touch with the State
Factory Inspection Department regarding children at work, and to follow up all cases of
children whose certificates have been returned, to see that they return to school if not at
work. Correspondence has been successfully utilized to accomplish some of these ends.
///• Issuance of Work Certificates,
1. Establishment of birth and school records in accordance with the legal require-
ments.
2. Medical examinations for health certificates, as required by law. The physician,
nurses and clerks are to make and record medical examinations and follow up children
whose permits are held up, until remediable defects are corrected, or are refused because of
physical disability. These children must be kept track of, to see that they get medical
assistance when necessary or return to school if not allowed to be at work. The school
medical record of a child is of service here.
3. Mental Tests — At present only marked subnormality is recorded in moat offices.
Intelligence tests are now used most effectively by many large corporations. Their use in
this department is essential in aiding in the selection of suitable work for normal as
well as for subnormal children.
IV. V€>cation Bureau,
1. Continuous research in occupations open to children is necessary for the purpose
of advising children wisely regarding work, and for the purpose of accumulating informa-
tion in respect to the health hazards for young people in various types of work. Too
little is known on this subject at the present time. Such information must be available to
the physician diagnosing a child's physical capacity for employment.
2. Placement and Guidance — Connects children who have received work certificates
with jobs, and has the advantage of all the facts established by previous examinatioos as
to the child's physical and mental qualifications, for use in vocational guidance work.
K, Research*
Through the many contacts which this bureau would have, and the large amount of
information in its files, special studies o^ related questions would be of value, as wdl at
periodical analysis of information in the files.
VL Advisory Committees,
Note — In the two months which have elapsed since the field work to
this report was completed, steps have been taken by the Cleveland Board of
Education towards the formation of such a bureau. The Bureau of Attend-
ance of the Board of Education has been enlarged and its functions extended.
Health and Industbt 619
Records have been established which wiU carry the medical, social and school
history of the child from the time when he first enters school to the date
when he leaves school to apply for working papers. Vocational advice to
such children is to be provided, and the possibility of arranging for employ-
ment work is being consideired. Greater emphasis is being put on a child's
physical status, ascertained by medical examinations, as the determining
factor in deciding whether or not he shall receive a permit to work.
SUMMARY OF RECOMMENDATfONS
/. Recommendations Requiring Legislation.
1. The Ohio State Child Labor Law should be amended in the following particulars:
Age Requirements — ^The employment of boys before they are 16 years of age should
be forbidden. Age and schooling certificates should be required of all boys under 18
years of age at work. This makes the age requirements for boys and girls the same.
In all cases in the law where an ''age and schooling certificate" is mentioned the law
should be changed, to read "age, schooling and health certificate," inasmuch as the health
certificate received by the child going to work is one of the most important factors to be
considered in certifying a child for employment.
2. The Ohio School Code should be amended in the following particulars:
Educational Requirements — Girls 16 to 18 years of age are not now required to continue
schcx>l if not employed. The law should be amended to include this requirement and to
make similar requirement for boys 16 to 18 years of age.
Health Certificate — ^The section of the law relating to a health certificate for a child
going to work should be changed. In no case should a child receive a certificate based on
a previous record of the child's health. A thorough medical examination, made by a
qualified physician, should be the requisite for every health certificate issued. These
certificates should be issued in such a manner and for such periods of time as to insure
periodical examinations of children over the two years from 16 to 18, or while they are
^mgAoytd on a certificate basis. Every health certificate should be issued for the specific
job for which the child makes application for a permit. There should be included a pro-
vision for an adequate force of examiners and assistants, for the work of examination and
follow up.
Phdge rf Employer — ^Added to this section of the law should be a clause requiring
that the promise signed by the employer specify the exact nature of the work which the
child is required or permitted to do.
Agricultural Work and Domestic Sercice are not now included by the Ohio Child Labor
Law in the occupations under its supervision. There should be an age limitation of at least 12
for these occupations and a limitation of hours of work, similar to those limitations in hours
of work In other occupations. A health certificate should be required of every child.
Rcculatian of cooditioos of work may involve some difficulties needing the cooperation
620 Hospital axd Health Subyet
of other agencies. Examinations for health certificates can be conducted in the same man-
ner as for other occupations by the existing machinery without great difficulty.
3. The City Ordinance regulating street trades should be enforced, pending the
inclusion of these trades in the State Child Labor Law. -Certificates to bpsrs to engage in
this work and badges to be worn by them while at work, as specified in the ordinance,
should be received f^om the work certificate office of the Board of Education, where eadi
boy will receive a medical examination showing him to be physically fit for this kind of
work, before he can receive a permit.
//. Recommendationa re Exiating Departments, State or Locat,
1. Enforcement of the State Child Labor Law is under the direction of the Industrial
Commission of Ohio. The law is not at the present time adequately enforced. Methods
of work should be improved and the personnel for inspection increased, in order to elimi-
nate the illegal employment of children, the extent of which the findings of this study
indicate.
2. Enforcement of the State School Law is similarly inadequate. It is under the dire^
tion of the Board of Education. The number of School Attendance officers should be in-
creased and the organization of the Attendance department and the Work Certificate
Office revised. The School Census maintained by another department of the Board of
Education should be more closely related to the department of Attendance, to aid in tiie
work of checking up on the attendance of children, and especially those of working age*
3. Medicid Examination for Work Certificates — The present organization is under the
direction of the Department of Medical Inspection of the Board of Education. It needs
to be considerably expanded and its working force increased. Health standards for chil-
dren going into industry should be formulated, patterned after those soon to be issued by
the Federal Children's Bureau Committee on Health Standards for Children in Industry.
One of its functions, still to be developed, should be sufficient contact with the industrial
field to assure familiarity with the jobs open to children, in order that the examining
physicians may be able to decide intelligently as to the desirability of diiferent kinds of
work for the various children examined.
4. Mental Examinations for Work, Certificates — There is at jiresent no means of de-
termining the mental capacities of children wishing to go to work, other than the school
record, which is too brief to furnish any information except the fact that the child has
completed the required school grade, except in the case of children who have been known
in school as markedly subnormal. There should be in close relation to the work of medical
examination for health certificates facilities by which to determine more accurately the
mental capacities of children wishing to work, in order to aid in the selection of employ-
ment for them. *
5. Educational Training — More educational preparation for the transition firom school
to industry is necessary. It is not within the province of a health survey to make specific
recommendations as to how this shall be done, but the Board of Education or the State
educational authorities should give this question careful consideration m the near future,
and make provision for more effective industrial education. In particular the Board of
Education should provide at once for systematic and thorough health instruction in the
EALTH AND iNDUdtBT 621
■ammar grades. Knowledge of the elements of hygiene and sanitatkxi is essential to the
lild entering industry as well as knowledge of the character of the health hazards which
t win encounter in industry.
6. Junior Emphymeni — ^The jiinior employment work at jiresent under the direction
r the Public Employment Bureau should be carried on in more direct connection with
lat department of the Board of Education having supervision of all children going to
ork, in order to have unified control and direction, making contradiction of purpose
apossible. Until such time as it is possible to effect this consolidation it is recommended
lat the relation between the departments be made close and direct, in order that the
pinion of those examiTiing a child applsring for a work certificate may direct the efforts of
le employment bureau in finding suitable employment for the child.
7. AUendanee Department — ^Plans have been made recentiy to enlarge and extend the
mctions of the Attendance Department of the Board of Education. Sufficient promi-
ence should be given to the medical and mental examinations in all questions relating
> the issuance of work certificates and to vocational guidance, as the medical and mental
laminations, properly conducted, give unequaled opportunity to make adjustment be-
veen the law and individual variation in capacity and physical development. More de-
endence should be placed on the results of careful examinations of children in deciding
I to their employment in various occupations, thus lessening hardship or unfairness in
dividual
.^
622
Hospital and Heai^th StmysT
TABLE I.
Classiflcation of 1,521 Industrial Organizations by Size Groups
Including Employes
Oroupby SuKof
Number of Per Cent of AU Number of
OrganixatioiM Or^pnisa- Bmployes
" inwoup
1 ,000 and over 39
500 and over 80
400 and over 100
300 and over 134
200 and over 182
100 and over 294
1 and over 1 ,521
Less than 1 , 000 1 , 482
Less than 500 1 ,441
Less than 400 1 ,421
Less than 300 — 1,387
Less than 200 — 1,339
Less than 100 1 , 227
2.56
5.25
6.57
8.80
11.96
19.32
100.00
97.44
94.75
93.43
91.20
88.04
80.68
84,359
112,535
121,362
132,802
144,564
155,246
196,246
111,887
83,711
74,884
63,444
51,682
41,000
Per Cent of
AUBmployes
AUOroope
42.98
57.34
61.84
67.67
73.66
79.10
100.00
57.02
42.66
38.16
32.33
26.34
20.90
2,163 0
1,406.6
1,213.6
991.0
794.2
528.0
129.0
75.4
58.0
52.6
45.7
38.5
33.4
1,000 and over 39 2.56 84,359 42.98 2.163.0
500 to 1,000 41 2.69 28,176 14.36 687.2
400 to 500 20 1.32 8,827 4.50 441.3
300 to 400 34 2.23 11,440 5.83 336.4
200 to 300 48 3.16 11,762 5.99 245.0
100 to 200 112 7.36 10,682 5.44 95.3
Ito 100 1,227 80.68 41,000 20.90 33.4
Totals 1,521 100.00 196,246 100.00 129.0
TABLE II.
Medical Service In Industrial Organizations
Group by Sise of Total Number ' Total Total Per Per Per Per
Orsanisations Number Organ. Number Number Cent Cent Cent Cent
Organ. with Employes Employes Orjgan, Enqw. Emps. Orgsn.
in Medical in Recvg. in in Served Senred
Group Service Group Service Oroup Group cmTAU ofAO
f Served Served Emps. Orgin
1,000 and over 39 32 84,359 72,196 82.05 85.58 36.78 2.10
500 to 1,000 41 30 28,176 20,786 73.17 73.77 10.59 1.97
200 to 500 102 7 32,029 2.118 6.86 6.61 1.07 0.46
Ito 200 1,339 3 51,682 365 0.22 0.70 0.18 0.20
Totals ^ 1,521 72 196,246 95,465 4.73 48.64 48.64 4.73
1,000 and over 39 32 84,359 72,196 82.05 85.58 36.78 2.10
500 and over 80 62 112,535 92,982 77.50 82.62 47.37 4.07
200 and over 182 69 144,564 95,100 37.91 65.78 48.45 4.53
land over 1,521 72 196,246 95,465 4.73 48.64 48.64 4.73
Health and Industry 628
TABLE III.
Personnel of Medical Departments
Number No. of No. of No. of No. of No. of No. of
Organ. Number of No. of Full- Part- Phsra. Trod. Rrac Oeii-
Oroop bj Siae of with Med. Bmployet Ind. Time Time on Nurtes Nurtes cal
^ r Service - - — — —
Served
Disp.
Phsrm.
Phsrm.
CaU
72,196
53
6
41
8
20 , 786
30
1
16
8
2,118 .
7
0
4
1
365
3
93
0
7
1
62
1
95,465
18
1,000 and over 32 72,196 53 6 41 8 69 12 14
500 to 1,000 30 20,786 30 1 16 8 18 7 0
200 to 500 7 2, 118. 70 4 1 6 0 0
1 to 200 3 365 3011010
Totals. 72 95,465 93 7 62 18 93 20 14
TABLE rV.
Administrative Relations of Fifty-six Medical Departments
Group by Six of MBDICAL DEPARTMENT RESPONSIBLE TO
OrganiaatioQa Administration Production Emplosrment Claims Total
1,000 and over 7 5 15 2 29
500 to 1,000 8 5 8 0 21
200 to 500 10 3 0 4
1 to 200 2 0 0 0 2
Totals ~ 18 10 26 2 56
TABLE V.
Medical Service in Mercantile Establishments and in Public Utilities
No.
Batab.
with
Bfolical
Service
No. of
Dit-
■ariea
No. of
Em-
jploycs
Stfved
No. of
Fun-
Timr
Phyt.
No. of
Part*
Time
Phsra.
No. of
Phyt.
on
CaU
No. of
Tmd.
Nurtes
•
No. of
Prac.
Nuraes
No.
with
Viatc
Nura-
iat
Mercantile.. .
^ 6
6
9,107
1
3
2
5
2
2
Public Util
^ 6
7
13,302
0
7
1
6
1
2
TotaliL-^-
^ 12
13
22.409
1
10
3
11
3
4
624 Hospital and Health Subybt
TABLE VI.
Accident Frequency and Severity Rates for Cuyahoga Ck>uiity
Based Upon Ohio Industrial Ck>nunission Report for
July to December, 1914
For six months period:
Accidents causing death „ 44
Accidents causing permanent partial disability 330
Accidents causing disability over seven days. 3,892
Accidents causing disability two to seven days. 4,571
Time Loss:
Cases fatal (6,000 days each) „ 264,000 days
Permanent partial disability 52,127 days
Temporary disability, over seven days. 103,976 days
Temporary disability, under seven days... 9 , 199 days
Total time loss, all accidents, six months. 429,302 days
Accepting estimate of Bulletin 9 (1915), Industrial Commission, employes in industry
numbered 185,000.
Estimated number reportable accidents annually 17,344
Frequency rate (number per 1,000 full-time workers) _ 93.7
Estimated number days lost per year.„^ ^ 858,604
Severity rate ( days lost per worker per year) 4.53
TABLE VII.
Accident Frequency and Severity Rates for Groups of Operatives
Employed Within Selected Areas
rSMMM A^^^r>^
the Period of June Ist to November 30th, 1919
■*^» >i^a«a^# x^
^#T^aBU
Crroup
Number
of
Employes
Accidents During Six Months
7 Dasrs More Estimated
and than Yearly Freq.
Fatal Less 7 Dasrs Total Rate
Batunated
Yearly
Time Loss
ScTcr*
ity
Rate
I.
24 , 298
3
905 215 2,246 92.4
33,927
1.3'
II.
19,600
6
2,147 520 5.346 276.3
74,345
3.7
III.
10 , 193
2
11
1,371 287 3,320 325.7
33,945
3.3
Totals
54.091
4,423 1,022 10.912 201.7
142,217
2.6
Time losses were estimated by reckoning a fatal accident as equivalent to 6,000 days.
Employing average values previously published by the Industrial Commission, tem-
porary disability of seven days or less was reckoned at 2.1 dayt; temporary disability of
more than seven days, at 28.2 days.
Health and Industry 625
TABLE VIII.
Comparative Accident Frequency and Severity Rates in the Con-
struction and Metal Trades
Based Upon Statistics Published by the Industrial Commission of Ohio for
Cuyahoga County, July to December, 1914
Construction Metal
Trades Trades
Number of employes. 20 , 000 72 , 900
Accidents (6 months):
PataL 19 10
Permanent partial disability. 30 71
Temporary disability. 1 , 393 3 , 825
Total number accidents . . 1 , 442 3 , 906
Accidents (calculated for one year) 2 , 8S4 7 , S12
Accident frequency rate 144 . 2 107 . 1
Corrected for assumed 10-hour day, 200-day year 216.3
Corrected for assumed S-hour day, 200-day year 270.3
Calculated time loss, days per year. 290 , 868 246 , 858
Accident severity rate —....»........... — . .^....... .....^„..^..^ — ^ .......... 14.5 3.38
Corrected for assumed 10-hour day, 200-day year 21 .0
Corrected for assumed 8-hour day, 200-day year^ 27. 2
The corrections above noted are made in consideration of the fact that many workers
in the construction trades do not work a 3,000-hour year, which is the normal basis of
computation of frequency and severity rates.
The time losses given in this table were calculated from those published by the Indus-
trial Commission, with the exception of allowances for fatal accidents, which were reckoned
as each equivalent to a loss of 6,000 dasrs.
626
Hospital and Health Subvet
TABLE IX.
Glassiflcation of 79 establishments employing women, presenting numbers of
various establishments* numbers of women therein employed,
and group totals.
Oroup
No. of
BctablUh.
ncnts
Qfxwp
Total
Industrial
••••••••• m^
•*••
11
••••
7
,,,,
6
..„
3
•«••
2
• *a«
5
57
No. of
Nature of
Oroup Member*
Metal Trades. 3 , 691
Knitting and Textile..... 4 , 642
Garment Trades. 2 , 700
Candy Factories. 371
Paper Box Factories. 220
Tobacco Factories. . 375
Miscellaneous 614
Group
Total
12,613
Mercantile
7
7
Department Stores.
—
6,730
Personal Sennet
6
3
2
11
Laundries .
Hotels
Restaurants
505
708
245
k
«
1,458
Public Utilities.
2
2
4
Telephone Companies.
Telegraph Companies
1.675
430
2,105
Totals..
79
22,906
ILTH AND InDUSTBT
627
s
(A
3
Cn
^4
s
s
s ? s
s
I
M
3
C«>
C«>
s
Ut
(*>
cn
M
z I
M
^4
!-• h« cn
8 S
C«>
00
M H*
3 3 I
cn 1^
S 8 i
cn
f
?
3 «'
00
I
<i
?
,s
1 <^
i <
N« N« H* h^ P
•^ ^ cn •- r.
c«i j
00
if
r
11
1-1
§
3
^
6«8
HospiTAi. AND Health Stibt
a
s
8
t
u
o
II i
X
PQ
is
^8
8 a
« 2
9?
§
H .
S
I
;;
tS
^' 8! S
* -H «
«* s
Ok
to
CO
i> 55
^ en
9^ S
l!iJ ^
Jj^
I
o
9
c«
■n
m ^
c«
c« ^
o
H
§
S K
tv to
c«
^ e^
00
CI
c«
00
to
CI
o
CI
o
00
00
I
CO
lO
t ^
i i ^
2 ?
•0
e>«
CO
en
CO
m
c«
c*
CO
ALTH AND lNi>USTRY
(MI9
TABLE XII.
assiflcation of starting weekly wage rates foe women in 55 industrial
establishments emplojring women.
Group
12-13
DoUan
13-14
DoUara
14-15
DoUara
. 15-16
DoUara
16-17
DoUara
17-17.50
DoUara
Totals
iL-
4
1
2
7
2
6
2
5
1
2
21
ting and Textile..
11
nent- ..j
1
••««
5
1
,,,,
•M.
7
iy.
•~i
4
•M.
••••
2
MM
6
xUaneoiUu
3
1
2
2
2
10
Totals..
8
8
16
11
10
55
TABLE XIII.
Classification of luncheon facilities in 56 industrial establishments
emplo3ring women.
jroup Cafeteria
aL 11
ting and Textile 5
nent, 3
ly. 2
reUaneous. 2
Totals. .- 23
Luncfaroom SeUing
Supplementary
Lunch
Lunchroom
Only
No
Lunchroom
Used
Tota
3
7
2
23
••••
3
3
11
* 1
3
•»M
7
••«•
2
1
5
8
10
23
56
wo
Hospital and Health Subvet
TABLE XIV.
GlaMiflcatioii of 33 industrial establishments employing women and hsfing
centralized employment seiricey by sixe-groups based on total
number of employes.
Group
l,OSO«iid
Over
S00tol,0S0
200 to SCO
1 toaoo
Totab
M4ftf^1
6
3
6
1
16
Knitting and Textile
1
3
0
0
0
0
5
0
1
1
1
2
C«idy
If Iscellaneoiis,
1
0
0
2
8
11
8
6
33
TABLE XV.
Classification of 23 industrial establishments emplojring supervisory women,
by size-groups based on total number of employes.
Group
MetaL
Knitting and Textile.
Garment .^ ..
Candy
Iwliacellaneoiu.
Totals.
1,000 and
Over
4
0
0
0
0
500 to 1,000 200 to 500
0
4
5
0
0
3
0
0
1
0
1 to 200
0
0
1
3
2
Totals
7
4
6
4
2
23
^X<TH AND InDVSTBT
6^1
i
S5
00
VI
Is
(/I
I
(/I
2 ?l
ai
00
00
(/I
6
B
Z
. I
C/l
(/I
o
S5
o
Ol
VI
81
"" xf
3
5*
00
s
VI
00
S9
VI
v>
v«
$
VI
o
00
M
VI
VI
00
o
5
3
VI
s
VI
00
<o
Ol
t
<o
ai
S5
00
VI
o
0»
v»
lO
* if
5 ?l
VI
8 ?^l
VI ^
-"■ sf
VI
VI
VI
?
i
O
2 ^
e
B
P
a
8?
Wt HoaPITAL AND HkALTH SlTBfET
TABLE XVII.
Number of Children at Work, By Age and Sex
From the Work Certificate Records, September, 1918 to September, 1919
Septtember, 1918 to
June* 1919
1,444
2,057
Pcmiits
June-September, 1919
581
546
Total
atWoffc
2,025
•••••>•••«•.
2,603
^■■■B A9^« *••••»••*•*•■
ToUl 3.501 1,137 4,6M
TABLE XVIII.
Number of Children at Work, By^Age and [Sex
From the Records of the Industrial Ciommission of Ohio, 1919
Ociical _Wa8e Sales Totri
Wot ken
Boys. ^ 617 2,248 92 2,957
Girls. 573 1.416 83 2,072
Total.. 1.190 3,664 175 5,029
TABLE XIX.
Comparison of Tables 16-18 for Number of Children at Work
Work CertificMe Ind.
School
Ace« 15-18 A«e« 15-16 and Ace« 15-18
16-18
Boys 9.068 1.444 2.957
(1518) (15-16) (15-18)
Giris. 6.778 2.057 2.072
(16-18) (16-18) (16-18)
Total _ 15.846 3,501 5.029
Health and Industry
688
TABLE XX.
Occupations Employing Children Under 18, By Age and Sex
Analysis of Records of Industrial Commission of Ohio, 1919
Bogf»-
Clerical Workers.:
Wage Bamers.
Saleiq|)eopie »«..
Total ._.
Mtmc-
turing
Service
Trade.
WhoteMle
Telephone
and
Tefegraph
Total
15
309
116
157
20
617
67
1,778
56
316
31
2,248
1
3
•••«
88
92
^ 83
2,090
172
561
51
2,957
Wage Bamers.
Salespeople
Total.. .^
12
12
205
92
187
77
573
688
43
299
386
1,416
6
—
77
••w«
83
899
135
563
463
2,072
Clerical Workers.
Wage Earners..
Salespeople
Grand TotaL.
27
514
208
344
97
1,190
67
2,466
99
615
417
3,664
1
9
—
165
—
175
95
2,989
307
1,124
514
5,029
Per Gent of Total Number Employed of Each Group by Sex
ToUd
617
573
20.9%
27.6%
Wage Bamen
No. PttCent
2,248 76.0%
1,416 68.4%
No.
92
83
Per Cent
3.1%
4.0%
No. P«r Ceat
2,957 100%
2,072 100%
1,190 23.7% 3,664 72.8% 175 3.5% 5,029 100%
9S4 Hospital and Health Suk?it
TABLE XXI.
Dtstribution of Qiildreii in All Occupations and in Leading Manv:
factures for 1915 and 1919
, From the Records of the Industrial Ck>inmis8ion of Ohio, 1915 and 1919
Boy Girls
Occupation
Construction,. ...
«
Manufacturing.
Trade, Retail and Wholesale
Td|<^>hone and Telegraph Work..
Total.-.
(
I
.A
r
I reading Manufacturers
Autos and Auto Parts.
Bolts, Nuts, Etc
Clothing, Men's and Women's.
Confectionery
Copper, Tin, Etc
Electrical Machinery .-^..
Foundry and Machine Shop Products.
Gas and Electric Fixtures.
Hosieiy and Knit Goods
Printing and Publishing
Sowing Machines
Stfcel Works and Rolling MiUs....^
Woolen and Worsted Goods.
1915
1919
1915
1919
58
83
0
It
1,638
2,090
859
899
37
172
6
.%
323
561
299
563
44
51
35
463
2,100
2,957
1.199
2.073
1
Boys
Girls
1915
1919
1915
1919
66
120
53
18
44
76
6
3
26
37
286
115
8
0
32
76
76
61
0
19
71
277
14
S3
200
334
12
S3
24
96
• 23
187
36
15
121
29
202
242
26
81
0
160
'' 0
10
76
4
0
0.
20
1
7
.42
Total ^ 849 1,423 580 686
LTH AND Industry
nS5
TABLE XXII.
Weekly Wage Rates for Children By Occupation and Set
From the Report of the Industrial Cominissioii of Ohio for 1919
5.00—
r.oo—
1.00—
LO.OO—
fl2.00—
^15.00—
^18.00—
^21.00—
f25.0a—
MO.OO—
M5.00—
tal
Coaitnic*
Manufac-
turing
Service
Trade,
RetaUand
WholeMk
Telephone
and
Telesraph
Total
Total
0
20
4
29
1
54
0
2
2
17
0
21
75
1
13
3
23
1
41
0
4
0
2
0
6
47
7
8
5
35
2
57
1
1
5
24
0
31
88
5
31
11
19
5
71
0
14
7
8
0
29
100
34
87
23
74
11
229
0-
47
9
49
4
109
338
14
268
43
109
12
446
1
201
40
177
328
747
1,193
11
567
49
138
10
775
5
3 71
33
172
86
667
1,442
4
473
16
87
6
586
2
178
14
83
20
297
883
2
424
19
40
0
485
57
14
23
8
103
588
3
154
0
4
2
163
18
5
7
10
41
204
42
0
0
1
44
0
6
2
1
5
14
58
3
1
3
0
8
.
0
2
307
0
2
514
5
13
95
2,989
1,124
5,029
i,oi»
996
Hospital and Health Subyet
TABLE XXIIL A
Analysis of Records of 100 Newsboys in Cleveland, Showing AgCi
School Grade and Mental Capacity
School Grade
igfi
I.
II.
III.
IV. V.
VI.
Total
6
4
m»m»
^^^^
.... ....
•...
4
7
1
3
••••
.... ....
»...
4
8
....
6
2
.... ....
....
8
9
....
2
2
.... ....
•••.
4
10
1
....
2
5 4
....
12
11
1
....
2
5 12
1
21
12
(Special 2)
....
10
5
17
13
(Special 6)
2
5
12
25
14
....
....
'V
2
1
3
15
—
•
1
1
2
rota]
I 7
11
10
10 34
20
100
Mental Capacity
Good Fair Poor Total
1
2
3
3
7
11
9
8
4
1
3
5
5
11
1.
2
1
2
5
3
6
3
2
4
4
8
4
12
21
17
25
3
2
44
31
25 100
TABLE XXIIL B
Analysis of Records of 100 Newsboys, (]!ontinued, Showing Age,
Health and Hours of Work at Night
Health
Age Good Fair Poor Total
6
3
..„..
1
4
7
•••.
1
3
4
8
4
1
3
8
9
1
1
2
4
10
6
2
4
12
11
8
3
10
21
12
8
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THE CLEVELAND HOSPITAL AND HEALTH SURVEY
REPORT
list of Parta and Titles
L Introduction.
General Environment.
Sanitation.
n. Public HealthfServices.
Private Health Agencies.
m. A Ph>gram for ChildlHealth.
rV. Tuberculosis.
V. Venereal Disease.
VI. Mental Diseases and Mental Deficiency.
Vn. Industrial Medical Service.
Women and Industry.
Children and Industry.
Vni. Education and Practice in Medicine»[(Dentistry» Pharmacy.
IX. Nursing.
X. Hospitals and Dispensaries.
XI. Method of Survey.
Bibliography of Surveys.
Index,
Xhe complete set may be obtained at a cost of $5.50 plus the
postage and single parts at 50 cents each plus the po8tage»{rom
THE CLEVELAND HOSPITAL COUNCIL.
808 Anisfield Buildingp
Cleveland, Ohio
I ill
PHatod hj
TnPwHim
E Jucation anJ Practice
in Meaicine, Dentistry,
Pnarmacy
Part Eight
Cleveland Hospital and
Health Survey
Education and Practice m
Medicine, Dentistry,
Pkarmacy
Part Eight
Cleveland Hospital a n^d
HealtK Survey
Copyright. 1920
by
The Cleveland Hospital Counxil
Cleveland, Ohio
Published by
The Cleveland Hospital Council
308 Anisficld Rldg.
Cleveland - Ohio
Pref
The Hospital and Health Survey of Cleveland was made at the request
he Cleveland Hospital Council.
The Survey Committee appointed to be directly responsible for the
k and through whose hands this report has been received for publica-
i consisted of the following:
Malcolm L. McBride, Chairman;
Mrs. Alfbed A. Brewster,
Thomas Coughlin,
Richard F. Grant,
Samuel H. Halle,
Otto Miller,
Dr. H. L. Rockwood,
Howell Wright, Secretary
'he staflF responsible for the work were:
Haven Emerson, M. D., Director,
and the following collaborators:
Gertrude E. Sturges, M. D., Assistant Director;
Michael M. Davis, Jr., Ph. D., Director of the Hospital and
Dispensary Survey;
Josephine Goldmark, B. A., Director of the Nursing Survey;
Wade Wright, M. D., Director of the Industrial Hygiene Survey;
Donald B. Armstrong, M. D., Director of Tuberculosis Survey;
S. Josephine Baker, M. D., D. P. H., Director of the Infant
and Maternity Survey;
T. W. Salmon, M. D., Director of the Mental Hygiene Survey;
W. F. Snow, M. D., Director of the Venereal Disease Survey;
Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey.
The expenses of the Survey and of the publication of the report have
1 met by appropriations received from the Community Chest, through
Welfare Federation, of which the Hospital Council is a member.
The report as a whole, or by sections, can be obtained from the Cleveland
3ital Council. A list of the parts will be found in the back of this volume,
bher with prices.
TABLE OF CONTENTS
I. Medical Education and Practice in Cleveland.
Medical College of Western Reserve University. Page
Position in Community 651
Present Problems of
Construction 653
Endowment 654
Community Relations 655
Discussion of Instruction Now Offered™ _„ .^ 656
History of the College and the Distribution of its Graduates 659
Post-graduate Instruction..,. „ \ 662
Medical Practice
Classification of Cleveland Physicians by Specialties. 663
Hospital Staff Service l, 664
Professional Organizations ^ 664
Discussion of Autopsy Service 667
Recommendations ^^ 669
II. Quacks and Patent Medicines, in Relation to the Foreign Bom of Cleveland.
The Picture
The Immigrant — Susceptibility of foreign temperament 672
The Quack 672
How the Quack Reaches the Immigrant 674
The Objectives
Means of Investigation and Prevention ^ 676
Means of Prevention
Education of Public 677
Regeneration of Foreign Language Newspapers 678
Counter Attractions 678
Recommendations 682
III. Dentistry in Cleveland
Private Practice of Dentistry 683
Free Dental Work
At public schools 684
At 3 health centers 684
At City Hospital .„ ^ 685
TABLE OF CONTENTS— Con/mM^
Dentistry in Cleveland — Continued Page
Dental Service at College of Dentistry 685
Dental Service in Hospitals 686
College of Dentistry 688
The Dental Hygienist 689
Recommendations 690
Pharmacy in Cleveland
Number and Education of Pharmacists 691
Laws Dealing with Pharmacy
Enforcement of Law 692
Abuses Which Are Tolerated 693
Cooperation of Pharmacists with the Division of Health 694
School of Pharmacy of Western Reserve University
History 694
Buildings 695
Faculty 695
Finances 695
Needs ^ 695
Proposed Manufacturing and Professional Service for Hospitals 696
Recommendations „ 697
Medical Education and Practice
in Cleveland
By Haven Emerson, M. D.
HOOL OF MEDICINE OF WESTERN RESERVE UNIVERSITY
"T THERE there is but one institution of learning in a community, deal-
Jy ing with education in the liberal professions primarily concerned
with the prevention and care of disease, the responsibility for pro-
ems and accomplishment is easy to fix and the resources to be looked to
' advancement are sharply limited. In Cleveland through eliminations,
*rgers and absorptions the Western Reserve University finds itself at the
>nient the only institution in Cleveland responsible for the preparation of
ysicians, dentists and pharmacists for the legal practice of these profes-
•ns. For nurses also the only agency oflFering education in the pubUc
alth field is provided by the University.
Since public service in the field of medical practice and in preventive
^ciicine can not rise higher than its source, it is natural that where failures
imagination, scope, technic and standards in the prof essions are found
* inquirer turns to the University to seek the cause. University education
subject to the same three main limitations as aflfect education in general
d they are apparently, in the order of their importance, the ideals of the
ichers, the character of administrative leadership and organization, and
^ material resources to provide the teachers and the facilities for their
velopment.
For the noticeably deficient recognition by the laity and by the medica
ofession of Cleveland, of many specialties in medicine which now demand
^g preparation, exclusive devotion and constant study in order to reap the
tiefit and provide the service which modem knowledge permits, we can
t but hold the policies of the medical teachers responsible. Under both
^icine and surgery important and necessary sp)ecial branches have devel-
•^d elsewhere which are not provided for in Cleveland. In tuberculosis,
rdiology, neurology, psychiatry, urology, industrial and preventive medi-
^^, and orthopedics, opportunities have been and are still lost which the
^ical school owes to students, practitioners and the sick of the city. There
much encouragement in the fact that during the past college year de-
vious have been reached which should broaden the field of surgery by pro-
ding for a department of orthopedics having a large measure of independent
-Velopment, and under the general head of medicine will arrange for a de-
ftrtment of psychiatry and neurology with obligations to provide for the
^ssary clinical teaching in these specialties. Much more could still be
one to encourage and assist undergraduate students and recent graduates
> cultivate new and special fields in research and practice as is common in
her centers of medical education.
65^ Hospital and Health Survey
The contact made with a wide circle of workers in medical and kindred
fields, especially among those concerned with the social and preventive appli-
cation of medical sciences in Cleveland, gradually developed the conviction
among the members of the Survey staflF that the regard, respect, dependence
and affection felt by the public for the University fall far short of what one
might expect. Little exact knowledge was found to be possessed concerning
many of the important problems of medical and dental education by those
in responsible positions as trustees and executives.
In the Medical School the constitution and activities of the executive
committee of the faculty seem to meet all the needs and yet contact between
the faculty and the trustees is on an uncertain and unsatisfactory basis.
Definite assignment of duties and responsibilities are not called for from the
trustees. It is a matter of first importance that the appeal for support
for education should be based on recognition by the public of eminent sw-
vice given to it by the University, and upon entire confidence in the practical
value of the training given and of the researches undertaken.
In the words of the business salesman, the University has not sold itself
to the Cleveland public. Leadership, organization and service are needed
with this object in view.
To this end it is suggested that much strength to the University organi-
zation might be expected by enlisting the active interest and work of trus-
tees who are still in the midst of the actual problems of industry, professions
and public service, as well as those to whom the honor of trusteeship is
rather a recognition of past accomplishments and of readiness to be generous
in financial support.
Among the trustees should be those chosen by the alumni of the various
professional schools from their own professions, oflScially delegated to repre-
sent the graduates. From no representative group of citizens will be found
those who will serve the University more faithfully or bring to its councils
more vision, ideals and influential support than from the body of graduates
of the Medical School.
As to the third element in determining a university's ability to meet its
public obligations: namely, material resources for teaching and research, it is
worth noting that at the present time when building costs are so exorbitant
and teachers of all kinds are so ill paid, the simplest business logic w^ill advise
investment largely in men, brains and service with, for the time being, no
more outlay on buildings than is necessary to give adequate facilities for the
teachers, the classes and such research as can only be done within University
buildings. Once the relative importance of the various financial needs
which the professional colleges face is outlined, the generosity and pride of
Clevelanders in their important public undertaking, the Western Reserve
University, can be counted on to find the funds.
Professional Education and Practice 653
Problems of Construction and Endowment
In considering the relative importance of the two large undertakings
which face the trustees : namely, the erection of new Medical School build-
ings and endowment or more adequate financial support for the teaching
departments of the Medical School, and the erection and maintenance of a
University Hospital Group, a few fundamental statements of fact and ex-
pressions of opinion are offered before presenting concrete recommendations
for order of procedure, as suggested for the consideration of the Board of
Trustees.
In the first place, the University now controls at City Hospital, at Lake-
side, at the Maternity Hospital and at the Babies' Dispensary and Hospital,
such facilities for cHnical teaching as meet the most ambitious needs for the
highest grade of medical education, and very broad opportunities for re-
search in both laboratory and clinical branches of medical science.
At Lakeside and at City Hospital 936 beds offering clinical material in
medicine, surgery, pediatrics, contagious diseases, tuberculosis, venereal dis-
ease and mental disease are available and under exclusive University control
for 12 months in the year. Twenty-two beds for maternity cases and 1,500
confinements a year in in- and out-patient services are available for teaching
purposes. With the proposed doubling of the capacity of City Hospital, to
which the city committed itself by vote at the primary elections in April,
1920, the field for clinical study at that hospital will be still further increased.
The City Hospital will probably always include groups of patients who can-
not legally be cared for except in such a public hospital. The City Hospital will,
in all probability, always have a larger group of patients available for clinical
instruction in contagious diseases, tuberculosis, venereal diseases, mental and
nervous diseases, chronic, incurable and inoperable medical and surgical
cases than are likely to be or should be accommodated in any privately con-
trolled institution, even if devoted exclusively to teaching purposes. The
value of this asset in clinical teaching can hardly be over-emphasized.
The close physical situation of Medical School buildings, in relation to
the home of other faculties of the university departments, is considered very
desirable, if not absolutely essential, for the broadest and most catholic
relationship between the various teaching groups.
The control by a university medical school of its own hospital, in order
to permit of intensive study and special methods of education in groups of
patients selected particularly for their value in medical education and re-
search, is considered entirely desirable and the complete dependency of a
medical school upon a public department for its sole hospital facilities is not
considered safe in the present crude and politically precarious condition of
municipal government in Cleveland, as elsewhere in the United States. The
physical separation of the City Hospital from the Medical School buildings,
which it may be presumed will ultimately be located in the vicinity of the
University campus, would not necessarily put any particular inconvenience
in the way of its use by medical students, although the time of medical
654 Hospital and Health Survey
teachers might be wasted to a slight degree unless there were certain labora-
tory or research facilities added to the City Hospital equipment at the ex-
pense of the University.
It is believed that the first project for which money should be raised and
plans made for construction, equipment and maintenance, is a building or
buildings for the Medical School, to include the various facilities needed for
teaching and research, such as can be carried on outside of tlie immediate
walls of the hospital.
It is recommended that, at the same time that the project for Medical
School buildings is undertaken, the trustees prepare a plan for the financial
support, either by endowment or with annual pledges, which will provide
adequately for the salaries and service needs of each department, so as to in-
sure the provision of personnel to give the University a 100% return for
its investment in its greatest asset — the brains of its teachers.
It is recommended that the trustees of the University devote their best
efforts to accomplish such changes as may be needed in the City Charter
and such action as may be necessary from the officers of the city government
as to insure the api)ointment of trustees selected from representative groups
of citizens by the Mayor, to be responsible for the administration of the
City Hospital. In support of this recommendation it must be said that
the University has a greater stake in the i>ermanency of policy, in the non-
political character of administration, and in the standard of equipment,
service and support given to the City Hospital than has any other group
in the community. It would probably cost upward of $^5,000,000 at
present construction costs for the University to obtain, through private
means, anything approximating the range of material for clinical teaching
that will be availal^le and at their service at the enlarged City Hospital. It
must be noted that the value of this material in medical education is now
and always will be jeopardized y)y ])olitical mischief or accident until the
present method of appointing the superintendent of City Hospital and his
responsibility practically direct to the Mayor, to whom alone he is indebted
for his appointment, is replaced by a method of appointment and adminis-
tration which resembles more closely the system found necessary to insure
continuous and high grade hospital i)olicies and administration in private
institutions under boards of trustees. It is, furthermore, felt that the Uni-
versity owes to the public the use of its prestige and influence to get the City
Hospital out of ])olitics, if for no other reason than that the sick poor at
City Hos])ital are entitled to as constant and scientific medical ser\nce as
the University would expect to provide in its own privately controlled insti-
tutions.
When the above three main accomplishments have been successfully
carried to completion or have been brought, by the eflPorts of the University,
within promise of accom])lishment, and when funds have been obtained
which would justify undertaking a building program, at a cubic foot cost for
construction considerably less it is lioped than prevails at the present time,
Professional Education and Practice * 655
the plans of the University Trustees for a joint hospital project, involving
the Babies' Hospital, Maternity Hospital and Lakeside Hospital should be
carried through essentially as they are at present worked out but not neces-
sarily as a single construction undertaking. There is good reason to expect
substantial benefits to result from prosecuting all these projects at the same
time, if the relative importance of the several undertakings is kept continu-
ously in mind.
Of the needs of the University Medical School and of the needs of the
community for hospital beds it is quite clear that a hospital service for chil-
dren of all ages is much greater than is the need for beds for maternity or
for general medical and surgical patients. It is, therefore, recommended
that as soon as funds can be provided the trustees proceed with the erection
of the so-called Babies' Hospital project, which it is understood will provide
for children of all ages to a total of 150 beds. The next in the order of im-
portance, and the next by considerable margin of importance in terms of
medical teaching or community need, would be the construction of a Mater-
nity Hospital which is planned for 100 beds. In approximately the same
position, but perhaps slightly less urgent as a need for medical education,
though obviously needed by the community sooner or later, is the erection
of the new Lakeside Hospital. As soon as funds can be provided, therefore,
should come the construction of the proposed 500-bed hospital for general
medical and surgical patients, including a pavilion for patients with mental
and nervous disordei;s for the department of psychiatry.
Community Relations
Although the minimal hospital bed needs of the community indicate
that Cleveland will require the additional 400 beds which the University
Group project would provide for the total bed capacity of Cleveland, the Sur-
vey cannot recommend that $12,000,000 be spent for this purpose when
medical teaching needs do not demand more beds and when that number
of beds could be provided for the city through additions to other hospitals
at a half, and possibly at a third, of this expense, if built solely with the ob-
ject of providing adequate hospitalization for the sick.
Among the reasons often voiced in Cleveland for lack of full professional
and public trust in and support of the Medical School is that, under the
reasonable argument of needs for clinical teaching, the nomination of pro-
fessional staffs of hospitals is permitted by the trustees of certain hospitals
to rest with the faculty of the Medical School. Whether or not there is jus-
tice in this criticism it is apparent that no asset accrues to the Medical School
if it is in a position of exclusive control over facilities not really needed for
teaching purposes. It is suggested that any formal affiliations with hos-
pitals except those now maintained at the City Hospital arid the three organi-
zations of the University Hospital Group, (Lakeside, Maternity and Babies')
be severed, unless the boards of trustees of the hospitals specifically request
the University through its medical faculty to relieve them of the responsi-
bility of selecting the members of the professional staff of their hospitals.
Further than this it is thought that the funds and energies of the Univer-
656 ■ Hospital and Health Survey
sity and its teachers should not be devoted to operating public health ser-
vices such as a city- wide prenatal and maternity service, to an extent greater
than is needed in the teaching and research in medicine. To demonstrate
rather than to operate in such public fields would seem the wiser role.
Another matter of importance to the University in its relations to the
public is its contribution of part-time service, supervision, and direction through
members of its teaching staflf to the work of various bureaus of the Division
of Health. It is thought that it would be wiser for the University teachers
to be held in an advisory capacity rather than in a financial relation as part-
time employes of the city. The present relationship does not bring credit to
the University although the services are of a grade which the city does not
seem prepared to pay for at their true value. Any criticism of the public
health service bears back upon the University teachers who share in the
responsibility and in the emoluments.
Curriculum, Instruction and Faculty OROANizArroN
Now that there is such a strong and increasingly well-informed current
of public opinion in matters relating to preventive medicine and health
development it would seem a particularly propitious time for the University
to undertake in its Medical School, education of its medical students in their
responsibilities to the public as quasi-health officers, as private practitioners
and as students of the broad facts of epidemiology. There is no clinical
subject, major or minor specialty, which is not susceptible of treatment to
the end that preventive as well as diagnostic and therapeutic objectives
may be taught in each patient. Systematic instruction in public health
problems and methods is now an obligation of every medical school, which
can no longer be escaped on the plea of an overcrowded curriculum.
In proposing that industrial hygiene be developed as a department of
the medical school or better as a separate small school under the wing of the
medical school the particular local need of Cleveland's employers for trained
medical officers in their plants and the great variety of industrial hasards
not at present adequately studied and guarded against in the interest of the
employes, are to be particularly emphasized. It would be unwise to confuse
the training of industrial physicians with the training of physicians .for
careers as public health administrators.
Details of a course of lectures, demonstrations and laboratory work
have been given to the members of the medical faculty concerned, by the
members of the Survey staflf in charge of the Industrial Health Survey.
Special reasons for urging endowment for a department of industrial
hygiene will be found in the section devoted to industry. Part VII. Now
that orthopedic surgery and psychiatry bid fair to see special provision made
for them, there remains among the major needs a special opportunity for
urology under the aegis of the department of surgery.
Professional Education and Practice 657
Generous praise must be given for the quality and scop)e, the leadership
nd product of the laboratory sciences as taught by the medical faculty.
The study of physiology and functional pathology is well coordinated by
3ecial teaching in clinical study at the bedside.
While the department of anatomy has ample provision for staff and re-
earch and is particularly favored by the State laws under which a collection
f material of very great value has been obtained in the course of many
ears of work, the fire risk of the present unsuitable quarters gives serious
ause for anxiety. It is certainly unfortunate that the teaching of em-
ryology and histology are not as well coordinated with general anatomy as
re physiological chemistry and general physiology. The students do not
t present get the best that the teaching staff of this department
nd the modem conception of anatomical teaching permit.
Full-time teaching positions for the head of the main clinical depart-
ents and for the chief assistants in clinical instruction are much to be de-
red and would be welcomed in the department of medicine as they have
ien established in the department of pediatrics.
Private practice ambitions will always run counter to the best tradi-
ons and quality of medical teaching.
There is no organization of clinical departments for staflf conference,
nd the result is a feeling of detachment and lack of interest, particularly
mong those whose teaching never comes under the critical and stimulating
ye of the head of the department. Policies and standards of instruction
^here there are several hospital services used for teaching can only be put
n a sound basis by frequent departmental staff conferences. With the ex-
cption of the departments of pathology and physiology there is little, if
ny, contact established between teaching at the Medical School or Lake-
Me and the teaching at City Hospital.
With the existing active executive committee of the medical faculty to
elieve that body of the burden of business detail and to be ready for quick
ction when need arises, there is oflfered an excellent opportunity to democ-
itize and broaden the influence of the faculty and of the forces within it,
y extending membership and vote to a larger proportion of the teaching
aff. It is of great importance that those responsible for the various divir
)iis of teaching meet for discussion and interchange of opinions as to general
licies of the school. Although the so-called voting faculty of 24 might
pear to give a broad and adequate representation, a little study of its
mbership shows how restricted it is.
658 Hospital and Health Surety
Medical voting faculty consists of:
Votes Members
1 - Jh^esident of the University .
2 _ Senior or emeritus professors, inactive,
not teaching or in touch with the
college work.
1.— Research and elective teaching pro-
fessor only.
20 Active in teaching.
24
Among the 20 active teachers are four who teach less than thirty-five
scheduled hours a year. One associate professor in a clinical specialty has a
vote but has no clinic and teaches only 16 hours a year.
If there were departmental staff organizations so that the head of a
department really represented his department with full knowledge of the
opinions, teaching practices and so forth, of his colleagues and assistants,
even this limited group (20) would give a good working representation, but
there is much irrelevancy in the assignment of voting power apparently, for
while the laboratory subject of bio-chemistry with an assistant professor is
not represented, otology, gynecology' and genito-urinary surgery have each
a vote.
There are four assistant professors who teach eighty or more hours each
and yet have no voice in the faculty; not that representation should be
based on the hours of teaching .but that the faculty would be strengthened
by the i)resence of men who are devoting so much of their lives to medical
teaching, men whose youth and ambition is now rather a neglected asset.
The danger of clique domination by clinical interests, where the great
resources of hospital and college laboratories for private advancement are
available, is always to be feared in medical schools, and to meet such a
possibility prompt democratization of the voting faculty is recommended.
L<ick of sufficient junior assistants particularly at City Hospital forbids
the thorough working up of the amazingly fertile material in clinical medi-
cine, surgery and pediatrics. Diseases of metabolism, tuberculosis, cardiac
disease and nu^ntal diseases ap])ear to have but little consideration in the
general ])lan of training of third and fourth year medical students.
The teaching of surgery at Lakeside is almost exclusively carried out
by the ])aid resident house officers, the head of the department confining his
field to demonstrations and operative clinics. The surgery taught at City
and at St. Vincent's hospitals is not brought into any definite or constant
relation in the way of subject matter or secjuence with the teaching at Lake-
side, 'i'here is generous ])rovision for research in both surgery and medicine.
OFESSIONAL EDUCATION AND PRACTICE 659
The teaching of obstetrics and of pediatrics in the fields of private
ictice and of preventive medicine is excellent. The department of pedia-
cs lacks adequate dispensary service for children over three. The de-
rtment of obstetrics has more material than it needs for teaching pur-
ses. If there is to be a truly modem and just division of responsibility
tween these s]:)ecialties, the new bom babe at the maternity hospital and
the homes reached by the out-patient delivery service, should be turned
er at once to the care of the ]:)ediatrists. A baby should not be an ob-
'trician's responsibility once it is separated from the mother, and the
>st important age from the point of yiew of prevention of infant mor-
ity is precisely the period when the babe is now under the care of the
stetrician.
The Medical School lacks the attention and service for organization,
velopment and coordination of its various departments and functions
lich are primarily the duty of the Dean of a professional school. The
ison for this is not lack of imderstanding or appreciation of the problems,
t the overwhelming occupation of the Dean in an absoH)ing and widely
;tributed private and hospital surgical practice, and in a considerable
lount of clinical surgical instruction and demonstration. To attempt to
iintain adequate direction of the intricate problems of the Medical School
luires more time and undivided attention than can at present be given by
; Dean. His rare and invaluable services in the field of surgical anatomy,
thology, diagnosis and operative treatment can ill be spared or his organ-
ng ability be demanded at the expense of his professional career.
History of the College and the Distribution of Its
Graduates
A brief sunMnary of the important facts about the Western Reserve
liversity Medical School and the part its graduates play in the professional
» of Cleveland may properly be included here.
Organized in 1843 this school officially joined the University in 1881.
1914 there was merged with the Medical School of Western Reserve Uni-
rsity the Medical Department of Ohio Wesleyan University or the College
Physicians and Surgeons, itself a product of mergers of the Charity Hos-
)spital Medical College, which combined with the Medical Department of
ooster University in 1870, and the latter institution which merged with
B College of Physicians and Surgeons in 1896.
From 1844 to 1899, the Western Reserve University School of Medicine
iduated 1,085 physicians. From 1900 to 1919 it has graduated 571 phy-
ians. There graduated in 1920, 45, and the attendance of the school
ring the academic year 1919-1920 was 223, divided by classes, first year
, second year 34, third year 41, and fourth year 54. It is the policy of
» school to limit its classes to fifty students. Laboratory facilities are
adequate for more.
660 Hospital and Health Survey
The number of the teaching staff is 102 distributed by departments as
follows:
•
Anatomy „ 8
Biochemistry 2
Physiology 3
Pathology- „ 11
Hygiene and Bacteriology 3
Pharmacology and Therapeutics __ 4
Medicine 23
Pediatrics 9
Surgery „ 37
Obstetrics and Gynecology ~ 12
112
In 10 instances teachers hold positions in two departments. At Lake
side Hospital forty teachers hold staff positions, at City Hospital twenty-
three, at St. Vincent's Charity Hospital nine, and at Maternity Hospital
four. These also include ten duplications. Forty p)er cent of tlie clinical
teachers .are Western Reserve University graduates.
The total required hours of work in the present four year course at the
Western Reserve University Medical School are 5,136 hours, with electives
88 hours, or a grand total of 5, "^"^4. At Nortliwestem University at Chica^
tlie total required is 4,3'2^ hours. At the University of Michigan it is 4,545
hours, and at Inland Stanford 4,184 hours.
The following table sliows the present distribution of graduates of this
school in the practice of medicine in Cleveland.
Wkstkun Rkservk University (iraduates Rf:maixing in Cleveland
No. Practising in Cleveland Per Cent
16 2.67
38 7.26
72 24.2
90 37.6
57 44.5
58 28.4
Years-Group
No. of Graduates
1860-79
596
1880-89
523
1890-99
297
1900-09
239
1910-14
128
1915-19
204
Total 1987 331 16-6
Three hundred and thirty-one or ^8.3% of 1,169 physicians in Cleveland
are graduates of Western Reserve University Medical School. Of the 309
2SSIONAL EDtCATION AND PRACTICE
661
al staff positions in Cleveland, 75 or 24.2% are held by Western Re-
University graduates and 31 or 10% by Western Reserve University
^rs, graduates of other schools, or a total of 84.2% of hospital staff
ms held by Western Reserve University graduates and teachers.
he following three tables are of considerable interest to teachers and
tioners of medicine in Cleveland.
TABLE /.♦
Medical Department, Wettern Reserve University, Cleveland
0 .
Itimated
Popula-
tion of
City
Classification
by Council o
Medical Edu
cation •
No. of Stu-
dents
Registered
M
V
9
2
0
0<S
TOTAL FEES
u
Number of
Teachers
Weeks in the
College Year
Executive
Officer
i06,938
A
94
21
18
$130 $130 $130 $130
84 34 F.C.Waitc, Sec .
60 . 663
A
107-64 t
14
12
142
135
135
135
114
34
«
60 , 663
A
135-^1 1
35
29
142
135
135
135
89
34
«
160,663
A-
144-1 7 1
22
21
162
155
150
155
96 34
«
60,663
A-
153^t
30
30
162
153
150
155
90
33
«
139,431
A
169
38
37
162
155
150
155
93
34
«
156,975
A
178
49
49
162
155
150
155
96 34
«
i56,975
A
165
32
32
175
160
154
155
107
34
CA.Hamann,
Dean
»74,073
A
181
46
46
175
160
154
155
111
34
tt
it
i74.073
A
180
41
41
175
160
154
155
110
34
«
u
he statistics were taken from the Educational numbers of the Journal of the American Medical
ion, 1910. through 1919.
his number represents students of Cleveland College of Physicians and Surgeons (absorbed by
Reserve University in 1910) who received instruction at Western Reserve and degree from Ohio
n.
TABLE //♦.
Distribution of Medical Students at Western Reserve — By States
"o
■•* O
^= b3 &^ .,
- - • « •< S oa k..
S S ^ -S o •= g 2 3 g .? S S g 2 S >*
- -3 .2 6 a S -0 ^ g g 5 :5 .S .2 .2 o -g l
0
O
a
G
9 9
B >
o >t
•a 2
^ I
O 0.
1
1
1 ..
1 1
1 1
1 1
14 2-
3 5 11
3 6 2 3
2 5 12
3 2 3 2
2 2 2 2
2 11..
2 3 2 2..
13 4 2 11
1
2
.. .. 1 1 1 . ... 1 .. 69 -- 8
.. .. 1 1 1 . 1 1 2 139 .. 8
1 . 2 1 1 -. 1 1 2 132 1 11
1 L 1 1 .. 1 1 1 1 114 2 16
1 .. 1 . ... 1 1 .. 2 113 2 13
.. .. 1 2 121 1 13
1 2 138
1 2 130
.- 1 1 139
1
2 3 2 11 1
2 136
10
8
9
11
9
lis. s 1 1 > 5 a
o Q § a -g g a 1 ? I -g
11 1 .... 1 1 1
1 112
2 1 3.2
.. .. 1 .. 2 3 12
... 1 1 3 4.3
11115 6 16
12 116 5 .. 3
.. 2 .. .. 3 .. 1 .. 3 .. 4
.. 2 .. .. 3 .. 1 1 4 .. 6
. 17 5 13
CO
i
H
O
H
94
171
176
161
157
169
178
165
181
180
pied from the Journal of the American Medical Association.
66<2
Hospital and Health Survey
TABLE in*
Medical College Craduaten
Year
Non-
Sectarian
Homeo
pathic
Eclectic
Physio-
Med.
16
Nonde-
script
14
Total
4,440
W. R. U.
Qrads.
21
Total
1910
4,113
183
114
.5
1911
4.006
152
110
5
....
4,273
14
.3
1912
4,206
185
92
....
....
4,483
35
.8
1913
3,679
209
93
....
\
3,981
22
.6
1914
3,370
154
70
....
....
3.594
30
.8
1915
3,286
195
55
....
....
3,536
38
1.0
1916
3,274
166
78
....
....
3,518
49
1.3
1917
3,134
180
65
....
....
3,379
32
.9
1918
2,454
114
42
....
60
2,670
46
1.7
1919
2,423
89
28
—
116
2,656
41
1.5
* Statistics compiled from Table VI. page 502. Journal of the American Medical A99ociation, Auc- 1^
1919, and Educational Numbers of Journal of the American Medical Associaiion, 1910 through 1919
The Western Reserve University Medical School is classed as A, 1907 to 1919, by the
Council on Medical Education of the American Medical Association.
Instruction for Graduates
An important service undertaken by the Medical School during the sum-
mer of 1920 has been the oflfering of systematic instruction to medical grad-
uates in clinical medicine and surgery, including the necessary accessory
training in anatomy, pathology, laboratory aids in diagnosis, and such co-
operation from teachers in various s]:)ecialties as is necessary. The concep-
tion of the program is broad, the spirit of the teachers is of the finest and the
fees are moderate, and there may be expected from the modest beginning d
this year with a class of 23, such steady development and appreciation of
the work as will go far to win generous professional support for the Medical
School and its ideals. Once endowment is provided or annual support is
assured for the teaching of medical undergraduates, there should be a public
appeal made to support graduate teaching in the medical sciences, not alone
in summer but as a necessary service for the University to provide for the
profession throughout the year. Both the short courses in diagnosis and
treatment such as arc now being offered and courses leading to the proper
training of specialists, taking one or two years of combined laboratory and
hospital teaching, are urgently needed in this countiy.
ESSIONAL EorCATION AND PRACTICE 663
MEDICAL PRACTICE
Physicians in Cleveland Classified by Specialty
liere areil,169 registered physicians in Cleveland, distributed accord-
> their^own statements among the different fields of practice as follows.
General „ 878
Surgery
Surgery 87
Orthoi>edic Surgery 4 91
Internal Medicine 16
Tuberculosis 10
Neurology and Psychiatry
Neurology 3
Psychiatry 2
Neurology and Psychiatry 7.- 12
Obstetrics and Gynecology
Obstetrics 14
Gynecology 12
Obstetrics and Gynecology 4 30
Pediatrics.-. _ 23
Ophthalmology, Otology, Lsuyngology and Rhinology
Ophthalmology 12
Ophthalmology and Otology 3
Laryngology and Rhinology 4
Otology, Laryngology and Rhinology 21
Ophthalmology, Otology, Laryngology and
Rhinology 15 55
Laboratory Specialties
Pathology 1
Clinical Pathology 2
Roentgenology 9
Bacteriology 1 13
Anesthesia 3
Dermatc^ogy .^.^...... ...........^im..... 9
Urology ^^ 1^
Public Health 1
Not in practice
14
Retired... «.«............-.....-.-.— ~-^-.— —....— ~-~.~———.—— ^
1,169
664 Hospital and Health Survey
Hospital Staff Service
Estimating the number of internes and physicians retirediorjnot prac-
tising at 119 there is left a total of 1,050 physicians in active practice (one
to every 758 of the population of Cleveland in 1920). Of this number
or 29.4% are on hospital staffs.
233 or 22.2% are on the staff of one hospital.
55 " 5.2% " " " " " two hospitals.
15 " 1.4% " " " " " three "
■'0
V
■/c
1 " .09% is " " " " five ** (as pathologist).
5 " .5% " " " " " four "
Tliat 29.4% of all the practising physicians of Cleveland should control
the opportunities of education and personal advancement afforded by^80%
of the hospital beds of the city is not entirely satisfactory.
In Boston about 42% of the practising physicians enjoy hospital oppor-
tunities. In New York it was learned from a recent study that 51.6%lof
the registered physicians have hospital or dispensary aflSliations (12.6% only
dispensary affiliations, 12.8% both hospital and dispensary affiliations and
26.2% only hospital affiliations).
Of 545 physicians who have served as internes in Cleveland hospitab
chiefly within the past ten years, 196 or 36% are now practising in Cleve-
land. These graduates who represent the best product of our present
methods of medical education sliould be attached as soon as possible after
leaving their hos])ital to some hospital service, at first in the dispensan' or
as assistants in tlie laboratory, but with a definite future of clinical oppor-
tunity open to them through merit and the willingness to sacrifice some
immediate financial gains for the sake of a higher professional training.
Professional Organizations
Professional organization in Cleveland resembles that of otlier large
cities and has provided the resources in the shape of library and meetings
whicli are a necessity in a rapidly developing profession and one in which
criticism by one's fellows and discussion of results and scientific reports play
so important a part.
Cleveland Academy of Medicine
Previous to 1902 there were two medical societies in Cleveland: the
Cleveland Medical Society and The (^uyahoga (bounty Medical Society.
In 190^ the Cleveland Acadcmv of Medicine was formed bv the union of
the two societies mentioned above. The Academy membership is approxi-
mately 600. The general meetings are held once a month on the third
Friday of the month in the auditorium of the Cleveland Medical Library
Association. The Clinical and Pathological section meets on the first, and
the Experimental medicine section on the second Friday in the month.
The Eye, Ear, Nose and Throat Section has not met for some years. Tlie
:)FEssioNAL Education and Practice 665
- ■ -- — ' ' I-.- , ..■-■—■■■- -■ ■■_— ■—■—■- ■■ ■■ ^^■^^^— .
idemy is the county medical society and is the local constituent unit of
Ohio State Medical Association and of the American Medical Associa-
Recently a more aggressive spirit has come over the Academy and with
services of full-time lay assistance, the officers have undertaken the pub-
ition of a bulletin and have declared their intention to interest themselves
i the rest of the profession in the modem problems of health insurance
i legislation of various kinds affecting the professional and economic status
physicians in Ohio.
The responsibility for the deplorable conditions which exist practically
decked among the foreign bom population, due to the exploitation
the sick and the well by quacks and patent medicine interests, rests to
Qe degree if not chiefly with the indifference of the organized medical
Session. The attention of the officers of the Academy of Medicine is
led to the report on Quacks and Patent Medicines in Relation to the
reign Bom of Cleveland, which follows at the end of this chapter.
EVELAND Medical Library AftsociATiON
In 1894 the Cleveland Medical Library' Association was formed. Pre-
us to this time a considerable number of books, purchased from funds
itributed by the County Medical Society, had been gathered in Case
irary. In 1895 a contract was entered into with Case Library. The
irary set aside space for the Association books and agreed to care for and
d them and, if reimbursed for the amount expended for binding, to de-
T the books to the Association upon demand. In 1898, on account of
i of space, it was necessary'' for the Library to terminate this arrange-
it. After due deliberation the property now occu])ied by the Library at
8 Prospect Avenue was purchased by the Association. In 1906 a fire-
of stack-room and auditorium were added. In 1919 the property adjoin-
on the west was purchased.
The Cleveland Medical Library Association is incorporated under the
0 laws. The management of its business affairs is in the hands of a Board
Trustees, who act through an Executive Committee. The traditional
cy is the re-election of officers to ensure continuity of policy and con-
ation in the handling of funds. The working librarian serves on a full-
» basis. The hours are 9:30 A. M. to 10 P. M. To the general public
extended reading privileges. Only members are permitted to withdraw
b.
According to the Librarian's report for 1919 the total number of volumes
t,312. 847 books were loaned during the year and 1,853 visitors to the
ary were registered. The Library receives 166 different journals.
The Library is supported by the dues of its members — about 260 in
ber — and the income of invested funds, the total of the funds being
what over $270,000. The funds are handled largely by two trust
lanies.
666 Hospital and Health Survey
The Library is restrained from combining with any other society or
organization by terms of the Allen gift, the principal of which is $£00,000.
The Library which has capacity for doubling its present contents k used
to only a small fraction of the needs of the profession. That less than six
readers a day visited the Library and less than one book was borrowed for
each medical practitioner of the city in 1919, is a commentary upon the
acquisitiveness of the physicians in the field of modem medicine, and reflects
also a lack of adequate advertisement and propaganda by the Library Asso-
ciation itself of its own resources.
The policies of the Library are liberal and its financial support sufficient
to meet many more needs for medical references than seem to be felt by the
profession in Cleveland.
The Cleveland Medical Journal.
The publication of the Cleveland Medical Journal wsls discontinued
during the war and has not as yet been resumed. \Vhile the Journal was the
official organ of the Academy it had no other relation with the Academy
and was owned aitd published by a separate corporation as a public-spirited
enterprise, not for profit. The Academy contributed to the Journal, each
year, $2.00 ipev member. There seems to be no urgent need for the resump-
tion of this journal at a time when every economy must be practised to per-
mit the survival of those which serve a wider audience and offer space for
most of the important contributions to medical science.
Private Medical Organizations
There are several private medical organizations serving to some degree
social and scientific needs of the profession. Among these are the Cleveland
Homeopathic Medical Society which was organized in 1865 (there are at present
about 150 members), the Cleveland Colored Medical Society organized
in 1916 (30 members, 18 of whom are doctors, 8 dentists and 4 pharmacists),
and the Cleveland Public Health Association, a branch of the American
Public Health Association, organized May 21, 1919 (the membership is 4o,
and is limited to those who are members of the national organization).
Professional Opportunities
The medical profession has suffered severely in its development in
Cleveland by reason of the serious shortage of hospital beds. Visiting ser-
vices which will be needed when the necessary increment of beds is added
to existing hospital capacities should provide openings for most of the pro-
fession willing and trained to give a high grade of service in hospitals.
There is lacking in Cleveland that unity of spirit among the physicians
which comes from a just distribution of equal opportunities and from generous
support, encouragement and advancement of the young and ambitious by
their seniors.
ssioNAL Education and Practice 667
better trained group or with higher professional ideals would be hard
1 than the recent graduates of the local medical school. They are
d to a quicker recognition, particularly those who have dedicated
jlves to various of the s]:)ecial fields of laboratory and clinical prac-
nes of effort not sufficiently appreciated in Cleveland.
ccording to information obtained from those chiefly concerned
;eneral medical practice and consultation work in internal medicine,
is a very unusual indifference among Cleveland physicians to the
of laboratory'- tests in confirmation of diagnosis or as checks upon
1 impressions and physical findings in the cause of disease. The use
tests in medical practice now available in the fields of blood chemistry
imunology is practically unknown in Cleveland.
Autopsies
comment which could not fail to come to the lips of any visiting
ian, particularly from European medical teaching centers, would
ily be that the use of the autopsy is not appreciated as, at the same
the most valuable postgraduate education for hospital physicians and
ns, and the cause of a resp)ectful humility among teachers and students
n the presence of the secrets of disease.
uring 1919 there were recorded 455 autopsies in the hospitals of Cleve-
and it is fairly clear that autopsies are rarely performed outside of
als on private patients and about as rarely, in the honest meaning of
rm, under the auspices of the Coroner's office.
f the 455 recorded autopsies it will be seen from the following list
51 were performed in the hospitals where medical teaching is carried
,mely, at City, Lakeside, St. Vincent's and Maternity.
Autopsies Performed in Cleveland Hospitals in 1919
City 209 approximately
Fairview 0
GlenviUe 1 or 2
Grace unknown
Huron Road 5
Lakeside.^ 1 10
Lutheran^ 0
Maternity ^ 8
Mount Sinai 50
Provident- ..^-.. 0
St. Alexis _ unknown
St. Ann's 20 orphanage children •
St. Clair 1
St. John's 20
St. Luke's 5
St. Vincent's 27
Woman's 0
Lakewood a few
455
668
Hospital and Health Survey
Even at the ^hospitals where post-mortem study is urged and has its best
chance in Cleveland the percentage of deaths which come to autopsy is piti-
fully small as can be seen from the following list.
Lakeside Hoapital
Year
1914
1915
1916
1917
1918
1919
Deaths
Autopsies
Year
1917
1918
1919
Percentage
226
85
38
243
107
44
284
114
40
273
97
35
350
64
18
317
110
City Hospital
37
Deaths
Autopsies
Percentage
1,168
156
13
1,211
' 202
17
863
207
24
St* Vincent's Hospital
Year
1916
1917
1918
1919
Deaths
131
182
178
331
opsies
Percentage
16
12
18
10
21
12
16
5
The pathologists of the hospitals are well aware of the neglect of the
post-mortem as an invaluable educative resource, but interest is rarely as
keen among the surgeons and physicians on duty.
Public Health administration and the ])ractice of curative medicine alike
would be gainers if a post-mortem examination were required in every death
occurring in the hoR])itals of the city. It is distinctly a duty of the Hospital
Council to take a definite stand in this matter, see that hospital superin-
tendents feel their responsibility for obtaining consent for autopsies from
the family or friends of the deceased and ai)ply this necessary control obser-
vation to the clinical and operative services of the attending staff.
No better statement as to the action it is desirable to take can be found
than the following quotation from the writings of the leading pathologist of
Cleveland.
OFESSIONAL EDUCATION AND PRACTICE 669
"Investigations of the cause of the general shortcoming of American medicine in
dying the accuracy of clinical diagnosis lead to a variety of explanations and an equal
icty of suggestions for improvement. The latter may be thus summarized:
There should be:
1. Education of the public as to the importance of post-mortem exr
aminations to public health.
2. Improvement of legislation: (a) obviation of the necessity for
written permission to perform a necropsy, and (b) recognition of the differ-
ence between anatomic dissection and the necropsy.
3. Improvement of hospital regulations.
4. Increased development of the interest of physicians in the necropsy.
5. Encouragement of the selfish interest in post-mortems on the part
of intelligent relatives of the dead.
6. Assignment, in large hospitals, of certain persons whose special
duty it shall be to secure permission for post-mortem examinations.
7. Information given the family as to the conditions disclosed by the
necropsy.
8. A request for necropsy in every fatal case in hospital or private
practice.
9. Establishment in the hospitals of regular clinical pathologic con-
ferences.
We would suggest, in addition, that the subject is of direct importance to the devel-
3nicnt of industrial medicine and that those interesting themselves in this subject point
•It to the employers and employes the value to medicine and industry of post-mortem
^^minations. The suggested alteration of actuarial figures regarding life insurance is of
'^ilar importance to the so-called health insurance.*'
RECOMMENDA TIONS
It is recommended that:
1. New trustees who are still in the midst of the actual problems of industry, of the
"ofessions and of public service, be added to the present number of trustees or be ap-
^ted when the terms of those trustees now serving expire.
2. One or more trustees, chosen by the alumni of the Medical School from their
tm number, be elected to the Board.
3. Medical School buildings be erected at a site which will permit of convenient
Qtact between the medical faculty and the faculties of the other University schools.
4. In addition to its control of the exceptionally abundant facilities of the City Hos-
al for the teaching of clinical medicine to undergraduates, the University Medical
KX)1 maintain such affiliations as it now has with Lakeside, Maternity and Babies'
670 Hospital and Health Survey
Hospital, permitting medical research and study in methods of teaching which can hardly
be carried out with such entire liberty in an institution of the public nature of City Hospi-
tal, where political and financial difficulties may interfere occasionally with the best inter-
ests of scientific medical teaching and study.
5. The trustees discontinue formal affiliations for the Medical School with other
hospitals than the City Hospital and the three included in the University group, so far as
systematic teaching activities are concerned.
6. At the same time that the project for Medical School buildings is undertaken
the trustees prepare a plan for financial support, either by endowment or through annual
pledges, which will adequately provide for the scdaries of the teachers and the maintenance
and service needs of each department of the Medical School.
7. The trustees of the University devote their best efforts to obtain such changes
in the City Charter as may be found practicable and such action from the officers of the
city government as may be necessary to insure the appointment of a board of trustees to
be responsible for the administration of the City Hospital, such trustees to be selected
from representative groups of citizens by the Mayor and to be appointed by him.
8. The building of the new hospital group, either as one construction undertaking
(if ample funds are available) or in sequence (in the following order of preference — Babies'
Hospital, Maternity Hospital and Lakeside Hospital) be commenced when the constructioo
of Medical School buildings, the provision of endowment or adequate annual support for
teaching and the removal of City Hospital from the probability of political mismanagement
have been assured, or at least have been so planned for that their accomplishment will
parallel, if not precede, the group hospital construction.
9. Neither funds nor the energies of University teachers or institutions be devoted
to the operation of public facilities and medical services, except in so far as these can be made
to contribute or are found necessary for the teaching and study of the medical sciences.
10. The University discourage the employment of its officers on a part-time basis
in positions under the city government.
1 1 . Systematic instruction in the problems and principles of preventive medicine be
included in the curriculum of undergraduate students without necessarily adding a new
department or increasing the number o/ hours of instruction now given to medical stu-
dents.
12. A department for the training of physicians in the field of industrial medicine
be established as soon as adequate funds can be provided, this department and its func-
tions not to be confused with such efforts as the University may undertake for the train-
ing of physicians and others for the career of public health administrators.
13. The trustees push forward vigorously with the present plans for a department
of orthopedics, under the general department of surgery, but free to develop its own teach-
ing and research policies, with clinical facilities independent of those of general surgery.
14. A department of psychiatry with a similar independence under the general
department of medicine be organized and provided with independent clinical facilities.
15. A department of urology be added to the independent special departments
under the department of surgery.
Professional Education and Practice 671
16. The extension of the principle of full-time teaching positions for the heads of
the main clinical departments and for the chief assistants be undertaken as soon as salaries
can be assured, adequate to attract trained teachers and to permit of their having ample
time for research.
17. The medical faculty adopt the policy of having staff conferences in each depart-
ment to provide for uniform teaching policies and practice in the various clinical hospital
services used by these departments.
18. The voting faculty of the Medical School drop its inactive and absentee members
and add not less than ten more members of the teaching staff, assistant professors, demon-
strators and others, in order to make of this body a real academic forum, democratic in
nature, and permitting a much broader representation from those carrying the major
burden of the teaching work.
19. To the Department of Pediatrics be assigned the responsibility and care for
new-bom babies at the Maternity Hospital and in the maternity service of the City Hos-
pital.
20. The trustees of the University encourage and give their active support to the
new iindertakipg of the medical faculty in the field of medical education for graduate
physicians.
21. The Hospital Council take an active interest in increasing the performance of
pott-morteni examinations for the sake of improving the quality of medical and surgical
services in the hospitals.
672 Hospital and Health Survey
Quacks and Patent Medicines
By Mary Strong Burns
THERE are many perils in being an immigrant in Cleveland, but one
of the most disastrous to his pocket, health and native faith is the
quack medical practitioner. With an estimated 513,000 of the city's
731,156 population either of foreign birth or foreign parentage in 1917, we
have abundant op^^ortunity to realize that it is not possible for the foreign-
born with limited education and no English to pass unscathed through a
labyrinth of new customs — good, bad and indifferent.
The doctor, as popularly conceived by the uneducated, is a mystery at
best, something of a magician from whom the patient dares expect only a
small part of the truth and no explanation of it. The immigrant learns
that the reputable doctor of medicine must have "\I. D." after his name (even
though it means as little to the immigrant as to the street gamin w' ho ** guessed
it meant More Do]:)e"), and when he pauses before an office door placarded
"M. T. D., D. C, D. S. T., Ph. C." he may be forgiven for iiAagining that
he stands before an even greater ** Professor" than the law requires. He
finds as wide a choice of doctors as of religions, and as he hesitates, bewildered,
the more watchful and aggressive forces find him.
Of these the (|uack doctors are most successful because they set forth in
that particular foreign language iiewspa|)er which the immigrant reads as
the one intelligible guide to his new country, a convincing statement of skill,
learning and sympathy, promising (with reservations so deftly inserted as
to be ahnost unnoticeable) health free or at mininuim cost. Even though
the immigrant feels well and in no need of medical care the quack's repeated
message and the long list of '* troubles and diseases'* is ever present and
suggestive, so that the susceptible imagination of the future victim is soon
won over to a conviction of some bodily frailty. The quack, at the first
examination, finds more serious ailments, the *'cure" of which will generally
necessitate an expenditure to the limit of the patient's resources and large
enough to include the high cost of advertising.
The foreign language newspapers derive from 30 per cent to 60 j)ercent
of their advertising income from the fraudulent statements of quark prac-
titioners and patent medicine interests. It has been conservatively esti-
mated that the Italian paper // Progrcsso and the Polish pa|>er Ameryka
Echo circulated here derive (JO per cent of their income from these sources-
In one of these, one advertisement of **Parto-Glory, '' containing 7^3 words,
cost about 81 "2.5.
There are twenty-one newspapers not printed in English circulated in
Cleveland, published locally. These are mostly pa|>ers of national circula-
tion. There are also eleven foreign language papers. Taking all together,
twelve different languages arc used: Bohemian, (ierman, Greek, Hungarian,
Italian, Lithuanian, Polish, Roumanian, Slovak, Slovenian, Swedish and
Ukrainian. The [)a])ers published here, with the exception of three, carry
ROFESSIONAL EDUCATION AND PRACTICE 67S
ily advertisements of physicians and medical agencies doing business from
Cleveland office, and nearly one-third of their advertising income is derived
t)m this source. The papers published out of town but circulated in Cleve-
.nd are: four published in New York and one each in Chicago, Detroit,
jrsey City, Middletown, Pa.; Pittsburgh, and Toledo. These do not con-
lin advertisements of Cleveland quacks, although they are not limited to
cal advertising. They do, however, contain advertisements of 62 quack
x^tors from other cities, and of these only two from Detroit are duplicated
the list of out-of-town quacks who advertise in the foreign language papers
iblished in Cleveland.
Of the 25 physicians having offices in town and advertising in the Cleve-
nd foreign language newspapers, one uses papers in six languages, one, four
nguages, three, two languages and twenty, one language. Thirteen of these
tysicians advertise only their address and office hours. This is an admit-
dly ethical and legitimate procedure among foreigners. The doctor may
us announce his presence to people of his own race. Because of this prece-
»nt the quack practitioner may use a more elaborate form without arousing
ispicion, the foreign-born reader often getting the idea that the newspaper
self is setting forth the doctor's skill and goodness. Thus eight of the
venty-five physicians advertised to treat at their offices '*all sicknesses of
len and women, esjjecially sicknesses of the blood, heart, kidneys, lungs,
erves, nose and throat;'* two treat "blood and skin diseases," and two
thers treat "men only,*' evading a more open reference to venereal disease.
In this class is the type of office whose apparent head, the quack doctor,
s under the control of an unscrupulous business syndicate. This syndicate
manages offices in a number of large cities, guaranteeing salaries and a cer-
tain percentage to the doctor in charge, but claiming the fees of the patients.
In one of these offices in C-leveland when business was interrupted by arrest,
the receipts for the year were found to have amounted to $40,000. If illegal
practice is detected the business manager of the syndicate appears, pays the
fines, closes the office and spirits his doctor away to an office in another city
vhere a new name and locality will make him more valuable than ever.
After the affair has slipped out of the public mind, the syndicate opens its
Cleveland office at a different address and in charge of a new agent and the
game l)egins again. The agent of the syndicate may or may not be a licensed
Pfactitioner. He may have had his license revoked in another state. In
4ny case his medical knowledge is less in demand than his skill at getting a
^h return for any imitation of it. If a license is necessary to avoid sus-
picion and the agent does not possess one, some unsuccessful, though once
'thicaK practitioner is lured into the game on the promise of a small regular
alary, and when the crash comes he is usually left to be the scapegoat and
?rve the sentence.
The eight out-of-town physicians advertising in foreign language papers
ublished in Cleveland have offices as follows: one in Akron, one in ('hicago,
iree in Detroit, one in Paterson, X. J.; one in Syracuse, N. Y. A private
nic in Xew York advertises in a German paper. The Hungarian paper
bli.shed the notices of the Paterson and Svracuse doctors and of two from
674 Hospital and He-\lth Sur\t:t
Detroit; the Roumanian those of Akron and Chicago doctors, and one from
Detroit. The advertisements of these out-of-town physicians show that five
would treat '*all troubles," one will treat "men only," one "rheumatism
and kidney troubles," and one chronic diseases. One states that he will
send medicines and advice; one offers a book, The Friend of Youth; one de-
clares "Hundreds travel to see me, no treatment through letters;" another
invites, "Come, or ask advice."
The appeal of the quack is effectively adapted to the susceptible foreign
temperament. In the picturesque phraseology of his own tongue the reader
is tempted, cajoled, lured, warned and roused to fear; trading on his natural
credulity, the wording of the advertisement is carefully managed so as to
imply, rather than guarantee, a cure. The appeal of money saving is most
frequent. "My advice is free;" "I will help you with the best medical care
for such price as you can pay;" "I do not charge for examination if you are
one of my patients;" "X-Ray examinations only $1;" "Pay after you are
cured." This tyj)e of appeal is in constant use. Other types are here set
down.
The appeal of encouragement: "No matter what illness you have if you
have failed to find health from others, come to me;" "With success I have
cured many. What I have done for others I can do for you;" "Men and
women my specialty."
The appeal of fear, urging to prompt action: "Remember that neglect-
ing your trouble makes it worse;" " I have saved hundreds from the operating
table."
The appeal through promise of a common language: "You can hold
conversation with me in your own tongue;" "Come to me and be weD
informed about your sickness and understand how you can be cured;''
"Here we speak Hungarian;" "We speak Polish," etc.
The appeal of race: One florid description of sundry abilities is headed:
**To my sick Roumanian Brothers;" "To my sick Lithuanian Brothers"—
the nationality mentioned changing with the language of the paper. Another
who still practises in spite of past fines and sentences uses this subtle method,
"A message to the Italians. Sick Italians, do not be discouraged. Thou-
sands of our (»ountrymen have found health and happiness by going to see
Dr. Landis. His treatments are simply marvelous!"
The appeal of special skill and "method cures": "I use X-Ray and
electrical machines and my own new methods of treatment. By these
methods you will recover health in the quickest possible time;" "To save
the stomach my practice is to inject the medicine directly into the arteries,
which hastens considerably the process of restoring to health."
The appeal to the imagination: "Formerly doctor to the Czar;" **A
Polish doctor returned from U. S. Army Service in France. Come and
place your confidence in me."
Professional Education and Practice 675
The appeal to sentiment: "If you are well yourself, yet there are some
who need help. Send us the names of others who are sick and save them
while there is a chance."
The type of appeal is more vivid and dramatic in ItaHan, Polish and Hun-
garian papers; while that in Swedish, Lithuanian and German is more matter-
of-fact.
No fake advertising was found in the Greek pap)er, Atlantis.
In addition to the appeal of the quack, the foreign language press abounds
in advertisements of patent, or more properly, proprietary" medicines offered
by "medical institutes," "medical companies," drug manufacturers and
retail drug stores. These usually claim in the newspapers to be remarkable
cures for almost everv disease that one mav have, while the label on the
bottle is more modest since that must conform to the food and drug act.
This act, known as the "Pure Food Law," is supposed by many to be a seal
of perfection, whereas it merely insists that the manufacture^' shall make
no false or misleading statement on the label of the bottle as to its contents
or curative power. It does not affect products made and sold within the
state. It prohibits the use of certain dangerous drugs unless their presence
is declared, yet allows other dangerous drugs to be used and not declared.
While the label must tell the truth the advertiser need not be so ])unctilious
and in his hands the patent medicine takes on new powers. Some of the
advertisements ask the patient to send by mail to the factory for medicine.
Others would send medicine and instructions for treatment by mail. Still
others announce that their product may be bought anywhere. The Roman
Medicine Company announces, "Our institution is under the supervision of
well-known medics from the old country. It was established to relieve our
countrymen of their sufferings. After years of labor and research we dis-
covered what is indispensable to cure our brothers of their sickness. Put a
cross (X) on the illness from which you are suffering and send it to us. We
will serve you free of charge with every necessity." Here follows a tempting
array of "troubles," minor ailments and pains. One has only to choose.
In addition to these perils by newspaper there are also perils by propa-
ganda. Cards of reputable physicians have been sent out with prescrip-
tions by retail druggists who implied that the doctor was also endorsing the
sample of patent medicine enclosed. Recently a yoang woman, whose dress
and manner suggested that of a public health nurse, was found visiting in
the homes of women with families. She came ostensibly to advise them on
the care of children and ended by selling a book in which patent medicines
from several large wholesale houses were repeatedly recommended for treat-
ment. These wholesale manufacturers of patent medicines employ clever
lawyers at high salaries to protect their interests. If the preparation comes
into disrepute under one name it may be used under another. Tan-lac has
had several names. As a Dr. Cooper's Medical Discovery it was sold by a
man in sky-blue uniform with buttons of five-dollar gold pieces, who drove
through the country in an automobile.
676 Hospital and Health Survey
The Ohio State Medical Board is the instrument upon which Cleveland
has relied for the detection of its quacks. There is only one state medical
inspector for a city of nearly 800,000 people. This is obviously too great b
task for one person. The State Medical Board publishes no report except
for the Governor and the Secretary of State, on July 1st of each year. The
following statement was submitted to us by the Board:
From July 1, 1918, to June 30, 1919, certificates of four physicians
and surgeons to practise medicine ^ere revoked; one certificate suspended
and certificate of one limited practitioner revoked; nine applications for
revocation are pending; 8 mid wives were prosecuted and convicted; one
acquitted.
One hundred and sixty :three cases investigated; 28 convictions secured:
3 cases acquitted.
There were two dismissals and one disagreement.
Fifteen against whom charges were filed agreed to cease practice.
Fifteen more left the state.
Forty cases were pending on June 30, 1919; a number of these pending
cases have since been tried and conviction secured.
The state medical inspector for the city offered an informal account of
her work, all records having been sent to Columbus as made, to await the
compiling of the annual report in July. There have been a number of con-
victions of doctors and midwivcs for illegiil practice and criminal abortion,
and other cases are being prosecuted. The work is evidently being done
conscientiously and is as far-reaching as the efforts of one inspector can
reasonably make it.^ However, a judicious and wider publicity of the ac-
complishment of the State Medical Board might be of distinct educational
value in the community. The patient victimized by the quack does not
realize that his plight is the concern of anyone other than himself.
It is difficult to state how large a numl)er of Cleveland patients are treated
through the mails by out-of-town quacks, but as practically every fraudulent
scheme depends upon the mails at some time or other in it5 development,
we are safe in believing that the Federal Authorities have not received
complaints from all those who have been defrauded.
The Federal Fraud Order Law, in use since 1914, gives the Post Office
Department authority to close the mails to anyone using the mails in schemes
to defraud. This may be an enormously effective weapon against quacks
doing a large mail-order business. The post office collects evidence enough
to be sure of conviction, then issues the Fraud Order. The quack, if he has
not already vanished, has a right to refer to the court, but a reversed judg-
ment has never been recorded. In a word, the Federal Post OflSce will
only attempt cases which it is sure of convicting. This law is also sharply
limited l)ecause the Post Office Department cannot move until the mails
have been actually used in an attempt to commit fraud. It must w^ait until
it receives a complaint from someone who has been defrauded.
Professional Education and Practice 677
The quack advertiser has pur]X)sely shaped his proposition to come within
the letter of the law and to so avoid the attention of the Federal eye as long as
possible. He knows his own danger and at the first symptom of detection
[collects his bounty and "skips the country/' leaving the evidence powerless
to convict and his victims without redress.
•
The Fraud Order Law has proved a radical cure for the cases in which it
has been utilized, but the number of these is small. Its scope should be
enlarged and its scheme of inspection made to include those who advertise
with intention to defraud, for in this matter prevention is both education
and cure. The value of this law depends largely not on its passive acceptance
but on its aggressive enforcement. The patient who has been the victim
should not be expected to make the complaint. There should be some
unbiassed agency or group of agencies combining the knowledge of the Bureau
of Immigration, State Medical Board and National Vigilance Committee of
Advertising Clubs to receive the complaint and present the case to the
Federal Authorities. Such an agency or bureau possibly and properly oper-
ating under the aus])ices of the Cleveland Academy of Medicine, could be of
untold benefit to the many cases of venereal disease who have so often be-
come the prey of quack practitioners through lack of sufficient provision for
treatment at hospitals and dispensaries. It could also furnish evidence of
the need of further legislation to restrict the use of the mails from carrying
idvertisements relating to venereal disease.
The American Medical Association has prepared and ]3ublished a series
rf pamphlets on nostrums and quackery for the use of the public. These
bave a limited circulation among those who least need their warning. With
liscriminating field work this circulation could be increased. The priest,
Mrhose congregations have had sad experiences, the large industrial plants
md their public health nurses, the libraries and popular magazines could be
jsed to good effect. The emphasis in such education might be placed first
upon the hallmarks of honest, intelligent treatment of disease, and second
upon the fact that each one must stop — look — listen and then think for him-
self before he trusts.
Assuming the theory that the AdJemv c)f Medicine must not take any
iction on quack behavior, we might urge that dispensaries and prophylactic
enters should feel free to teach as wel 1 as to practise the ethics of medical
«rvice, supplementing the mysteries of diagnosis and .technic with a pro-
p*ain of cheerful consideration for the patient and of eliminating the diffi-
culty of an alien language by sympathetic and patient interpreters who are
lot too highly intellectualized to miss the human side in the medical interest
►f a ca.se.
The Americanization Committee of the Cleveland Bar Association has
already become interested in the dealings of shyster lawyers with the foreign-
bom. This interest could be stimulated to secure valuable cooperation from
the court when quack practitioners are being prosecuted and defended with
unprincipled skill by their shyster lawyers.
678 Hospital and Health Survey
*
The foreign-language newspapers cannot afford to give up their bad types
of advertising unless they can get something equally remunerative to replace
it. One small foreign-language paper refused quack and patent-medicine
advertising to an amount of $1,500 a month because its people were being
exploited and victimized. As a result it could barely pay expenses, but the
editor declared he *'felt at peace without stained money." It has, however,
gradually resumed much of what it once refused — an instance of '* the heroic
for earth too hard."
The American Association of Foreign-language New^spapers was recently
reorganized under the leadership of well known business men, one of its
stated purposes being to improve the advertising in the foreign-language
press of this country. They are pointing out to American advertisers the
possibilities of the foreign-language paper as a medium for reaching new
readers. In conjunction wnth the Better Business Association of the Cleve-
land Advertising Club, this may be of assistance, providing the foreign-
language papers do not have to surrender the control of their individual
policy. The large foreign-born population is too valuable a field to be
neglected by advertisers. The foreign-language press might offer to the
future citizen the stimulus of the best the country affords of resources and
responsibilities. At present its misuse amounts to almost a civic disaster.
Should we be better satisfied to receive the immigrant who comes to our shores
suspicious, distrustful, prepared to be duped and tricked both by Americans
and fellow countrymen — w4io have had a chance to learn the ways of
the country' .^ Can we not look upon this ** ignorance, gullibility, child-like
credulity," or whatever we call his eager belief and w^onder at our world,as
something worth saving, precious because readily convertible into citizen-
ship as loyal and even more fervid and spontaneous than our native New
Englander, Texan or Rocky Mountaineer will feel free to express.
The quack has conquered where the ethical practitioner has failed to
attract, because the quack has taken the ** infinite pains" of a genius to win
his prey. As commercialist and practical psychologist he is an exj)ert. The
clean honesty of the ethical practitioner is not equally painstaking. It
should not be asked of the ethical practitioner that he cope with quacken%
but because he is pledged as his *' brother's keep)er," shall he not note in the
successful appeal of the quack to his patient the things which are promised
along with the cure — friendly consideration as a stranger, a sympathetic
hearing and a frank diagnosis explained so as to be understood.'^ These are
of value whether the cure comes or not, for to the imaginative foreign tem-
perament a serious illness sympathetically interpreted by the doctor is less ap-
palling than some trivial indisposition left unexplained. Is it not possible
to have some more flexible attitude on the part of the medical profession
and some more aggressive attitude for ourselves as the public in the matter?
Our health regulations no longer permit people to expose themselves un-
necessarily to contagion. Is the menace of quackery to be ignored? We
see in our midst a multitude of people from other w^orlds being fed with tales
in their native tongue of fake cures by fake operators. We watch and think
**It will be bitter bread for them." The doctors watch and think "It is all
Professional Education and Practice 679
wrong but we may«ot speak." The foreign-language newspaper counts its
advertising cash returns and prints on, thinking **The National Vigilance
Committee of the Associated Advertising Clubs of the World allows it, the
city of Cleveland allows it, the public does nothing, the income justifies it."
Only the future warns: '*The immigrant's instinct for belief in his new
country is a tremendous asset to the nation and to the city of his choice.
The opportunity of justifying this belief and for providing education and
citizenship is open to the foreign language newspaper. It is the written
word, the organ of authority, but those who control its policy are in turn
controlled by larger business interests and these are prostituting its high
office for commercial gain. Let the city waken and protect its right."
Translations of Advertisements Shown in Facsimile on Page 680
1. 'TO MY SICK HUNGARIAN BROTHERS*
If you have failed to find help, come to me, as I have practised many years and can
give health with treatments to such men and women as are nervous or ill with complicated
sickness, suffering because someone has given the wrong treatment or neglected it. With
success I have cured such sick who could not get cured elsewhere. What I have done with
others, I can do with you. Don't spend more time but come to me today. Advice free.
If you suffer with chronic nervousness, blood, skin, or complicated trouble, or abdomen,
stomach and liver trouble, rheumatism, back or muscles, headache, constipation, dizziness,
eruptions, disease of the head, throat, nose — visit me. I have succeeded with such sick-
nesses by treatment. Respectfully I will give you my opinion and after a good examina-
tion will tell you what I can do. Get advice from me now as waiting is often dangerous.
Doo't forget that advice is free.
Office hours from 9 a. m. to 8 p. m. — Sunday from 10 a. m. to 2 p. m.
Dr. Kenealy,
647 Euclid Ave., 2nd Floor, Cleveland, Ohio.
Over New Idea Bakery Republic Building Next Door Star Theater"
"Translation of advertiaement in Hungarian published in Szabadaag.
2. "CHRONIC AND NERVE DISEASES CURED*
If you are afflicted with an upset stomach or kidneys or bladder, consult me today.
Seek help where it can be found. Years of experience in the treatment of all nervous ail-
ments, either chronic or complicated, have enabled me to give you scientific electrical treat-
ments that will help you in cases where other methods have failed, and therefore many have
been freed from t(»ture and danger of an operation. Remember: that delay and improper
treatments are dangerous. Come to me if you wish to have the services of an expert
Dr. Lewis, Specialist
Office hours: 9 a. m. to 8 p. m. — Sundays 10 a. m. to 2 p. to,
749 Sixth Avenue (between 42nd and 43rd Streets), New York City.
*Tr«Dilation advertiaement in Italian published in II Progresao]
iSi iilil
Professional Education and Practice 681
3. "A MESSAGE TO THE ITALIANS!*
Sick Italians, do not be discouraged if you have not been able to obtain the desired
cure even after having been visited by different doctors, or been in many hospitals.
Hundreds, or rather thousands, of our countrymen have found health and happiness
tyy going to see Dr. Landis. Dr. Landis with his 25 years of practice in New York, having
studied in the greatest universities and hospitals of America and Europe, is just the man
vrho will put you on the road to health. His treatments are really wonderful. His office
is equipped with the most costly electrical machinery, which cannot be foiind at all doctors*
offices and which is indispensable for an efficient cure.
Dr. Landis has experimented with a method cure of electricity which has given wonder-
ful results and which allows individuals to get well without having to leave their work.
If you suffer with pains in your back, or rheumatism, or sickness of the chest or blad-
der, ^ith weakness or anemia or any other illness, be it chronic or recent, consult Dr.
Landis and you will certainly find a sure cure. All consultations are absolutely free.
Remember that in any sickness to wait is always dangerous. Why wait? Go this very
day. Italian is spoken.
Dr. Leonardo Landis, 140 East 22nd Street, New York City.
(Between 3rd and Lexington Aves.)
Office hours: Every day from 10 a. m. to 7 p. m. Sunday from 10 a. m. to 1 p. m."
"Translation of advertisement in Italian published in II Progresso.
4.
**X-Ray examination $1.00.'
If you are sick, notwithstanding what the nature of your sickness is, if you are dis-
couraged, do not give up hope but come to me.
I treat all sicknesses of men and women and especially sicknesses of the blood, skin,
stomach, kidneys, lungs, nerves, heart, nose and throat by the assistance of X-Ray and
electrical machines and my new methods of treatments. By these methods you will recover
your health in the quickest possible time.
I do not guess. The secret of my success lies in the careful research as to the cause of
your sickness. I use X-Ray, microscope and chemical analysis and also all learned meth-
ods to find the cause of the sickness.
If you are bruised or injured, come to me and I will help you.
My personal observation of the methods used in European clinics in Berlin, London,
Vienna, Paris and Rome in my 20 years* experience with sicknesses that have grown old
among men and women, gave me results that proved a success.
I consider 606 and 914 great medicines for the blood.
AH treatments are absolutely painless.
"Translation of advertisement in Polish published in Polonea W. Ameryce.
682 Hospital and Health Survey
You can depend on an honest opinion, honest treatment, and the best treatments
at the lowest prices that everyone can afford.
If your sickness cannot be cured I will tell you. If it can be cured I will cure it in the
quickest possible time.
We talk in Polish and Slovak.
Doctor Bailey, Specialist, 5511 Euclid Avenue, near East 55th Street.
Office hours 9:30 a. m. to 8 p. m."
RECOMMENDA TiONS
/• Lmgislation:
(a) A more aggressive use and increased scope of the Federal Fraud Order Law.
(b) A uniform Medical Practice Act between states, to be urged by the Cleveland
Academy of Medicine.
2. AdminiBtration:
(a) A Local Bureau organized to receive and act on complaints of medical fraud.
This Bureau would make known its function to the public and to all Public Health agencies,
who in turn would report such cases.
(b) Increased Inspection and prosecution by the State Medical Board.
(c) Development of the Americanization Committee of the Cleveland Bar Associa-
tion for cooperation in prosecution.
J. Education:
(a) Extended instruction in the ethics of medical service among medical students,
and also to patients in hospitals, dispensaries, health centers etc.
(b) General health education in popular courses (in a foreign language when neces-
sary) in citizenship classes, industrial plants, churches, community centers etc.
4, Standardisation of Foreign 'Language Prets:
Fraudulent advertising to be replaced by advertising and genercd reading matter of
good standard, through the assistance and supervision of the Chamber of Commerce, the
Cleveland Advertising Club and other civic bodies, for the protection and education of
the foreign -bom during his transition from immigrant to citizen.
5. Counteraction:
Giving all would-be patients first-aid treatment of psychology and self-control.
Democratizing the highest types of medical service so that the best shall be available
for all.
Professional Education and Practice 683
Dentistry m Cleveland
By Haven Emerson, M. D.
ASIDE from or rather in addition to the persistent forces which tend to
drive any profession onward and upward in public esteem, the dental
profession in this country has been advanced in its own conception of
service and in its scientific application of prevention and treatment of dis-
ease by two movements of much importance. The demonstration of the
benefits of oral hygiene and periodic cleansing of the teeth of children by
Dr. Fones, of Bridgeport, Conn., and the proof of casual relationship between
focal infection in root canals and other dental lesions and a multitude of
secondary joint, cardiac and general constitutional symptoms may be said
to have dominated much of the modern crusade for better dentistry, for
preventive dentistry and for the close professional cooperation between
dentistry and medicine in private, hospital and public health work.
In all of this Cleveland dentists have taken an active and leading part
and the city is fortunate in having within its limits those who direct the for-
tunes of the Dental College, the Research Laboratory, the Cleveland Dental
Society and the Cleveland Mouth Hygiene Association.
According to the best information there are about 550 registered dentists
in Cleveland, of whom 290 are members of the Cleveland Dental Society,
which is the local professional body, a constituent of the state and national
dental societies.
If the Ohio Dental Practice Act required an annual registration of all
dentists, as is the case in several other states, an accurate statement of the
number of dentists legally practising dentistry in Cleveland could be made.
The better control of illegal practice which such law permits has proved to
be of great value to the profession and to the public, in New York State
among others.
The private practice of dentistry in Cleveland presents no abuses or
inadequacies except such as arise from the selfishness and ignorance of an
occasional practitioner who fails to measure up to the present day standards
of his profession. The well-to-do and those of moderate means can obtain
adequate dental care without excessive expense and of a high grade whether
for preventive or reparative purposes.
From the reports of the highest type of supervising dental oflScers in the
army during the war, it was found that well over 75% of the crown and
bridge and root canal filling was done so poorly as to develop or permit the
development of pus pockets with all the dangers of secondary low grade
sepsis and its numerous sequelae. Mechanical dentistry, done for a price
instead of aseptic technic used in the spirit of modern surgical science,
seems to be at least as much of a cause of disease as the neglect of oral and
dental hygiene by the poor and ignorant.
There are quacks and commercial low grade practitioners in this as in
the medical profession, because there is often more money in such methods
684 Hospital and Health Survey
for the illegitimate and irresponsible than in a professionally conducted oflBce.
The Jews of the Woodland Avenue region suffer particularly from the
services of dental quacks.
Free dental work in Cleveland is supplied at six public schools, at three
health centers and at one hospital (City Hospital). There are ten chairs in
use and 156 clinic hours a week, or a total of 6,900 hours a year of service
offered. The work is mostly for children and for hospital out-patients. A
dental dispensary used for teaching purposes, operating 80 chairs, is main-
tained on a more than self-supporting basis by the Dental College. The
fees charged are similar to those charged by beginning dental practitioners.
In Boston five institutions offer either free or at -cost, dental services
with a total of 247 chairs used for 5,956 hours a week and 309,71^2 hours a
year. In the city of Rochester, N. Y., there are 38 chairs almost exclusively
for children's work.
The six school dental dispensaries are supported by the taxpayer's money
through the Board of Education. Each unit includes a dentist and an
assistant and is open five days a week for three hours at each session and for
40 weeks a year. Children are referred from among school children by the
school medical inspectors and nurses. The extent to which the work has
grown and the range of service given is seen in the following table:
Patients
Visits
Emergency
Prophylaxis
Amalgam
Deciduous extraction
Permanent extraction
Surgery referred
Oxyphosphate of copper
Oxyphosphate of zinc
Arsenic
Roots filled
Abscess treatment
The three mouth hygiene dispensaries operated by the Cleveland Mouth
Hygiene Association at three of the health centers are operated for fifty weeks
of the year, five days a week and three hours at each session. The outfit
and personnel of each is the same as that provided for the school dental
clinics. The cost of these is met from the Conmiunity Fund as a part of the
budget presented by the Welfare Federation.
A dental surgery open a half day (of three hours) a week for out-patients
needing operative relief and extractions, and six half days (of three hours
1917 Total
1918 Total
1919 Total
1,969
3,473
4.421
4.454
6.411
6,976
651
1.267
1.621
383
661
1.196
839
1.654
3.165
1.608
1.927
3,911
142
56
18
192
15
183
127 *
670
1.399
112
115
61
126
61
5
188
87
5
109
136
67
Phofessional Education and Practice 685
*ach) a week for the hospital patients is provided by the city at City Hos-
pital.*
At the College of Dentistry of Western Reserve University a public den-
tal clinic is operated for all kinds of dental work. This is more than sup-
ported by the charges made, which are not very different from charges of
beginning practitioners with a clientele of mechanics, clerks and small trades
people. The lack of adequate bookkeeping prevents any statement of the
margin of profit earned by this dental dispensary. The profit of $24,000
ndicated in the last annual report of the University is obviously erroneous
IS nothing is charged for building or upkeep, depreciation, light, heat and
M> forth or for the overhead cost of teachers and supervisors.
Self-supporting public pay clinics, operated under strict professional con-
Tol as to services and prices, are needed and would meet a real demand for
liose of moderate means.
Dental care for the poor is limited largely to extraction and remedy
>f gross pathological conditions causing obvious inconvenience or pain. Lack
>f knowledge of the needs and possibilities of oral hygiene is responsible for
the neglected teeth of most dispensary patients. Dental clinics where a
small fee is charged are badly needed in the congested districts.
It is admitted that if all who needed dental care applied to existing den-
tists for treatment, there would not be enough dentists to do the work on a
basis and with the facilities of private practice.
The three Mouth Hygiene dispensaries, operated five half days per week,
are the only available and acceptable service (except the private dental
practitioner) for thirty to thirty-five thousand parochial school children.
Fifteen Mouth Hygiene units, each composed of a dentist, a dental hygienist
and an assistant, operated eleven half days per week, would serve this group
of children quite well; i. e., would provide the prophylactic service neces-
sary for eighty-five or ninety per cent of these children and would provide
for from one-third to one-half of the repjiir service necessary.
The public schools of Cleveland should increase their present equipment
from six dispensaries operated fiv^e half days per week to thirty-five Mouth
Hygiene units operated eleven half days per week, which would care quite
well for seventy or seventy-five thousand children.
The amount of surgical service under anaesthesia required would be in-
creased by the fifteen Mouth Hygiene units above referred to, to the extent
that probably five half-day clinics will be required every week at the City
Hospital. Should the Board of Education undertake to solve their problem
as above suggested fully double the amount of surgical service will be required
in addition. Attention should be called to the fact that after a very few
years the surgical service will undoubtedly decrease, for if the Mouth Hygiene
movement is of real value there should be little demand for the surgical
service for school children after the first seven years. It would be desirable
to have three hospitals suitably located provide for the surgical dental service.
*A full-time resident dental turgeon hqa been placed on duty now, and the clinic is open all day,
I even dasrs a week.
686 Hospital and Health Subvet
We suggest that this service could well be united with the nose and throat
service as the equipment in many respects is similar.
All the groups with whom the Survey staff have come in contact, such as
visiting nurses, charity and social agencies, settlement houses and the foreign-
born have emphasized the inadequacy of dental service in Cleveland, ^^'hen
it is seen that almost as much public dental dispensary service is provided
in Boston in a week as in Cleveland in a year, the reason for complaint is
plain.
It would be wholly superfluous to offer arguments for the need of mouth
hygiene among the children in the public or parochial schools. The
matter is amply argued by records of the incidence of dental defects in the
oflSce of the bureau of School Medical Inspection and by the record of ac-
complishment a few years ago at the Marion School.
Dispensary dental work in every case has fallen short of its possibilities
where there has l)een either no supervision, or supervision by unpaid or
underpaid men. The service in Rochester would never have been a success
without Dr. Burkhart, or his like, as a leader; nor would the service in Bos-
ton have been a success without Dr. Cross, or one of his kind, at the head.
In the same way the work in Cleveland will not be a success if we expect to
secure as a leader in this work a man at $3,300.00 a year, nor can the work
be carried on much longer without paid supervision.
DENTAL SERVICE IN HOSPITALS
It 'is accepted in many hospitals of many cities that the professional staff
is incomplete without dental surgery represented and sharing in staff respon-
sibilities. A dentist should be appointed on the attending staff of every
one of the larger general hospitals of Cleveland, with a definite service in
wards and dispensary.
»
The hospitals and other institutions in Cleveland now providing some
dental surgery for patients are as follows:
Mount Sinai Hospital
There are on the staff of Mount Sinai Hospital two dental consultants.
Dental and Oral Surgery is the only service provided. Such cases as seri-
ously need prophylaxis are sent to the Dental College. The Dental and
Oral Surgery dispensary is open from 8:30 to 10:00 a. m. on each Monday
and Thursday. The Dental and Oral Surgeons, being members of the staff,
enjoy the privilege of operating upon private patients at the hospital, for
which they may receive fees as in all departments of the hospital; however,
no compensation is received by the dentists from dispensary or open ward
patients. The present dispensary facilities are one dental chair with the
necessary equipment, located in the annex where, with the present staff and
time (two mornings per week), about eight hundred cases per annum may
be cared for. Cases are admitted for dental surgery only. The hospital
Professional Education and Practice 687
plans the enlarging of this service in the near future, together with the
addition of prophylactic service. There is no opportunity to develop a purely
dental oral surgery service for out-patients at the present time.
Cleveland City Hospital
The City Hospital maintains a dental surgery department, the operating
room being situated in an amphitheater in the female division on the ground
floor of the main building. The outfit consists of one operating chair, vari-
ous nitrous oxide machines and a fair equipment of instruments for dental
oral surgery, together with instruments for other forms of dental service that
are likely to be necessary in the care of the regular hospital patients. The
staff of the City Hospital consists of a Visiting Dental Surgeon, a Visiting
Dental Anaesthetist, a Resident Dental Surgeon, temporarily spending half
time; and one or two nurses assigned to the service as needed. Out-patient
service for dental oral surgery is rendered on each Friday from 1 to 4 p. m.
An average of fifteen extraction cases are cared for each afternoon. During
the past two years (some fifteen hundred anaesthesias have been ad-
ministered. This service is inadequate in volume and should be increased at
the earliest possible time. The most reasonable and economic manner of
increasing the service in the present building will be by providing two or
more separate operating rooms (adjacent but entirely separate) and each
having its own equipment. A waiting room should be provided for the
dental cases. The corridor is now used. The entire service should be
upon the level of the main floor and as near as possible to an entrance to the
building. With the suggested arrangement the volume of cases could be
largely increased with a minimum outlay of expense and a minimum increase
in staff personnel.
Children's Fresh Air Camp
A dentist spends two half days per week at the Fresh Air Camp. He
cares for the children of the institution only. Simple extractions are made
under novocain. More serious work requiring general anaesthesia is referred
to the City Hospital.
Jewish Orphan Asylum
Two dentists each spend a full day per week at the Asylum. General
service is rendered the children. Simple extractions are made with the use
of novocain. More serious cases requiring a general anaesthetic are taken
on occasions to the dentist's private oflSce. Service is for the children of the
institution only.
St. Luke's Hospital
There is no official dental appointment on the staff of St. Luke's Hospital.
However, a dentist administers anaesthetics almost constantly and is recog-
nized by the staff, but has no appointment. On rare occasions this dentist
removes teeth, but no dental service is provided.
688 Hospital and Health Subvet
Lakeside Hospital
At present there is no ofRcial dental service at Lakeside Hospital; how-
ever, we are informed that such is under consideration and will probably be
inaugurated at an early date.
Cleveland State Hospital foii the Insane
The State Hospital has not at the present time a dentist on its staff and
has not had for a year or two past. We are informed that they have no
appropriation for that purpose, therefore do not anticipate such an appoint-
ment in the near future. The State Hospital for several years furnished
dental service to the inmates.
St. Vincent's Charity Hospital
At the present time there is no dental service at St. Vincent's Charity
Hospital. In many respects Charity Hospital would be an ideal location
for a Dental and Oral Surgery.
Mention of dental service in industry will be found in thp Industrial
Hygiene Survey, Part VII. A limited service of high quality is provided
in five establishments approximately at cost. There is urgent need for more
dentists in industry and the need would seem to justify inclusion of some of
the special dental hazards in industry in the dental curriculum.
( OLLEGE OF DENTISTRY
This professional school has passed through many financial, educational
and administrative vicissitudes and at present is within reach of standards
and support which will entitle it to rank with the best.
Its present needs are more teaching room, a moderate increase in its equip-
ment, a small outlay for a simple teaching, reference and periodical librar\%
improvement in the teaching of anatomy and pathology in conformity with
the high conceptions and standards of these departments in the medical
school and a considerable increase (10) in the teaching staff, especially of
full-time men in the laboratory and clinical courses.
More students are now accepted than can properly be accommodated
and taught. An increase of 50% in the space is needed, if an entering class
of 75 is accepted. It is estimated that $'£00,000 will be needed for additional
space in the next five years. Probably $10,000 would meet the lack of
equipment now.
The absolutely indispensable in the way of books and periodicals for
teachers and students would cost about $4,000.
To pick teachers of dentistry simply from among successful practitioners
will continue here the same misfortunes and inadequacies which have been
a plague to medical education. The men selected must expect to make
teaching a crareer and be fit to employ permanently as such.
Professioxal Education and Practice 689
As soon as the obligations assumed by the University when it took over
.he school from its commercial supporters are paid off. an endownnent should
be raised for the support of dental teaching. Within the next five years
this school needs a million and a quarter of dollars to provide the grade of
education for which applicants are clamoring, in numbers the University
cannot accept.
The College of Dentistry would profit greatly from organized interest,
criticism and support by the Cleveland Dental Society. The school
uid the profession cannot get along without each other and for the credit of
both they should have mutual support, which does not exist at present.
There are no facilities. for graduate education of dentists. They should
be developed and oflPered by the college.
THE DENTAL HYGIENIST
In the interest of public service, to provide trained aids to the prac-
.ising dentist, to keep pace with the practice in leading states of the country,
t seems evident that the College of Dentistry should undertake the training
)f dental hygienists and should support the efforts of the organized profes-
;ion to obtain the amendments in the State Civil Code necessary to legal-
ze this profession in Ohio.
Dental repair work among children has been reduced by 50% by the em-
Joyraent of dental hygienists.
The modifications in the State Civil Code proposed by the Cleveland
Slouth Hygiene Association (affecting bv slight changes in the wording
jections 1320A, 1321A, 1320B, 1321B, VmC, 1321D, 1321E, 1323A, 1324A,
13£4B, 1324C) are strongly approved, and it is our opinion that the changes
night well go further and |)ermit the practice of dental hygienists in private
)flSces of dentists as well as in institutions. Such modifications have been
nade and have met with uniform satisfaction in eleven other states, includ-
ng Connecticut, Massachusetts, New York and Maine.
There are two imp)ortant professionally supported activities in the field
)f dentistry of considerable importance in Cleveland. One, the Dental
Hesearch l>aboratory of the National Dental Society, has been a center of
mportant studies in the interest of exact scientific practice. The other,
i distinctly local organization, the Cleveland Mouth Hygiene x\ssociation,
nust be credited with most if not all that has been done in the field of public
education in preventive dentistry and oral hygiene in the city. From modest
)eginnings in 1897, when its influence was first felt in the better teaching of
chool children, this Association developed increasing puplic support and
esources. In 1905 it maintained the dental dispensary at City Hospital.
n 1914 money was raised suflScient to pay exp^enses of operating six school
lental dispensaries. Since then the Board of Education has paid for them.
The work of the Association has continued to be effective and their
»udget of $11,533 for 1920 to defray the expenses of the five dispensaries
t Health Centers was approved by the Welfare Federation.
690 Hospital and Health Survey
The Survey is indebted to officers of each of the professional groups
above considered for information and advice.
RECOMMENDA TIONS
It is recommended that:
1. Measures be taken to obtain such amendments to the State Civil Code as will pennit
the licensing of dental hygienists and their employment in private practice and in
public institutions, imder the direction of licensed dentists.
2. The State Civil Code be amended to require the annual registration of licensed dentisti.
3. The training of dental hygienists be undertaken by the College of Dentistry.
4. Sufficient financial support be obtained for the College of Dentistry to provide ad^
quate increase of space, teachers and equipment, a library, and freedom from debt on
account of obligations to commercial interests.
5. The Board of Education aim to provide a gradually increasing service which within
the next five years will put all 'school children under adequate periodical dental
inspection, cleansing and repair. Prophylactic cleansing of children's teeth twice a
year is adequate. Tooth brush drill should be a part of school education.
6. Those responsible for the children attending the parochial schools institute dental
service similar or equivalent to that advised for the children of the public schools.
7. Administration of all public dental school and dispensary services supported by the
tax payers be put under the direction of one competent full-time paid dentist, within
the Division of Health or under the Board of Education.
8. The dental surgical service at City Hospital be increased fourfold.
9. The dental surgical service for out-patients at Mt. Sinai be increased as soon as fimds
can be obtained.
10. The Hospital Council prevail upon at least two other of the privately endowed hos-
pitals to establish out-patient dental service.
1 1 . A dental surgeon be appointed on the visiting staff of each of the larger general hos-
pitals and a dental interne be provided to carry out such prophylactic and reparative
work on patients as their condition permits or requires.
12. A dentist be provided at Warrensville Infirmary.
13. Both medical students and nurses receive in their preparation to practice, instnictioD
in the principles of the cause and prevention of dental disease and that nurses receive
practical training in the technic of cleansing patients' teeth.
^OFESSIONAL EDUCATION AND PRACTICE 691
Pharmacy in Cleveland
By Haven Emerson, M. D,
A S the knife is to the surgeon, so the drug or chemical iis to the physician,
/\ and there must be keenness and strength and appropriateness in each.
Whether we look upon the pharmacist as the dispenser of package
;oods over the counter, the compounder of special remedies or physicians'
iiescriptions, as an analytical chemist or as a wholesale manufacturer of
tandard drugs and biological products, he is as indispensable an auxiliary
0 the physician in the medical service of the community as are the dentist
iid the nurse. His education, the conditions of his employment, his protec-
ion against illegal practitioners, his standards and his aspirations are all
latters of importance to the public health and to the welfare of the sick.
In the absence of any authoritative or official registry of licensed or gradu-
te pharmacists in Cleveland, and using the figures available from the roster
f the Northern Ohio Druggists' Association and the lists in the hands of
>cal wholesale drug supply houses, we can estimate that there are at the
resent time about 400 drug stores and probably 500 or more registered
hannacists and registered assistant pharmacists in Greater Cleveland.
Probably ten per cent of the above number have had no college training
nd it is safe to say that seventy-five per cent have had it. What number
ave had some college training but did not graduate in pharmacy it is im-
ossible to estimate.
The length of courses taken by those who graduated was either two or
tree years.
The major portion of the pharmacists here who have had college training
eceived it at the Cleveland School of Pharmacy prior to the time when it
lecame an integral part of Western Reserve University. Some few gradu-
ted from Ohio State University, Ohio Northern University, the University
1 Michigan, The Cincinnati College of Pharmacy and the Philadelphia
!^llege of Pharmacy.
PHARMACY LAWS
Prior to August, 1915, anyone could take the state examination offered
►y the State Board of Pharmacy for registered pharmacist or registered
issistant pharmacist if he had served an apprenticeship of four years in a
etail drug store.
If the applicant had attended a school of pharmacy he usually received
redit on his "experience requirement" for the time he spent in school.
Schools of pharmacy made no requirement of high school education for
n trance until a few years ago when they began to require one year of high
*We are indebted to Mr. Edward Speate, Dean of the School of Pharmacy of Western Reserve
nnrerstty for valuable aid in preparing this chapter and for information dealing with drug Bupplies for
taprfals and in the question of proprietary medicinal preparations.
69d Hospital ani> Health Survet
school training. Some few university schools have of course for some years
past demanded high school graduation as a requisite for entrance.
In 1915 the Ohio Legislature passed a law requiring two years of hi^
school study for entrance into recognized pharmacy schools and that the
applicant be a graduate of one of these recognized schools. The matricuknt
must also obtain an entrance certificate from the State Board of Pharmacy
and this certificate is issued by an entrance examiner who may evaluate
credits or give examinations to obtain them. This entrance ex-
aminer himself must be a college graduate with the degree of A. B. or B. S.
and must not be connected directly or indirectly with any pharmacy
school. This examiner besides his experience as a high school teacher is to-
day an employe of the State Department of Public Instruction.
The legislature in 1919 passed an amendment to the Pharmacy Law
requiring four years of high school for entrance into a pharmacy school.
This must be upon diploma after four years of study in a high school, normal
school or academy, or be by examination given by the state board entrance
examiner.
The course of study given to a student in a recognized school must con-
form to the Pharmaceutical Syllabus of 1913, which was prepared by the
American Pharmaceutical Association, the American Conference of Phar-
maceutical Faculties and the National Association of Boards of Phannacy.
The least course given must be of two years' duration, consisting of certain
didactic and laboratory hours totaling not less than 1,200 in all. The course
must be given entirely in the day time and two months must elapse between
the two school years. Not less than three full-time professors must be
employed.
Some of the Ohio schools and notably the Western Reserve University
school exceed this minimum. Here the school years and hours per week
are of university length and the work is of university grade. A total of
more than 1,700 hours is given for this two years' course. Four full-time
instructors and nine part-time instructors are employed.
Among the laws governing the practice of pharmacy are to be found all
the Pure Food and Drug laws. Narcotic laws, Prohibition laws. Poison laws
and special regulations governing the sale of drugs in drug stores.
ADEQUACY AND ENFORCEMENT OF LAWS
The laws now governing pharmacy would be entirely adequate if there
were not so many exceptions to them. As they now stand they are quite
rigorous enough concerning what is to be sold and how it is to be sold in drug
stores, but the exceptions to the laws permit anyone to compound patent
medicines and sell simples, such as E])som salts and the like, in stores other
than drug stores or from wagons or by house-to-house canvass. Many
poisonous substances may also he sold if put uj) in packages bearing proper
labels.
ROFSSaiONAL EDUCATION AND PRACTICE 698
One of the tendencies of the present time is for druggists to cease manu-
Lcturing preparations for their store use and to buy these preparations
sady made. This has been brought about partly by the fact that manu-
icturers have secured laws through which they may purchase tax free alco-
ol for the manufacture of such preparations as tincture of iodine and cer-
un other preparations where there is absolutely no question of the alcohol
eing completely denatured. The objection to this lies solely in the fact
hat the Government denies this privilege of economical purchase of alcohol
o the retailer, by requiring this alcohol to be secured in large quantities and
t> be denatured with the iodine or other substance at the distillery. This
nables the manufacturer to make and sell many standard drugs much
heaper than can the retailers. The same privilege should be extended to
he retailer or to groups of retailers. Anything that limits the retail drug-
isVs professional practices tends to discourage and suppress his ability. In
ike manner the prescribing of proprietary preparations by the physician
essens the druggist's practice and hence his ability to compound. Few
physicians think out and write their prescriptions witii a definite purpose for
he use of each ingredient.
The habit of "counter prescribing" is not as prevalent as is supposed
lut is always augmented in a neighborhood where a dispensing physician
esides. Two things will overcome this practice entirely, one is strict enf orce-
oent of law relative to this practice and the other is education both of the
physician and of the pharmacist. It is rare to see a druggist who is a thor-
oughly educated and cultured man do very much counter prescribing or do
nore along this line than to sell medicines of the customer's own selection.
[t is not rare to find this druggist often advising the customer to go to a
>hysician.
A much better tyx)e of drug store service would be available if the law
requiring a registered pharmacist to be actually in a retail drug store, hos-
[>ital or industrial plant pharmacy, and other places where drugs are com-
[K>unded and dispensed, were rigidly enforced.
That these exceptions are tolerated is due to the lack of knowledge on the
part of the public as to the danger of indiscriminate: sale of drugs and poisons
and to the apathy of physicians in supporting measures to remedy these
conditions.
About the only thing that may not be done outside of a drug stor^ is
prescription fiUii^g.
The State Board of Pharmacy is permitted to hire only one inspector to
see that drug stores have a registered pharmacist in them at all times and to
see that proper registration of bulk poisons is made. This inspector may not
receive much over $1,400 per annum and of course he must be responsible
for the entire state. This means that not even the drug stores are forced to
obey the laws, to say nothing of the dispensing of drugs indiscriminately by
unqualified persons in hospitals, industrial plants and stores other than
drug stores.
694 Hospital and Health Survet
The clause of the Ohio Statutes requiring a registered pharmacist to be
in actual and personal charge of a drug store at all times is not rigidly en-
forced, due largely to lack of inspectors to secure evidence, and indeed it
seems scarcely necessary to attempt its enforcement when drugs may be
indiscriminately compounded and sold by anyone if only the vendor does
not call his place of business a drug store.
The city of Cleveland has no rules, laws or regulations governing drug
stores, with the exception of the narcotic ordinance and the general 'sanitaiy
ordinances.
COOPERATION WITH THE HEALTH DEPARTMENT
The druggists of Cleveland, through their organization. The Northen
Ohio Druggists' Association, an incorporated body, have been able to aid
the Health Department greatly in correcting many abuses in sales of drugs
and medicines. They have appointed an advisory board who meet with the
City Chemist, at his request, upon matters in which they are interested.
When mistakes have been made in prescription filling, in drug stores, these
mistakes have been brought to the attention of all the stores and aid has been
given the department in the rectifying of these mistakes.
The most important feature of the work is in tKe review of patent medi-
cines. The druggists have agreed not to stock patent medicines unless they
have been submitted to the City Chemist for approval of label and claims,
and whenever the City Chemist issues an order for the removal of a patent
or proprietary medicine from the Cleveland market the druggists have loused
to sell this preparation until the order has been rescinded. The force (rf this
is that the City Chemist need not bring suit against the druggist or druggists
in question to restrain a sale, but that the burden of proof is upon the manufac-
turer and he must either convince the City Chemist of the merit of his clainos
or must bring suit against him. No suits have been brought by such manu-
facturers, nor is it at all likely that such suits will be brought, as long as there
is judgment and honesty used in issuance of the orders by the City Chemist;
for the bringing of a suit would require the disclosure of the ingredients of
the proprietary medicine and at once the value of the nostrum would be
dissipated since secrecy and the claims of a therapeutic value based on worth-
less or inert ingredients is the basis of this whole colossal fraud. The inge-
nuity and effectiveness of this melhod of repression of valueless or fraudu-
lent patent medicines is worthy of imitation in other cities and states. This
and the appreciation by the press of the value of honest drug advertisements
would soon stop a national disgrace, save the public millions of loss annu-
ally and spare the ignorant and the ailing the disappointment of useless
medication.
THE SCHOOL OF PHARMACY
The School of Pharmacy of Western Reserve University was founded in
1883 by the local druggists. At that time only a series of lectures were given
to apprentices. From this small beginning it grew until two courses were
ROFESSIONAL EDUCATION AND PRACTICE 695
iven, one of two years' duration and one of three years' duration. Until
le fall of 1917 these courses were arranged so that the student could go to
jiool three days a week and work on alternate days in a retail drug store,
'nice the fall of 1917 the student has been required to put in full university
ours in school, both per week and per year. The two-year course is now
effected upon the basis of giving the student two years of college work of
miversity length and quality. The school is located in a building in the
teart of the business district, which today, due to traffic and business condi-
ions, does not permit the use of delicate instruments for instructional pur-
Mwes. The surroundings detract greatly from the educational value of the
diool.
The faculty consists of four full-time instructors, three of whom have the
miversity degree of B. S. and two of whom have an additional degree of
SL S. One of those with a degree of B. S. has no pharmaceutical degree, but
"MO 61 them have the degree of Pharmaceutical Chemist. The fourth in-
structor mentioned above has the degree of Graduate in Pharmacy and
lie d^ree of Pharmaceutical Chemist.
Part-time instruction is given by nine other men, one with the degrees
if A.B., A. M. and M. D., another with the degrees of A. M. and LL. B.,
mother with the degrees of A. B. and A. M., another with the degree of
LB. The others are laboratory assistants, one of them a senior in the
t)Qege of liberal arts during the past year.
As the School of Pharmacy grows the laboratory assistants will, as op-
K)rtunity offers, be chosen from among the graduate students.
The School of Pharmacy has been financed during all these years from
intion fees and by gifts from the local druggists. This method of financing
oes not permit of very much development toward better things and indeed
t present almost forbids growth.
The School of Pharmacy needs:
(a) Locatsoo on the University campus, a move which is pUuined for the
immediate future.
(b) Bndoiwment of appraadmatdy one million dollars, or pledges for annual
support amounting to the interest on that amount at five per cent.
(c) Greenhouses and a medicinal plant garden, to serve the double purpose
of providing live material for demonstration and research (instead of
relying at present upon the dried "cadaver" material of the commercial
market) and of furnishing fresh drugs of standard tested quality to the
hospitals of the city. The value of fresh herbs, as in the measurement
and study of the effects of belladonna and digitalis, for instance, is obvi-
ous. The effect of soil, temperature and other cultural conditions on the
quality of drugs could be studied with great advantage.
(d) BsqMnsion of the courses to permit of granting a degree of B. S. after
four 3rears of study, to properly qualified students, men and women. This
should permit of a four-year study of chemistry and should
696 Hospital and Health Subvet
include physics, mathematics and certain academic or cultural studies
and languages to permit the pharmacist to be an educated as well as a
trained graduate. This plan is now in existence in all the large universi-
ties of the Middle West and West. The pharmacy tehoob east of Ohio
are nearly all on the every-other-day plan, as mentioned above. New
York and Pennsylvania schools will not go upon the basis of requiring
high school graduation for entrance for another couple of years.
(e) Additional instructors. The school is now doing no research and it can
neither maintain its present standing nor progress unless its teachers be
productive. The research problems confronting the student of phar-
mscy are many and it is indeed discouraging to scholars to be so bur-
dened with teaching that they can give no thought to research. Valu-
able cooperative research facilities should be made available through
joint studies with the Department of Pharmacology of the Medical
School, which has already made so many notable contributions to scientific
therapeutics.
»
(f) A Manufacturing and Professional Service for Hospitals. The School
should equip a manufacturing laboratory -where preparations, liquid,
solid and tablet form, should be produced for the hospitals. This would
not only create an incentive for good work on the part of the students
but would show them during their formative period that habits of exact-
ness are necessary and that their work is directly related to public health.
The elimination of high overhead charges and the manufacture on a cost
basis in such quantities as the hospitals How use cannot help but materially
lessen cost of all such materials to the hospitals. It is inferred in the above
writing that each hospital maintains a phanr.acy and complies with the
Ohio Statutes in employing a registered pharmacist. The Survey recognizes
that this is not a true statement of existing conditions. It may be, however,
that small hospitals could have their ward requisitions or prescriptions filled
at certain hours by a traveling pharmacist and his corps of student assistants,
or could send them to a larger hos))ital at certain intervals and have thbm
taken care of properly in that way.
The School of Pharmacy of Western Reser\'e University can offer a serv-
i< e to the hospitals of Cleveland that may be said to have two direct objects.
The first is to enable the hospitals to render a much higher type of medical
service to the public, and the second is to lower the cost of medicines to the
hospitals. Under the first heading, which is one entirely in keeping with
the ideals of good hospital service, the Pharmacy School should be askedjo
serve in an advisory capacity.
1. It should supervise the organization and arrangement of the hospital
pharmacies.
2. It should aid in the purchasing of pharmacy supplies, inasmuch as it is
impossible to buy drugs and chemicals intelligently without a direct
knowledge of the items themselves and of the firms from which they are
bought. The tendency of modem times is to view drugs and
Professional Education and Practice 697
as commodities only. This' has been brought about by the rapid growth
of "patent" and package medicines and for this reason price is' sometimes
the only deciding factor.
3. It can advise in regard to the proprietary medicines now in use in the hos-
pitals to avoid the duplication of preparations and to show when many of
these preparations, if needed, can be manufactured by the hospital phar-
macy or by the schoc^ organization as discussed later.
^ '- C21 zzjiyz^' BXid otherwise test the drugs, preparations and chemicals
»hQt- are purchased after competitive bidding, in order that sick room sup-
plies may meet standard specifications. This will insure to the physicians
a knowledge that the substance supplied is exactly what it should be.
If the above suggestions be carried out it will result in systematizing the
>hannaceutical work of the hospitals which, unfortunately, is often lightly
>assed over in perfecting the other seemingly much more important services
>f the hospital. It will also result in directing all purchasing through one
oflSce, such as is maintained by the Hospital Council, and thus the supply of
any one item for a given period for all hospitals will be purchased at
one time, entirely upon specification and with the result of a better price
for the quantity purchased. Under this last, or the second heading, the
School of Pharmacy should likewise carry out two things:
Furnish its senior students to the hospitals for internships.
This would accomplish two purposes. It would provide cheap but
fficient help to the hospital pharmacist, enabling him to render a service in
he hospital that he is unable to give under the present arrangement. This
s especially true where free or part-pay clinics are conducted and medicines
lispensed. Besides demonstrating the value of an educated and not **rule-
f-thumb" pharmacist to the hospitals themselves, it will send out to
he . public men better equipped to serve it by reason of this high
ype of practical training. It need scarcely be added that it will further
he pharmacist's own knowledge of his responsibility to the public whom he
erves.
A school of pharmacy to be efficient should have the same academic
tandard as a school of medicine. Unless the school of pharmacy is sup-
orted as are hospitals and medical schools the same menace will result as
ccurred in the era of proprietary medical schools and commercial hospitals,
nd the public health will suffer instead of gain at the hands of its graduates.
RECOMMENDATIONS
9
It is recommended that:
The interest of the Academy of Medicine and of the Hospital Coimcil be united
with that of the Northern Ohio Druggists' Association and of the Division of Health, to
bring action through the State Legislature for adequate personnel and appropriation for
the enforcement of existing laws dealing with the presence of the registered pharmacists
in drug stores and hospitals.
698 Hospital and Health Subi-^*
2. Amendments in the laws of the state be obtained which will bring to an end
the pernicious practice of house-to-house, street vendor and other irresponsible kinds of
drug selling and will restrict the sale of drugs to such stores as have a registered phar-
macist on the premises during business hours.
3. Amendment in the state law be obtained which will permit retail druggists, tiiniiigli
controlled cooperative action, to obtain the benefit of the same economies in the pur-
chase of tax free alcohol as are now the exclusive privilege of the large manufacturers
4. The policy of the Division of Health in suppressing the sale of fraudulent proprietary
medicines be vigorously supported by the Chamber of Commerce, the press and by
the advertising interests of the city.
5. The trustees of the University move as rapidly as practicable to meet the needs as
indicated above, particularly in the matters of providing (a) greenhouses and a plant
garden, (b) teaching staff adequate to permit of research as part of the duties and
privileges of the instructors, (c) space and equipment to permit the school to offer the
services of its instructors and students in the process of education, to the hospitals of
Cleveland and for the testing, standardizing and manufacture of drugs and chemicals.
6. The Cleveland Hospital Council invite the School of Pharmacy to survey the
tions and costs of hospital purchase and compounding of drugs and chemicals, with the
object ultimately of obtaining from the staff and students of the school in return for
certain privileges offered by the hospitals for the training of students in practical phar-
macy, the consultation service and economies in purchase and manufacture which may
be expected from such a professional and educational group.
7. Each hospital not now purchasing drugs and chemicals through the Central Purchasiiig
Bureau furnish the Bureau with a list of drugs and chemicals purchased by them for
the past five years, or failing such record, for the ensuing year, in order that the bulk of
the trade may be estimated and action taken by the Hospital Council and the School
of Pharmacy in the interest of economy.
THE CLEVELAND HOSPITAL AND HEALTH SURVEY
REPORT
List of Parts and Titles
I. Introduction.
General Environment.
Sanitation.
II. Public Health Services.
Private Health Agencies.
III. A Program for Child Health.
IV. Tuberculosis.
V. Venereal Disease.
VI. Mental Diseases and Mental Deficiency
VII. Industrial Medical Service.
Women and Industry.
Children and Industry.
VIII. Education and Practice in Medicine, Dentistry. Pharmai^.
IX. Nursing.
X. Hospitals and Dispensaries.
XI. Method of Survey.
Bibliography of Surveys.
Index.
The complete set may be obtained at a cost of $5.50 plus the
post<')<;c and single parts at 50 cents each plus the postage»from
THE CLEVELAND HOSPITAL COUNCIL,
308 Anisfield Building.
Cleveland, Ohio
Nur sin gf
Part Nine
ClcTeland Hospital and
Health Survey
Nursmgf
Part Nine
Cleveland Hospital and
Health Survey
Copyrifrbt. IMO
by
The Cleveland Hospital Council
Cleveland, Ohio
I'ubiishcd by
Tlie (Jleveland Hospital Council
308 AnisBeld HIdg.
Cleveland • Ohio
Pref
The Hospital and Health Survey of Cleveland was made at the request
le Cleveland Hospital Council.
rhe Survey Committee appointed to be directly responsible for the
k and through whose hands this report has been received for pubiica-
consisted of the following:
Malcolm L. McBride, Chairman;
Mrs. Alfred A. Brewster,
Thobaas Coughun,
Richard F. Grant,
Samuel H. Halle,
Otto Miller,
Dr, H. L. Rockwood,
Howell Wright, Secretary
The staff responsible for the work were :
Haven Emerson, M. D., Director,
and the following collaborators :
Gertrude E. Sturges, M. D., Assistant Director;
Michael M, Davis, Jr., Ph. D., Director of the Hospital^ and
Dispensary Survey;
Josephine Goldmark, B. A., Director of the Nursing Survey;
Wade Wright, M. D., Director of the Industrial Hygiene Survey;
Donald B. Armstrong, M. D., Director of Tuberculosis Survey;
S. Josephine Baker, M. D., D. P. H., Director of the Infant
and Maiernity Survey;
T. W. Salmon, M. D., Director of the Mental Hygiene Survey;
W. F. Snow, M. D., Director of the Venereal Disease Survey;
Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey.
The expenses of the Survey and of the publication of the report have
met by appropriations received from the Community Chest, through
S\"elfare Federation, of which the Hospital Council is a member.
"he report as a whole, or by sections, can be obtained from the Cleveland
>ital Council. A list of the parts will be found in the back of this volume,
ther with prices.
TABLE OF CONTENTS
Page
ctory Note 707
raes' Training in Cleveland.
flospital Training Schools
Standards of Compariaon 709
A University Training School 710
Results of Field Study 712
Organisation of the Training School.^ 713
Entrance Reqiiirements 715
Capacity of Hospitals and Service Offered 716
Instructicxi
Teaching of Nursing Procedures. 724
Teaching of Fundamental Sciences 728
Instruction in Other Subjects 732
Conditions of Work
Ratio of Nur^jes to Patients 735
Hours of Duty 736
Vacation.. 738
Provision of Ward Helpers 738
Living Conditions. 740
Recommendations 741
Postgraduate Courses
University Course in Public Health Nursing
Origin 745
Organization 745
Finances : 746
Staff- 746
Students 747
Instruction 748
Field Work. 748
Recommendations 751
Institute of School Hygiene 752
blic Health Nursing
Introductory
Scope of Survey 753
Some Elements-of Success 754
Value of the Generalized System 754
Some Causes of Failure 755
TABLE OF CONTENTS -Caniinued
Pai
Central Nursing Committee
Organization 75
Activities 75
Recommendations 75!
Division of Health
Scope of Work 758
Present Staff 759
Analysis of Activities 759
Analysis of Administration 764
Recommendations 769
Visiting Nurse Association
Scope of Work 773
Present Equipment . 774
Analysis of Activities 774
Analysis of Administration 778
Recommendations 781
Board of Education
Scope of Work ^ 78^
Staff . 783
Analysis of Activities 783
Analysis of Staff and Administrative Methods 786
Recommendations 788
University District
Analysis of Administration 790
Analysis of Activities 790
Supervision 795
General Summary 79?
Recommendations 796 i
Prenatal and Maternity Service
Present Service 79?
Types of Patients to be provided for 797
Types of Nursing Care Needed 798
Appropriate Agencies for a City- wide Service 798
Recommendations .. 803
Industrial Nursing
Function of the Industrial Nurse 803
Types of Service Rendered 804
Some Causes of Failure 806
III. Some Notes on Private Duty Nursing.
Unnecessary Employment of Full-time Graduate Nurses . 808
Employment of Trained Attendants 809
INTRODUClX)RY NOTE
rHE Nursing Survey and Report has \)een in charge of Josephine Gold-
mark, Secretary of the Committee for the Study of Nursing Education,
and Anne H. Strong, R. N., Assistant Secretary of the Committee,
The field work for the study of hospital training schools was done by
ilrs. A. F. Piggott, Maryland State ins|)ector of training schools. A brief
tudy of the teaching in the larger training schools was made by Miss A. H.
Cumer, professor of physiology at Mt. Holyokc College. In writing the
eport on the hospital training schoo^s, assistance was rendered by Miss
^auline Angell.
The investigation of public health nursing agencies in Cleveland was made
ointly by Miss Elizabeth G. Fox, Director of the Bureau of Public Health
Mursing of the American Red Ctoss, and Miss Janet M. (Jeister, Western
Secretary' of the National Organization for Public Health Nursing. T<^)
Miss Fox credit is due for outlining the plan for a Prc»natal and Maternity
Nursing Service and for the detailed recommendations to the various pub-
MO health nursing agencies. Both these investigators. Miss Fox in particu-
lar, assisted in the writing of these reports.
The field work for the study of industrial nurses was done by Mrs.
Anna M. Staebler, Secretary of the Massachusetts Committee on Health in
Industry, and some supplementary studies in this field were contributed by
Miss Wilma I. Ball, Secretary of the Consumers' I/cague of Ohio.
To all the cooperating societies, who released tlieir workers for the Nurs-
ing Survey for varying j)eriods of time, acknowledgment and thanks are
due.
Nurses Trainingf in Cleveland
Hospital Training Schools
THE study of hospital training schools in Cleveland has covered the
thirteen schools recognized under the State Law. Of these, four were
studied in much detail (City Hospital, Lakeside, Mt. Sinai and St. John's);
remaining nine were more briefly inspected (Cleveland Maternity, Fair-
Bv, Glenville, Huron Road, Lakewood. St. Ann's Maternity, St. Alexis,
Luke's and St. Vincent's.) The investigation centered upon all those
Cors in the hospital and the training school which are related to the nature
1 adequacy of the training; the adequacy of service to patients in the hos-
al was considered only in so far as it bears upon the work of the students.
The hospital training schools in Cleveland exhibit, in greater or less
gree, the general characteristics which are found in similar institutions
ewhere. The excellence and the weaknesses inherent in the established
stem of instruction, both theoretical and practical, are amply illustrated
the various schools of the city. They share that spirit of devotion and ser-
% which has for a half century been the distincti6n and the legitimate
ide of the training schools for nurses; they share also in varying degree
e lack of standards and of independent organization, the inadequacy of
iching and equipment, and the exploitation of students, which has been too
*n accepted in lieu of education.*
STANDARDS OF COMPARISON
The objects of study and standards of comparison taken in the study of
eveland training schools have in the main been those set forth as "reason-
»leand desirable" in 1919 by -the Committee on Education of the National
iague of Nursing Education. Without subscribing to the details of the
iTJculum there set forth, we have measured the training schools by these
cognized standards together with certain additions of our own.
•
The standing of each hospital with relation to the desirable standards is
scussed in this report; a separate detailed account of each hospital has been
bmitted to the authorities of the institution.
This record brings out the strong and the weak points of nursing educa-
>n in Cleveland, and shows concretely how much remains to be done to
ing the training schools up to the level which they should reach to meet
^^ clinical opportunities and the clinical needs of the city. .
To introduce radical innovations into any established human institution
obviously a slow and delicate task. In their business of nursing the sick,
»e hospitals cannot at once, or even within a short period of time, be deprived
f their present labor supply. Any changes must of necessity be gradual,
^i in the following report the standards followed and the recommendations
• The investigation upon which the report it baaed wat made in the winter of 1919-1920. Notable
•Prove'nenta have already been made in a number of the hospital training schools since that time and
^^9 others are under consideration.
710 Hospital and Health Si:rvct
made for immediate adoption only approximate the conditions under which
students should ultimately be trained.
Within the required limits, undoubtedly many desirable changes in indi-
vidual hospitals can be indicated, which will improve the training now given.
But these changes should be recognized as merely ameliorative. They rep-
resent temporary improvements, not the fundamental reorganization of the
training school under university auspices, which is needed for the future
development of nursing education.
A UMVERSITY TRAINING SC HOOL
In the possibility of a <*entral training school under university auspices,
Cleveland has the opportunity of making an important contribution to the
ultimate solution of the problem, the independence of hospital and training
school, the recognition of the imrse-in-training as a imiversity student
throughout. A preliminary' university affiliation has already been tempo-
rarily and partially tried in Cleveland. The successful wartime expedient
of providing college instruction in the fundamental sciences for 88 student
nurses during the summer of 1918 set the pre(»edent for an extension of such
a university connection.
Moreover, the university has already given proof of its bnjadniinded
interest in permanently providing training of college grade for young women
who desire to enter this increasingly important branch of public service, tlir
profession of nursing. A preliminary plan has been proposed by the uni-
versity for a future scliool or department of nursing, subject to obtaining'
financial support for such an undertaking.
The i)lan proposed, while still tentative, is highly conuncndable in in-
cluding various features essential for the success of such a central university
scliool. Briefly sttited, it proposes to give a definite period of college training,
chiefly in the introductory sciences but with some cultural studies, an equal
lengtli of time for hospital training and a final academic period for additional
courses in the nursing specialties. For the graduates of these courses Iwth
the nursing diploma and the university degree are to l)e granted.
Ill this proposal for a School of Nursing a distinctive contribution is made.
In the few other cities in which such a five-year college and hospital course
is offered, the courses are in combination with but one or two hospitals; the
Cleveland plan would be offered in cooperation with several hospitals to
start with and with as many additional ones as **can maintain standards of
training high enough to warrant their recognition.''
Somf: JJknefits of the Fxiversity Traimm; Srii(K)L
Belter Students and Better Instruction
One of the main benefits of a university connei!tion such as the one pro*
|)osed would be to attract to the profession of nursing young women who
are now repelled by the inferior teaching provided, and the subordination
of their education to the needs of the hospitals. In the pre-mirsing period
Cursing 711
f instruction, it will be possible to give science teaching of far higher grade
nd with laboratory equipment far better than provided in the ordin^rj'
lospital course.
mproving Instruction on the Wards
A second benefit, upon which general stress should l>e hiid, is the oppor-
unity afforded to the university to exert its influence in raising the edu-
ational standards of the hospitals which desire affiliation. It is clear that
•ne essential element of this plan must be the cooperation of the hospital
a offering instruction in the wards of such a quality as to deserve the uni-
ersity degree. In our subsequent discussion of the (Cleveland hospitals
he success or failure of teaching in the wards is indicated. In the possi-
bility of refusing aflSliation to hospitals whose instruction in nursing pro-
edures, either in the class room or in the wards, is below standard or educa-
ionally wasteful, the university school can be a potent force for good. It
hould use its power of approval or disapproval freely, for in no other way
han by scnitiny and criticism of the grade of teaching provided by the
lospital can the educational side of the training school be sustained against
he exigencies of hospital needs.
Traimnci for Advanced Work in Administration, Teachincj,
AND Public Health
The sjx^cial function of the university course will be to prepare the leaders
in the different fields of nursing. Impartial investigation finds crying need
for more adequately trained teachers and administrators in the hospitals.
Such a course would supply administrative heads with lK»tter fundamental
training and a wider background than are now general. The limited edu-
cation of many who are in positions of res])onsibility in the training schools
has heen one cau§e of their difficulty in grappling with the per|)Iexing prob-
lems of the schools.
Similarly, .such a course would help to ])rovide more adequately trained
nursing instructors. The le.sser educational qualifications of instructors hi
schools of nursing as compared with instructors in colleges and other pro-
fessional schools is very marked. In the schools of mirsing the instructors
are frequently required to teacrh many subjects, often more than teachers in
country high schools; yet for tliis great task, they have them.selves had only
their own nurse's training, of perhaps some years past, sometimes supple-
'Hented by courses at Teachers' C'ollege, New York. Even after years of
experience and the most painstaking work, the instruction often reflects the
limited background of the teachers. A university training school would be
^f high value in providing teachers with more actual information as well as
•'^me knowledge of methods of teaching.
Thirdly, the university training school will fill a nmch needed place in
providing the training essential to meet the demands of public health nurs-
in/jf. Here, the final period of academic study would include case work and
712 Hospital and Health Survey
the many phases of social service, without a knowledge of which the miners
training alone cannot fit a woman for acceptable work in this rapidly devdop-
ing field.
A Shorter Basic Training for All Nurses
In addition to training for advanced work the university should assist in
providing better science teaching for the rank and fife; that is, for students
who have either no wish or no ability for specializing in the higher branches
of nursing, but who would take advantage of a good basic nursing training,
especially if it were shorter than the present three-year course. Such stu-
dents would obtain in the university the training in ihe preliminary sciences;
they would, under a plan to be subsequently worked out in detail, be gradu-
ated after a basic training of about two years and four months, with the
diploma of nurse but without a university degree. Such nurses would be
available primarily for bedside care. They would not have the added
training and experience which is needed to fit for the exacting needs of
public health nursing and for teaching and administrative positions; but by
a reduction of the present three-years' course, the bedside nurses would be
available in larger numbers and help to meet the present shortage.
Such a shortening of the course would be possible both through the better
teaching in the college and also through the elimination of non-educational
housekeeping duties and of the present indefensible repetition of services.
It will be noted that in the foregoing discussion no definite length of
time has been proposed either for the full university-hospital course oi* for
the briefer basic training. At present the 3-year course is the rule and a 5-
year course has been suggested for the central university school. How far
these courses may safely be reached by elimination of the non -educational
features noted above, still remains to l>e determined.
Studies of hospital training schools in other cities, of which the Cleveland
Survey has been one, are now ia progress by the Committee on Nursing
Education. From detailed observation of the work and instruction of first,
second and third year students in different types of hospitals a composite
picture will be obtained of the total careers of students and the training
afforded at each hospital. This study will aid materially in determining
how the ])resent course may l>e reduced without sacrificing any of the essen-
tial services. Sufficient time has not yet been afforded to complete these
intensive studies on which will be based our ultimate recommendations for a
detailed curriculum for both ty|)cs of university students.
RESULTS OF FIELD STUDY
It is obvious that no general statements can cover the Cleveland training
schools as a whole. Their procedures naturally differ with their size, their
age, financial resources, religious affiliations, etc. The results of our field
study arc here summarized so far as possible. The standing of the hospitals
is shown with relation to the standards regarded as desirable under present
conditions, that is, while students are still use<l to staff the wards. The dis-
URSING 718
ssion falls under the following heads: organization of the training school,
inimum entrance requirements, capacity of hospitals and services ofiPered,
fraction, conditions of work and living conditions.
ORGANIZATION OF THE TRAINING SCHOOL
The relationship between schools of nursing and hospitals should be
lentially the same as that created between medical schools and hospitals.
le school of nursing, like the medical school, exists primarily to give tech-
^ education to students who are to obtain part of their training in the
irds of the hospital. It follows necessarily that many important factors
the training school for nurses fall wholly outside the administrative scheme
a hospital.
(a). The best organization of a school of nursing is clearly the university
;anization, in which ward training is given in such hospitals as come up
the conditions of teaching and of living required by the university for edu-
tion of its students.
(6). Until the university organization is formed a similar arrangement
ight be effected by an independent board, capable of directing the educa-
»nal policies of the training school, which could contract with the hospital
give the necessary ward training supplementing the laboratory and di-
•ctic teaching supplied. Among the Catholic hospitals or in hospitals
Ministered under religious organizations which have no Boards of Trustees
which are subject to the Bishop of the Diocese, an advisory committee
ig^t be established at once to direct the educational policies of the train-
s'schools.
(c). In such hospitals as may still continue to keep the training school
part of the hospital organization, there should be appointed by the Board
Trustees a training school committee, composed of both men and women,
direct educational policies. This committee should be composed of rep-
ientatives of the Board of Trustees and other persons known to have had
perience in education and also members of the alumnae of the school.
ie superintendent of the hospital and the director of the training school
the hospital and representatives of the medical staff selected by the medical
icutive committee, though not members of the training school committee,
>uld sit with the committee.
The superintendent of nursing in the hospital should be appointed by the
ard of Trustees of the hospital, on nomination of the superintendent of
J hospital, with the concurrence of the training school committee. It is
isidered desirable that the superintendent of the hospital should delegate
the superintendent of the training school the appointment and dismissal
nursing personnel.
The oflSces of principal of the training school and superintendent of
rses, that is an educational and administrative office, may or may not be
abined in the same individual. When they are combined the head of the
ining school should be designated ''Superintendent of Nurses and Prin-
il of the Training School, "
714 Hospital and Health Subvet
So far as. concerns the tnake-up of the committee, in Cleveland only one
of the 11 general hospitals studied had a training school committee approxi-
mating the desirable form.* This hospital is St. Luke's. It is worthy of
note that the committee has on it an alumna of the school and that it has
taken a special interest in providing, so far as is i)0:?sible with unsuitable
buildings, unusually homelike conditions of living for the nurses.
Some variations from the above form of the training school committee
are the following:
At Lakeside eight of the twelve members are women.
At Huron Road the committee consists of only three members, all oJ
whom are attending physicians. One is also a member of the Board of
Trustees, and one is an instructor at Western Reserve University.
None of the ten remaining hospitals has a training school committee.
' AtMt. Sinai this lack may in part account for the fact that the living
conditions for the students and the equipment in class rooms and labora-
tories fail to conic up to the high standards of the other departments of this
hospital.
An advisory board at the City Hospital has recently disbanded and the
.appointment of the chairman of a new committee was at the time of the
investigation under consideration by the Director of Public Welfare.
None of the (•atholic hospitals has a training school committee; nor
has Fairview, (ilenville, or Lakewood. A former training school committee
at F'airvicw has reccntlv })cpn abandoned.
«
Cost Ac xoi ntinc;
An adequate system of cost accounting is practically unknown in train-
ing schools. Cleveland is no exception to the rule. For none of the hos-
pitals,is it possible to state tlie per caoita cost of student nurses, including
maintenance as well as instruction. Nor on the other hand, is it possible
to state the financial value of work done by the students and staff and the
saving to hospitals from the utilization of their services.
MoNKV Allowanck to Sti'dexts
Tlic otKc prevalent c.istoni of ])aying students a small yearly sum during
training is gradually beinu: abandoned. To attract students of good calibre,
it is clearly more desirab.c to devote such funds to improving the course of
training. Better teaching, cqui])ment and living conditions are a greater
attraction for desirable stndents than a small financial inducement. In-
deed, some hospitals instead of i)aying their stndents are charging a small
fee for instrnction.
In Cleveland the old cnstoni of paying students exists in all but two
hospitals. Lakeside and St. Luke's. Even in these, the system still prevails
in the custom of ]>rovi(ling uniforms and textbooks.
'The two special hospitals, Cleveland Miternity and St. Ann's, are omitted in thit section.
^ U R S UN G 715
MINIMUM ENTRANCE REQITIREMENTS
The Ohio state law requires that students be at least 18 years of age when
hey enter the training school. Most of the Cleveland training schools do
lot go beyond this requirement, but four, Huron Road, Lakeside, Lake-
irood and St. Luke's, make 19 the minimum age for entrance. In four schools
, few students under 18 had at the time of our investigation, l>een accepted;
.t the City Hospital, there were 2 who entered under age, at Fairview 3, at
»t. Alexis 2, and at St. Vincent's 3.
The age at entrance of 459 students in 9 hospitals was obtained and
howed that in all but S of these hospitals, the median age at entrance was
to or over.
Age at Entrance*
Age Required
Median Agef
19
22
19
22
18
21
18
20
18
20
18
20
18
19
18
19
18
' 18
Huron Road
Lakeside
St. Vincent's
GlenviUe
Mt. Sinai
St. John's
Cleveland City
Fairview..
St. Alexis
* Data on this point were not obtained from Lakewood and St. Luke's.
t That is. ranging all the ages from highest to lowest, the median is the age of the student in the middle .
Minimum Educational Requirement
According to the Ohio law, tlie niinimuni educational requirement for
•iitrance into the training scFiooI is completion of one year of high school.
Of the 11 hospitals considered in this connection, 4 (Huron Road, Lake-
ide, Mt. Sinai and St. Luke's) require graduation from high school for en-
rance. At St. Luke's this requirement has just been put into effect, and
he first class entering under the new regulation is made up entirely of high
chool graduates. In the other three schools, the recjuircment is of longer
tanding, and all three make exceptions to tlie rule, as is shown in tlie fol-
>wing table.
The personal histories of o'iH students in 11 hospitals were obtained
id showed that .S47, or (>5^v , had completed four yctirs of high school, as
JIows:
716 Hospital and Health SuBvn
Education at Entrance
Total No. No. with 4 yean of
of Students* High School or more Percent
133 125 93
Mt. Sinai 64 60 93
St. Luke's 59 50 84
Huron Road.. 33 26 78
Cleveland City 63 33 52
Fairview 24 12 50
St John's 30 11 36
St. Alexis 9 3 33
St. Vincent's 78 20 25
GlcnviUe 22 5 22
Lakewood 13 2 15
Total 528 347 65
Exclusive of the three Catholic training schools, St. John's, St. Alexis
and St. Vincent's, and the S smallest training schools remaining, Fairview,
Glenville and Lakewood (which, as i^ later suggested, might well combine
in giving theoretical instruction to their students), the percentage of students
qualified for college entrance is 83%.
* In a few hotpttalt data it not available for one or two students.
CAPACITY OF HOSPITALS AND SERVICES OFFERED
Desirable Standards
To qualify as fitted to give an adequate training of nurses, a hospital
should provide the requisite number of patients and variety of suitable
services. According to the standard, a general hospital under municipal
or private endowment, neither too large nor too small, is best fitted for this
need. As a teaching field the general hospital of 400 to 500 beds is held to
rank first, if it gives not only the four main branches — medical, surgical
children's and obstetrics — but certain special branches, such as communi-
cable diseases, mental and nervous disorders, etc.
If all of these branches are not included in the clinical resources of the
hospital, they should be made available for the students through affiliation
with other hospitals.
Hospitals of more than 500 beds, while they frequently offer a richer
variety and number of services, labor under greater difficulties in the way
of securing adequate supervision and instruction of the students.
Hospitals having less than 400 but more than 150 beds also offer excellent
teaching facilities. Those of less than about 50 beds cannot maintain schools
of Accepted standards.
I NG 717
Findings
1. Hospitals of M6re than 400 Beds
it'.',.}
The City Hospital r :
llevelaud the only hospital of more than 400 beds is the City Hosr
th 781, of which 481 beds are utilized for training. The diflSculties
ing adequate supervision for so large an institution have here been
d by the insufficiency of the nursing staff for actual care of the sick.
>rtage of students and of proper ward help has led to the diversion
jate nurses to routine care of patients from their primary duty of
lion and instruction of students.
5, for example, the graduate nurse responsible for the supervision of
5 having training in the children's wards of 40 beds, had only 2 stu-
id 1 attendant for the care of these patients. In addition she was
d nurse in the adjoining temporary influenza ward of 23 beds, where
only 1 student and an attendant to assist her. In this emergency,
erintendent of Nurses was trying to secure another graduate for the
a ward, which had just lieen opened.
Tvision and instruction were clearly impossible; the first object was
ily to care for the patients as well as difficult conditions permitted,
technic on the part of the students was observed and under the
tances could hardlv have failed to occur.
i iced Opportnn ities
s clinical opportunities, this hospital offers an unusually wide range
rience. In contrast to all the other Cleveland hospitals, it offers
isive and acute medical service with definite segregation of chronics
Mirticularly adequate field for training in pediatrics and commimi-
seases, including venereal disease.
training school, however, is not able to make the most of these
opportunities. The medical, surgical, obstetrical and children's ser-
e inadequately staffed, poorly equipped, badly housed in the gloomy
n building, and have been allowed to become run-down and below
i.
contagious and venereal disease services, on the other hand, might
further developed to afford opportunities for affiliation for students
fier hospitals.
contagious disease service* is in a new building with modern pro-
for the efficient care of patients and consequent good training of
J. Moreover,' supervision is good and theoretical instruction is given
ame time with the practical exf>erience on the wards, so that the two
>roperly correlated. Commendable precautions are taken to protect
lents from infection and to i)revent them from carrying it to others.
purpose the hospital is exceptionally well equipped.
718 Hospital and Hualth Subyit
This department is necessarily more fully staffed than other deoart-
ments, even at their expense. The pupil nurse service is supplemented by
aflSIiating students from two other hospitals. That the exceptional oppo^
tunities tor training are appreciated by the students is evident from a comment
from the superintendent of Glenville Hospital, one of the affiliating sdioob
afterward visited. "This service is an elective one for senior students.
So faA' all senior students have asked for it, and on return here conmient
most enthusiastically on their experience.''
Other Cleveland schools of nursing might well take advantage of affiKi-
tion with this contagious hospital, thus securing a much needed experience
for their students. Such affiliations would also release a certain number cf
City Hospital students for the other services there, as the four to six montk
of contagious disease experience required of them at present could be shortened
if an adequate nursing service in this department were otherwise provided.
In the specific (venereal disease) wards, also, more favorable conditions
for training are noted, and valuable experience for the student is found heie,
especially in the Women's Department, which includes 12 beds for obstetrics
complicated by venereal disease. The capacity of the venereal disesR
wards is 50 men, 42 women and 8 children, and the building has recent^
been renovated to meet the demands of the service. The training possibili-
ties are good and affiliation could well be arranged for students from other
schools wishing to include this experience in their preparation for the pubfic
health field, or even in their general training. Such an arrangement would
help to remedy the insufficiency, of the nursing staff at present, which makes
it impossible for the nursing duties to be properly organized.
The buildings for the tuberculosis service and the chronic patient ser-
vice in which the nervous and mental cases are housed, although they mi^t
afford valuable clinical oportunities, cannot offer adequate training until
radical changes have l>een made.
4. Hospitals of Between '^90 and 140 Beds
The second group of hospitals considered have the following number
of beds.
St. Vincent's 290
Lakeside.- 289
Mt. Sinai.. 255
St. Alexis.. 250
St. John's 158
St. Luki's ^ _ 140
While these hospitals offer a sufficient number of beds to comply with
the recommendations for a good teaching field for nui*ses, a consideration rf
tlie variety of services provided is also needed in order to gauge their ad^
(|nacv for the purjioses of training.
ftSING 719
Predominance of the Surgical Services
I the main, the outstanding fact is the inadequacy of the medical ser-
and the specialties, broadly speaking, on the one hand, and on the other
ledominating claims of the surgical services, at the expense, of the for-
The predominance of surgical services is the natural result of the in*
lent number of hospital beds, the emergencies of surgical need taking
denoe of medical needs, and the added fact that a hi^er proportion of
isd cases than of medical require hospital care. The predominance of
3al services obviously makes for a badly balanced scheme of instruc-
It is plainly impossible to give a well-rounded nursing education
so large a proportion of the student nurses' time is absorbed in purely
»1 or predominatingly surgical work. This lack of proportion is
f illustrated in the records of practical experience of individual students
nous hospitab.
ber of Beds and Percentage of Admissions
he most obvious evidence of the extent to which surgical training
nates other services lies in the proportion of beds assigned to each and
e pox^ntage of admissions.
t Lakeside there are 85 surgical beds to 61 medical; St. Alexis has 124
cal to 50 medical; St. John*s 89 surgical to 29 medical; St. Luke's 56
cal to 36 medical; St. Vincent's 123 surgical to 42 medical. At St.
s, on the day this hospital was visited, of the 25 beds in the women's
cal department, 17 or over two-thirds, were occupied by surgical cases,
ft. Sinai an even proportion is maintained, namely 47 surgical beds to
edical.
joalysis of the available figures showing the admissions for two hospitals
ates still more clearly the extent to which Cleveland hospitals are given
to surgical cases. At Lakeside in the year 1918 surgical admissions
8,388 as contrasted with 1,819 medical, and in 1916 (that is, when the
e surgical staff was available), there were 4,160 surgical admissions as
1st 1,498 medical. The latter figure included admissions in pediatrics.
t. Luke's the record of admissions for 1919 shows that 25% of the cases
medical as against 55% surgical.
ber of Days Spent in Surgical Services
he bearing of these facts on the nurses' training is shown by the record
eir actual days spent in surgical services.
hus, from a study of the records at Lakeside it was found that of 17
•rs who had been in the hospital 2 years and 9 months, 12 had already
From 7 to 10 months' training in the surgical wards and operating room,
^h the time planned for these services is 6 months. Of the remaining
3 had had 6 months, 1 had had 5 months, and 1 had had 4 months in
! services. When gynecological and gauze room experience is added,
»11 as 75% of the time spent in private service, which may legitimately
ckoned as surgical, these 17 seniors had spent from 14 to 19 months
s various surgical services.
720 Hospital and Health Sisvet
In contrast to the time spent in the surgical wards and operatiog room
(ranging from 5 to 10 months) is th? time spent by these 17 seniors on med-
ical wards, ranging from a little less than 2 months to 6 nionths. Tlie
median * is about three months and three weeks as against a median of seven
months in general surgical experience.
At St. Luke's, 6 seniors, who had been in training from 'i,}/^ to i% years,
had spent from 6 to 13 months in surgical services. This does not indiide
the months spent in the private service, a large proportion of which is sur-
gical.
These same students had spent from 4 to 8 months in the medical wank,
the median being between 5 and 6 months as against a median between 9 and
10 months in 3urgi<*al experience.
The actual experience of H seniors at St. Vhicent's shows a similar dis-
proportion. With two exceptions, these students had not yet completed
"^Yi y<*ars of their training, and yet already 3 had had 9 months, 1 had bad
10 months. 4 had had H months, 3 had had 13 months and 1 had had 14
months in the various surgical services.
The medical experience of these same students ranged from 4J^2 ^ ^H
months, the median being a little less than 6 months (174-177 days) as against
a median of Vl months in surgical service.
That it is not impossible to approximate more nearly the program rf
services ]>lanned is proved by the example of Alt. Sinai. This hospital if
more successful than any other in this group, in keeping the surgical experiencr
to the specifie<l time, even tliough the time planned is somewhat long. Sx
months each are allowed to medical nursing and surgical nursing, including
nursing of ])rivate patients.
•
The records of 7 seniors, who had been in training 34 month> or over,
showed that in surgical service in the wards, the students sp)ent from S
months to a little more than 5 (160 days); the median is 4^2 months, b
medical ward servit^e, the 7 students spent from 2)^2 to 7 months, the meditf
l>eing nearly 6 months (171 days). On private duty, the students W
spent from a month and 3 wc(»ks to 5 months, the median being a little more
than 3^2 months (107 days).
As private duty is for the most part largely surgical, it is reasonable to
conclude that at this hospital surgical service, which on the wards wi*
slightly lx*low the time plainied, is supplemented by the private surgic*
duty, and the medical servic^e, which in the wards approximates the 6 montb
planned, i^ iiot unduly ])rolonged by the private duty.
In the o|)eratirig rof)m all seven seniors under discussion exceeded the-
months planned for this service. Two of these students, however, wef
specializing, and their time was pun)osely prolonged. Only one of tk
remaining five overstayed the time planned by as much as one month: the
other four exceeded the time bv one to two weeks.
* That is, ranging all the months from highest to lowest, the median is the figure showing the HMdW*
number of months.
(J R S I N G 721
From this summary, it appears that with the exception of Mt. Sinai the
idency is to devote at least twice as much time to surgical training as to
dical.*
.General Inadequacy of the Medical Service for Training
This inadequacy is due to two causes, the predominance of the surgical
vices, and the large proportion of chronics. The predominance of the
rgical services and the consequent curtailment of training in the medical
•vice, has been dealt with above. The proportion of chronics in the
idical wards visited ranged from 40% to 58% in the three hospitals in which
is condition was observed. At Lakeside, on the day when the medical
irds were visited, 8 of the 19 patients on the men's ward, and 4 of the 11
tients on the women's ward were chronics. In order to make the most
the inadequate medical service for teaching, the students at Lakeside are,
f an excellent practice, required to hand in written c^se reports while on
ity in the medical wards.
At St. John's, on the floor assigned to medical cases, ii4 were under treat-
ent on the day of the inspection. Of these 14 were chronics and 2 were
irgical cases. At St. Vincent's there were 14 patients in the women's
edical ward, of whom 6 were chronics, two of them in reality boarders of
veral years' standing. At Mt. Sinai and St. Luke's no data on this point
ere obtained. At St. Alexis chronics are segregated on a special floor,
ut in this hospital, owing to the lack of graduate nurses, training is given
the women's wards only, so that students receive no experience either
edical or surgical, in the nursing of men patients.
). Communicable Diseases
At the time of the investigation, none of the hospitals in this group pro-
ded any experience whatsoever in communicable disease, except for occa-
)iial cases which develop in the hospital and cannot be transferred. This
ilure is all the more striking, owing to the rare opportunities for training
communicable disease oflFered at the .C'ty Hospital, of which the small
ispital of Glenville, for instance, has taken advantage.
). Pediatrics
Only two hospitals of this group, Lakeside and Mt. Sinai, have an ade-
ate number of beds for training in this branch. The other four hospitals
her provide no beds for this service, or provide a very small number,
lidi are almost all used for surgical cases and thus afford no training in
liatrics proper.
. Obstetrics
Of the six hospitals under discussion, three offer obstetrical training within
ir 01^ wards. These are Mt. Sinai, St. John's and St. Luke's. Except
St. Iiuke*s, no provision is made for out-patient obstetrical training, the
dent nurses thus failing to obtain experience in outside prenatal work, or
* Reeocds of actual experience were not available for studentt at St. Alexit and St. John's. From
of beds, it it evident that in theae hospitals, as in St. Vincent's, at least two-thirds of the
is
722 Hospital and Health Suryiy
in carina for patients in their homes. At Mt. Sinai there is a large out-patioit
prenatal clinic, but students are not assigned to work in the district. Tbe
follow-up work there is done by the social service department. A few stn-
dents, who elect public health work, may have prenatal experience in the
University District. At St. Luke's, student nurses have training in all three
branches of obstetrical work, prenatal, partum, and post-partum.
Lakeside and St. Vincent's* provide obstetrical training through affilia-
tion, the former at the Cleveland Maternity, and the latter at St. Ann's.
The Cleveland Maternity affords training both on the wards and in the dis-
trict, but Lakeside did not, at the time of the investigation, avail itself of the
outside prenatal and partum experience for its students. Moreover, the
type of supervision for student nurses given by the Cleveland Maternity is
inadequate and scarcely up to the standards of modem public health work.
Students from St. Vincent's have no opportunity for out-patient work.
The sixth hospital in the group under discussion, St. Alexis, has at present
no obstetrical training either within its own wards or by affiliation.
(f) . Nervous and Mental Diseases
Except for occasional cases, these hospitals offer no experience in the cue
of patients suffering from nervous and mental diseases, nor is there indeed
any opportunity for offering such training to students. At the City Ho^itil
there is a large group of mental cases, which should afford a desirable fieU
for training. But the absence of any modem methods of treatment makes
this impossible at pre^^ent. In contrast to the now accepted methods d
treatment in enlightened institutions, patients are under close confinement
and practically in custodial care in gloomy cell-like rooms.
(g). Private Service
The public wards are the best training ground for student nurses, aiid
by far the greater proportion of their time should be spent there.
It has been suggested that the ratio of private to free beds should
not exceed one to four in hospitals which train nurses. Two of the hos-
pitals in this group, Lakeside and St. Vincent's, have a ratio nearly twice as
high as is considered desirable, the ratio in each case being 1 :2.7. The ratio
at Mt. Sinai is 1 :5.5\ at St. Luke's 1 :4; at St. Alexis 1 :3.9 (exclusive iJt beds
on the floor used for chronics) ; at St. John's 1 :3.7.
Mt. Sinai follows the excellent practice of relying mainly on graduate
nurses for the staffing of the private rooms.
The days spent in private service by students at Lakeside range from 87 ;
to 306, the median being 195 days, or slightly over six months. The time
planned for the service at Lakeside is four months. At St. Luke's the range
is from 131 to 210, and the median between 140 and 155 days. At Mt. Sinai, j
the range is from 53 to 149 days, with the median 107 days, about three \
months less than the median at Lakeside, and a month less than at St. Luke's.
Information as to the time actually spent by students in private service
was not obtained from St. Alexis, St. John's and St. Vincent's Charity. St
Cubbing 728
k^cent*s Charity plans that each student shall devote six months to private
loty nursing. It is apparent that undue emphasis on the private service
soDfltitutes a distinct weakness in the training at Lakeside and St. Vincent's
Charity and the same tendency is noticeable at St. Luke's.
8. Hospitals of Between 140 and 50 Beds
Exclusive of Cleveland Maternity (61 beds) and St. Ann's Maternity
(55 beds), to which, as special hospitals, these standaids do not apply, there
lemain four smaller general hospitals. These can provide the necessary
irariety of services only by affiliation with larger institutions. These are:
Fatrview 100 beds
HurooRoad _ 87 "
QlenviUc..- 70 "
Lakewood. ^ 53 "
The medical ser^']ce in all four hospitals is limited and affords but meagre
raining for nurses. In fact, it appears that the only services adequate for
urses' training are surgery and obstetrics. Even in the surgical service,
ittle or no experience is afforded in such important branches as orthopedics
nd diseases of the eye and ear. In obstetrics also, training is limited.
Vifh the exception of the Huron Road students, who affiliate at Cleveland
Eternity, the service is entirely lacking in partum and post-partum care in
he homes. Students at G^enville and Huron Road receive prenat;^,l train-
tig in the University Health District. Lakewood and Fairview students do
lot get this experience. In all four hospitals too large a proportion of the
raining is in the private service.
For medical, communicable, ner\'ous and mental diseases, as well as for
lediatrics, all of the hospitals of this group need affiliation, to give adequate
saining. Glenville makes an excellent beginning by requiring four months*
iflUiation in pediatrics and providing elective courses in communicable
liseaaes, both of these at the City Hospital. Glenville was at the time of
the investigation the only hospital in Cleveland to recognize and take ad-
rantage of the unusual clinical facilities offered there. The other three
liospitals in this group do not make good theii* own deficiencies by any such
ifliUations, thus failing to recognize the primary importance of these services
in the nurses' training.
4 Out-Patient Departments
Of the 11 general hospitals, 5 have no out-patient department. Of the
S remaining institutions, Mt. Sinai offers the most complete opportunity for
training, as almost all the services are represented in active clinics. Lake-
nde records show a higher daily average of patient attendance than Mt.
Sinai* but Lakeside lacks prenatal and dental service. St. Vincent's Charity
lacks pediatric, orthopedic, prenatal and dental services. The work at St.
Luke's is reported to be ''that of a specialized industrial clinic with chiefly
urgical interests. " The medical clinic is small and an eye, ear, nose and
Jiroat clinic has just been started. There are, however, active prenatal
Y^4 Hospital and Health Subvet
kud gynecological clinics, where students may receive valuable tnuBing.
The Huron Road dispensary is given over almost entirely to surgical cases;
medical cases are only occasional. The City Hospital has a weekly denUl
clinic, which is very active, but there is no other dispensary service.
Since a detailed report has }>een made on the organization and work of
the ( leveland dispensaries, they are not further treated in this report. None
of them are fully utilized as teaching fields for student nurses. Likewise
social service departments are not treated here, since a special study has
been made of the work of these departments.
5. Public Health Nursing
At j)resent a \'ery small number of students take advantage of the ex-
ceptional training for ])ublic health work offered in the University Teaching
District. In this District, Cleveland has made a distinct contribution
of the highest grade to the development of generalized city nursing. In no
city is a better opportunity afforded for training and supervision in such
work, if sufficient time is given to take advantage of it.
Two months of this training are now allowed by five hospitals. The
course is elective at City, Lakeside and St. Luke's. It is required at Glen-
ville and Huron Road. Mt. Sinai allows four months of training in the Uni-
versity Teaching District, but the course is available for only three or !our
students each year. At City also it is ])ossible to elect a four months' train-
ing in the District.
INSTRUCTION
Teaching of Nursing Procedures
Demonstration Room
A special room for the teaching of nursing procedures is provided at seven
of the eleven hospitals considered in this section.* At St. Vincent's, how-
ever, the room was not in use at the time of the investigation. At Glenville,
Huron Road, St. Ann's and St. Luke's the same class room is used for nurs-
ing procedures that is used for other subjects.
At Lakeside and City the class room is large; at Mt. Sinai it is adequate:
at Glenville it is small. At the others the room is fair as to si25e. The room
at St. Ann's is crowded with material used in connection with thi^ lecture
courses.
At only three hos])itals is the demonstration room equipped with running
water and gas or electric stoves. These three are Glenville, Lakewood, and
Mt. Sinai. At the City there is a stove but no running water; at Fairview
and St. Luke's there is running water but no stove. The other hospitals
rely on facilities in adjacent rooms.
All the rooms are supplied with material sufficient for demonstration,
though there are special difficulties in hospitals which have no special room.
At Huron Road a bed is brought in when needed. At St. Ann's material
for demonstration is said to be brought froni the wards when needed. At
St. Luke's the material is brought over from the hospital by the instructor
* Information on mott of these points was not obtained from St. Alexis and CleTdand Ifatenuty
Roa|>itals.
rksiNG 7%5
At O&lv two hospitals is the demonstration room supplied with material
Ficieiit for practice by individual students. These hospitals are Fairview
I Mt. Sinai.
Methods of Teaching
With the exception of St. Vincent's, where students were being taught
irely on the wards at the turn of the inspection, there is class room in-
iction in the theory and practice of nursing in all eleven training schools.
All are supplied with a Chase doll for demonstration. In addition,
dents are used for demonstration except at St. Ann's, St. John's, and St.
ke's.* At Lakeside, patients are brought over from tlie wards as sub-
ts for the demonstration of some procedures, especially for such proced-
s as bathing and hair-washing. Patients serve as subjects at Glenville
asionally, and at Fairview also patients are occasionally used, but only
the wards.
Practice in the Class Room
Special periods for practice in the demonstration room are assigned at
iron Road and St. John's. At Huron Road, a practice hour of 1 hour
ily is allowed, except on Saturday. At St. John's, 3 hours of practice a
ek is required of probationers and 1 hour a week of juniors and seniors,
way of review.
At Fairview, City, and Lakeside, no special period is assigned, but part
the demonstration period is used for practice by individual students. At
t. Sinai the study hour is frequently used for practice. At St. Luke's
?re is no opportunity for practice between classes, as the room is in use
• other subjects and all material removed. Glenville and St. Ann's like-
%e make no provision for practice in the class room.
Class room practice is supervised by the instructor in the six hospitals
lich make any provision' for such practice of procedures, f
Hours
The hours devoted to class room instruction in the theory and practice
nursing by Cleveland training schools are as follows:!
St. Luke's 170 hours
Mt.Smai.„ 151 "
Lakeside 120 "
Lakewood... 120 "
HurooRoad. 100 "
St. John's 65
City 1 60
St. Vincent's 60
Fairview.... 50 "
QlenviUe 48 "
* At Hisroa Road no information wat obtained at to the use of students and patients as subjectsifor
MMMtratHm. At Lakewood the course was in process of organisation, and the use of students as sub-
«<
«<
t SupervMed practice is planned at Lakewood.
tCoorse at 8t. Vinoeot's not given at time of inspection. t
im Hospital and Health Subyet
St. Ann's Maternity Hospital gives 10 hours to affiliating students. At
Cleveland Maternity 24 procedures are demonstrated to affiliating students
Correlation of Theoretical Work with Practical Work in the
Wards
Obviously, the test of theoretical instruction in nursing is its applicatioD
in the wards. The teaching of practical procedures, to be fruitful, must be
associated not only with demonstrations and practice in class, but with dose
supervision of the student's work in the wards as soon as possible after tbe
class work. Without such close correlation of theory and practice, nursing
technic tends to be lax and unintelligent.
Example of Good Correlation
Of the thirteen hospitals in Cleveland a high standard of correlation was
found only at one hospital, Mt. Sinai. Here the teaching of nursing pro-
cedures is not only excellent in the class room, but is followed up by carnal
assignment of students for practice in the wards in the same procedures
which they have just learned in the class room, with thorough supervisioD
by the instructor. The provision of standardized equipment, both in the
class room and in the wards, has been a very considerable factor in making
possible uniformity of nursing procedures, and has contributed to the accu-
rate technic of the students observed in the wards.
The fact that students are not hurried when on duty in the wards, but,
owing to the provision of ward attendants, labor-saving devices and adequate
equipment, have time to carry out the procedures exactly as taught, also
contributes to the uniform excellence of technic observed.
The graduate nurses in charge of wards have been appointed on account
of special qualifications. The head nurse of the children's ward is a graduate
of the Boston Children's Hospital; the head nurse of the obstetrical ward
has had postgraduate training at the Chicago Lying-in Hospital; and the
nurse in charge of the operating room is a graduate of St, Mary's, Rochester.
Minnesota. Thus student nurses have the advantage of instruction given
by specialists in their own departments.
St. Luke*s was in the midst of reorganizing its instruction at the time of
the investigation, but already had developed methods which should result
in excellent correlation. For example, all procedures are demonstrated to
the head nurses in the class room, in order to enlist their interest and co-
operation in the teaching of students and to insure uniformity of method.
Failure to Correl.\te Theory and Practice
The var>'ing lack of success in correlating theory and practice in nursin^r
procedures at the other Cleveland hospitals is due to different causes.
L€urk of Equipment
At the City Hospital, where exceptionally good provision is made f (Mr class
room teaching, the entire lack of many essentials in ward equipment wouU
Curbing 727
oake it impossible to exact good nursing technic, as taught in the class
oom, even if there were adequate supervision of ward practice.
Lade of Organization
At Lakeside, owing to other required duties, the instructor of prac-
ical nursing has not sufficient time to supervise adequately even the proba-
Joners on the wards. Moreover, no provision is made for the immediate
ipplication of class room teaching. For some students there may be an
nterval of some weeks before they have opportunity to put their class room
leaching into practice.
Conflict of Teaching toith Administrative Duties
At four other hospitals, Fairview, Glenville, St. Alexis and Lakewood, the
beaching of practical nursing is carried by. the superintendent of nurses in
ftddition to her administrative duties. This arrangement obviously docs not
dlow enough time for either teaching or organized supervision of nursing
technic. The pressing demands of purely administrative interests continuaUy
thrust into the background the apparently less immediate needs of teaching.
At two other hospitals, Huron Road and St. Vincent's, a somewhat
similar interference with proper practical teaching is found. At Huron Road
a head nurse is expected to give the class room and practical instruction in
nursing procedure while her primary duty is management of a ward or floor.
At St. Vincent's, the supervisor of the gynecological and women's medical
wards was the instructor. Obviously, the successful combination of two
such functions is impossible.
No opportunity was presented to see the instruction in nursing procedures
at St. John's, owing to the illness of the instructor at the time of the investi-
gation.
Instruction at the Maternity Hospitals
The remaining hospitals, Cleveland Maternity and St. Ann's Maternity
are special hospitaL, giving obstetrical training to second and third year
students, and to students of advanced standing. In the case of these stu-
dents, acquaintance with nursing procedures is presupposed, except in the
special field of obstetrics. In addition, both hospitals offer courses of 15
months in obstetrics to women who have had no previous training in nurs-
ing. At Cleveland Maternity, demonstrations, supervision and instruction
on the wards are given by graduate nurses. At St. Ann's, the teaching and
supervision are below standard, since they are in large part carried out by
graduates of the fifteen months' course in obstetrics only.
While far-reaching recommendations have been presented in the section
on Psenatal and Maternity Nursing Service, which may by some be con-
sidered as implying unjust criticism upon the quality of nursing service now
given by the Maternity Hospital, it is particularly to be noted that it is
not the quality of professional care either by physicians or nurses which is
criticised. It is not conceived by the staff of the Survey that among the
functions of a university teaching hospital is the administering of a city-
7ti8 Hospital and Health Subvei
wide prenatal service. Lack of good administrative organization, inadequacy
of supervision, lack of continuity of the present nursing service for maternity
cases, are the main reasons for the recommendations that the Visiting Nurse
Association and not the Maternity Hospital assume the broader functions
proposed. Without the initiative, the standards, the demonstrations in
this field made by tlie Maternity Hospital medical and nursing staff, Cleve*
land could not now even consider such a thorough-going program of maternity
care as is proposed. Cleveland's mothers owe much to the Cleveland Ma-
ternity Hospital.
Opportunities for Case Study
Case study is required of studeqt nurses only kt Lakeside and Mt. Sinai*
At Lakeside this good feature is found only in the medical wards.
Teaching of the Fundamental Sciences'^
In most schools of nursing instruction in the fundamental sciences is
weak, owing to the lack of good teachers and of equipment, and the lack d
preparation on the part of the students. Yet the employment of teachcR
is in itself an advance over former methods of instruction.
Most hospitals are equipped with one or more rooms in which it is pos-
sible for students to gather around a table, view specimens, and otherwise
witness a demonstration by the instructor, of the principles to be taught. But
this is not real laboratory instruction, which should provide for individual
experiment and observation.
None of the eleven general hos])itals studied in Cleveland is prepared to
give individual laboratory instruction in all four of the fundamental science
courses. Details of the e(}uipment provided are given under each science
course. None of the hospitals makes any separate allowance for laboraton'
supplies, demonstration material, or reference library.
Instructors are often overtasked with administrative duties. The teach-
ing staff at Lakeside is materially hampered by the necessity of attending to
many details in the administering of the school.
In five of the ten hospitals considered in this section, the same person
who administers the training school is expected to carry all or at least the
heaviest part of the teaching. At the City Hospital, the acting superinten-
dent of the training school teaches 7 subjects, spending 19 hours weekly in
class work in addition to the nursing administration of a hospital with nearly
800 beds. An emergency at Fairview makes the instructor also the acting
superintendent of nurses, though even in normal times she shares many of
the responsibilities of administering the school. At Glenville and Lake-
wood, the administration of the training school and the instruction of nurses
is carried on by the same person. At St. John's, the superintendent of
nurses carries in addition to 18 teaching hours, the administrative duties of
her position in which she seems to have no assistance even for the clerical
work.
* In thtt section St. Alexia is omitted throughout, owing to the absence of tsrsteaxatised *iMtiuctio&
and of records concerning the course given during the srear since this training school was started.
4 l?*tt«iNG 729
It needs no argument to prove that such duties cannot successfully be
ombined. The more pressing demands of administration take precedence;
he teaching must inevitably suffer. If a higher standard of instruction is to
« established, the appointment of full-time instructors is an urgent neces-
ity. The only alternative is a central school of nursing, to which students
nay be sent for instruction.
(a) Chemistry
Six hospitals give instruction in this subject, City, Fairview, Glenville,
At. Sinai, St. John's and St. Vincent's. Four others, Huron Uoad, Lake-
ide, Lakewood and St. Luke's, avail themselves of chemistry courses in the
learest high schools. Lakewood pays a fee of $80.00 for the course; the in-
truction for the students of the other hospitals is furnished gratis by the
ity, through arrangement with the Board of Education.
t
Method
Of the six hospitals in which chemistry is taught, three have some indi-
'^idual laboratory work; City, where half the time allowed is given to the
aboratory, Mt. Sinai, and St. Vincent's, where only a few hours of labora-
ory instruction are provided. In the others, the instniction is almost wholly
»y lecture with occasional demonstration.
Mt. Sinai gives a preliminary course to students who have not had
chemistry in high school. A more advanced course is given to all student*.
The teaching of chemistry in the high schools ap|>ears to be of high grade
hough limited in scoj)e.
Equipment
Of the six hospitals which provide their own course in chemistry, only
►ne, the City Hospital, has adequate equijiment for both laboratory work
nd demonstration. At Mt. Sinai and St. Vincent's, the supplies appear to
>e adequate for demonstration purposes. At St. John's, Fairview and
Jlenville, the equipment is inadequate for either method of instniction.
Hours
The hours devoted to this subject in Cleveland training sehcKils are a.»<
allows: •
Lakewood 40 hours (High School affiliation)
Mt. Sinai 33 "
Lakeside. 30 '' (High School affiliation)
Huron Road _ 30 ''
St. Luke's. 24 "
City 20 "
St. Vincent's 20 *'
St. John's 18 *'
Glcnvillc -. 12 "
Fairview 10 "
780 Hospital and Health Subtkt
(6) Anatobct and Phtsioloqy
All of the ten hospitals give some instruction in this subject.
Method and Equipment
In one hospital, Huron Road, instruction is almost wholly by formal
lectures and quisses, with demonstrations at intervals; in the others, mainly
by recitations on assigned texts with some demonstrations. In only two
hospitals. Lakeside and Mt. Sinai, is there in addition some individual
laboratory work« though the equipment Ls very meagre.
Hours
The hours given to this subject in Cleveland training schools are as fol-
lows:
Lakeside ^ „ 70 houn
Mt. Sinai ^ 62 "
St. ^^ncent'a.- ^ 60 "
St. Luke*a^ ^^ ^ 56 "
Huron Road ^ 51 **
aty ^ 50 "
St. John's.. -. 50 **
Olenville _ .40 "
Lakewood 36 "
Pairview 30 "
The time allotted to anatomy and physiolog>* in 4 schools outside of Cleve-
land is as foUo^-s :
University of Cincinnati 150 hours
University of Minnesota „ 144
Johns Hopkins..- „ 110
ChOdren's (Boston) 100 "
vr^ Dietetics
|iK the ten ireneral luv^pitals eight give SDUie instruction in this subject.
i. e.. City, Fair\-iew. (tlenville, Huron R(^d« lakeside, Lakewood, Mt
Sinai and St. Luke's. Two other hospitals, St. John*5 and St. Mncent's,
send their students to the Y. W. C A. for instruction in this subject. With
the exception of Lakeside and St. Luke's, all these courses strongly empha-
sire cooker>\ and cive a niiuimuni amount of instriK^tii^n in the hasic principles
»»f nutrition.
This failure is all the mone serious owiui; to the grvkwing recognition of
the primary imf^K^rtauce of nutrition. espe^Mally in relation to chitdreo and
the movement for Child Welfare in which nurses hear increasing responsi-
hilitv.
Lakeside aud City have ^c^od laK.>ratories titted for tcftdung dietetics
.ilthoui^h at the City :t i> not adequately supplied with iodividaal otensik
7 R 8 I N O 781
Huron Road the laboratory is fairly adequate. The remaining five hos-
ds provide decidedly inferior equipment for teaching this sub|ect. In
le instances the room provided is imsuitable (such as the main kitchen at
Luke's), and in others there is a lack of utensils for individual work.
Hours
The time allotted to this subject in Cleveland training schools is as fol-
Mt. Sinai ^ 60 hours
Lakeside. ^ 52
St. Vincent's. .45
St. John's : 45
St. Luke's. 44
City 40
Huron Road 40
Fairview... _ 32
Lakewood. 25
GlenviUe 24
it
it
tt
tt
tt
tt
it
it
it
In four schools outside of Cleveland the hours given in dietetics and
)kery are as follows:
University of Minnesota^ 70 hours
Philadelphia GeneraL ^ .^ ^ 66 "
Children's (Boston) 56 "
Boston City — ..^..... — ............. ..i,. 56
(d) Bacteriology
All of the hospitals give some instruction in bacteriology, but in none is
ire adequate equipment for the individual laboratory work essential for
s subject.
Equipment
Material for demonstration in bacteriology is good at Mt. Sinai» and
rly good at Lakeside and St. Vincent*s. At all the other hospitals this
lipment is very meagre.
Hours
The time devoted to this course in Cleveland training schools is as fol-
rs:
St, Luke's.-. ..
Huron Road..
Mt.
City.
St. Vincent's.
Fairview
Qlenville
36
hours
24
21
20
20
20
12
12
11
782 Hospital and Health Survey
. • At St. John's, this course is combined with hygiene.
, ' •■ « . .■••■•
In four schools outside of (]!leveland, the hours given in bacteriology are
as follows :
University of Minnesota .99 hours
Children's (Boston) _„ ^ ^ _ 76 "
University of Cincinnati 75
Presbyterian (Chicago) 70
Method
In only one of these, Mt. Sinai, is individual laboratory work given, and
even there with inadequate space and too meagre equipment to make tlus
form of instruction eflPective. The course is divided into half laboratory and
half recitations on assigned texts.
Lakeside, which has no laboratory work, could probably arrange for it
by utilizing more extensively the possibilities of the pathological department
of the hospital. Half of the course at Lakeside is devoted to demonstration
by the instructor and half to lecture and recitation.
At the other eight hospitals, the method of instruction varies, being mostly
demonstration at St. Luke's and St. Vincent's, and mostly lectures at Fair-
view and Glenville. The others combine these methods. At St. John's the
work in bacteriology is not given as a separate course, but in combination
with the course in hygiene.
Instruction in Other Subjects
The length of the course is only one factor, and by no means the most
important factor, in determining the value of the instruction. Yet the pro-
portion of time devoted to \'arious groups of subjects is highly indicative.
Comparisons of the time devoted to instruction in the more advanced
subjects are diBScult to make, since the classification and arrangement of
subjects show wide variation. Thus, in one school the lectures on gynecolog)'
are included in the course in surgical diseases, in another in the course in
obstetrics, and in others, as a separate series. In the same way the lectures
in operating room technic, orthopedics, and eye, ear, nose and throat dis-
eases are sometimes given as separate courses, and at other times included in
the gencnil surgical lectures.
In the same way, it is difficult to make comparisons of instruction in
the (iiflPerent branches of medicine. Thus, communicable diseases, nervous
and mental diseases, occupational diseases, venereal and skin diseases, and
pediatrics, are given as separate courses in some schools, and in others two
or more are combined into a single course. In one, all these subjects are given
as one course, under the title of medical diseases.
Notwithstanding these differences in classification, comparisons can
fairly l>e made between groups of allied subjects. Thus, we may combine
in one grou]) under the general title of surgical subjects the following: eye,
URSING
783
IT, nose and throat diseases, gynecology, operating room technic, orthope-
ics and surgical diseases. The number of hours of instruction given to these
irgical subjects in 9 Cleveland training schools, ranges from 34 to 73. One
rhool cannot be included, since in that school gynecology is included in
jstetrics.
Again, comparisons may fairly be made by grouping under the single
3ad of medical, the following subjects: communicable diseases, medical
iseases, nervous and mental diseases, pediatrics, and venereal and skin
iseases. In this group of medical subjects, Cleveland schools give from 52
» 109 hours of instruction.
HouBS OF Instruction in Three Groups of Subiects
Medical
City 90
Fairview.™ 61
Glcnvillc 56
Hurcm Road 82
Lakeside 92
Lakewood..^ 54
Mt. Sinai. 52
St John's-^ 109
St. Luke's _. 62
St. Vincent's 88
Surgical
43
34
48
65
70
59
73
44
60
Preliminary TOTAL
Sciences All Subjects
130
472
76
365
88
365
122
596
162
672
112
469
176
655
148 1
598
140
572
145
505
In obstetrics the hours given range from l!2 at St. Luke's to 31 at Huron
►ad. Except for Lakewood, which gives 18 hours, the time devoted to
s subject in the other hospitals is from "^O to 30 hours.
The total number of subjects listed in the curricula of the Cleveland
dning schools ranges from 17 to 29, in addition to the four fundamental
ences already considered. These four sciences, viz. anatomy and physi-
^gy» bacteriology, chemistry, and dietetics and cookery, may be considered
5 preliminary subjects, or those introductory to the specifically technical
d professional work to follow. In nursing schools already affiliated with
lieges and universities, the tendency is to consider these subjects pre-
luisite to the strictly professional training.
It is significant that the Cleveland hospitals devote to these four sub-
Is from 20% to 28% of the. total time devoted to class instruction, leaving
ly from 72% to 80% to the subjects that constitute the main body of pro-
sional instruction. It is instructive to compare, for example, the time
i^oted to the group of medical subjects, which ranges from 8% to 19% of
? total time allowed for class room instruction, or to the group of surgical
)jects, which ranges from 7% to 13%, with the time devoted to the pre-
inary group which ranges from 20% to 28%. When it is recalled that
time aUowed for the preliminary subjects, though large in proportion to
* Figures not ootnpambte, stnoe gynecology is included in course in obstetrics,
t Includes a courte in hsrgiene which is combined with bacteriology.
784
Hospital and Health Sxtbyet
the total hours of instruction, is in reality meagre, the disproportionate
time allotted to purely professional subjects is a still more serious indicatioa
of the inadequacy of the curriculum.
This fault, common to nursing schools in general and not peculiar to
Cleveland schools, illustrates the emphasis that has universally been placed
on the manual side of the nurses' training, to the exclusion of sufficient class
room instruction.
Proportion of Total Class Hours Devoted to Medical and Surgical
Groups Compared with Proportion Devoted to Preliminary
Sciences*.
Medical
City 19%
Fairview 16
Glcnville.„_ 15
Huron Road 13
Lakeside 13
Lakewood - 11
Mt. Sinai 8
St. John's 18
St. Luke's 10
St. Vincent's 17
Surgical
Preliminary S
■ 9%
27%
9
20
13
24
10
20
10
24
12
23
t
26
12
24
7
24
12
28
Method of Instruction
^ In the presentation of most of the purely professional subjects three of
the hospitals, Fairview, Glenville and St. Luke's, rely mainly on the lecture
method. In the otlier hospitals there are recitation periods in connection
with most of the lecture courses. At two hospitals, Lakeside and St. Vin-
cent's, periods are, in many subjects, set aside for demonstration.
The courses in psychology and venereal and skin diseases, however, are
purely lecture courses except at St. Vincent's where recitations and demon-
strations are given. Likewise, the course in mental and nervous diseases is
taught entirely by lecture exc^ept at Lakeside, Mt. Sinai and St. Vincent's.
The correlation between class and watd instruction in Cleveland traininjt
schools seems on tlie whole to be as carefully planned as in other schools of
comparable standing. As long as students staff the wards at need, com"
plete correlation of theory" and practice is probably impossible. Yet in many
instances in Cleveland there was evident failure to come as near as possible
to the best practice. Thus, with the exception of St. Vincent's, the classes
in surgical diseases and medical diseases are given in the student's second
year in the school, after she has presumably for many months had the care
of both medical and surgical patients.
The difficulty encountered by small schools in giving proper instruction
to their students is illustrated by Lakewood which is unable to give aD
* Other aubjects not apecified in the composition of these groups are omitted in this aectioo.
t Figures not comparable since gynecology is included in course in obstetrics.
' U R 8 I N G 735
•
>iijrses each year, since the number of students in each class is small. For
cample, the course in anatomy and physiology is given in alternate years,
hus instruction in this fundamental subject is not given to some students
Qtil their second year. In the same class, therefore, are students in the
icond year, first year, and preliminary period. These last are the only
indents who receive this instruction at the time when it should properly
B given.
The advantages that would result from combining with other schools
re obvious.
In aU of the Cleveland schools* important courses are given in the even-
ig, a highly undesirable practice.. Evening classes not only deprive students
f time for recreation, but also require mental activity when students are
itigued from the day's work in the wards.
St. Vincent's makes extreme demands upon its students in this respect.
n this hospital 94 hours of class instruction are given after six o'clock in the
vening. In this evening work is included all or part of the foUowing courses:
<andaging, massage, medical diseases, surgical diseases, obstetrics, eye, ear,
ose and throat diseases, venereal diseases, psychology and ethics. Three
ther hospitals, Fairview, Glenville and Lakeside, give 50 hours of instruc-
ion or more in the evening.
CONDITIONS OF WORK
Ratio of Nurses to Patients
The ratio of student nurses to patients which is desirable for teaching as
'^U as for eflSciency of service, is influenced by differing conditions in different
•ervices and even in different wards.
The best general opinion places the desirable ratio in an active ward
«Tvice at about 1 nurse to 5 patients on day duty; 1 nurse to 10 patients on
li^t duty.
In Cleveland, of the 8 hospitals for which information is available, 5
lospitals meet this desirable ratio for day duty. These hospitals are: Huron
md. Lakeside, Mt. Sinai, St. John'sf and St. Luke's. Of the remaining
Jiree hospitals, Fairview and St. Vincent's fall short, having a ratio of 1
Uirac to 8 patients, while the City Hospital provides only half the requisite
lumber of student nurses. This lack is in part supplemented by helpers in
Qme wards.
For night duty, only 1 hospital, St. John's, comes up to the desired figure.
lie others range from 1 nurse to 12 patients at Mt. Sinai, to 1 nurse to 'il
itients at St. Vincent's. At the City Hospital, the ratio was given as 1 to
5, but examination of the hospital's own records showed on the night of
inuary 2^d that it had been possible to provide only one nurse to 40
itients.
* Information on this point wa» not obtained from Huron Road.
t On the day of in^>cctioo a lower ratio was found, i. e. 1 :9.7 on medical floor; 1 :8 in women's surgical
736
Hospital and Health Survey
The ratio of students to patients in private service must necessarily be
higher because this is a room service. According to the standard, 1 nuiae
to 3 patients is correct for day duty; 1 nurse to 5 patients at night. In almost
all the hospitals the ratio either just meets or falls slightly below the desiied
figure for day duty. Night duty shows a wider deviation from the standard,
St. Vincent's providing only 1 to 16 patients.
HOURS OF DUTY
1. Day Duty
In the past, the failure of the trainng schools as educational institatioDS
has been due largely to the excessive hours of labor required. To state the
case is to prove it. To expect study or inteUigent appUcation from students
is manifestly impossible in addition to the *' nine-to-ten-hour working daj»
the twelve-hour night and the seven-day week,*' which, according to the
standard curriculum, is "still required in most hospitals." During the past
year the introduction of the eight-hour day has made marked advances.
Eight Hours
In Cleveland three of the thirteen training schools have nominally ai
eight-hour day. These are Huron Road (where there is, however, a nine-
hour day in private service). Lakeside and Mt. Sinai. This good showing ii^
however, lessened by the fact that in all three hospitals class work and std(f
and meal times fall, as is customary, in the students' so-called "free oflf-duty
time." At Mt. Sinai class work exceeding one hour per day is counted is
time on duty, at Huron Road extra time is allowed off "when possibfe."
At all three hospitals one half -day off is given on Sundays. In some service
there are additional hours off on Sunday. All three hospitals give one
half-dav off weeklv.
Eight and One-half to Nine Houks
At the City Hospital the hours of duty range from SJ^ to 9, and arc
reduced to 4}/^ on Sunday, (^lass time is occasionally counted as time on
duty. A half-day weekly is allowed.
Nine Hours
The remaining nine hospitals have a nine-hour day on five days of the
week. AH give one-half day off per week and vary in tlieir hours on Sundayi
St. John's and St. Vincent's having nine hours*, and the others ranging
downward to four and a half.
It should be noted that at Fairview and Lakewood, class time is counted
as time on duty, and at Glen vi lie tliis is occasionally done. In consequence
the work on the wards at these 3 hospitals is often less than nine hours, pa^
ticularly in the junior year. At St. John's juniors have only 8 hours on
the wards.
* On every third Sunday hours of duty reduced to 2 and 1 1-2 houm respectively, at these t«o
hospitals.
3 I N G 737
2. Night Duty
5 educational value of night duty lies in part in the added responsi-
md initiative which it entails for the students. Obviously, however, the
of this service is obtained at the cost of added physical and nervous
n. The assignment to night duty should, therefore, be neither too
L duration nor too frequent; and careful provision should be made to
to the students on night duty quiet and privacy for sleep in the day
These primary precautions in the interest of health and education
often to be ignored. Moreover, the study of individual students
frequent examples of exceeding the period of time planned for night
jht duty should be assigned with special reference to the nursing ex-
« to be obtained which may obviously be great in medical and obstet-
frvices, but is negligible in a surgical service. ^
Length and Frequency of Night Duty
Eight Hours
reside, Mt. Sinai and Fairview have eight-hour duty. At all three
lis the term of the service is nominally two months. Mt. Sinai sue-
in keeping night duty substantially within the limits set for it, but at
de continuous periods of night duty though not intended to exceed
s, have in fact, according to the hospital records for the present senior
un as long as 16 weeks. No data on this point were obtained from
;w.
ceside and Fairview plan three periods of night duty, Mt. Sinai four,
ig respectively six and eight months.
Over Eight Hours and Less than Twelve
ir hospitals fall in this group.
veland City requires nine and a half hours night service, with one hour
a night lunch. The term of duty here is only two weeks at a time.
veland Maternity and Glenville have 10 hours, Glenville having six
of six weeks each, totalling nine months.
ron Road has 11 hours in periods of one and two months, totalling
onths. This hospital gives one night off duty per week.
Twelve Hours
e hospitals have a twelve-hour night, with a half hour off for a night
These hospitals are Lakewood, St. Alexis, St. John's, St. Luke's,
icent's. Of these, two have a half -night off at regular intervals, Lake-
nonthlyy and St. John's fortnightly. The term of duty ranges from
iods of eight weeks each (or nearly a year) at Lakewood, to three or
y more periods of one month each at St. Alexis.*
tiM 13th ho^»ital, St. Ann's, affiliating students are not assigned to night duty.
738 Hospital and Health Subvei
Classes During Night Duty
Lack of consideration for the students' health and study is apparent in
the custom of holding classes in the early morning or at early afternoon
hours, before the nurses have satisfied the primary need of sleep.
In six of eleven hospitals in Cleveland, there are early morning classes for
students on night duty. These six hospitals are: City, Glenville, Himm
Road, Mt. Sinai, St. Luke's, and St. Vincent's. One hospital, Fairview, has
classes in the early afternoon at two o'clock. The four remaining hospitals,
Lakeside, Lakewood, St. Alexis and St. John's, have classes at a more rea-
sonable hour, that is, after three o'clock.
Time Off After Night Duty
The strain of night duty is often recognized by allowing a brief vacatioD,
after each term of service. With the single exception of Lakeside, this cus-
tom is followed by the Cleveland training schools. The time off varies km
one to two and a half days. At St. Vincent's three days off are given.
Sleeping Quarters for Night Nurses
To afford quiet and privacy for rest during the day to the students on ni^t ,
duty, special rooms or dormitories should be provided for them. Four
hospitals, St. John's, St. Vincent's, City and Cleveland Maternity, halt
such an arrangement. In the other hospitals little effort is made in this
direction. As most rooms are double, it may frequently happen that a day
and a night nurse vshare a room. An attempt is made to put room-mat0
on night duty at the same time, but this is difficult and often impossibk to
arrange.
Vacation
With four ex(*t*ptions, Cleveland training schools give a 3-weeks' vacation
each year. The s(»hools which allow only ^ weeks for vacation are the Cityi
St. Ale.vis, St. Vincent's and St. Luke's.
Provision of Ward Helpers
One of the most obvious wastes of the student's time and energy in the
prt\sent orpuiization of training schools is the excessive amount of house
work rtM|uirtMl, and the failure to supply ward helpers.
The hospitals in Cleveland differ greatly in this respect. In most of
them it is taken for granteil that the student nurse performs a large part of
su(*h tlutios. Vtoux a(*tual observation in the wards it appears that witk
the oxivptit>n of one hospital, fn>in two to eight hours daily are spent hj
studiMit nurses as iHH'asion arises in non -educational duties such as:
Making surgical supplies.
Running sterilixer.
Cleaning and mending gloves.
R S I N 6 739
Dusting an^l cleaning wards and service rooms and rooms of private patients.
Folding and putting away linen.
Setting and carrying trays, washing dishes.
Washing soiled linen, tending switchboard and front door.
Vt Lakeside 3 probationers and 3 advanced students are regularly
^ed to the gauze room where three-quarters of the time is spent in the
ine preparation of surgical supplies. It is planned that each student
1 spend a month and a half in this service which can scarcely have any
^tional value after the first two weeks, and comes appropriately in the
>ationary period.
The only considerable attempts to relieve the nurse by providing ward
•ers are at Huron Road and, to a greater extent, at Mt. Sinai, where
students devote more time to strictly nursing duties than in other
reland hospitals. At Mt. Sinai the installation of thoroughly modem
pment has simplified the problems of housekeeping in general. The
T involved in caring for patients is reduced to a minimum by the liberal
rision of portable equipment and by the introduction of labor-saving
ces.
Moreover, the students' time is saved at this hospital, by employing at-
lants to perform a multitude of routine duties, which have been learned
tudents during the preliminary period and are educationaUy valueless
hem at a later stage.
rhe failure of other hospitals to supply such service makes the example
It. Sinai and Huron Road all the more noteworthy. It is worth while
escribe the arrangement for ward helpers at Mt. Sinai in some detail. On
ate floors attendants are employed to do all dusting, caring for flowers,
Bering the telephones. Half an hour before meals, they set trays in the
kitchen, the nurse serving only the hot food. The attendant carries
s to and from the patients' rooms. In the afternoon she is employed
laking surgical supplies. The attendant works 8 hours per day, and re-
es $40.00 per month and one meal a day. In the public wards lay helpers
employed only during vacation period.
!n the surgical supply room two full-time women are employed at $50.00
month with three meals a day, and two part-time women three hours
I day. These women were employed as diet kitchen maids at $25.00 per
th, and asked to be employed in the surgical room at their hours off in
afternoon. In. the operating room one full-time woman is employed at
00 per month and three meals a day. She cleans instruments and the
a, and makes surgical supplies.
[n the obstetrical department ward helpers do the same general duty as
the other wards. In addition, the attendant has charge of all clean
1, sweeps and dusts the nursery, and holds the babies during supplement-
feeding. Thus, the housekeeping duties of the students are reduced to
linimum, such as scrubbing babies' individual basins, and sterilizing
n. While students are suppoj^d to make surgical supplies in spare time,
as noted that in fact, their time was fully occupied with strictly nursing
es.
740 Hospital and Health Subtet
Undoubtedly the elimination of routine housekeeping duties and other
non-educational tasks has done much to foster the study by student nurses of
cases on the wards, and their unusual intelligence in discussing these cases.
But even at Mt. Sinai it is estimated that the student may spend daily
one and a half hours folding and putting away linen and aboat an hour
cleaning wards and service rooms, and the unique opportunities of the dis-
pensary as a training field are only partly utiUzed because students' time
there is more than half filled with routine cleaning and arranging supplies.
LIVING CONDITIONS
The Nurses' Residence*
To counterbalance the strain of abnormal conditions met in the hospital
wards, the student nurse needs the relief of outside interests and a wholesome
home life. These needs are too often left unprovided for when the nurses
are lodged in ordinary houses improvised as homes for a large student body
without proper bedrooms or lavatory equipment, and without any special
rooms for study or recreation.
If the nurses Uve in the hospital building, they do not have sufEdent
opportunity to shake off the ward atmosphere. ' Even mild social recreations
are often made impossible by the close proximity of the patients. Tie
nurses' residence should, therefore, be a separate buQding in the near vicinity
of the hospital. It should be constructed to meet the needs of a nurses'
home, with reception and recreation room, library, class room, study room
and single bed rooms, with proper lavatory equipment and such accessory
rooms as kitchenette, laundr>' and sewing room, exclusively for the use d
the students.
In Cleveland all of the hospitals but two, house their nurses in separate
buildings. These two are Lakeside and Huron Road, which set aside a
separate wing with the entrance through the hospital. At St. Vincent's
and St. John*s, although there is a separate building, it is reached only
through the hospital, and is undesirably located in the rear.
The nurses' residence at the City Hospital is the only nurses' residence in
Cleveland which is satisfactory-. The other nurses' homes were originalty
built for other purposes. Four of these, Huron Road, Mt. Sinai, St. Alexis,
and St. Vincent's, provide no nurses' reception room. Four, Glenville, Lake-
wood, St, Alexis and St. John's, provide no separate recreation room. None
have a room set aside for study.
The general and reference libraries are inadequate at City, Lakewood,
St. Alexis and St. John's, either on account of lack of books and magazines,
or o^ving to their inact'essibility.
Two Cle\'eland hospitals. Lakeside and St. Luke's, have a social director
for the students.
In the nurses' homes in Cleveland, the double room is the rule, the single
room the exception. Even more undesirable than the double room is the
ICAtcroity ssd St. Ann's omitted iA tins
i S I N G ' 741
itory. Six of the eleven nurses' homes visited, lodge some of their
nts in dormitories. At St. Vincent's sixty-five, of a possible eighty-
students, are housed in dormitories having from three to ten beds each.
bviously, the nurses' residence should have adequate hygienic surround-
for the nurse and provision for personal hygiene and immaculate clean-
i. Ample lavatory facilities are a necessity, the provision of one bath-
to six students being regarded as the minimum requirement. The
s' residence at the City Hospital is excellent in this respect, and, in
ion, stationary basins are provided in each room. There is also a large
cry adjacent to the dining room, though by a curious omission there
o toilets in this lavatory.
be other institutions make fairly adequate provisions with respect to
•al lavatories, excepting St. Luke's and one floor at St. John's.
Dietary
ince student nurses are engaged in arduous physical and mental work,
ul selection of their food is a matter of prime importance. This appears
ceive reasonable consideration in the Cleveland hospitals.
he nutritional value of attractive service should not be overlooked. A
eria service, three meals a day for three years, is not satisfactory, es-
lly in the case of persons who must be on their feet long hours every
In Cleveland three of the hospitals. Lakeside, Lakewood and Mt.
, rely on cafeteria service, good of its kind. Under existing labor con-
is, it is justifiable, but it should clearly not be a permanent feature of
urses' dining room.
RECOMMENDATIONS
1. A UNIVERSITY SCHOOL OF NURSING
t is strongly urged that a University School of Nursing be established at the earliest
lie date. This school should be on the same academic basis as are other under-
ate schools of the University. The instructors should be members of the University
AU students should fully meet the usual requirements for admission, and the com-
universtty and hospital course should lead to the Bachelor of Science degree. The
tic instruction, both in class-room and laboratory, should be given by the school.
a order to obtain the necessary ward practice, the training school should make con-
with the several hospitals whereby the latter should agree to receive students for
Dg in specified branches of nursing. Affiliating hospitals should be required to meet
andards of instruction and conditions of work established by the University, in order
he training shall be of grade equal to that furnished in practice fields of other schools
: Univernty.
*iine must necessarily elapse before a University School of Nursing can be success-
planned and launched. In the interval the Cleveland Training Schools should take
iiate steps to improve the present course of training.
742 Hospital axd Health Subvet
The recommendations which follow embody some of the obvious changes needed to
improve working and living conditions for the student nurses and to strengthen tiie is-
struction now given.
•
The recommendations as to the content of the curriculum and the rdative length of
courses are not here given. On these points it has not yet been possible to formulate
conclusions, as noted earlier in this report (see page 712). Studies of hoqntal tnuning
schools in other cities, of which the Cleveland Survey has been one, are now in procrcH,
by the Committee on Nursing Education. From detailed observation of the ward experi-
ence and instruction of students in different types of hospitals, material is being gathered
on which the Committee will base its ultimate reconmiendations for i. detailed curricufaniL
The recommendations which follow will, it is believed, not only improve the trni-
ing but will help to attract students of higher calibre, who have been repelled by the un-
necessary physical hardships and inferior instruction of the present training schools.
2. ORGANIZATION OF THE TRAINING SCHOOL
Various proposals as to the organization of training schools are presented in detaS
on page 713 of this chapter and need not be repeated here.
CoBt Accounting
A separate and detailed budget for the training school should be prepared, and t
system of cost accounting should be adopted to show the total cost of the traimnc
school, including instruction, maintenance, etc., and covering the value of serncci
rendered by the students and staff of the school.
Money Allowance to Studentt
Cleveland training schools should abandon the practice of paying students, and should
use funds thus released to build up their educational work.
Payment to Lecturer »
The growing practice of paying the members of the medical staff who teach in the
school of nursing should be generally adopted.
3. MINIMUM ENTRANCE REQUIREMENT
The minimum educational requirement for admission to a school of nursing should
be not less than completion of high school.
4. SERVICES OFFERED
Hospitals which cannot offer adequate clinical facilities for instruction in the four
main branches (medical, surgical, children's diseases and obstetrics), as well as in the im-
portant special branches of communicable diseases and mental and nervous disorders,
should provide such opportunities for their students by affiliation with institutions capable
of offering them.
It is urged that all students who exj^ect to enter public health work should be aUowed
to elect the eight months* course, but at the least they should be allowed the foiu* months'
period of training in the University District.
Nursing 748
Dispensaries and social service departments should be utilised for training students,
soon as adequate teaching and supervision are assured.
5. INSTRUCTION
Instruction in the fundameotal sciences and in the other necessary branches can best
be afforded by a central training school, under University auspices, such as is recom-
mended above.
If such University affiliation should not prove feasible, or if there is delay in joining
it, it is recommended that several training schools of similar grade in Cleveland combine
in furnishing theoretical instruction to their students. No lower educational requirement
for admission should be accepted than that required for University .entrance.
Teaching of Nurnng ProemdurmM
Whatever combination with other schools may be made in the future, whether under
University or other control, it is clear that a demonstration room and equipment for teach-
ing nursing procedures will continue to be needed in every hospital that admits students
for training. It is therefore urged that every school not now so supplied for demonstra-
tion and individual practice, should provide these needed facilities without delay.
The technical work of probationers and also of more advanced students should be
supervised by the instructor. Bvery student should be carefully taught each nursing
procedure in the class room before she is allowed to carry it out on the wards. Moreover,
each student should be supervised by the instructor when she carries out any procedxve
for the first time, and she should not be assigned to any duty regularly until the instructor
has made sure that she is proficient, and has notified the head nurse to that effect. Pro-
cedures should be demonstrated to head nurses by the instructor.
Similarly, the teaching of diet in disease must always be given at least in part within
the hospital in order to correlate class instruction with the actual feeding of patients on
the wards. It is therefore urged that every hospital not now possessing adequate class-
room and laboratory facilities for the teaching of diet in disease should provide these
facilities immediately. Equipment similar to that needed for teaching dietetics is needed.
Teaching of Fundamental and Technical Suhjectt
Prior to the establishment of a central school of nursing various immediate improve-
ments in teaching and equipment should be made in the fundamental sciences and the
technical subjects. These improvements have been indicated in sepcu-ate reports to the
different hospitals.
6. CONDITIONS OF WORK
Neither day nor night duty should exceed eight hours out of the twenty-four. Class
hours should be included in this time. Students on night duty should in no case have
cinsari until after a period of at least eight hours has been allowed for sleep. Night work
should be limited to short terms of not more than one month each. To compensate for
the strain of night work a brief vacation should be given at the completion of each term.
744 Hospital and Health Survet
7. LIVING CONDITIONS
The provision of suitable living conditions and opportunities for recreation are tufed
as matters of first importance.
The nurses' residence should be separate from the hospital, but in close proximity to
it. It should contain reception and recreation rooms, library, class and study rooms,
and accessory rooms for the exclusive use of the students, such as kitchenette, laundry
and sewing rooms. Students should have single bedrooms, and there should be generoos
provision of bathrooms and lavatories.
For students on night duty special sleeping rooms should be provided, which should
be situated so that quiet and freedom from disturbance are assured.
Special attention should be given to providing recreation, both indoors and out
Facilities for indoor recreation might well include a gymnasium and swimming pool, and
should, at the least, include good facilities for dancing. If space permits, tennis courti
should be provided fqr the exclusive use of the nurses.
It is recommended that social directors should be appointed, who should be chaiged
with directing the recreation and social life of the students.
8. REDUCTION OF PRESENT THREE-YEAR COURSE
With the practical development of the recommendations given above it should prove
possible to reduce the present three-year course for all nurses. At this time, for the ressoo
given above (see page 712), it is not possible to make specific recommendations as to the
amount of time by which the regular nurses' training may safely be reduced. The hiffiia
standard of admission, the elimination of uneducational house work, better instrucdoo,
practical and theoretical, a better balanced provision of services, will enable the course to
be reduced by at least eight months.
The principles underlying such reduction of the present three-year course are two:
1. That all nurses-in-training should Yiavt the same basic education,
after which they may be graduated with the certificate or diploma of nurse;
2. That in addition, courses should be provided leading to special
diploma for public health nurses, for teaching and administrative positions in
hospitals, and for specialties in private duty.
This plan is proposed in the belief that nurses graduating from the shorter basic
training will be available primarily for bedside care. The more advanced courses will
attract students of higher calibre who are needed for the nursing specialties, especially iot
teaching and administration in hospitals and for public health work. It is the conviction
of the Nursing Survey that without a thorough clinical training the responsible duties in
these rapidly developing fields cannot be successfully met.
9. TRAINING OF COLORED STUDENTS
The question has recently been rai^jed as to providing opportunities for colored stu-
dents to obtain the nurses* training in Cleveland. At one hospital — ^the City Hospital-'
this is a question of practical moment. There can be no doubt that at tiie City Hospftali
where the training school is maintained by the city, all citizens have equal rights. Tbe
N G 745
afforded by the city should therefore be available for all students, irrespective
So far as concerns living arrangements at the hospital, the possibility of friction
y be removed by following the custom of allowing colored students to live at
ng their training.
Post Graduate Courses
WESTERN RESERVE UNIVERSITY COURSE
IN PUBLIC HEALTH NURSING
Origin
impulse that led to the founding and development of this course
3 from a group of lay women interested in the Visiting Nurse Associa-
To them it became apparent, as visiting nursing broadened from
remedial work into constructive efforts for family health, that
mration afforded to nurses by hospital training schools was
it to prepare them for the social and preventive work required in
lly developing branch of nursing. Additional instruction both in
*oom and in the field was clearly needed.
the same vision and energy from which Cleveland has richly profited
forms of nursing and health work, plans for a course of training
le and put into effect. For 5 years the course thus established was
y the Visiting Nurse Association, with the assistance of the De-
of Sociology of Western Reserve University, the Associated
, the Anti-Tuberculosis League, the Babies' Dispensary and Hos-
I the Department of Medical Inspection of the Board of Education,
ting Nurse Association took the financial and administrative re-
ty, secured a director, and set aside as a practice field the area now
)y the University Public Health Nursing District.
e work of training developed, it became clear that direction might
)ropriately be exercised by an educational institution than by an
organization. After 5 years, therefore, the Visiting Nurse Asso-
•ansferred the management of the course to the University, and in
ecame a constituent part of the Division of Health Administration
hool of Applied Social Sciences.
Organization
organization effected was excellent. By becoming an integral part
niversity, the stability and educational purpose and standards of
e were assured. At the same time, through the appointment of an
committee and the establishment of the University Public Health
District, the course has maintained its close connection with public
irsing activities, and has secured a unique field for the instruction
its in practical work.
Vdvisory Committee is composed of 13 niembers, of whom a lay
s chairman. The superintendents of nurses of the following organi-
B members: the Division of Health, the Board of Education, the
746 Hospital and Health Survey
Visiting Nurse Association, and the Babies' Hospital and Dispensary. Tbe
Dean of the School of AppUed Social Sciences is also a member^ and the
others are lay women respresentative of the group to whom Cleveland owes
much of its progress in various branches of health work. The Director of
the course is secretary of the Committee. So long as such a group forms its
I)olicies and directs its activities, the maintenance of proper balance between
theoretical and practical work seems assured.
The University Public Health Nursing District is perhaps the most
potent single factor in rendering the course one of the best in the country.
This crowded district was selected as a practice field on account of the varied
experience it affords for public health nursing. The course is planned on
the principle that the students for effective training must not only observe
the Work of others, but must themselves carry responsibihty, under eicpert
supervision, for actual practical work. The plan presupposes that field
work corresponds to laboratory work in other departments of the University,
and that it should, therefore, be controlled by the School in order that it
may be carried on according to sound educational methods.
With the exception of school nursing, the work in the University District
is almost entirely generalized. This arrangement is of great value to the
student, since it eliminates the waste of time inevitably resulting from
assignments of work distributed among several different agencies. But
stiU more important, it teaches the student methods of dealing with ev&y
type of health problem encountered in the families she visits, and thus
forms an excellent preparation for community work. In post-partum work,
however, the opportunities are meagre, since much of this service at the
present time is carried by the nurses of the Cleveland Maternity Hospital.
The organization of the University District, and the character of the field
work are described in a special report.
Finances
The budget is prepared by the Advisory Committee. Expenditures
must be approved by the Committee.
The expenses of the course, above receipts from tuition fees, are met by
the University and contributions from the Visiting Nurse Association and
the Anti-Tuberculosis League. The Board of Health gives the supplies used
for its own especial activities in the district, but is not empowered to appro-
priate funds for the work of a private organization.
Staff
The teaching staff consists of the director, 5 nurse instructors in the
University District, the instructors in the several courses given by the School
of Applied Social Sciences and a number of lecturers.
The director of the course holds the ap])ointment of Assistant Professor
in the University, and teaches one course. She is directly responsible to the
Dean of the School and to the chairman of the Advisory Committee. In
addition to administering the work of the course, she is responsible for de-
M U R 8 I N G 747
ailed supervision of the work of the University District. She also lectures
Q training schools, serves on the Central Committee on Public Health
Cursing, and in her official as w^U as personal capacity she is called upon to
idvise and assist in many nursing activities in the community. It is clear
hat the responsibilities of her office are many and heavy.
The work of students in the University District is directly supervised by
he five instructors. These nurses, all of whom are graduates of the course,
lave been selected for their ability to teach and to supervise. That their
irork is of a high order is shown in the report on the University District.
)ne of the instructors acts as assistant director in addition to her other
luties. Her responsibility for administration is however limited except dur-
ng the absence of the director.
Students
For admission to the course, applicants must be graduates of approved
raining schools for nurses, and must be eligible for membership in the Na-
jonal Organization for Public Health Nursing. They must also be graduates
>f high schools, or have received an equivalent preliminary education. To
the latter requirement, however, a number of exceptions have been made.
Application for admission to the course is made on the regular blank of
the School of Applied Social Sciences. Since this blank calls for no details
t)f the nurse's training, it is not especiaUy well adapted for this group of
Applicants. Letters are sent to the high school and nurse's training school
Attended by the applicant requesting a general statement in regard to her
work and her personal qualifications. Three personal references are also
required, and to each of the persons whose names are given, a letter of inquiry
is sent.
Credentials of applicants are evaluated by the Advisory Committed in
conference with the Director of the Course and the Dean of the School. The
final decision in regard to admission is made by the Dean.
Students who complete the course satisfactorily receive certificates.
Students not registered for the entire course are admitted for four months
of training in field work. No certificates are granted for this work, but those
who complete the work satisfactorily receive 15 points of University credit.
These students must have the same professional and educational qualifica-
tions as those taking the full course.
Pupil nurses from any training school meeting the standards set by the
Ohio State Association of Graduate Nurses may be received for two months'
experience in the University District. These pupils must have completed two
years of training, and must have had their training in surgery, and in ob-
stetrics, if possible.
748 HospiTAi. AND Health Sxjbvbt
During the year ending June 1, 1920, the following number of students
was enrolled:
One- Year Course, Graduate Nurses ^ ^ 19
Four Months' Field Work:
Graduate Nurses 31
Pupil Nurses ~ 11
Total-..^ ~ 61
Sixty-four pupil nurses were received for two months' training. These
pupils were admitted monthly, the number varying from 5 a month during the
summer months to 10 a month during the winter.
The total number of nurses, not including those who graduated in 1920,
who have received certificates, is 45.
Instruction
One regular course is offered, which leads to a certificate. It extends
over one academic year, and is divided into two parts, one devoted largely to
didactic work, the other to field work.
The didactic work is given during the first semester, and consists of the
following courses :
Public Health Nursing , 30 hours
Hygiene and Preventive Medicine 24
Bacteriology 96
Household Problems.. 29
Practical Sociology 60
Problems in American Society 30
Case Work with Families 72
Mental Hygiene 10
During the first semester the students spend two afternoons (6 hours)
weekly in work with the Associated Charities.
Additional courses may be taken by students exempted on the basis of
previous work from one or more of these courses. During the year 3 students
so exempted took courses in psychology, government and social legislation.
The character of the didactic work of the course could not be judged,
since tlie investigation was carried on in the second semester, after the lec-
tures had been concluded. It was, therefore, impossible to evaluate the
class room teaching. Tlie subjects selected, however, are those sp)ecially
needed by nurses preparing for public health work.
Field Work
One semester, or approximately 4 months, is spent in field work. Ordi-
narily, this work follows directly after the semester devoted to theoretical
work. The field work is, however, given three times during the year. In
J R 8 I N G 749
le cases the students take field work in the summer months, and begin
theoretical work subsequently.
The usual division of field work is the following:
University District 11 weeks
School Nursing 3 weeks
Hospital Social Service or Humane Society, or other
Special Agency (observation) _ 1 week
Industrial Nursing (observation) ^ 1 or 2 weeks as elected
Rural Nursing (observation) 1 or 2 weeks as elected
During the first week a number of excursions are made in order to ac-
lint the students with Cleveland social agencies and social workers.
In the University District students carry on the usual activities of the
iting Nurse Association, and the nursing work of the Department of
ilth, in which anti-tuberculosis work and infant welfare work are in-
led.
Supervision in the University District
To each instructor is assigned a number of students, including both
duate and pupil nurses. Seven is the maximum number of students
gned to one instructor. Each student is assigned by her instructor to
ibdivision of the district, and as her knowledge and skill develop, she is
easingly held responsible for the work in her particular section.
When students begin their field work, they are taken out one at a time
y occasionaUy two at a time) by the instructor, who gives the instruction
he home and does the work required, while the student observes. A
rough discussion of the visit follows. On a subsequent visit the roles
reversed, the instructor observing while the student conducts the visit.
s procedure is repeated with different types of visits, such as to prenatal
s, communicable disease cases, and so on, until the student has been
iually introduced to the various types of work usually encountered in
district.
rhree times daily the students report at the station, to receive assign-
its, to plan their work, and to carry out the necessary oflSce detail. An
ortunity is afforded at these times for conference with the instructors,
this way the instructor is enabled to keep constant oversight of the stu-
ts' work, and the students have an opportunity for immediate consulta-
i and advice upon problems arising in the families they visit.
Every morning a conference is held by the Director, which is attended
dl the instructors and students. These conferences, in which the students
i an active part, constitute an invaluable part of the training. The
^am may consist of demonstrations of nursing technique, instruction in
procedures, consideration of social or other problems in individual
ilies, or discussion of subjects of general professional interest.
Students thus have the benefit of demonstrations given by the instructors
le homes, of direct supervision of their own work in the homes, of in-
750 HospiTAi. AND Health Suhvet
dividual conference three times daily with the instructor in the office, and of
group discussion in the morning conferences. By this careful teaching they
are enabled to derive the full benefit from their experience in field work.
The nursing technic of the students who were observed gave evidoice
not only of good supervision, but even more impK>rtant, it showed that the
students had a knowledge of the principles of hygiene and sanitation. Some-
times nursing work is done in which the technic is mechanical, — ^where the
nurse observes, the details as they were taught her but does not use intelli-
gence in adapting the underlying principles to the special circumstances she
encounters.
In the University District, however, the reverse was found. In their
scrupulous attention to detail in the home, in the beautiful care given the
patients even in the most difficult surroundings, in their careful disposal of
soiled linen and dressings, in their regard for the patients' modesty and
comfort, the students in the University District showed that their woik
was not merely a routine, but was based on an application of the underlying
principles of public health and of good nursing.
School Nursing
For experience in school nursing students are assigned to the Nursing
Division of the Board of Education. During the 3 weeks spent in school
nursing they are expected not only to observe, but also to assume responsi-
bility under direction for a part of the work.
Industrial Nursing
The experience in industrial nursing consists mainly of observation in 8
or 4 factories. Altogether 12 industrial concerns in Cleveland are cooperat-
ing with the University District in offering the students opportunities to
observation and experience. It has been possible for a number of students
to spend a week each in observing the work in the Goodrich Tire Co. m
Akron.
Clinics
Unusually ample facilities for observation and training in clinics 9Xt
available for the students. All students, except the pupils admitted for^
months only, attend the following: Clinic for Well Babies, Prenatal Clinid
Tuberculosis Clinic, and the Babies' Dispensary (sick babies).
In the University District Health Center prenatal clinics are held twice
a week, and prophylactic baby clinics three times. These clinics are cop*
ducted by the instructors and attended by the students, who thereby obtaiD
valuable experience in clinic management. Students usually spend 12 houis
in all at the Clinic for Well Babies, and 4 to 6 afternoons at the Prenatal
Clinic.
Six hours for 3 weeks are spent by students at the Tuberculosis Clinic of
another Health District (Health Center No. 8). The hours of obser\'ation
are followed by lectures and discussions.
R S I N G 751
Babies' Dispensabt
in important part of the clinic experience is the training at the Babies'
lensary, where the students spend afternoons for a period of two to three
cs. During this time 16 hours are devoted to lectures and discussion,
hich 8 are lectures on sick babies by physicians, and 3 are classes in prac-
work given by the Superintendent of Nurses. One hour each afternoon
tent in reading the literature of diseases of children. The practical work
ists of attending examinations during which the cases are explained by
doctors, and of some supervised work in the clinics; of instruction in the
al Service Department; and of work in the Milk Laboratory, where,
Jfications are taught.
rhe excellent standards of infant welfare work established by the Babies*
yensary are reflected in the child hygiene work in the University District.
eflFectiveness of the teaching is shown by the readiness of mothers to
)erate in preventive work, their ability to follow the nurses' directions
ailk modification, and their willingness to bring their children to clinics
observation as well as for treatment in illness. It is clear that the work
:he Dispensary constitutes a valuable part of the students' practical
aing.
Conclusion
The tests of public health nursing are many and various, — as many, per-
s, as the types of people and of needs that are met. But underlying all
difiFerences of race or creed, of age or individuality, is the common ques-
i: How does the public health nurse meet her problems? Not merely
7 well does she nurse this or that patient, or how well did she cheer this or
t person, but what total impression does she make on her families, how
does she succeed in solving the total family health problem? Has she
ght her families anything of hygienic living, has she gotten their confi-
ice, has she observed and taken measures to deal with evidences of illness
'ailures in habits of health in other members of the family beside her im-
liate patient?
Judged by such standards, the course in public health nursing has clearly
ieved a large measure of success. Various factors already described have
rated to bring about this result. Special recognition should, however, be
m to the devotion of the professional staff, and to the public spirit and
reciation of the modem public health nursing movement which has been
wn by the University authorities and the lay committee who are jointly
tonsible for this notable contribution to nursing education.
[n general, then, the Course in Public Health Nursing is admirably
mized and highly effective. Its usefulness could be even further increased
m expansion of its staff, better oflSce facilities, and ampler provision for
>partum service, in accord with the following recommendations.
RECOMMENDATIONS
1. A fiill-time assistant director should be appointed, who should
share the teaching and relieve the Director of part of her routine duties.
752 Hospital, and Health Subvet
The Director should thua be enabled to devote more time to devdoping the
work, to increasing facilities, and to extending the training.
2. Another instructor should be appointed.
3. A private office should be secured for the Director, and additional
office space for the instructors and students. «
4. The number of post-partum cases nursed by each student should
be increased as soon as possible.
5. In view of the need throughout the country for trained pubtic
health nurses and the exceptional opportunities for training afforded in
Cleveland, efforts should be made to secure the greatest possible number
of students, and the staff and teaching facilities should be sufficient so that
all qualified applicants may be admitted. The greatest possible number of
pupil nurses should be enabled to take the four months' training in field
work.
INSTITUTE OF SCHOOL HYGIENE
The Institute of School Hygiene, organized by the Cleveland Board of
Education with the cooperation of Western Reserve University, gives a six
weeks' summer course to graduate nurses who have had practical experience
in public health nursing. This Institute includes eminent experts fiom
various parts of the country- upon its instructing stafif and attracts sevcnl
hundred students who are enthusiastic about the benefits derived therefrom.
The course offered is a real contribution to graduate nursing education, sd
deserves to be generously supported so that it may be continued and ex-
tended in future years.
Nursing 758
Public Healtk Nursing in Cleveland
INTRODUCTORY
IN the development of public health nursing in the United States, Cleve-
land has played a leading part, various features of which stand out con-
spicuously for their high degree of excellence, as standards set for the
whole country.
Among these successful elements, the most conspicuous are the existence
of the Central Nursing Committee for the city, the concentration of activi-
ties m a small number of agencies, the development of generalized nursing
and the existence of the Univeristy Public Health Teaching District.
Underlying all these activities and essential to their success has been the
unusual degree of interest and responsibility on the part of the various
authorities and boards in charge, both professional and lay members. With-
out this sustained backing, the different organizations at work could not
have achieved the success of which, in spite of various shortcomings and
misdirected efforts, the Nursing Survey found proof in its detailed appraisal
; of the field.
The recent opening of the beautiful Nurses' Club with its exceptional
<9portunities as a professional and social center, illustrates concretely the
a{)preciation of nursing work in Cleveland and the generous participation of
lay workers in the best interests of the profession.
Scope of the Survey
The organizations carrying on public health nursing which were studied
^y the Nursing Survey were the following: the Division of Health, the
Visiting Nurse Association, the University District, the School Nurses, and
Some Out-Patient Departments of Hospitals. Nursing at the Babies' Dis-
pensary and Industrial Nursing were also studied. Findings and recom-
'Jiendations as to the work of each agency are given later in this report.
•
Our study covered the details of organization and administration, the
Personnel and plans of work. In addition our investigators accompanied
^tiTses into the field, in the clinic and health center, the school, factory and
^EMne and observed their personal contacts with individuals and families.
*V>r by this test obviously such work stands or falls. No matter how well
planned and administered in theory, or how lofty the aims and ambitions of
^^nizations, they can ultimately be judged by nothing more or less than
5^ the performance of their agents in the field, by the success of their efforts
^preventive as 'well as curative work.
The statistics of attendance at clinics or health centers, or the number of
^i«ts made per nurse or district does not tell the story completely without
^^Hwervation of the quality of service; the success or failure in teaching the
elements of hygienic living as weU as giving nursing care, or protecting the
immunity from disease.
754 Hospital and Health Subvet
Some Elements of Success
Common to all the organizations studied' is the unusually fine spirit of
the staffs, whose members almost without exception were found consden-
tious and alert. The existence of the Central Nursing Committee and the
concentration of work in a few organizations obviously makes for greater
uniformity of method and treatment than when diverse agencies are at woik,
and lessens the chances of duplication or misunderstanding.
The most notable contribution, however, made by Cleveland in the
public health field is the success of the generalized nursing system, demcn-
strated most completely in the small University District, with its high ratio
of nurses to population, by the Visiting Nurse Association less completely
in a larger area and by the municipal staff so far as it has been adopted for
the city as a whole. No other city of its size or larger has ventured to adopt
a generalized municipal system. Few smaller cities have done as mudi.
Cleveland is thus leading the way in one of the most hopeful developments
of the modem public health work.
Value of the Generalized System
By generalized nursing is meant in this report the system by which a com-
munity is divided into small districts, one nurse being assigned to each dis-
trict to do all the necessary varieties of nursing and of instruction in habits
of health in that district.
In successful generalized nursing, the resources of the separate nursing
specialties are pooled. Overlapping of visits for special purposes is elimi-
nated; overhead charges for maintaining separate services are reduced. The
generalized nurse, doing either instructive or bedside work, is enabled to
cover the ground, to find new cases and grapple with family problems as the
specialized nurse in many instances cannot.
The assertion is often made that under the generalized plan, the special
needs of public health work, such as child hygiene or the care of tuberculosis,
is neglected or less successfully carried on than when the nurse is trained
along one such line, and devotes herself exclusively to her one specialty.
This is a controversy of long standing; it is undoubtedly true that demon-
strations of the value of one spe<'ial service such as the work of the Ma-
ternity Centre Association in New York, or of many tuberculosis societies,
are of great value in setting standards of performance or in developing a
more ])erfect technic than is often possible in the excessively large districts
and with the excessive number of patients carried by many general visiting
nurse associations. Yet where generalized nursing has had Uie fairest trial
in Cleveland, that is in the University Public Health District, where the
number of nurses to r)oi)ulati()n and the supervision of the work is most
adequate, no branch of nursing appears to have suffered from being merged
into the general service, but has on the contrary gained. Where the nursing
has been partly generalized, that is under the over burdened nursing service
of the Division of Health, the bedside care of the sick has, as we shall sec,
been neglected; under the Visiting Nurse Association, the instruction of the
family in hygienic habits has not received sufficient emphasis.
1
Cursing 755
Obviously, for the success of generalized nursing, highly skilled super-
ision is a prime requisite. Direction by specialists must keep the balance
between the various needs of the different nursing specialties. In our
ecommendations for the organizations studied special emphasis has therefore
»een laid on methods of administration and supervision.
«
Some Causes of Failure
. Inadequate Numbers of Nurses
Where failures were found in the work they were due, in Cleveland as
Isewbere, to two main causes: insufficient number of nurses and inadequate
►r faulty supervision. The volume of work undertaken is far too great for
he size of the different staffs, and too great for their combined numbers.
According to the best opinion for a generalized service the ratio of nurses
o population should be about in proportion of one to 2,000. In Cleveland,
t)UDting all but industrial nurses, the proportion is about one to 5,228 pop-
dation.
The distribution of nurses is as follows :
Division of Health (66 at work at time of investigation) 80
Visiting Nurse Association 32
Board of Education 31
University District 10
Total 153
Population, 796,836.
Ratio, approximately 1 to 5,228.
To reach the reconmiended figure of 1 to 2,000 population the total
lumber should be 400 nurses. To reach even the ratio of 1 to 3,000 popula-
ion, the total number should be 266, an increase of 113 nurses over the present
igures.
•
With the present shortage, it is manifestly impossible to do justice to all
chases of the work.
The second main cause of failure which disclosed itself in various of the
>rganizations studied is the lack of adequate or correctly conceived super-
nnon. Indeed, supervision of the right order proves itself to be the crux of
imblic health nursing. It is essential not only for planning the work of the
itaff and coordinating their activities but as a stimulus and guide for the
individual nurse in her function of teaching the principles of health as well
IS giving bedside care.
Supervision of the right order nieans the actual accompaniment of nurses
in their home visiting. It brings to their help, especially in the non-acute
»aes, where little change is seen from visit to visit, a fresh point of view,
fl;reater experience, an ability to see new angles of old cases.
756 Hospital and Health Subyet
Again and again, as the following reports show, the presence or lack of
intensive supervision in the different organizations studied discloses itself
in the quality of the work.
It is for lack of stimulating direction that the work of the school nurses
tends to become routine; that the nursing service of the Division of H^th
tends to become an extension of a clinical service, centered on the clinics,
rather than a true public health nursing function, going out into the homes.
The Central Committee on Public Health Nursing
ONE of the most valuable assets for public health nursing in Cleveland
is the existence of the Central Committee on Public Health Nursing.
This committee is probably unique among agencies for the directing of
public health nursing, in its composition, and in its influence in matters d
public health. It is not too much to say that the high rank of Cleveland as
a center for various branches of public health nursing is due in large part to
the existence of this committee and the interest in public health nursing
which it reflects. To the work of the committee is to be ascribed the un-
usually high standards of the nurses in the municipal nursing services as well
as in the* private organizations.
Organization
Several years ago this Central Committee was created, representing each
of the organizations doing public health nursing in the city, composed of two
representatives from each, one of whom was the superintendent of nurses
and one a trustee, board member, or executive officer, **for the maintenance
of uniform standards of training and of public health nursing throughout
the;;city."
The following organizations were included :
Division of Health of the City Department of Welfare,
Board of Education,
Babies' Dispensary and Hospital,
Visiting Nurse Association,
Anti-Tuberculosis League, .
Western Reserve University Teaching District.
Each organization selected its own representatives and the whole gronp
chose a chairman and vice-chairman who might not be from among its
members, but were added to the committee, and engaged a secretary on part
time.
The committee does not meet at regular times, but whenever there is a
problem to be studied and acted upon, perhaps not oftener than four or five
times a year at present. Its decisions are not binding, but are presented
in the form of recommendations to the organizations represented, and have
almost invariably been voluntarily approved and acted upon.
7 R 8 I N G 767
AcTiVlTlES
The matters that have been considered by the Central Committee, and
idards determined are:
1. The receiving of all nune applicants and securing credentials.
2. . The passing on all credentials, accepting or rejecting the applicant.
3. The assignment of applicants to the various public health nursing
organizations, and exchange of applicants from one organisation to another.
4 Discussion and recommendation of uniforms.
5. Recommending salary schedules.
6. Study of bags and equipment.
The chairman of the Central Committee (always a layman) and the
lerintendents of nurses form an eligibility sub-committee which performs
duties under numbers 2 and 3. All professional standards are determined
this sub-committee. The assignment of applicants to the various staffs
letermined by this sub-committee on the basis of first, expressed prefer-
« of applicant; second, urgency or emergency need; third, the date on which
t request for additional nurses was filed by the superintendent. There
( been no dissension among the superintendents over the assignments.
Tses are told of the work of all agencies and allowed to express preference
hey have any. They are assign^ to the agency of their choice if there is
acancy.
RECOMMENDA TiONS
The Central Committee has already performed a notable service in har-
nizing the problems of personnel, professional standards and salary
ledules, and it is thoroughly representative in its composition. But
litional factors must be continuously considered for the effective growth
public health nursing in any city :
Coordination of the activities of the various public health nursing
A well balanced development of different types of work in accordance
■ with a coherent program for the city.
Continuous study of the expanding needs of the city, and of new de-
velopments in public health nursing.
Maintenance of uniformly high standards.
The Central Committee appears to be the body logically to be charged
ii the responsibility for the additional factors enumerated. Therefore,
is reconmiended that the Central Committee assume the following func-
DS in addition to those it already has, its decisions, however, as hereto-
e, not to be binding upon the organization represented.
758 Hospital and Health Subth
New Funetiong
1. Coordinating all nursing agencies of the city and obtaining agree-
ment among them as to the functions to be performed.
2. Review of all plans for new projects or for modification of current
programs of participating agencies, based on data from the Welfare Federa-
tion.
3. Creation of several sub-committees for .research and consideration
of special professional problems. Some of these might be for the present:
Prenatal and maternity service.
Industrial nursing.
Generalized nursing.
4. A campaign to recruit students for training schools and graduate
nurses for public health nursmg.
5. Adding to personnel representatives from the Chamber of Com-
merce and industrial nurses, and placing them with others on a sub-committee
on industrial niu-sing.
6. Adding to personnel representatives from the proposed Obstetrical
Council and placing them with others on the sub-committee on prenatal
and maternity service.
7. Appointment of a sub-committee to advise with the Division of
Health, and with its p>ermission to sup>ervisc the proposed extension district.
Division oi Health Nursing Service
Scope of the Work
THE nursing service of the Division of Health covers a wide range of
activities including nearly every form of public health nursing coming
within the range of any municipal health department's functions and
many more than are usually undertaken by municipalities. Starting witi
the prevention of communicable diseases in 1909, the service has been ex-
tended year by year until it now includes eight branches of public health
nursing, as follows:
Undertaken in
Prevention of communicable diseases 1909
Tuberculosis work _ 1910
Infant Hygiene „ ^..^ 1911
Prevention of Blindness -- -- . 1912
Regulation of Midwifery — — — _ 1912
Supervision of Boarding Homes for Babies ~~— _ 1913
School Nursing in the Parochial Schools — _-_. 1917
Prenatal Nursing ...^^ — —..—.«« 1918
d B S I N 6 759
These servicesTwere maintained as separate units, each with its own staff
lurses, until early in 1917 when the separate staffs were combined into one,
field divided into smaller districts, and each nurse assigned a district and
d responsible for all kinds of work within that district. Cleveland is to
congratulated on its advanced stand in thus adopting a generalized muni-
al nursing system. ,
The Present Staff
The present staff (March, 1920) consists of an assistant director, three
cial supervisors, seven field supervisors and seven assistant field super-
3rs, in addition to a field staff of 66 nurses. There are two stenographers
each of the seven Health Centers and the Nursing Service shares the use
ieveral at the main oflSce in the City Hall.
Analysis of Activities
Communicable Diseases
In seven districts sanitary oflScers place and remove placards on houses
which there is a contagious disease. In these seven districts the nurses
it patients having scarlet fever and diphtheria.
In the remaining district (District number 1) the nurses do the placing
i removing of placards and visit patients having contagious diseases
ich are placarded as^foUows:
Cerebro spinal meningitis,
Infantile paralysis
Diphtheria,
Scar'et fever,
Whooping cough,
Measles,
Chickenpox,
Typhus fever.
Cholera,
Plague,
Leprosy.
Diseases rarely occurring in Cleveland.
In none of the districts do the nurses visit smallpox patients or families
>m which a smallpox case has been removed.
The nurse's duties include explanation of the sanitary code; the establish-
ent of isolation of the patient and instruction of the family concerning the
aintenance of isolation; the establishment of quarantine. The nurse also
termines what persons are to have permits to leave the house and she
lues the permits; she takes release cultures unless the doctor on the case
efers to do so himself; arranges for hospital care for the patient and the
zing of nursing care.
760 Hospital and Health Suryet
M - - ■ ' -T TW^W -■ ■ ■ I - M M^^lIM ■ M ^^M ■ ^^M 1^ ■
Conversation with the nurses and supervisors and study of the records
leads to the strong impression that attention is largely focussed on the issu-
ing of permits and the time-consuming taking of cultures, rather than on the
care of the patient, the instruction of the family in caring for him, or on
measures for their own protection. ''Nursing care is rarely given," is the
unanimous opinion of both nurses aijd supervisors because in their estima-
tion, "it isn't needed."
Typhoid patients have been visited only since the fall of 1919 and then
only for the purpose of filling out a questionnaire in the attempt to trace the
source of infection. No attempt is made to care for the patient, to teach
the members of the family how to care for him, nor how to protect them-
selves. Neither is any effort made to see that the patient has such care;
only 5 cases out of 165 came to the attention of the Visiting Nurse Associa-
tion last year.
^-
Pneumonia cases are not visited or reported to the Visiting Nurse Asso-
ciation to be visited.
Outside of Districts I. and VIU., no attention is paid to measles or
whooping cough. While from the point of view of checking the spread of
a contagious disease it may be futile to do more than to placard these dis-
eases, from the point of view of the future health of the patients, instruction
in nursing care and supervision are badly needed to prevent the frequent,
serious and often fatal sequelae. Such oversight and care could be given by
the staff of the Visiting Nurse Association.
Tuberculosis
Scope:
The tuberculosis work includes the maintenance of 35 tuberculosis
clinics a week, and the follow-up work in the home. Every patient who comes
to a clinic is visited in his home and if his case is positive or cannot be satis-
factorily diagnosed he is ** carried on the books" and visited occasionally,
if the doctors are willing. All cases reported as positive by doctors and all
patients whose sputum has been sent in for analysis are visited. Likewise,
all patients referred to the Hospital Admission Bureau to be sent to the
City Hospital, the State Hospital or Warrensville, and all suspicious or
positive cases referred by other nursing or social agencies are visited.
Plan:
Unless they attend the clinic regularly, an effort is made to visit all these
patients once a month to give detailed instruction in treatment of the pa-
tient and prophylaxis. Nursing care is supposed to be given to all those
in need of it who are unable to pay seventy-five cents a visit. Those able
to pay this amount are supposed to be referred to the Visiting Nurse Asso-
ciation, but only 51 cases were cared for by the Visiting Nurse Association
between October, 1918, and October, 1919. The statement is made that
there is little need of nursing care. It is intended to have the whole family
and other persons who have been exposed, especially the children, examined
at the Health Center or by a private doctor. If a very suspicious or posi-
Nursing 761
tive case fails to return to the clinic, a form letter is sent. If there is no
re^>onse a second is sent containing a threat to send an officer after the
patient. This is often efficacious, but if it brings no response, the officer is
sent. Apparently this method is used with some frequency.
Performance:
While diagnosis and instruction at the clinic and the effort to secure
clinic attendance are emphasized, study of the home conditions, the arrange-
ment for prophylactic mode of living at home, careful instruction and nurs-
ing care are inadequate and home visits are far too infrequent. Nursing care
is rarely given. The nurses do not have time to hunt up incipient or ad-
vanced unreported or undiagnosed cases.
The records show that there is an average of about 100 tuberculous
patients to each nurse. The reports show that in one month the average
number of visits made by the nurses to patients tuberculous, suspicious and
non-positive was .47 per patient.
In a second month it was .64 per patient. The supervisors stated that
it was not possible to visit even the positive cases once a month, and the
suspicious and contact patients were visited at intervals varying from two
to six months. The records verify these statements. It is, therefore, evi-
dent that the patients are not seen frequently enough for effective curative
or preventive work, and that little attention can be given to securing exami-
nation of the family and others exposed. There is no easily applied check
in the records to show the frequency of clinic attendance and home visits.
Nor is there any study of the sources from which the cases come to reveal
areas of the city which should be brought under surveillance.
In accompanying nurses in their districts much time was lost in attempt-
ing to locate some tuberculous patients who had moved away a month
before. If the nurses were able to call on their patients more frequently it
would be easier to keep in touch with them when they moved.
Child Hygiene
Scope:
This service included the maintenance of well baby clinics at 13 prophy-
lactic stations; follow-up visiting of these babies in the homes; visiting all
bdbies attending the Babies' Dispensary and Hospital; visiting all babies
whose births are reported, and visiting babies discovered in the course of
routine work in the districts or reported by doctors and neighbors.
Performance:
From the records it appears that each nurse has under supervision an
average of about 200 babies. Study of the records shows that an average
of .4 visits is paid each baby each month; that is, each baby is visited about
once in every £ to £J/^ months. One in every 9 babies comes to the clinic
once during the month.
762 Hospital and Health Suryet
Attention is largely concentrated on feeding of babies; instruction in
infant hygiene both at the clinic and in the home is somewhat ne^ecied.
Home visits are too infrequent and irregular. From the records it appeals
that nursing care is rarely given and then very inadequately. These condi-
tions are due to the fact that the nurses have too large a number of patients
per nurse to care for.
Yet individual instances of good home visiting were found. Thus, in
accompanying one nurse in a visit to the mother of twin babies, the investi-
gator was impressed with the nurse's sympathy and good teaching. With
three older children and a husband to take care of, the mother, herself half
sick, had prepared the babies* milk modification excellently, and showed the
results of thorough instruction. She brightened at the nurse's entrance.
Prevention of Blindness
Baby eye work was done by the Babies' Dispensary and Hospital until
January, 1917. At that time it was turned over to the Division of Health.
It was done at first by a special group of nurses until August, 1919, and was
then put into the general service.
Nurses are sent to care for ophthalmia neonatorum cases the same day
they are reported, and they try to return as often as necessary. Where the
case is acute and home care inadequate it is sent with its mother to the hos-
pital.
There are no figures to show the number of such cases or the care given.
The opinion of the director of the staflF is that it is well done.
Trachoma is a reportable disease and all cases reported by doctors or by
the Board of Education are visited by the nurses.
Midwife Supervision
This work is entirely under the control of a special supervisor. There
are 160 licensed midwives and 110 practising without licenses. The licensed
midwives are visited in their homes at irregular intervals for the purpose of
giving them instruction in prenatal and infant hygiene, technic, and exami-
nation of their bags and stubs. Some are visited frequently; some not
oftener than once a year. They are not supervised during delivery, nor
do they receive demonstrations. There is little time or opportunity for the
discovery of illegal practitioners. Much more frequent visits are necessary.
(For further discussion of the midwife situation see report on child
health work, Part III.)
Supervision of Boarding Homes
The nurses are supposed to visit each home in which babies are boarded
out under license from the State Board of Charities and to send a report to
the Humane Society. There are no records to show the frequency of these
visits or the thoroughness of the work done. All these babies get special
milk free from the Health Center, and the matron is expected thou^ not
compelled to bring the babies to the Health Center regularly.
Nursing 763
A visit to a boarding home with one of the nurses in the course of our
investigation, gave evidence of good home teaching. The baby was anaemic,
with an acute vaginitis, had broken places on lips and irritation of mucous
membrane in mouth, the latter indicating a probable digestive disturbance.
Instructions in regard to vaginal care evidently had been very good, for the
trouble was clearing up rapidly.
Parochial School Nursing
• In March, 1917, the Division of Health Nurses undertook some work in
17 Parochial Schools, increasing to 21 schools for the school year 1918-1919.
9323 pupils in these schools received one physical inspection (by a nurse
alone). In addition to sending a note to the parents, an eflFort was made to
follow up all children found to have defects. No tabulation has been made
to show what percentage of defects the nurses succeeded in having cor-
rected. Incomplete as this service was, it consumed a good deal of time and
effort, and no doubt certain appreciable results were obtained.
For the school year 1919-1920 all the remaining parochial schools were
added to the list making a total of 68 with a school population of approxi-
mately 35,000. To have carried on the work at all for so many schools
would have consumed the full time of at least twelve nurses and twice that
number would be needed to get real results. As the entire field staflF of the
Nursing Service averaged only about 50, it was obviously impossible to de-
vote the necessary time to school nursing in addition to the many other
heavy duties. No attempt was made, consequently, to carry out the pro-
gram of the previous year. A single observation was made of each school
room full of pupils to discover any evidences of contagious disease. A visit
was undertaken once a week to each school to get a list of absentees and to
give the sisters an opportunity to consult the nurse about any special cases.
The nurses undertook to visit as many as possible of the children who were
seldom absent or whose absence was not explained.
Such work cannot be called school nursing. Until the staflF can be in-
creased to devote the equivalent of the full time of twelve nurses to this
iervice, it would seem better to concentrate all the work in a few schools
(those in one district) where it can be done intensively and adequately.
Prenatal Nursing
The extension of advice and supervision to all prenatal patients except
those under care 6f a private physician was undertaken in 1918. Those
unable to have a private doctor were carried until visited by the out-patient
nurse from St. Luke's or from the Cleveland Maternity Hospital. No definite
routine has been established and no attempt is made to do urinalysis or take
blood pressure.
Little effort has been made to work up this service, the nurses frankly
admitting that they have too much to do to undertake this additional bur-
den. Less than one visit per month is paid each prenatal patient. Tho-
rough work (according to the standard of the New York Maternity Center)
764 Hospital and Health Surtkt
is not undertaken. Again until the staff can be augmented in suffident
numbers to make thorough work possible, it would seem advisable to dis-
continue this service except for one district and in that district to make
it a part of the city-wide service elsewhere described.
Analysis of Administration I
Organization I
The chart of organization of the Division of Health places the Nursiitf j
directly under the Commissioner's office, serving all bureaus as needed and |
directly under his control. For budget purposes the nurses are distributed j
among the bureaus of Child Hygiene, Communicable Disease, and Tuber- !
culosis. As a matter of fact there is a single staff of nurses doing general- I
ized work under one director, who is responsible to the Commissioner.
Headquarters Staff
At present the staff at Headquarters consists of: Director of Nurses,
Assistant Director and three Special Supervisors, one having supervision of
parochial schools, one of eye work and midwifery. The third is responsibk
for various duties, compiling the monthly statistical reports, such as bi-
weekly Health Center staff meetings, visiting nurses who are sick, and per-
forming several other odd duties.
The work is so arranged at headquarters that none of the staff are charged
with responsibility for analyzing the character and results of the work, for
studying the needs and personalities of the staff and developing them, for
promoting true leadership in supervision and for extracting the majdmum
value of generalized work through building up family health work. TTk
headquarters staff instead are engaged in more or less routine duties whidi
give them no time or opportunity for these broader, fundamental duties.
The absence of a special office for the director tends to immerse her
constantly in unimportant det lils that should be carried by others.
Staff at Health Centers
Spirit of Staff
The present staff at each Health Center consists of a nurse supervisor
and an assistant supervisor and from 6 to H field nurses.
Each center has a fine spirit of team work and loyalty The helpfiiL
generous cooperation of nurses and supervisors calls for commendatiofl.
The cooperation between the Health Centers and other social agencies is
close and pnxluctive of good results. In discussing their cases, the nurses
have their information well in hand, and are not easily confused.
The spirit of the work cannot be criticized; on the contraiy, the spirit of
servnce that dominates the work is admirable. All of the supervisors and
nurses who were seen are evidently working ver>' hard and against the odds
of having too much to do, and of trj'ing to do it without carrfuUy organised
plans.
Cursing 767
In spite of the fact that in every Center but one, the supervisor, her
issistant, and two full-time stenographers spend practically all their time
n clerical and administrative work, the nurses find it necessary to sF>end an
iverage of two hours daily, out of their seven-hour day, in w^ork in the Center.
Dbservation might possibly show the time so spent to be even greater,
specially in the Centers where the nurses return at noon or at four o'clock
for new calls. There is only one Center of which this statement does not
bid true. Much of this time is taken up in clerical work. A simplified and
coordinated system of records would eliminate a large amount of this routine
TOrk.
The compilation of the monthly statistical reports is a very difficult task
because of the cumbersome and confused method of reporting. The record
system, having been developed piecemeal and service by service, is far from
coherent. Many figures are gathered which serve no useful purpose, and
Sgures necessary for a proper appraisal of the work and an accurate nieasure-
»ent of results are not obtainable. An altogether unjustifiable amount of
the nurses' time, both at the City Hall and in the Health Centers, is con-
sumed in keeping up this complex and voluminous system of bookkeeping.
Reorganization is needed, but it is doubtful whether anyone in the Division
rf Health is qualified to evolve a properly simplified method of record keep-
ing. An expert should be engaged to reorganize the system, both in the
^ity Hall and the Health Center, and thus save valuable time now being
lasted in unnecessary clerical work. The proper person to provide forms,
■0 organize records and to analyze the tabulated information received through
ie nurses' reports, would be the statistician of the Division of Health, as
woposed in the chapter on Vital Statistics.
After such a system had been installed it should, so far as possible, be
■^imed over to an oflSce manager. It is highly desirable that such an oflSce
twnager be appointed in the oflSce at the City Hall and one at each Health
^ter, to whom the greater part of the detail work could be shifted in order
iat the supervisors may have an opportunity to attend to their more im-
M)rtant duties of direction.
The laborious work now spent in keeping the milk book — to mention
>nly one instance — could be turned over at once to the office manager.
The Staff of Field Nurses
Abundant evidence is available to show that the nurses are heavily over-
«>aded with work and are carrying far too many patients per nurse, and
^vering too large a territory to do eflFective work. They average 260 fam-
*es each. The number is considerably higher when estimated by indi-
*^)duals. They are overburdened with the intricacies of the complicated
'^Ccwd system and the large amount of time spent in the clinics leaves in-
?flicient time to develop home visiting. As a result, the nurses are often
*8couraged. The average number of home visits is over 300 per nurse per
'^nth. The patients scarcely receive an average of oi\e. v\s\V \)^t t£vq.tn\>cv.
768
Hospital and Health Survr
The nurses are doing their best under this accumulation of overwork, but
cannot be expected to obtain substantial results when they are able to give
so little attention to constructive teaching to patients in their homes.
New Nurses
New nurses do not receive proper introduction to their work. They are
sent out with another nurse for a day or two and receive only such instnic-
tion as a very busy Supervisor can find time for in the Health Center. No
other instruction is given. The character of the nurse's work is not studied,
her weaknesses found and methods of correction pointed out, nor is there
any way of developing the abilities of a nurse. No efficiency records are
kept. Such a record should not only analyze the nurse's ability and work,
but it also should demonstrate the supervisor's ability to know the nurses,
to fit them into districts, to develop strong points and to direct enthusiasm
and energy into proper channels. The record of the nurse should be dis-
cussed by the Center supervisor and the director of nurses, and the nurse
put into the district she can best serve. At present the supervisors have no
regular method of trying to fit the nurse to the district. If it is apparent
that she is not getting cooperation, she is transferred, but this happens in-
frequently.
Unifohms
The nurses wear any kind of street clothes they choose. They go in and
out of district homes giving nursing care in suits and woolen dresses. This
is not only exceedingly bad practice but detracts from the usefulness of the
nurse, since she is not readily recognizable as a nurse while at work in the
district, and her costume is not suitable for giving nursing care.
Probably one reason that so little actual nursing occurs is the fact that
the nurses do not wear uniforms. Even though they are protected by a
gown, they are over cautious in approaching the bedside of a contagious or
infectious case. If eflFective work is to be done in home visiting, teaching
by actual example must take place, and this cannot in wisdoDGi occur unless
the nurse is in a washable uniform. Moreover, the smart uniform adds to
the dignity and impressiveness of the nurse.
GENERAL CONCLUSIONS
The principles and plans of the Nursing Service of the Division of Health
are, in general, excellent. Its performance, however, does not equal iti
ideals, mainly because it has not increased its staflF sufficiently to carry the
ever increasing volume of work. The majority of its shortcomings can be
laid at the door of the insufficiency of numbers. The rest are due to a top-
heavy plan of management and insufficient supervision.
At present emphasis centers around attendance at Health Centers, diag-
nosis and prescription for treatment. The nursing service is in reality an
extension of a clinical service rather than a true public health nursing sen"
ice. Home visiting is an adjunct rather than the prime activity of the nurse.
What is needed is greater frequency of visits in the home, and also longer
J R 8 I N G 769
its so as to enable the nurses to pay more careful attention to the health
the family, to the teaching of hygienic habits, and the giving of nursing
e.
A Proposed Extension District
In order to afford an opportunity for the city to extend its nursing serv-
further in the direction of a generalized system, without at present im-
ing further duties upon the staff as a whole, it is desirable that such fflc-
sions be undertaken in one district only, which might be designated tne
tension District. One of the present Health Center Districts might be
'oted to this purpose.
In this district two experiments making for a completely generalized
vice might be tried. In addition to the present activities of the nursing
BF, the^following services might be undertaken:
1 . Prenatal nursing as a part of the city-wide plan.
2. School nursing in the parochial schools.
If these experiments prove successful there might later be added:
1 . General medical and surgical nursing service.
2. Obstetrical and post-partum nursing.
In order to provide every opportunity to make such an extension di»-
trict successful, it should have the following favorable factors:
1. A district of approximately 50,000 people.
2. The direction of a well trained public health nurse who has had
experience with generalized work, including visiting nursing.
3. A supervisory staff of four supervisors.
4. A nursing staff of 18 nurses (1 to 3,000 population).
A sub-committee on^generalized nursing of the Central Committee might
requested by the Health Commissioner to act as an advisory committee
the Extension District and expected to exercise close oversight of its con-
:t and results.
RECOMMENDATIONS
It is therefore recommended as follows:
ACTIVITIES
Communicabim Diaeaae Prevention:
That more attention be given to protection of members of the family other than the
lent, to arranging for adequate nursing of the patient, and to instruction regaiding
rentioo of sequelae.
Thatpoeumonia, measles, whooping cough and typhoid cases be reported to the Visitiag
«e Aaiociation, which will seek permission of the private doctor to %\\« i\\it^\&2^.
770 Hospital and Health Survet
2. Tuberculotit Work:
That this service be continued and greatly increased, especially in the field of home
visiting for instruction and nursing purposes, and in an effort to discover new cases. All
tuberculosis patients should be visited at least once a month and those in need of csre
much more frequently. Much more effort must be given to having the family and tboK
exposed examined.
3. Child Hygiene:
That this service be continued and amplified. Much more home visiting is impera-
tive for careful instruction in infant and child care and for nursing care. That a standard
routine be adopted and mechanical methods devised to check it up. All babies should be
visited at least once a month and sick babies daily.
4. Supervision of Midwivet:
That this work be increased; visits be made more frequently; time be provided for
hunting illegal practitioners, for demonstration and for inspection of technique and de-
livery.
5. Prevention of Blindness:
That the present routine be continued, but it should be made certain that the care
given is adequate in frequency and quality.
6. Supervision of Boarding Homes for Babies:
That a definite routine of visits and procedures be established, extending to these
babies constant oversight in all matters of health and general care, as well as feeding.
7. Parochial School Nursing:
That the present entirely inadequate and nearly futile effort of providing service for
all parochial schools be discontinued. That all parochial school nursing be concentrated
in the proposed Extension District, wh^re an intensive piece of work may be done.
8. Prenatal Nursing:
That this service be restricted to the proposed Extension District, as a part of the
city-wide maternity system.
9. Extension District:
That one of the present Health Center districts be set apart as an Extension District
for the purpose of initiating new projects or methods before undertaking them on a dty*
wide basis, in accordance with the detailed suggestions made above.
ADMINISTRATION
/, Organization:
(a) That all nursing service now carried on or to be carried on by the Divisioo o»
Health be under the direction of a Director of Nurses, who should be immediately fwpoo*
sible to the Commissioner of Health.
L7 R S I N 6 771
(b) That the nursing service for the Bureaus, whose work requires the services of
nng (such a3 the Bureau of Communicable Disease, the Bureau of Child Hygiene,
the Bureau of Tuberculosis) be performed by the general staff of nurses, and that the
xr relations shall be maintained through consultation by the Director of Nursing,
the Directors of the three mentioned bureaus, all policies and decisions being subject
he approval of the Commissioner of Health.
Headquarter* Staff:
(a) That the positions of Director and Assistant Director be continued as at present.
(b) That the present plan of special supervision be discontinued and reorganized as
}ws:
That four assistant supervisors be appointed, each to have charge of
the general oversight of certain activities, as follows:
1. Baby and child hygiene.
2. Communicable disease.
3. Tuberculosis.
4. Midwifery, boarding homes, eye work.
The fourth assistant supervisor to have an assistant.
(c) That these supervisors should have two functions, acting as special consultants
iieir own field, and as instructors in their special services. These supervisors should
*k out and conduct a scheme of continuous education for the staff. They should be
sensible for the instruction of new nurses in the routine policies and procedures of the
'k and in the special technique and practices of each special st rvice. They should also
responsible for classes, consultations and conferences for the whole staff.
In their capacity as special consultants they should be responsible for the study and
lysis of the nursing work accomplished, both as to quality and quantity, and the de-
3pment of this work in their own special services. They should make studies in co-
ration with the directors of the various bureaus of the Division of Health, and should
a^ liaison officers between 'these bureaus and the nursing service. They should act as
QDnecting link between the Nursing Service and the special outside institutions related
their work.
(d) That there should be an office manager resix>nsible for all the business details
the office, and for all the records. This position should be sufficiently well paid to
ke possible the employment of a thoroughly competent woman.
(e) That the Director of Nursing should have a private office.
Recordt:
That the record system be simplified; that a record expert or the statistician of the
iriaion of Health be employed to set up a simple, practical and effective record system
1 that the statistical work be done by the office of the statistician of the Division of
alth rather than by the nurses.
I
The record system for the Health Centers and Headquarters should be uniform, and
office manager should be held responsible for it. In order to secure con.tixv\i\t.'^ oxA
770 Hospital and Health Survk
2. Tuberculotit Work:
That this service be continued and greatly increased, especially in the field of boox
visiting for instruction and nursing purposes, and in an effort to discover new cases. AB
tuberculosis patients should be visited at least once a month and those in need of cut
much more frequently. Much more effort must be given to having the family and tboK
exposed examined.
J. Child Hygiene:
That this service be continued and amplified. Much more home visiting is impera-
tive for careful instruction in infant and child care and for nursing care. That a staDdard
routine be adopted and mechanical methods devised to check it up. All babies should be
visited at least once a month and sick babies daily.
4» Supervision of Midwives:
That this work be increased; visits be made more frequently; time be provided for
himting illegal practitioners, for demonstration and for inspection of technique and de-
livery.
5. Prevention of Blindness:
That the present routine be continued, but it should be made certain that the care
given is adequate in frequency and quality.
6. Supervision of Boarding Homes for Babies:
That a definite routine of visits and procedures be established, extending to these
babies constant oversight in all matters of health and general care, as well as fcfding-
7. Parochial School Nursing:
That the present entirely inadequate and nearly futile effort of providing service for
all parochial schools be discontinued. That all parochial school nursing be concentrated
in the proposed Extension District, whcire an intensive piece of work may be done.
8. Prenatal Nursing:
That this service be restricted to the proposed Extension District, as a part of the
city- wide maternity system.
9. Extension District:
That one of the present Health Center districts be set apart as an Extension District
for the purpose of initiating new projects or methods before undertaking them on a city'
wide basis, in accordance with the detailed suggestions made above.
ADMINISTRATION
/. Organization:
(a) That all nursing service now carried on or to be carried on by the Division oi
Health be under the direction of a Director of Nurses, who should be immediately respoo'
sible to the Commissioner of Health.
U R 8 I N G 773
(f) That new nurses be taken out by the field supervisor for at least two or three
y^ before they are allowed to gq alone, and that they be then visited at frequent
ervals by the field supervisor (once a week for a month) while at work in their district.
(g) That new nurses attend weekly classes at the City Hall, to be conducted by the
ecial supervisors, to be trained in the technique and methods of work in the special fields.
(h) That the weekly conference now being held for the whole staff at the City Hcdl
continued, and be included in the scheme of education worked out by the special super-
iors.
Salaries:
That the salaries of the staff nurses, the field supervisors and the special super-
isore, be increased to meet the schedule recently recommended by the Central Nursing
Committee.
'. Uniform:
That a wash uniform be adopted and worn by all members of the staff (except the
Headquarters Staff, if so desired).
The Visiting Nurse Association of Cleveland
Scope of the Work
THE Visiting Nurse Association of Cleveland undertakes to extend home
nursing care, except in communicable disease, to anyone in the city not
cared for by any other public health nursing agency. This service is
given free to those unable to pay for it; part pay is charged to those unable
^ pay the regular fee; all others pay the full fee. The pay. serves is not
f^tricted, but may be used by anyone except that it cannot be obtained at
* Jugular fixed hour, nor extending over one-half day, nor for cases in which
P'^'y attendance is wanted and no nursing care for illness is needed. Visit-
^^ nursing is also provided for policy holders of the Metropolitan Life In-
*Jfance Company, for which the company pays the Association at the rate
^^ sixty cents (60 cents*) per visit.
Nursing care in tuberculosis is given only to those patients able to pay
^ cents or more per visit; care is given in diseases of babies under three
l^rs, attended by private doctors, but not to babies attending the clinics
f the Division of Health ; and care is not given in illness among industrial
'^rkers who are provided with home nursing service by their employers.
With these exceptions the Association undertakes to care for patients of
^ ages and patients with all types of disease, acute and chronic, medical,
^gical and obstetrical, including also the making and teaching of milk
odifications for infants under the care of private doctors.
Like all visiting nurse associations of equal grade, the Cleveland Associa-
^H has placed chief emphasis upon the primary need of caring for the poor
*Cli«r8e hai now been chansed to $1.00 at recommended by the Survey.
77ii Hospital and Health Subvey
^igh grade service there should be assurance o** promotion and increase in salary for all
the clerical staff, based on merit.
4. Health Centers:
(a) That there should be a district supervisor , who should be responsible for tbe
administration of the Health Center, but whose principal duty should be the superviskn
of the staff nurses and their work in the homes. Fully two-thirds of her time should be
given to field supervision. She should not be subordinate to but chief over the dink
nurse and the office manager, suggested below.
(b) That there should be a clinic or dispensary nurse whose full time should be de-
voted to the Health Center, for the purpose of running the clinics and talking with patients
who come out of clinic hours. She should have no responsibility for home case work or
for field work.
(c) That there should be an office manager (not a nurse but a competent busmen
woman), who should have charge of the business management of the center and of all tbe
mechanical and record work, and receiving calls and relaying such of them as are emergent,
to the nurses in the field. There should be a uniform system for office management and
record work in all the centers. Scdaries should be paid in these positions high enough to
.nsure a thoroughly reliable, intelligent and businesslike personnel.
(d) That the practice of having two or three nurses in attendance at clinics be dis-
continued; that the clinics be conducted by the dispensary nurse with the possible assist-
ance of one staff nurse: that if more assistance is required, it be provided by a clerical worker
and not by a nurse.
(e) That a routine of field sup>ervision be established, and that the field supervison
render to the Director a weekly record of their work.
(f) That a separate room be provided in the Health Centers for the field supcrviso
and her field nurses.
(g) That districts be greatly reduced in size, possibly cut in half.
5. Field Staff:
(a) That the staff should be increased until no nurse carries more than 125 patieoti.
preferably 100. This will mean largely increasing the present staff.
(b) That the staff nurses consult with the field supervisor daily concerning their ci*
work and that she in turn take up any special case problems with the special supervise"
at Headquarters.
(c) That an efficiency report be prepared by the field supervisors monthly ^*
each nurse, to be submitted to the Director and kept on file.
(d) That each staff nurse prepare a monthly statirtical report of her work.
(e) That new nurses sp>end the first two or three days of their service in the id^
office to receive instructions from the special sup>ervisors in the routine, the records and the
general practices of the work.
U K S I N G 773
(f) That new nurses be taken out by the field supervisor for at least two or three
lys before they are allowed to gq alone, and that they be then visited at frequent
tervals by the field supervisor (once a week for a month) while at work in their district.
(g) That new nurses attend weekly classes at the City Hall, to be conducted by the
lecial supervisors, to be trained in the technique and methods of work in the special fields.
(h) That the weekly conference now being held for the whole staff at the City Hcdl
^ continued, and be included in the scheme of education worked out by the special super -
Salaries:
That the salaries of the staff nurses, the field supervisors and the special super-
SOTS, be increased to meet the schedule recently recommended by the Central Nursing
9nunittee.
Uniform:
That a wash uniform be adopted and worn by all members of the staff (except the
headquarters Staff, if so desired).
The Visiting Nurse Association of Cleveland
Scope of the Work*
THE Visiting Nurse Association of Cleveland undertakes to extend home
nursing care, except in communicable disease, to anyone in the city not
cared for by any other public health nursing agency. This service is
^iven free to those unable to pay for it; part pay is charged to those unable
JO pay the regular fee; all others pay the full fee. The pay. sirvcs is not
restricted, but may be used by anyone except that it cannot be obtained at
a regular fixed hour, nor extending over one-half day, nor for cases in which
only attendance is wanted and no nursing care for illness is needed. Visit-
ing nursing is also provided for policy holders of the Metropolitan Life In-
surance Company, for which the company pays the Association at the rate
of sixty cents (60 cents*) per visit.
Nursing care in tuberculosis is given only to those patients able to pay
75 cents or more per visit; care is given in diseases of babies under three
years, attended by private doctors, but not to babies attending the clinics
^the Division of Health; and care is not given in illness among industrial
'Workers who are provided with home nursing service by their employers.
With these exceptions the Association undertakes to care for patients of
^ ages and p>atients with all types of disease, acute and chronic, medical,
^gical and obstetrical, including also the making and teaching of milk
'Modifications for infants under the care of private doctors.
Like all visiting nurse associations of equal grade, the Cleveland Associa-
^n has placed chief emphasis upon the primary need of caring for the poor
^Chtfce has now been chanced to $1.00 at recommended by the Survey.
774 Hospital and Hel\ltu Survey
who cannot pay for nursing service. Second, is felt the need of caring for
persons of small means who may be able to pay a very small fee.
For persons of moderate income a pay service at cost has been recently
introduced and should be widely extended. The extension of. pay service
is not alien to the policies and purposes of any well organized visiting nune
association, but is a natural and logical development of its work. Such a
well organized hourly service, at a moderate price, under centralized
management is not unlikely in the future to solve the problem of the de-
creasing number and increasing cost of private duty nurses.
One of the striking developments in paid service, which the Cleveland
Association, like a few other leading nursing organizations, has recently takai
up, is a paid day and night service during delivery. This work fills a need
than which none is more important, but with which for lack of the necessaiy
personnel and funds, visiting nurse associations have in the past not attempted
to grapple.
The value of teaching family hygiene and giving attention to the health
and hygienic habits of the whole family is recognized by the Association,
but is not sufficiently emphasized as a definite function of the nurse.
The Present Equipment
In order to perform this work a staflF is maintained consisting of a super-
intendent of nurses, an assistant superintendent, three supervisors, and at
present 21 regular staff nurses and six substitutes, and a clerical staff con-
sisting of one office secretary' and one clerk at central office and one stenog-
rapher at each sub-station. There are a central office and three district
offices, all of which are ample in size and equipment for their functions.
Analysis of Activities
Study of the work performed by the Visiting Nurse Association proves
it to be of highest grade so far as it goes, but that it does not go far enough
The spirit manifested by the whole organization is lofty, and the work is
thorough, painstaking and kindly. ,
This Association has been of great value in demonstrating many activi-
ties to the municipality, such as the care of tuberculosis, industrial nursing.
and, together with the Babies' Dispensary, work for babies both sick and well,
etc. By turning over these successive activities to municipal and private
agencies, the present scope of the work aj)pears to be narrowing and to lack
extension into the new fields of services waiting to be developed.
The Board of Trustees of the Visiting Nurse Association has never lacked
vision for new opportunities of service. It will doubtless continue its policy
of extending into new fields as occasion oflFers.
Care of the Sick
The care of medical and surgical patients occupies the greatest part of
the nurses' time. Approximately four-fifths of the patients are medical or
r R s I N G 775
peal cases, only a very small percentage (less than 1%) of whom are
:>iiics. The kinds of illness cared for are many, but include very few
*s of tuberculosis or other communicable diseases or intestinal diseases of
Lucy. Between October, 1918, and October, 1919, 51 tuberculosis patients
16 intestinal cases among babies were treated. Yet the records of the
ision of Health show that the second highest cause of death in the city
Cleveland in 1917 was tuberculosis, and the third, diarrhoea and enteritis
[>ng children under two years of age.
While it is true that the Division of Health provides for the care of all
tagious diseases and for tuberculosis patients not able to pay 75 cents a
It, and of sick babies whose parents are unable to pay 75 cents, it never-
less is surprising that so few tuberculous patients over the 75 cent limit
re found in need of nursing care, and so few sick babies outside the scope
the municipal staflf. While the city record shows only 165 cases of typhoid
ring the year, a negligible number of these, only five, are on the visiting
rse list.
Moreover, few post-operative cases discharged from hospitals before com-
ete recovery are under visiting nurse care. Many hospitals dismiss sur-
cal patients as soon as they have recovered from the operation itself, who
ill require dressings of the wound for weeks and possibly for months. For
alien ts of little or no income these dressings should be done without cost,
isiting nurse service would seem to be the solution. Frequently, also,
rivate doctors are glad to turn over such dressings to the visiting nurse,
oing the dressings themselves only often enough to keep track of the prog-
ess of healing. Apparently, little such service is rendered by the Cleveland
Association, although there is presumably considerable need for it. Indeed
he Association should be called on for a wider service of the kind.
It is desirable that the hospitals should send the regular clinic agents to
'-all on patients merely to secure their return, or where there are special medi-
'-al or social conditions which the hospital has studied and with which it is
^ touch. But all patients leaving the hospital who need medical or surgical
^re are appropriate patients for the Visiting Nurse Association and an effort
»liould be made to have the hospitals refer them to the Association.
Observation of a limited number of home visits showed the quality and
Aaracter of nursing care to be excellent, being careful and thorough, and
lone with much gentleness, where the work of the nurses in their districts
^as observed by the investigator. Marked kindness, sympathy and interest
^^ shown by the nurses in most cases. It was apparent, however, that the
actual nursing care given was of first importance in the .eyes of the nurses;
^d that they failed to consider the health of the whole family as part of their
'^sensibilities and did not take sufficient advantage of opportunities to
■each prevention of illness, or home and family hygiene.
The records of the Association, however, show that a substantial amount
*f attention was devoted to social diagnosis and treatment, since practically
^ per cent of the patients cared for between October, 1918, and October,
pI9, were referred to hospitals, dispensaries, or other health or social agen-
ies.
776 Hospital, and Health Survey
While undoubtedly the giving of nursing care is the prime function of a
visiting nurse association, it seems clear that more teaching could be done
by the Cleveland staff without lessening the quality or quantity of nursing
care.
Many opportunities also present themselves to secure or advise treat-
ment— medical, surgical, dental, optical or hygienic — for members of the
family not coming within the range of the school, municipal or industrial
nurses. While the statistics in Cleveland do not show the amount of such
work done, none of the visiting nurses who were accompanied in the districts ,
seemed to be taking advantage of these opportunities as vigorously as they
might.
In the opinion of the Superintendent of the Association the sick among
the poor are receiving adequate care and are being brought to the attention
of the Association, through its cordial relations with other social remedial
agencies and their frequent calls. There are, however, no statistics to show
the number of patients so referred. The Superintendent thought that the
pay service had not reached its maximum usefulness, and that a decided ex-
tension of this service was needed, and would be of benefit to and well re-
ceived by those of small and moderate income.
Prenatal Nursing
It was found that prenatal care was being extended to patients under the
care of private physicians and to patients expecting to go to the hospital for
confinement or to have a midwife. It was not given to patients under the
care of an out-patient maternity service. It was stated that, although they
engagt*d the doctor some time ahead, very few of the pregnant patients
carried by the visiting nurses had medical oversight until the time of con-
finement. Hence the prenatal instructions given to those patients by the
nurses, with the d(x»tors' consent, are of special value as safeguards.
With the wide possibilities of benefit inherent in prenatal nursing both
for the individual mother and for the comnmnity, this nursing service should
go furtlier than it now does. Visits are a month or more apart, instead of
every ten days or two weeks as they should be for the best results; no urin-
alysis is made or blood ])ressure taken, and instruction might be somewhat
more thorough. The reason given was that the nurses did not have time to
make frequent calls of sufficient length upon these patients. They would
be glad to enlarge this service and could do so with great advantage if the
staff were increased suflBciently.
Maternity Service
The post-natal care given by the regular staff nurses was excellent. The
work of the s|)eiMal obstetrical nurses was not observed, but judging from the
high quality of the work of the rest of the staff, it is presumed that this was
well done also. This service is provided at any time to any home patient
under the care of a private physician and able to pay the fee of ?5.00* It i^
not provided to patients unable to pay this fee, since such patients are not
* TbiM fee has been chanced to $7.00 kxhcx the investication
Nursing 777
usually under the care of a private physician, but have hospital or out-patient
maternity care^ which provides nursing service. The maternity service of
the Visiting Nurse Association, though still on a small scale (234 confinements
in 1919), is steadily growing. It should be increased as rapidly as the staff
can be increased to care for it.
Factory Service
Two factories are in affiliation with the Visiting Nurse Association through
contract, one being supplied with two nurses and the other with one through
the Visiting Nurse Association. These nurses were former members of the
visiting nurse staff and are still supervised by its superintendent and her
assistant. They send to the Association a monthly statistical report and
attend the staff meetings. During the factory nurses' illness or vacation,
the Association supplies a substitute. The factories pay the Association for
this service, including salary, equipment and carfare, and the Association
|>ays the nurses, who wear its uniform. In the past such an arrangement
was maintained with six factories, but four have discontinued it. It is
Highly desirable that the Central Nursing Committee work out a plan for
some agency to assume this activity. Supervision of the 104 industrial
nurses in Cleveland is urgently needed. (For further details of nurses in
industry see Part VII.)
Out-Patient Maternity Affiliation
Up to January, 1920, both the out-patient maternity service of Western
Reserve and pf St. Luke's were in affiliation with the Visiting Nurse Asso-
ciation. Formerly this meant that the Visiting Nurse Association selected
the nurse, but recently the hospitals have selected the nurses, and they have
had their selection *' regularized" by passing their credentials through the
Central Committee and the Visiting Nurse Association. This affiliation has
come to be only a form since the A^ociation does not select or supervise the
nurses or have any authority over their work. All that remains is that the
nurses' salaries are paid through the Association. There appear to be no
advantages in this arrangement, and it is clearly a disadvantage to the Visit-
ni^ Nurse Association to be responsible for a piece of work over which it has
no authority. January 1st this affiliation was discontinued with St. Luke's,
but continued with Western Reserve.
The Medical College had a gift some years ago for a memorial nurse, the
** Powell Nurse," for its out-patient maternity service. The College believes
there was a stipulation that the nurse should come through the Visiting
Nurse Association, and is therefore unwilling to discontinue this perfunctory
aflUiation for fear of losing the right to this gift. It would seem that such
arrangements should be abandoned in favor of a city-wide single prenatal
service, recommendations for which are given elsewhere.
Pilgrim Church Service
Pilgrim Church pays $500.00 a year towards the salary of one nurse to
OBXt for the people in the neighborhood of the church. The church endeavors
to serve a non-sectarian group. The nurse has her office in the church ^buUd-
778 Hospital and Health Survey
ing, at the request of the church, in order to make a place where the nei^
bors can be cared for. She does many dressings in her office, and also in-
spects and watches over the church kindergarten. The church has marked
out the area in the city which it wants her to serve. This area is not an
appropriate one in relation to the rest of the West Side district. Nurses
going into one district must frequently cross this district. The western sec-
tion of it is more accessible to one of the other districts.
The nurse does not report to the West Side office or keep her records there,
the latter being kept in the church office.* The supervisor of the West Side
district, therefore, must come to the nurse's office in order to see her or to go
over her records. The result of this arrangement is that the nurse woiks
almost alone and receives very little supervision and assistance.
This arrangement appears to be inadvisable, both from the point of view
of policy and of administration. As a matter of policy, it would be awkward,
if contributions were to be received from other churches, to permit them to
determine the location of the nurse's district, and to have her office in the
church. This would result in confusion and disorganization of the present
well planned system of the Visiting Nurse Association. The precedent,
therefore, seems to be a bad one. From an administrative point of view, the
result is the undesirable isolation of one of the members of the staff, cutting
her off from intercourse with other members and from the assistance and over-
sight of her supervisor; also the necessity of maintaining district boundaries
which are exceedingly disadvantageous to the management of the work in
the West Side district.
Service Outside of the City
Lakewood has its own Visiting Nurse .Association, which is affiliated with
the Association in Cleveland. It has a separate Board of Trustees, who raise
funds, determine policies and administer the work. The nurses, however,
are supplied by the Cleveland Association, which also supplies substitutes
when needed. Salaries are paid through tlie Cleveland Association. These
Lakewood nurses attend the staff meetings of the Cleveland Association,
and are supervised by the superintendent of the Association or her assistant.
They wear the Cleveland uniform and send a monthly report to the Cleveland
Association.
Bratenahl Village, a well-to-do residential section, pays the Association
$5^50.00 a year to have a nurse call twice a week at the school to inspect the
children. There is also a school doctor, who attends occasionally, f^
nurse docs little home visiting.
Analysis of Administration
The administration of the activities of the Visiting Nurse Association
seems to be well planned, systematized and carried out. The main office
and sub-stations are managed in a smooth, businesslike way and for the most
• Since the recommendations of the Survey were received the records have been removed fean ^
PUgrim Church and the Pilgrim nurse reports three times a week to the Wert Side Station.
U R 8 I N G 779
rt the record systems seem to be adequate, fairly simple and kept up-to-
te. The amount of clerical work required of tlie nurses has been reduced
a minimum.
No record is kept of the source of calls, making it impossible to analyse
* frequency and amount of the use made of the Association by other agen-^
s. An annual analysis of the sources from which calls come would be illumi-
ting. It frequently shows that certain agencies are not calling upon the
sociation at all, or not as frequently as they might, or that agencies with
lom close relations were supposed to exist have in reality made few calls
on the Association. It gives definite evidence of the number of dismissed
tients turned over to the Visiting Nurses by the hospitals. It shows to
at extent the doctors are making use of the nurses. All the members of
; Visiting Nurse staff interviewed indicated that the doctors were giving
; Association excellent cooperation, but there w^ere no statistics to prove
s fact. A tabulation of the sources of calls would give all this information,
i afford a definite basis on which to determine where the service could be
ill up.
There is a cheerful, dignified spirit among the members of the staff,
Lh in the stations and in the districts. Devotion to the work seems to be
luine and whole hearted, and it is quite evident that the officers and staff
the Association are working constantly to insure a dependable quality of
vice. The harmony that exists among the supervisors and their constant
*rsight of the work in the field tend to stabilize the service and to insure to
; patients skilled and carefully planned services. The supervisors make
•ry effort to insure the best of care to the patients without overworking
t nurses While only four nurses were accompanied in the districts, one
vtrhom did not come up to standards, the work observed bore the marks of
isistency, honesty and well grounded preparation.
Two or three factors, however, tend to diminish initiative and ability to
.n and manage on the part of the staff nurses. These factors are the fol-
ring:*
(a) In two districts the supervisors allow the nurses too little planning
of the day's work. The nurses make out a list of their calls, and the super-
visor then changes the arrangement of them as she sees fit, or decides which
patients are to be seen and which are not. This takes away from* the staff
nurse the necessity of planning her own work and of managing and perform-
ing it in a way to bring about the best results. It lessens her sense of respon-
sibility and makes her very dependent upon her supervisors.
(b) The unit of the organization so far as records are concerned is the
supervisor's district and not the staff nurse's district. The districts occupied
by the staff have no name, letter, or distinguishing mark and no identity
The list of patients and the statistical report of the work is made out for
the whole district covered by the supervisor and not for the smaller districts
in which the nurses themselves are working. This means that there is no
* Since the Survey recommendations were received the following changes have been made. Every
»« now has her own district, keei>s her own day-book, makes out her own monthly %tat.\%\\c«\ t«v«^-
780 Hospital and Health Survey
way of picturing the work in each nurse's district as a single piece of wofk;
no method of measuring the work performed by individual nurses, conse-
quently no basis of comparison and no basis for pride in accomplishment.
This does not tend to build up individual initiative, or the spirit of competi-
tion with the work of other members of the staff. No use is made of the
census tracts of the city in outlying districts, either for the individual nurse
or fcr the supervisor's district. These fundamental districts as arranged
for use by the census should be used as units or by multiples for the Visiting
Nurse Association administration as for the district subdivisions of every
other private and public health agency.
(c) In two districts many of the nurses make a practice of returning to
the station three times a day.* This is a waste of time, and again weakens
the nurse's sense of responsibility for her work. The tendency is for her to
go to her supervisor constantly for advice rather than to think out her prob-
lems herself.
While there is thus no lack of supervision and in some cases too much
supervision in the administration of the work, there might to advantage be
even more supervision than there is in the home visiting. A study of the
supervisors' record for two months showed that during one month super-
visors went into the districts with the staff nurses 33 times, and the second
month 34 times, visiting in the first month 64 fa];nilies, and in the second 114;
yet in one month four nurses were not ever accompanied by the supervisor,
and in the other month six nurses were unaccompanied.
According to this record the supervisors spent an average of about one-
third of their time in the field, but not more than half of this was spent
in accompanying the staff nurses. The supervisors appear to make visits
alone in the district. This is not desirable practice, as it means that the nurses
are deprived of the supervisors' guidance in such cases and that the super-
visors are handling alone the most difficult situations, instead of using tbem
as teaching opportunities.
A good feature of the work is that the supervisors regularly attend the
case conferences held by the Associated Charities. Jt is desirable that the
staff nurses who occasionally attend these conferences, should also do so
regularly.
The nurses average seven and a half calls a day. If the nurses did not
return to the office so often more work might be accomplished without intff-
fering with its finish. With an enlarged staff and a saving of the nurses'
time in going back and forth, especially in the outlying districts, the activi-
ties of the Association might be doubled and many more persons get the bene-
fit of the fine services offered.
Experience in many communities has proved that until the city is able to
take over these nursing services in full, private organizations must perform
this function of helping save life and restore health. The overwhelming
majority of sick persons must be cared for in their homes: a very small pro-
* The nurses now are required to go to the station hut once a day.
j^ U R 8 I N G 788
i. Inspection of pupils by class rooms.
After the summer, Christmas and Easter vacations, the children
are inspected, a room at a time, by the doctor and nurse, for signs
of communicable disease, skin disease, running ears, or pediculosis.
Once a month the nurse makes a similar inspection, devoting about
7 to 10 minutes to an entire roomful of children.
3. Securing correction of defects found through the examinations by
means of:
Notes and messages sent to parents.
Consultations with parents at the school house»
^ Visits to the home.
4. Bfaintenance of ''dispensary hour" in each school for:
Treatments,
Dressings,
Emergencies,
Inspection of excluded children.
5. Health talks to individual pupils.
6. Health talks to classes in class rooms.
TheStaflf
The sta£F of the nursing bureau consists of:
1 supervisor of nurses,
2 field nurses,
30 staff nurses,
6 junior health workers,
12 stenographers (part time only).
There is a central office in the administrative building, but there are no
ffandi offices.
Analysis of Activities
Examination of Children
•
Since these examinations are made by the medical inspectors they need
BO comment in a study of nursing work. They are made rather rapidly,
osoally without the taking of medical histories, and except in a few instances,
^tfty are not complete examinations. Moreover, most of the corrections
'^Boomniended are routine recommendations, such as removal of tonsils and
^^oids, and treatment for dental and visual defects. It would ^AiQ;T^^
782 Hospital and Health Suryst
(c) 1 That one automobile be provided for each sub-ttation for use eapcdaSij m ^
outlying districts; thus also making possible more frequent visits of the super-
. visors, especially to the outlying districts.
2 That as an alternative, the nurses in the outlying districts be provided with t
sub-station, and come in to the district station only two or tiiree tixna
• a week. To these outlying districts the older and more experienced nones
should be assigned.
(d) That the Pilgrim nurse report to the West Side station and that the boundaries of
the Pilgrim District and the neighboring districts be changed to bring about a more sdvin-
tageous arrangement. The nurse could still maintain a dispensary service at the church if
(e) That the individual nurses' districts be made the unit of work, giving them •
fixed number or letter, and requiring a statistical report for each of these units mootUj.
and that the unit of district work be the official census tracts, singly or in multiples.
(0 That the individual nurse report to the district office only once a day.
(g) That the amount' of supervision of the nurses in the fiidd be increased and be
lessened in the station.
(h) That the nurses attend Associated Charities* case conferences more frequenttjr.
(i) That methods be devised of developing the individual initiative and resooroei ^
the nurses (a weeldy round table is suggested for the discussion by the staff, of diitritf
problems, case work, and allied subjects.) The nurses themselves might well plan 9kA
conduct these round tables.
(j) That a record of the source of calls be kept.
Nursing Service of tlie Board of Education
IN school nursing, as in the other branches of public health nursing, Cleve-
land is fortunate in having, through the agency of the Central Nursing
Committee, a high professional standard. In school nursing, as in tie
other branches, a valuable demonstration of work has been made. A to
spirit and diligent application have been found throughout the department
The failures which have disclosed themselves in the course of this investi-
gation are in the main due to the same causes as those in various other organ-
izations studied: that is inadequacy in numbers and faulty supervision-
Yet there is every reason to think that with adequate enlargement of the
staff, with proper supervision, and with a change of emphasis in the work to
reduce some of the less important activities and strengthen the more essen-
tial features, a school nursing system second to none can be built up.
Scope of the Work
1 . Assisting medical inspector with physical examination of children-
Every school child receives one examination a year; some of
fAo.se found to be defective are examined more than once.
[J fi 8 I N G 78S
«
i. Inspection of pupils by class rooms.
After the summer, Christmas and Easter vacations, the children
are inspected, a room at a time, by the doctor and nurse, for signs
of communicable disease, skin disease, running ears, or pediculosis.
Once a month the nurse makes a similar inspection, devoting about
7 to 10 minutes to an entire roomful of children.
). Securing correction of defects found through the examinations by
means of:
Notes and messages sent to parents.
Consultations with parents at the school house*
Visits to the home.
k Maintenance of ''dispensaiy hour" in each school for:
Treatments,
Dressings,
Emergencies,
Inspection of excluded children.
k Health talks to individual pupils.
S. Health talks to classes in class rooms.
The Staflf
rhe sta£F of the nursing bureau consists of:
1 supervisor of nurses,
2 field nurses,
30 staff nurses,
6 junior health workers,
12 stenographers (part time only).
rhere is a central office in the administrative building, but there are no
icli offices.
Analysis of Activities
Examination of Children
Since these examinations are made by the medical inspectors they need
K>iiiment in a study of nursing work. They are made rather rapidly,
dly without the taking of medical histories, and except in a few instances,
r are not complete examinations. Moreover, most of the corrections
•nmended are routine recommendations, such as removal of tonsils and
Qoids, and treatment for dental and visual defects. It would %lb^TCi^
784 Hospital and Health Survet
§
therefore, that the school nurses might be released from attending the doc-
tor during these examinations, and be replaced by junior health wc^kers,
thus saving much of the nurses' time for more productive work. Whew
less obvious and simple conditions are found, and treatment is more tech-
nical and personal, the nurse should consult with the doctor, in order to
receive more detailed instruction than is written on the record.
Inspection of Pupils by Rooms
The nurse spends an hour or more each school day in making room in-
spections, for the pur])()se of detecting skin lesions, running ears, pediculosis,
and symptoms of communicable diseases. These examinations of an entire
roomful of children are completed in 7 to 10 minutes. On account of the
preoccupation of the nurse with other duties, even these necessarily super-
ficial inspections can be repeated only at intervals of about 4 weeld. B^
tween examinations the teacher must be relied upon to notice symptoms
and to refer children to tlie nurse during the ''dispensary hour." Since
previous training and ex]>erience in such work cannot be expected of teacheR
the nurse should not only determine the physical condition of the chikiiti
at the time of her visit, but should also confer with the teacher and instnwt
her, so that she may render this service to the best of her ability during tb
long intervals between the nurse's visits. Teachers who are cooperative awl
become fairly proficient will need less frequent visits from the nurse, and
more attention can be given to school rooms of those who are new (A le»
interested. This cooperation l)etween the nurse and the teacher shonH
result in more effective supervision of the health of the children day by day,
than is now ])ossible.
CORKECTIOX OF DkFEC'TS — LaCK OF HoMK VlSITIN(i
The most important activities of school nurses are arranging for it
correction of defects, the improvement of conditions personal or environ-
mental causing defects, iuid the establishment of })etter health habits.
In the case of many "hildrcii, a real remedy for an abnormal condition
cannot be prescribed until the child's environment has been studied. Change
in the mode of living is often essential not only to the correction of physical
defects, but also to the complete restoration and maintenance of health
These changes in living can be accomj)lished in most cases only by thou|^t-
ful persuasive visits during which the nurse may talk over the child's condi-
tion at length with the parent, may discover what influences in his hon*
life are harmful, or what may be wrong in his hygienic habits, and may
advise the mother thoroughly and carefully concerning any changes needed-
Such visits arc the very heart of school mirsing.
Thus, for instance, a boy in one of the Cleveland schools, who had bw
skin trouble since babyhood, had been to many doctors and dispensai**
witliout relief. It was discovered by the nurse in a home visit that his die!
consisted chiefly of tea, coffee and sweets. *' We've plastered him with th
things the doctors were experimenting with," said his family, '*but nothing
helj)ed until you got after his food."
B I N G 787
and practised, the sta£F will have many problems to consult her about,
lent they have few.
is important to have monthly statistical reports made by each staff
studied and corrected by each supervisor and then referred to the
itendent or director. At present daily reports are made by the nurses,
ese are summarized monthly in the main office. A personal record of
cy and personality of each of her staff should be prepared by the
isor, after careful observation of the nurse and study of her work,
ansmitted every three months to the director, for permanent record,
ecords should be prepared monthly for new nurses for the first three
some measure the deficiencies apparent in the work are due to the
at the number of nurses and supervisors is inadequate. But from the
is of administration it is clear that the most serious weaknesses in the
L arise from the failure to appreciate that the supervisor is to be a leader
nsultant, whose duty it is to develop her staff, to help them see and
heir problems, to train their faculties and correct their mistakes, to
e their work and its results. The absence of such supervision is evi-
t the nurses' work, which is often routine in character, lacking in origi-
and in grasp of opportunity.
NURSEQ
5 staff nurses seem to be faithful, honest workers, performing their
conscientiously, but it is quite obvious that they lack sufficient super-
They clearly show a lack of leadership and development.
*y have too many children (approximately 8,000 per nurse) and too
school duties to accomplish the very necessary home visiting. The
lould be increased to give a ratio of 1 nurse to every 2,000 children,
nior health worker is provided for each nurse. Otherwise the ratio
be one nurse to every 1,500 children. There might be provided with
benefit to the service one "floating nurse" under each supervisor to
place of sick nurses.
Junior Health Workers
ise workers seem to be of a unique type, originated and developed in
md, on the whole with very good results, which are largely due to
eing well educated. All of them are college graduates.
;y have relieved the nurses of much routine work in attending the
during examinations, have been responsible for getting dental defects
ed, and have taken many children to dispensaries. There seems to
"eason why all of this work could not be given to them. Placing one
worker with each nurse would result in freeing the nurse for more
ant duties.
the other hand, to allow home visits to be made by these workers,
re information about children to whom Binet tests have been given,
ose referred to dispensaries, appears to be a mistake. Such visits,
lly the first named, give much opportunity for constructive health
ind require a trained discrimination in observation of health as well
&I conditions. They should, therefore, be transferred to the nurses.
786
Hospital and Health Survet
Health Talks to Classes
These talks on health habits could be very valuable if given according to
a definite graded schedule and system, in a regular orderly fashion. There
is a great difference in the subject matter and manner of presenting it to
first grade pupils and eighth grade pupils. The present unstandwiised
ungraded, and unsystematic method renders these talks of little vahie.
They should be made a definite part of the curriculum of every grade, and
should be given by the teachers whenever the nurses do not have time to
give them in this way. The present staff would not have time to give suck
systematic instruction.
Analysis of Staff and Administrative Methods
Supervisor
The supervision of this nursing service is lodged in the hands of one super-
visor and two field nurses. While the spirit and intentions of the supervisor
are excellent, there are certain marked shortcomings in the conduct o^fthf
work. Not only are there too few supervisors for the size of the staff, but
the purpose and aims of supervision are apparently misconceived.
It would assist the supervisor to carry the responsibilities of her position
if she were advanced in rank. She should have the title and salary of director
or superintendent of nurses.
Field Nurses
One field nurse has eight nurses assigned to her, and in addition is respon-
sible for staff nurse duties in one school and one eye clinic. She therrfoif
gives only half her time to supervisory duties. The other field nurse lus
22 nurses under her.
The field nurses in their supervisory capacity are expected to visit only
those staff nurses who have been newly appointed, or who are thought to
need special supervision. Last year several of the staff nurses received no
supervisor^' visits from a field nurse.
Both of these nurses spend much of their time in substituting for sick
nurses and the rest in training new nurses and laboring with poor ones.
The good nurses have, therefore, none of the benefits of supervision.
Radical change is needed here. These nurses should have the rank,
title, position, and salary- of supervisors. None of them should have any
staff work to do as is now the case on the West Side. As a matter of routine
they should spend two half-days a month with each of their staff nunes,
one half -day with her in the field, and the other half in the school.
To make proper supervision possible, it will be necessary to increase the
number of supervisors. There should be one supervisor for every ten nurses
at most.
Each supervisor should have an office in her district. She should be
responsible for the management of her district, and the work of the nurses
in it. She should hold definite office hours, when any of her staff can find
her for consultation. The staff should be encouraged and expected to
consult her frequently about case work. When the value of case work i*
Et 8 I N G 787
it and practised, the staff will have many problems to consult her about,
resent they have few.
t is important to have monthly statistical reports made by each staff
*, studied and corrected by each supervisor and then referred to the
rintendent or director. At present daily reports are made by the nurses,
these are summarized monthly in the main office. A personal record of
sncy and personality of each of her staff should be prepared by the
rvisor, after careful observation of the nurse and study of her work,
transmitted every three months to the director, for permanent record,
records should be prepared monthly for new nurses for the first three
hs.
1 some measure the deficiencies apparent in the work are due to the
that the number of nurses and supervisors is inadequate. But from the
^sis of administration it is clear that the most serious weaknesses in the
ta arise from the failure to appreciate that the supervisor is to be a leader
consultant, whose duty it is to develop her staff, to help them see and
their problems, to train their faculties and correct their mistakes, to
rze their work and its results. The absence of such supervision is evi-
in the nurses' work, which is often routine in character, lacking in origi-
Y and in grasp of opportunity.
NURSEQ
he staff nurses seem to be faithful, honest workers, performing their
IS conscientiously, but it is quite obvious that they lack sufficient super-
[i. They clearly show a lack of leadership and development.
hey have too many children (approximately 8,000 per nurse) and too
f school duties to accomplish the very necessary home visiting. The
should be increased to give a ratio of 1 nurse to every 2,000 children,
junior health worker is provided for each nurse. Otherwise the ratio
Id be one nurse to every 1,500 children. There might be provided with
I benefit to the service one "floating nurse" under each supervisor to
le place of sick nurses.
Junior Health Workers
hese workers seem to be of a unique type, originated and developed in
•land, on the whole with very good results, which are largely due to
being well educated. All of them are college graduates.
hey have relieved the nurses of much routine work in attending the
>r during examinations, have been responsible for getting dental defects
cted, and have taken many children to dispensaries. There seems to
> reason why all of this work could not be given to them. Placing one
h worker with each nurse would result in freeing the nurse for more
riant duties.
n the other hand, to allow home visits to be made by these workers,
cure information about children to whom Binet tests have been given,
those referred to dispensaries, appears to be a mistake. Such visits,
jally the first named, give much opportunity for constructive health
, and reauire a trained discrimination in observation of health as well
cial conditions. They should, therefore, be transferred to the nurses.
788 Hospital and Health Subvet
Conferences
In order to promote the enthusiasm and inspiration which comes from
the rivahy, competition and spirited discussion of new and live topics,
weekly meetings of the nurses are held each Saturday morning, of the whole
group or of sections of the nurses according to the size of assembly rooms
available at the headquarters or elsewhere. Unless interest in these meet-
ings is well maintained, perhaps in part by bringing in outside speakers
as occasion offers, but chiefly by prepared discussions by members of the staff,
the object of the meetings, that is, the building up of esprit de corps and
^ unity in the staff, will be missed. From time to time these should be turned
into carefully pre])ared case conferences, at which certain cases presenting
diflSculties, solved or unsolved, should be presented. Such conferences will do
mucrh to arouse in the nurse a sense of the importance of good case work and
a knowledge of the way to go about it. For the same reason the nurses shouM
be encouraged to attend the case conferences of the Associated Charities.
Records
At present there is little coordination in the records. The child's indi-
vidual record is kept in the school room. This record is very brief and tells
little of what is done for the child. The doctor's orders are on this card.
The work done by the nurse is usually, though not always, entered on the
correction slij) in her file. Home .visits are kept on still another card. An
effort to check tlie nurse's accomplishment against tlie doctor's recommenda-
tion is almost hopeless.
The individual health record of the child is keot on the teacher's desk,
supposedly to Veep the teacher informed of the child's physical condition.
These records follow the child from room to room together with his school
record. The teachers, however, arc uninterested because nothing appears
on this record that would give them a clear idea of the child's physical con-
dition. Therefore, it would seem much more intelligent to have this record
kept in the dispensary with the other records, and have them so arranged
that it would be possible to know the entire performance of health work in
regard to each child, unless, as proposed on page 312 of the child health
rei)ort, the records in the school room include all items of the child's health
liistory as they should.*
The method of using the correction slips for notations of home visits
I and corrections accomplished is exceedingly bad. It does not make for per-
manency, and there is no way of using them as a basis for statistical study.
The absence of a monthly report from the nurse is also a factor in making it
difl[icult to know what the nurse has actually accomplished. A simple,
accurate, and comprehensive report should be made by the nurse every
month as a part of the whole statistical report. In no other way can
she keef) a check on her own activities, know what she has accomplished,
and measure her progress.
RECOMMENDATIONS
The following recommendations are directed toward coacentrating the work of tbt
nurses on the more essential activities, which they alone can conduct.
* A new comuUitive record card has already been developed.
Cursing 791
ntrusted with the nursing care which in other parts of the city is given by
he nurses of the Division of Health. Owing to the character of the popiila-
ion there is little call for hourly nursing.
Because of the difference in the size of their respective districts, it is diflS-
ult to compare the amount of nursing done by the University District
taiF with that of the Visiting Nurse Association. Apparently there is little
iflFerence either in volume or quality, except that, because of the generalized
haracter of their nursing, the University students are able to give more
ttention to the family as a whole. Certainly visiting nursing has not suf-
aed by bemg made a part of this generalized service.
Owing to the higher ratio of nurses to population in this district, the at-
ention given to sick babies and tuberculosis patients can be more regular
nd thorough than that given elsewhere by the nurses of the Division of
lealth. As much emphasis is put on nursing care as on any other aspect of
he work, and full provision is made for it. In fact, as high a standard of
are is given to these patients as to other bed patients at home.
Child Hygiene
This service in the University District is similar in scope to that of the
j^ursing Service of the Division of Health. One or two exceptions are noted;
11 babies whos^ births are reported are visited and cases under the care of
, private doctor are not dismissed.
In January, 1920, there were 510 well babies attending the Prophylactic
ylinic, 1,885 well babies not attending the clinic, 843 sick and convalescent
»abies attending the Babies' Dispensary and Hospital, and 21 babies under
private doctors; a total of 3,259 babies under three years of age, or about 100
Mibies to each student nurse. Two or three children are often in the same
tome. The babies attending the clinic regularly are visited two or three
imes every six months. Sick cases are seen daily, or as often as necessary.
Veil babies not attending clinic are seen when possible, sometimes two to
ix months elapsing between visits. The director and instructors think it is
irorth while to carry these well babies even though they are not seenfre-
juently. The records show that the average is five visits a month per
Miby. The record also shows that a large proportion of the new babies
aken on each month are discovered by the nurses themselves as they go about
m other errands among their families. The best of nursing care, as has been
tated above, is given to sick babies. It would be desirable to have well
labies likewise visited more frequently.
Tuberculosis
The scope of tuberculosis work done by the University District corre-
ponds with that done by the Nursing Service of the Division of Health,
rhere is no tuberculosis clinic in this district, patients being referred to
lealth Center No. 2, unless able to have a private doctor.
It was evident that the patients were being well cared for and kept under
ratchful supervision. But although the nurses are willing and able to ^n^
790 Hospital and Health Subvet
teaching staff. The area coincides with Health District No. 8, estimated at
60,000 to 70,000 population. It is one of the most congested and poorest
parts of the city.
Analysis of Administration
Staff
The director of the course and of the field work is a public health nune
on the University payroll as an assistant professor. She teaches one count
at the University and is in general charge of the district, teaching and super-
vising the students and performing all the administrative duties. The direc-
tor's duties are many and difficult, and are indeed beyond the capacity of
one person. A full-time assistant director is needed to take over many
routine matters, so that the head may have free time for the more important
duties of her position.
Assisting her are five nurse instructors, one of whom is designated assist-
ant director, with limited administrative duties. Each instructor is a pub-
lic health nurse in charge of a part of the district and responsible for the
students assigned to her area. The district is thus divided among these five
supervisors, as is also the management of the clinics held in the district
Each instructor is in addition responsible for the teaching of certain practicil
subjects, particularly those in which she has had special experience.
There is no other permanent staff. With the exception of school nursing
and out-patient maternity work, nursing in the district is done by the stu-
dents of the course as a part of their training. The number of students actu-
ally at work in the district at any one time varies. There are graduate
students who are taking the full course, and others who are taking only the
four months' practical work. There are also ten undergraduate students
sent from nurses' training schools for two months' experience. The hi^est
number in the field during the past year has been 33 and the lowest 10.
There are also an office secretary, a business woman, who is responsible
for many business details, and three typists.
Plan
The district is divided into five sections, each in charge of an instructor.
These sections are again divided into sub-sections, one for each student nurse.
The number of nurses in each section ranges from two to six or seven. Each
student nurse has full responsibility for her sub-section in which she carries
on a generalized service, imder the direction of her instructor.
Analysis of Activities
Visiting Nursing
General visiting for free, part-pay and full-pay patients and for Metro-
politan Life Insurance policy holders is carried on in this district exactly as
done elsewhere by the Visiting Nurse Association, with the exoepticm of
attendance at confinements and minor operations. Tl^e student staff is abo
Nursing 791
entrusted with the nursing care which in other parts of the city is given by
the nurses of the Division of Health. Owing to the character of the popula-
tion there is little call for hourly nursing.
Because of the difference in the size of their respective districts, it is diflS-
cult to compare the amount of nursing done by the University District
5ta£F with that of the Visiting Nurse Association. Apparently there is little
diflFerence either in volume or quality, except that, because of the generalized
character of their nursing, the University students are able to give more
Attention to the family as a whole. Certainly visiting nursing has not suf-
fered by bemg made a part of this generalized service.
Owing to the higher ratio of nurses to population in this district, the at-
tention given to sick babies and tuberculosis patients can be more regular
and thorough than that given elsewhere by the nurses of the Division of
H^dth. As much emphasis is put on nursing care as on any other aspect of
the work, and full provision is made for it. In fact, as high a standard of
care is given to these patients as to other bed patients at home.
Child Hygiene
This service in the University District is similar in scope to that of the
Nursing Service of the Division of Health. One or two exceptions are noted;
all babies whos^ births are reported are visited and cases under the care of
a private doctor are not dismissed.
In January, 1920, there were 510 well babies attending the Prophylactic
Clinic, 1,885 well babies not attending the clinic, 843 sick and convalescent
babies attending the Babies' Dispensary and Hospital, and 21 babies under
private doctors; a total of 3,259 babies under three years of age, or about 100
babies to each student nurse. Two or three children are often in the same
home. The babies attending the clinic regularly are visited two or three
times every six months. Sick cases are seen daily, or as often as necessary.
Well babies not attending clinic are seen when possible, sometimes two to
BIZ months elapsing between visits. The director and instructors think it is
worth while to carry these well babies even though they are not seen fre-
quently. The records show that the average is five visits a month per
baby. The record also shows that a large proportion of the new babies
taken on each month are discovered by the nurses themselves as they go about
on other errands among their families. The best of nursing care, as has been
stated above, is given to sick babies. It would be desirable to have well
babies likewise visited more frequently.
TUBEBCULOSIS
The scope of tuberculosis work done by the University District corre-
sponds with that done by the Nursing Service of the Division of Health.
There is no tuberculosis clinic in this district, patients being referred to
Health Center No. 2, unless able to have a private doctor.
It was evident that the patients were being well cared for and kept under
tchful supervision. But although the nin*ses are willing and able to give
792 Hospital and Health Subve
all the bedside care necessary, they find that little is needed. Most of the
cases are ambulatory, many of them working, and very few bedriddei
Advanced cases are persuaded to go to the hospital. It is believed that
there were many bedridden cases in the district not under the care of tl
nurses, the fact would be known. The nurses are eager to find all such ps
tients. Just as in the case of children, the nursing is far more adequate an
of a higher standard throughout than that given by the nurses of the Divisio
of Health.
^The nurses believe that they are in touch with the majority of case
showing marked symptoms, but that there are probably a number of othe
cases missed for the following reasons:
1. Because the men are away at work all day when the nurse is about,
and no one in the family thinks that they are sick enough to report to her.
2. Because early cases conceal the fact that they are losing weight or
showing symptoms, and unless a nurse happens to see them she is not told of
them by the patients or family.
3. Because patients, both incipient and advanced, have more money
than before the war and go to private doctors who often fail either to diag-
nose the case, or to report it. Patients, moreover, change doctors frequently
and are often not under observation long enough to give them a chance to
diagnose or report the case, or else the doctor does not tell the patient what
is the matter, for fear he will go to another practitioner. Many such cases
used to go to the dispensary.
4. Because the district includes many p>eople of limited education and
opportunity, the last to appreciate a subtle or hidden danger.
For the same reasons the nurses believe that they are getting only fair
results in their efforts to persuade positive and suspicious cases and those
who have been exposed to infection to go to the tuberculosis clinic.
Similarly the nurses find it difficult to persuade members of the family
to be examined; they refuse to see the necessity of going to a clinic if they
feel well.
Patients soon grow restless in the hospitals. They complain of poor
food or of being lonesome, and come home as soon as they are a little better,
long before their malady is arrested. Many go back to work soon after
returning home.
A report of January, 1920, shows that out of 209 positive cases on the
books, 159 were attending a clinic; and out of 1,060 suspicious, non-tuber-
culous and exposed cases, 881 were attending a clinic.
The records further show that the average number of visits per month
per patient for the whole group is only .3. If the visits were restricted to
the positive cases only, the average would be 1 visit per month per patient.
From this it is plain that the visits should be more frequent. At present
each nurse averages 30 patients, under observation.
U B 8 I N G 793
Communicable Disease Control
The Division of Health reports all communicable diseases, except small-
x, promptly to the University District. The nurses visit all of them,
portable and not reportable, for the following purposes:
To place and remove placards.
To instruct in care, isolation and prophylaxis.
To issue work permits.
«
*
To give nursing care.
To take cultures.
To maintain quarantine.
The nurses find that through this work they have an excellent chance to
ive care, to teach, and to be helpful to the family when most needed. The
arses perhaps lose some of their popularity because of restrictions which
ley must place on freedom of movement, but on the whole the family do€*s
>t harbor resentment against them.
No great amount of nursing care is needed because both private and city
►ctors send most of the very sick cases to the hospital. The District serv-
- is willing and prepared to give as much nursing care as is needed. Teach-
g the family and caring for the patient are considered of as much impor-
nce as maintaining quarantine, issuing permits, or taking cultures. Nurs-
g care has been given to the few cases of typhoid which have been reported,
ieumonia has not been reported to the University District by the Divi-
>n of Health. It would seem well to have these cases reported also.:
This work oc'cupies about one-sixth of the nurses' time.
Prevention of Blindness
The University District provides care for trachoma cases, })ut has not
'dertaken to be responsible for opthalmia neonatorum.
Midwife Supervision
This service has not been taken over for the Division of Health.
Supervision of Boarding Homes for Babies
There are only four of these homes in the District, and they receive the
Hie oversight and .supervision as other homes in the District in which there
e bstbies. There is no doubt that more care and su|)ervision should be
^en to this group of infants.
Prenatal Nursincj
The nurses find most of the pregnant cases while they are out in the Dis-
ct and in the homes. Doctors do not report very many, and midwiven
794 Hospital and Health Survey
only a few. Births reported from this district to the Division of Health in
1918 were 1,618; for 1919 the figures were not obtainable. In 1919 the Uni-
versity District had 479 pregnant women attending clinic and almost as many
more under supervision at home. In the opinion of the director, one in
every two pregnancies in the district is carried. About one-third of the births
in the district are delivered by the Out-Patient Maternity Service, one-third
by midwives and one-third by private doctors. Private doctors send many
of their cases to hospitals.
The nurses urge women who are not consulting a doctor to go to the
prenatal clinic. They also send to the clinic private physicians* cases with
the physicians' consent, and patients who expect to have midwives. A pre-
natal clinic is conducted twice a week at Health Center No. 8. The nunes
try to visit prenatal cases at least once a month, and when possible once in
three weeks.
The cases reported to the Maternity Hospital Out-Patient Service still
attend the clinic and are cared for by the University District nurses, ff
they develop abnormal symptoms they are turned over to the nurses of the
Out-Patient Service. There has been some duplication of work by the nurses
of these two organizations.
Patients are referred to private physicians for maternity care, if able to
pay the fee of $50.00. If not, they are referred to one of the two Out-Patient
Maternity Services. Post-natal care is given by the Out-Patient nurses. As
this service is popular there is not much maternity service left for the ninse
of the University District. This is a disadvantage, as the students need
adequate practice in this field. On the other hand, the University District
alone has as many pregnant patients under supervision as there are under
prenatal care in all the other districts of the Division of Health combined.
School Nursing
No school nursing is done by the University District. It does not seem
possible for the present stalBf of the University District to undertake as inten-
sive work in the parochial schools as is now given in the public schools by the
Board of Education. The students get their education in this branch of
work under the Board of Education. It is deemed a wise decision that the
University District should not undertake school nursing, unless the number
of student nurses is increased.
Clinics
No tuberculosis clinics are held in the University District. It is hoped
that it will soon be possible to hold such clinics. Prophylactic baby clinics
are held three times and prenatal clinics twice a week. These clinics are con-
ducted for all purposes except medical services, by the instructors of the Uni-
versity District for the purpose of giving the public health nurse students
experience in managing clinics and familiarity with clinical resources. This
experience is indeed valuable for the students, but it puts a great deal of
responsibility upon the nurses who are already carrying a heavy burden as
» I N G 795
tors and supervisors of the districts. One instructor spends on an
e eight hours per week in her clinic, and another spends an average
en hours, in addition to the full day given every month to balancing
Ik book and compiling the milk report. These instructors must pre-
ir the clinic, do a large share of the clerical work (volunteer help has
en satirfactory and paid clerical help has been irregular), teach nurses
« on duty in the clinic and assume the entire responsibility of its man-
it and success. A physician is in attendance at each clinic session.
:>rder not to have the burden too continuous, rotation has been arranged
the instructors, but this does not lighten the volume of work. It
' changes the personnel. If the high standard of work in the teaching
b, for which tiie instructors are largely responsible, is to be kept up
bould not be required to give this time to the dispensaries. In order
3 this service under the University District, however, a special instruc-
the dispensary should be appointed. This will in any case be neces-
a tuberculosis clinic is opened. Such an instructor would very mate-
relieve the pressure on the other supervisors and make possible the
pment of newer principles and procedures in this important activity.
Supervision
e object of supervision in public health nursing is to detect weaknesses
jvelop strength in the nurses; to protect the patients; to prevent
ation of the nurses; to coordinate and utilize to the best advantage
ergies of the sta£F.
e criticism has been brought against the University District that it
fs too many instructors or supervisors. This question received earnest
oration, but evidences of over supervision though carefully sought,
lot found.
e director of the District, in accepting the responsibility of furnishing
; care to everyone who needs it within this District, must first consider
Hlth a constantly changing sta£F of nurses, the standard of nursing can
tt consistently high and uniform. She must also consider how the
demands for nursing can best be met without exploitation of the
, who in this District are all to be regarded as students in training.
iple proof was given that the character of the supervision is excellent,
xcellence was shown by the way in which the possibilities of nurses
irily of di£Ferent calibre were developed. Even the less well trained
le of less native ability showed in their work clear evidences of good
ig. It is probably due to the intensive work of the staff of instructors
le nursing standanis of the University District have been high, that the
t's interests are most carefully guarded and that the nurses have been
rotected from too much work in the field.
General Summary
B character and volume of the work in the University District prove
nursing program which is almost completely generalized except for
796 Hospital and Health Survey
school nursing can be carried out witli excellent results. No branch of nurs-
ing undertaken has suffered from its merging into this general service. An
excellent quality of service is given in all types of disease. Prenatal numng
is more vigorously developed than in any other district. Care of tuberculous
patients and sick babies is as thorough and constant as for other patients.
It should, however, be said that \nsits for instruction and prevention should
be more frequent. ^ larger number of students would make this possible.,
All communicable diseases, except smallpox, are attended and preventiw
measures are emphasized. In fact, the work throughout is painstaking,
conscientious, intelligent and of high quality.
The University District has proved also that it is possible to care for a
district satisfactorily without a permanent staff other than the instructon.
It has been shown that continuity of service can be maintained through the
instructors and that the students are capable of carrying responsibiUty for a
part of a district and receiving the best training and development by so doing.
The supervision, training and leadership given by the director and instructors
is of the highest quality.
It is evident, however, that the direi*tor and instructors in their efforts
to be fair to patients and nurses alike are carrying very heavy responsi-
bility. The method of remedying this has not revealed itself in so short a
study, but requires careful consideration. In spite of the constant burden
of work there is a cheerful devotion to duty that reflects itself in the work of
the nurses in the field. An a^istant director and instructor in charge of the
clinics would relieve the tension appreciably.
The University District has })een looked upon as an independent labora-
tory for exi>erinientation in policies and methods. In so far as this adds to
the teaching advantages, it is sound and advisable. Experiments which
might jeopardize or injure the success of the students' exi)erience and educa-
tion should }>c tried elsewhere.
The fact that the district is a teaching district and that the work must
have educational value has always l^ecn recognized and kept clearly in
mind. For this reavson the responsibility for the field work has, with Success,
been placed directly upon the students. On the other hand, the needs and
prerogatives of the patients have never been minimized or lost sight of. The
educational cliaracter of the work has proved to be to tlie patient's benefit
rather than detriment, just as it is true that medical attention in hospitak
attached to medical schools is usually l>etter than in other hospitals. The
students are, in fact, receiving thorough practice in public health nursing;
the patients are receiving a very excellent quality of nursing servit*e. Close
study faile<l to disclose any indication of the ex]>loitation of either group.
RECOMMENDA TIONS
1 . That the director be provided with an assistant on full time.
2. That an additional instructor be secured to take charge of the clinics.
3. That the number of students who can be accepted be increased. . t..;: .
u R s I N o 799
The municipal nursing sta£F, is, as we have seen, greatly overburdened,
1 in need of reorganization in the assignment of work and supervision,
e Division of Nursing is at present grappling with the problem of absorb-
; the duties with which it has been newly charged each year. It would,
^refore, be inadvisable at this time to propose to add to it another and still
ger undertaking. The city has neither funds nor facilities at this time to
dertake responsibility for obstetrical and postpartum nursing care. M ore-
ST, the city might not succeed in reaching patients under the care of pri-
te doctors, large numbers of whom have only moderate incomes, so that
!y cannot afford private nurses and must depend upon visiting nursing
«. In 1919, as we have seen, the total number of births delivered by
vate doctors numbered 69 per cent of all births registered.
Only two other agencies have been seriously considered for city-wide
itemity nursing service. These two are the Maternity Hospital and the
riling Nurse Association.
Maternity Hospital
The proposal to extend the nursing service of Maternity Hospital so as to
er a general prenatal and maternity service, does not commend itself for
rious strong reasons. It would indeed appear to be a fundamental mis-
ce. The Maternity Hospital has in the past performed a valuable service,
i as is the function of a University hospital, in teaching the possibilities
this field and demonstrating the actual saving of life which goes with a
matal, partum and post-partum service.
This hospital should continue to be, fundamentally and increasingly, a
ining field for nurses as well as for medical students, in the obstetrical
d. To attempt to extend its community work and to establish a city
vice, instead of developing and extending its valuable function of train-
[, would be to miss its proper office.
Moreover, the nursing service of a hospital by its nature does not cover
J great majority of registered births, that is, those occurring neither in the
rds nor under the out-patient department, but attended in their homes
private physicians or midwives. In 1919, of the total confinement cases
K)rted in Cleveland, 37.2 per cent were delivered by physicians in the
lies of private patients, and 30.8 per cent by midwives in the patients'
aes, or an estimated total of babies delivered by these two groups, of
000 or 68 per cent.
But even if these points were not conclusive, certain weaknesses in the
thods of work as at present carried on, would in a larger area be a serious
•wback to good service. The nursing care of this hospital is character-
1 by a lack of continuity in the nursing personnel and by a lack of the best
ceived type of supervision as described in other sections of this report.
Lack of Continuity
The lack of continuity is shown by the division of the work. Details
he organization of the Maternity Hospital clinics are v^wew \w VW X^W
800 Hospital and Health Survey
pensary Report, Part X. Here the chief points of the nursing service are
described.
The prenatal nurse, with iieadquarters in her prenatal station calls on
the patient and makes observations until the time of delivery. The patient
is then turned over to the delivery nurse of the hospital, who is taking i
special course in obstetrics. She may be a pupil nurse, or she may be i
graduate. She accompanies the medical student for delivery in the case
of each primipara, in all other cases the delivery nurse goes, if any one ol
them is available. Thus all the advantages gained by the prenatal nune
from knowing the patient and having won her confidence are lost. Tbe
post-partum nurse must begin the acquaintance over again. The recmtl
system is not such as to give the help which might be given in keeping up the
connection. The prenatal records appear to be inadequate in scope and
poorly kept.
Lack of Supervision
Prenatal Care:
For prenatal care, four full-time graduate nurses are employed. They
give service at the six prenatal clinics now operated, and spend the rest A
the time on home visits. They average about ten calls daily, rising in some
cases to fifteen calls. Where districts are densely settled and the cases
happen to be so grouped that transportation does not require much waste
of time, fifteen instructive visits may not prove to be impracticable, but m
general more than ten prenatal visits a day will be found to result in sacri-
fice of thoroughness.
Moreover, though all patients are supposed to be visited every two
weeks, and acute cases daily, it was stated in the course of the investigation
that these visits are not regular. A normal case, attending the clinic regu-
larly, may be seen at home only two or three times during pregnancy. Tk
nurses carry in tlieir bags blood pressure apparatus and equipment to make
urinalysis. But these are not used for every patient visited, as the best
practice requires. Abnormal cases are seen daily or every other day as iwfr
cated.
Th^ Director of Nurses makes an effort to see every case which is re*
ported to the clinic, but not necessarily with the nurses. Of sup)ervision i»
the field, as developed for graduate nurse staffs in tlie best public heall»
work, and essential as a stimulus as well as a guide, there is here none. Any
abnormal cases are discussed with the Director of Nurses. Abnormalities
found in home visits are reported verbally to the Director, who enters tli
information on the prenatal index card, made out when each net
case is admitted; but there is no detailed weekly or monthly report kept
by the. nurse as a record of her own performance. There is no system by
by wliich the frequency of the patient's visit to the dispensary or the nurse*
visit to the home is automatically checked up.
Delivery atid Po.st-Partum Care:
This care is given by tlie student nurses under supervision of the assist-
ant director. Each new nurse is taken into her district by the assistiot
IG 801
ut for only half a day. Thereafter, the assistant director drops in
y during a period of about a week.
are four nurses doing post-partum work, each averaging about
s daily. This number is, again, too large for adequate care and
in the home. If labor occurs during the day, either the director
istant director makes an effort to get into the home before the
jlivered. Each newly delivered case is seen by the assistant di-
day after the confinement. Oversight of the patient's condition
ired; but regular supervision of the nurses who, it must be remem-
here students-in-training, is not accomplished.
observation of five post-partum cases, it was evident that while
als, such as care of the breasts, external irrigation, care of the
received careful attention, the work was not up to the nursing
observed by the Visiting Nurse Association or in the University
)oubtless the unusually large number of cases carried by the Western
iidents accounted for this fact. The rooms were not left in as good
isirable, no uniform is required, one nurse being observed at work
i waist.
TATAL AND PoSTNATAL WoRK IN A GENERALIZED SeBVICE
rast to the specialized work of the Maternity Hospital, there is
n Cleveland the example of an agency which includes prenatal
generalized nursing service. This is the University District,
919 had 442 dispensary cases, which may be compared with 485
records studied at the Maternity out-patient department. The
s of the University District nurses upon 442 dispensary cases
1 391 or 3.1 per cent per patient as against 271 visits upon 483
cases or .6 per cent per patient by the Maternity nurses. In the
service, therefore, the home visits recorded were 5 times greater
than in the specialized service. The average number of dispen-
per patient recorded in the generalized service were much more
han in the specialized (2.4 in the University District as against
ernity).
paring the percentage of cases reached early in pregnancy, the
District is again far in advance according to the records studied,
ught almost half (46%) of its total cases under care by the sixth
ile Maternity had only 19.2 per cent under care at Uiat period
s apparent that the Maternity hospital records studied do not
sent the quality of the service rendered by this institution, but as
ent records of any service should be available as a basis for evalu-
it service, the results of this study of records are given.
800
Hospital and Health Survit
pensary Report, Part X.
described.
Here the chief points of the nursing service are
The prenatal nurse, with iieadquarters in her prenatal station calls on
the patient and makes observations until the time of delivery. The patient
is then turned over to the delivery nurse of the hospital, who is taking i
special course in obstetrics. She may be a pupil nurse, or she may be i
graduate. She accompanies the medical student for delivery in the cm
of each primipara, in all other cases the delivery nurse goes, if any one of
them is available. Thus all the advantages gained by the prenatal none
from knowing the patient and having won her confidence are lost. Hie
post-partum nurse must begin the acquaintance over again. The record
system is not such as to give the help which might be given in keeping up tbe
connection. The prenatal records appear to be inadequate in scope and
poorly kept.
Lack of Supervision
Prenatal Care:
For prenatal care, four full-time graduate nurses are employed. Tbtef
give service at the six prenatal clinics now operated, and spend the rest a
the time on home visits. They average about ten calls daily, rising in some
cases to fifteen calls. Where districts are densely settled and the caso
happen to be so grouped that transportation does not require much waste
of time, fifteen instructive visits may not prove to be impracticable, but m
general more than ten prenatal visits a day will be found to result in sacri-
fice of thoroughness.
Moreover, though all patients are supposed to be visited every two
weeks, and acute cases daily, it was stated in the course of the investigatioB
that these visits are not regular. A normal case, attending the clinic nfgor
larly, may be seen at home only two or three times during pregnancy. Tk
nurses carry in their bags blood pressure apparatus and equipment to make
urinalysis. But these are not used for every patient visited, as the best
practice requires. Abnormal cases are seen daily or every other day as indi-
cated.
Th^ Director of Nurses makes an effort to see every case which is re-
ported to the clinic, but not necessarily with the nurses. Of supjervisioB B
the field, as developed for graduate nurse staffs in the best public heatt
work, and essential as a stimulus as well as a guide, there is here none. Any
abnormal cases are discussed with the Director of Nurses. Abnormalities
found in home visits are reported verbally to the Director, who enters tte
information on tlie prenatal index card, made out when each ne*
case is admitted; but there is no detailed weekly or monthly report bp'
by the. nurse as a record of her own performance. There is no system \fl
by which the frequency of the patient's visit to the dispensary or the nurses
visit to the home is automatically chec^ked up.
Deliver}/ and Post- Pari um Care:
This care is given by the student nurses under supervision of the assist-
ant director. Eacli new nurse is taken into her district by the assistas*
I
S U R 8 I N G 803
tiunicipal staff. If the proposed Extension District of the Division of Health
s established as is suggested elsewhere (page 769) for the extension of the
tiunicipal nursing work, it would be desirable to substitute for the Visiting
^^urse Association the municipal nurses in that district, except for attend-
lice at delivery.
As the assumption of this service in the Extension District of the Di-
ision of Health proves practical and successful, and as the whole nursing
*rvice of the Division of Health is built up to meet its present activities,
sd becomes able to assume new functions, the ser\4ce might be turned
irer district by district to the Division of Health, or the prenatal service
ight first be turned over, the transfer of care during confinement and post-
irtum care being postponed.
RECOMMENDATIONS
It is therefore recommended:
1. That the Visiting Nurse Association give prenatal instruction and nursing care
the homes, reporting findings to and receiving instruction from the clinics daily. This
vice could be provided by the Visiting Nurse Association as a uniform service to all
lies.
2. That clinics be maintained under the proposed Obstetrical Council to serve the
fcire city by zones or districts according to agreement among the various hospitals,
raes for service within the clinics to be provided by the hospital wherever possible, by
s Visiting Nurse Association where impossible.
3. That nursing care during confinement be provided by the Visiting Nurse Associa-
o (a continuous graduate staff for deliveries to be provided by the Visiting Nurse Asso-
ftion for this purpose), or by students of the hospitals under the supervision of the
nting Nurse Association.
4. That post-partum nursing be provided by the Visiting Nurse Association for all
nics, or by student nurses imder the Visiting Nurse Association.
5. That in the University District, for the Visiting Nurse Association, the imiversity
df be substituted, except for attendance at delivery. That in the proposed Exten-
lo District of the Division of Health the Visiting Nurse Association be replaced by the
imicipal nurses, except for attendance at delivery.
6. That a uniform procedure be established for all districts and observed by all staffs.
7. That if the proposed Obstetrical Coimcil is formed, a sub-committee on prenatal
d maternity nursing from the Central Committee act as the sub-committee on nursing
the Obstetrical Council, and that the Central Committee be represented on the Ob-
etrical Council and vice versa.
Industrial Nursing
rHE Survey of Industrial Hygiene in Cleveland has shown that there
were, at the time of the investigation, seven full-time industrial phy-
sicians and 104 industrial and mercantile nurses. In 36 plants, 66
urses were working with part-time physicians.
These figures indicate clearly enough the responsibilities of the nurse ia
dustry, and the possibihties which lie before her in her contact with the
802 Hospital and Health Survet
Records of No. Dis- '
Dispensary pensary Aver- No. Home Aver-
Cases Studied Visits age Visits age
Maternity _ 483 708 1.5 271 .6
University District 442 1084 2.4 1391 3.1
St. Luke's... 141 No record of home or dispensary visits.
Mt. Sinai No record of home or dispensary visits.
The University District thus in a small district ^nd with a high ratio d
nurses to population illustrates the possibility of including prenatal and
postnatal care in a general nursing service for the sick which gives family
care and instruction.
While it is true that fruitful demonstrations of special maternity services
have been made in other cities, nevertheless an extension of the generalized
nursing service for the sick is especially appropriate, since Cleveland has
proved its ability to conduct generalized public health nursing with a cod-
siderable measure of success, as well as a true generalized nursing service is
the fields of sick nursing and public health nursing in the University Dis-
trict.
The Visiting Nubse Association
In the Visiting Nurse Association there is available an agency, doinf
generalized sick nursing in homes on a city-wide plan, with adequate and
skilled supervision; which already makes a specialty of medical, surgical
and maternity nursing, — excellently done and capable of further expansion.
This Association now serves all groups of patients, the poor and thoflc
of moderate income, midwife and private doctor's patients, as well as those
intending to have hospital care.
For an extended program to provide general maternity care, this Asso-
ciation could provide service by a graduate nurse trained in visiting nursing,
and could also provide supervision for student nurses if necessary. It would
aflFord uniformity and continuity of service, the same nurses being available
for all three types of care. Because of its large staff, small districts, and
other nursing contacts, it could greatly increase the usefulness and adequacy
of the clinics through the early discovery of pregnant patients, who would
be urged to seek medical oversight at once, at the clinics. Such patients
would also receive careful prenatal nursing at home if they could not be
persuaded at once to attend a clinic.
For these reasons, the Visiting Nurse Association appears to be the logical
agency in (^Icveland to which the extended prenatal and maternity services
for the city should he entrusted. It would mean a large expansion for this
Association entailing large expenditures, and responsibilities with which
the Association is well fitted to cope. No greater opportunity to serve the
community, and indeed to demonstrate such a service to the whole country,
could be offered.
After the demonstration had been made, it would be desirable and in
line witli i)ast policy in Cleveland gradually to turn over this service to the
Nursing 805
the nurse was not allowed to leave the dispensary. She was regarded by
the management, and had learned to regard herself, as a permanent
fixture of the first aid room, a mere mechanical agent for binding up cuts or
wounds.
Work Outside the Dispensary
Ranging upward from this most limited performance, there were ob-
served in Ceveland many varieties of work and of responsibility carried by
the industrial nurse. In some plants the nurse had in charge, under the
standing orders of the attending doctor, the entire first aid and emergency
treatment, and was responsible for all records, follow-up, re-dressings, etc.
In one such establishment the nurse made a rule of having the doctor, in
his daily visit, see all new cases and all infections.
Procedures naturally differ as to the nurse's responsibility for such mat-
ters as plant sanitation and the safety of employes. While supervision of
these matters is, in large plants, in the hands of specialists, in smaller fac-
tories such supervision was found to be a valuable part of the nurse's work,
especially when combined with instruction of the employes in matters of
sanitary equipment and safety.
Sharing in Prevention of Accidents
In contrast to the dispensary nurse and the repetition of cuts cited above,
other nurses in Cleveland were taking part in the prevention as well as cure
of accidents. One nurse regularly inspected the scene of accidents. While
this might lead her beyond her field, when technical knowledge of machinery
was needed, yet she had been able to point out obvious, overlooked causes
of accidents such as bad lighting or the presence of an obstruction in the
way of the employes.
The industrial nurse should have sufficient knowledge of the technical
proces^s used in her plant to know and advise on the safeguards provided.
Yet she is often totally uninstructed in such matters. On one occasion in
Cleveland the nurse was found wholly ignorant of certain types of respirators
provided for a certain process and hence incapable of advising the workers
with regard to using them.
Sharing in Prevention of Disease
Constructive health work and ability to gain the workers' confidence so
that they will consult her in matters of ill-health, incipient as well as acute,
should clearly be the center of the industrial nurse's business. The other
aspects of her work-first aid, safety, sanitation and welfare work — should
all be directed to this general end. The aim of maintaining health and
educating the workers — men and women alike — in matters of health should,
indeed, <Bstinguish the industrial nurse from other types of welfare workers.
Individual instances of good work along these lines were observed in Cleve-
land, but as elsewhere, it was on the whole slighted and too often ignored in
the multiplicity of other duties.
In many plants the nurse spends far too much time on recreational and
wdfare activities. Absorption in these is as alien to constructive health
804
Hospital and Heialth Subvk
large bodies of men and women who are congregated in industrial establish-
ments.
Obviously, no hard and fast rules can apply to all types of industrial
nursing; it must vary with conditions, with the size of plants, the type of
management and of employe, etc. But under all these diflFerences and with
all the varied duties which the industrial nurse may legitimately perform,
there should be one essential aim, common to all good public health nursing,
that is, the maintenance of health and the teaching of hygienic habits.
With so wide a field before her and in a branch of public health work so
new and unstandardized, it is not surprising that the industrial nurse has as
yet, broadly speaking, scarcely found herself. She stands too often between
the industrial physician, who for the most part regards her as a mere adjunct
to the surgical dispensary, and the employer or his representative, in whose
mind she is vaguely to function in creating better industrial relations in his
plant.
The danger, therefore, is that industrial nursing will be diverted on the
one hand into pure dispensary assistance, or on the other, into pure welfare
work. In neither of these, though both may be part of her iduties, lies the
sole function of the industrial nurse. On her training and f>ersonality it
will in many instances depend whether she develops a constructive type of
work, enlisting the management's and workers' cooperation, or is submerged
in the routine of first aid or of factory housekeeping or recreational activities.
The Nursing Survey made a detailed study of twelve representative ifl-
dustrial nurses in Cleveland to observe their work, the types of duties per
formed by them and the emphasis on prevention of illness and of accidents
as well as on treatment. The esUiblishments visited included metal working
plants, food and clothing factories, public utilities, and department stores.
Three of these plants had full-time physicians, the others had either a part-
time or no physician.
Work Confined to First Aid
Several of the nurses observed were confined in their activities wholly to
the first aid room; they were strictly dispensarj' nurses with no thought rf
resjwnsibility beyond dressing injuries and no encouragement on the part
of the management to expand their interests. The limitations of this type
of work were well illustrated bv one of these nurses whose business-like dis-
patch enabled her to handle quickly and eflSciently the large number of cases
passing through the dispensary, but whose lack of interest and coldness i*-
|x*lle(l any further advances on the part of the girl employes in iUnessor
trouble.
In contrast to this nurse was an older woman, also of the dispensary
type and less well equipped technically, but of warm human sympathies ww>
had gained the confidence of a large body of workmen in another pl*^^
through the contacts made in the first aid room.
An extreme instance of failure to connect first aid work with preventiofl
of injuries was observed in another plant where a man was treated three
times in one day by a nurse for cutting his hand at the same machine. Hei*
T R S I N G 805
<
nurse was not allowed to leave the dispensary. She was regarded by
management, and had learned to regard herself, as a permanent
lire of the first aid room, a mere mechanical agent for binding up cuts or
mds.
Work Outside the DisPENaAJiY
Ranging upward from this most limited performance, there were ob-
ved in Ceveland many varieties of work and of responsibility carried by
industrial nurse. In some plants the nurse had in charge, under the
Elding orders of the attending doctor, the entire first aid and emergency
itment, and was responsible for all records, follow-up, re-dressings, etc.
one such establishment the nurse made a rule of having the doctor, in
daily visit, see all new cases and all infections.
Procedures naturally diflFer as to the nurse's responsibility for such mat-
) as plant sanitation and the safety of employes, ^yhile supervision of
se matters is, in large plants, in the hands of specialists, in smaller fac-
ies such supervision was found to be a valuable part of the nurse's work,
ecially when combined with instruction of the employes in matters of
itary equipment and safety.
Sharing in Prevention of Accidents
In contrast to the dispensary nurse and the repetition of cuts cited above,
er nurses in Cleveland were taking part in the prevention as well as cure
siccidents. One nurse regularly inspected the scene of accidents. While
i might lead her beyond her field, when technical knowledge of machinery
3 needed, yet she had been able to point out obvious, overlooked causes
accidents such as bad lighting or the presence of an obstruction in the
y of the employes.
The industrial nurse should have suflicient knowledge of the technical
x^s^s used in her plant to know and advise on the safeguards provided,
yt she is often totally uninstructed in such matters. On one occasion in
eveland the nurse was found wholly ignorant of certain types of respirators
ovided for a certain process and hence incapable of advising the workers
ith regard to using them.
Sharing in Prevention of Disease
Constructive health work and ability to gain the workers' confidence so
uit they will consult her in matters of ill-health, incipient as well as acute,
»ould clearly be the center of the industrial nurse's business. The other
fpects of her work-first aid, safety, sanitation and welfare work — should
1 be directed to this general end. The aim of maintaining health and
beating the workers — men and women alike — in matters of health should,
deed, distinguish the industrial nurse from other types of welfare workers,
(dividual instances of good work along these lines were observed in Cleve-
nd, but as elsewhere, it was on the whole slighted and too often ignored in
e multiplicity of other duties.
In many plants the nurse spends far too much time on recreational and
Ifare activities. Absorption in these is as alien to constructive health
S06 Hospital and Health Survey
work as absorption in surgical routine. In one establishment the nurse
devoted two evenings a week to social meetings, while failmg to note obvious
health hazards in certain rooms and making no e£Fort to educate the giris by
talks on health either individually or in groups.
The transfer of woricers from jobs for which they are physically unfit to
other positions better suited to their physiques is a genuine health measure
which nurses may well recommend to the management. Such transfers had
been successfully recommended by nurses in Cleveland for various cases of
flat-foot and varicose veins. Some girls affected by a necessarily cold work-
room and others who were suffering from dermatitis had been benefited by
a change. These isolated examples show how great an influence the nurse
may have in prevention of the illness before it becomes acute, if she is per-
sonally familiar with the workers and on terms of confidence with them.
Education in hygienic habits is also clearly one of the nurse's first duties,
as yet little developed. One nurse had recently regained a valuable girl
worker and had lessened her susceptibility to constant colds, by persuading
her to give up chiffon waists in winter-time and to dress more warmly.
Another nurse encouraged hygienic habits in a good factory by makiiig
daily inspections, providing clean caps and aprons and urging persons
cleanliness. In one room unaffected by the artificial ventilation, she had
arranged to have the windows opened ten minutes, morning and afternoon.
Another example of good preventive work, along a somewhat different
line, was the nurse's successful insistence upon installation of a sterilizer in
the lunch-room of a plant in which employes known to be suffering from
tuberculosis and venereal disease were in contact with the other workers.
Some Causes of Failure
Too often, however, instead of tr^'ing to teach hygienic habits the nurse
relies merely upon giving drugs. Contrary to all good medical and nursing
practice, nurses were found habitually giving sedatives and medication for
many minor ailments. This widespread practice should be abandoned at
once.
Another serious fault in industrial nursing in Cleveland, which it shares
with industrial medical practice, is the lack of records and statistics. In
many cases neither the management nor the industrial physician encourages
or indeed takes any interest in the nurse's reports. Yet witliout re])orts and
records, the nurse cannot gauge her own progress or be in a position to prove
her points to her superiors. A simple and effective system of records, adapted
as necessary to the conditions of individual plants, and showing so far as
possible the relation of nursing care to such matters as compensation claims,
statistics of accidents, illness and absence of employes, is one of the most
urgent needs of industrial nursing in Cleveland. Provision of lay assistants
in record keeping as well as in the dispensary is greatly needed and would
release the luirse for her more important duties.
Lay assistants are desirable also for all routine following up of absentees.
In all cases of illness, too little emphasis on home visiting was found in Cleve-
land. This lack is unfortunate since a knowledge of home conditions and
3f U B 8 I N G 807
good contacts in the home are of first importance in obtaining the genuine
confidence of the workers. The services of the Visiting Nurse Association
of Cleveland should be called on for bedside care if necessary, after perhaps
one or two visits by the industrial nurse.
The isolation of the industrial nurse keeps her from contact with the
rapid developments of public health nursing and of industrial hygiene, with
which she should be acquainted and in which she should share. Few indus-
trial nurses have had adequate training for their special field, most have at
best learned through their own experiences and their native abilities. In
cities in which industrial nurses are a part of some agency, such as the
Visiting Nurse Association, they, like the rest of the staff, benefit from
belonging to such an organization and sharing its general standards and
practices.
The Nursing Survey has reconmiended the inclusion on the Central
Nursing Conmiittee of a representative of industrial nursing. The Industrial
Nurses* Club might be of much more technical professional value to nurses
than it has been in the past, and either it, or some similar organization,
should be actively organized. It should be a real center for developing this
most recent, and one of the most important, branches of public health nurs-
ing as it is capable of being developed in industry.
A discussion of Industrial Nursing also appears in the chapter on Indus-
trial Medical Service, Part VII.
808 Hospital and Health Subvet
Some Notes on Private Duty Nursing
Unnecessary Employment of Full-Time Graduate Nursis
IT is often asserted both by physicians and by trained nurses that in
many cases of minor illness or of convalescence, the services of a graduate
nurse are unnecessary and that such cases can be adequately cared fw
by less highly trained persons, or indeed by members of the family.
With the object of obtaining some more concrete information as to such
possible substitution, a brief inquiry was addressed to a small group of
private duty nurses in Cleveland. The number of cases reported on is too
small to be at all conclusive, but the replies received are suggestive and in-
dicate that a wider investigation might yield valuable conclusions.
Inquiries were addressed to 25 nurses. They were asked whether, du^
ing the past year, any of their patients could have dispensed with the care of
a full-time graduate nurse, either altogether or for part of the time. Replies
were received from 15 nurses. They were also asked which if any of the fol-
lowing substitutes could have replaced the graduate nurses, viz: a so-calW
** practical" nurse, members of the patient's family or an ** hourly" nunc,
that is, a graduate nurse engaged for an hour or two per day.
Use of Hourly Nurse Recommended
Of 275 cases nursed during the period reported on, 68 or a quarter (24.7%)
might, in the opinion of the nurses, have done without their services for aD
or part of the illness.
The outstanding fact which emerges from this brief inquiry is the ag^e^
ment among the nurses that of the 46 patients who could have dispensed
with their services for part of the time, 34 or almost three-quarters (73.9%)
could have been cared for by hourly nurses. This estimate is no doubt
in part due to the large number of acute surgical cases represented in tie
total group. For in such cases expert continuous nursing may obviously be
needed for only a short time, after which an hour or two per day might readily
suffice for the necessary daily nursing care.
Nature of Cases
Of the total number of cases reported, about three out of five were hos-
pital cases, and of these almost all were surgical. The remaining two-
fifths, mainly medical cases, were nursed at their homes. Only about one
in nine of the home patients was surgical.
Acute caseis reported upon far outnumbered chronic cases, both at home
and at the hospitals. The proportion of acute to chronic cases at home was
95 to 9, and in hospitals it was 159 to 12.
Two of the nurses stated that they did not take any except acute cases.
The inclusion of the reports of these nurses makes the proportion of cases
which could have been cared for without graduate nursing care less than it
would ordinarily be.
Number of Nurses Reporting Unnecessary Employment
Thirteen out of the fifteen nurses reported that they had been unneces-
sarily employed at some time during the period reported on. (For various
Nursing 809
r.
personal reasons the period reported on varied from four to seventeen months,
the average being somewhat over ten). The two nurses not having had such
cases were among the four reporting on a very short period, viz: from four to
m months only.
Amount of Unnecessary Employment
As has been stated, in 68 of the 275 cases reported on, the graduate full-
time nurse might have been otherwise replaced. Omitting one nurse whose
service consisted of an exceptionally rapid succession of acute cases, the
total number of cases of unnecessary employment amounted to 67 out of 226,
a 29.6%, which is more nearly representative of the group. In individual
^ reports the percentage of cases of unnecessary employment varies greatly,
nnging from 72.7% of all cases cared for by a nurse in the period in ques-
tion, down to 2% of all cases, the median being 44.4%. In other words, one
■j nurse had 11 such cases out of 20 cases in all; another had 8 out of 11; the
lowest proportion being 1 out of 49.
Similarly, the length of time spent in unnecessary employment by the
15 nurses varied greatly. No definite statement can be made on this point,
M information was sometimes lacking and sometimes uncertain. One
Durse reported as much as three months' unnecessary nursing in a year's
experience, or 25% of her total time; another 4 months out of 113^2 months
or S4.8%. The average length of time so spent for 10 nurses who were
able to give an estimate, amounted to something over l}^ months per nurse
per annum.
Possible Substitutes for Full-Time Graduate Nurse
Of the sixty-eight cases on which these graduate nurses reported un-
J^ecessary employment, about one-third could have been cared for by some
^ other arrangement during their entire illness. In fourteen of these cases a
pactical nurse, in seven cases a member of the family, and in one case an
"-' hourly nurse, would have sufficed.
The remaining two-thirds (46) could have dispensed with the full-time
p graduate nurse's services during a part of their illness only. As has already
keen stated, in thirty-four cases, she could have been replaced by hourly
nursing. In seven, it is believed that a practical nurse would have sufficed,
•nd a member of the family in the remaining five cases.
Thus, in the opinion of the 15 nurses consulted, the cases cared for dur-
ing the given period were divided as follows :
(a) A large proportion of cases in which hourly nurses could have relieved the fuU-
^noe nuraes after the most serious stage was passed, and one case which could have been
^otirdy cared for in this way.
(b) A considerable proportion of cases which could have used a practical nurse dur-
Qg the entire sickness, and a few in which such nursing could have been utilized for part
of the duration of the case only.
(c) A few patients who could have been nursed during their entire illness and a few
domg part of their illness by members of their own families.
EMPLOYMENT OF TRAINED AITENDANTS
In Cleveland as elsewhere the employment of trained attendants has
been a subject of controversy. On the one hand there is undoubted need
■>
f
810 Hospital and Health Survey
of persons capable of rendering personal service and some small degree of
nursing care to those who are ill but who do not need the services of a grad-
uate nurse. The present shortage of nurses for bedside care emphasizes the
desirability of making available the services of such a class of workers, in
order to release the graduate nurses for duties which they alone can compass.
Our brief inquiry into possible substitutes for the full-time graduate
nurse shows that in the opinion of these private duty nurses themselves, a
part of their cases might have been carried by attendants or "practical"
nurses as well as by ** hourly" nurses.
The Nursing Survey recognizes the value and need of the trained at-
tendant. It has been urged to formulate an educational plan and short
courses for the training of such workers. But to this plan there appear to
be at present several valid objections. For it must be recognized that the
employment of the trained attendant brings with it unmistakable dangers,
especially when, unequipped, she assumes the part of the fully trained
nurse. Against this danger the patient must in some way be protected.
The experience of the Visiting Nurse Association of Cleveland, in dis-
continuing its attendant service after almost three years' trial, appears so
far as it went, to have been conclusive. The failure was due to causes oper-
ative elsewhere as well as in Cleveland, that is to the difficulties of retaining
control of the work and the charges of the attendants, while responsible for
their employment.
That the pay of trained attendants can be very much lower than that of
the graduate nurses, it is probably unreasonable to expect, since their cost
of living is not materially less than that of the graduate nurses. That there
is a genuine demand for the trained attendant in her own sphere, the experi-
ence of the Visiting Nurse Association has amply demonstrated anew.
The question at once arises whether safeguards cannot be devised to re-
tain the benefits and minimize tlie dangers of such a service. From experi-
ence in other lines of work it would appear that no better safeguard has
been devised than through legislation defining the status of, and licensing,
both graduate nurses and those trained to give services of a different but
no less necessary order.
A precedent for such legislation already exists in many states but not
yet in Ohio, in the laws licensing the practice of dental hygienists (Connecti-
cut, New York, Massa<'husetts) that is, of persons authorized to practise
dental cleansing without use of instnmients and only under the super\nsion
of a licensed dentist. Here tliere has been established successfully the
licensing of two different grades of workers, for different grades of ser\'ice
in the same ])rofession. Penalties for fraud, or for practising under any but
the appro])riate name, should obviously be provided for in such legislation.
At the present time, and until the necessary regulation by city or state
ordinance, has been enacted, it does not ai)pear desirable to recommend the
establishment of courses for further training of attendants in Cleveland.
The framing and enactment of suitable legislation should take first place,
in plans for action in this matter.
THE CLEVELAND HOSPITAL AND HEALTHpURVEY
REPORT
List of Parts and Titles
•
I. Introduction.
General Environment.
Sanitation.
II. Public Health Services.
Private Health Agencies.
III. A Program for Child Health.
IV. Tuberculosis.
V. Venereal Disease.
VI. Mental Diseases and Mental Deficiency.
VII. Industrial Medical Service.
Women and Industry.
Children and Industry.
VIII. Education and Practice in Medicine, Dentistry, Pharmacy.
IX. Nursing
X. Hospitals and Dispensaries.
XI. Method of Survey.
Bibliography of Surveys.
Index.
The complete set may be obtained at a cost of $5.50 plus the
postage and single parts at 50 cents each plus the post£^e,from
THE CLEVELAND HOSPITAL COUNCIL.
808 Anisfield Building,
Cleveland, Ohio
PriBtMilfty
Tbk PmBoaB Pbi
Hospitals and
Disp
Part Ten
Cleveland Hospital and
Health Survey
Hospitals and
Di
ispensaries
Part Ten
Cleveland Hospital and
Healtli Survey
\
Copyright. 1920
by
The Cleveland Hospital Council
Cleveland, Ohio
Fubliibed by
The Cleveland Hospital Council
308 AnisHeld Bldg.
Cleveland • Ohio
Pref
The Hospital and Health Survey of Cleveland was made at the request
16 Cleveland Hospital Council.
Tie Survey Committee appointed to be directly responsible for the
: and through whose hands this report has been received for publica-
consisted of the following:
Malcolm L. McBride. Chairman;
Mrs. Alfred A. Brewster,
Thomas Coughlin,
Richard F, Grant,
Samuel H. Halle,
Otto Miller, *
Dr. H. L. Rockwood,
Howell Wright, Secretary
The staflF responsible for the work were:
Haven Emerson, M. D., Director,
and the following collaborators:
Gertrude E« Sturges, M. D., Assistant Director;
Michael M. Davis, Jr., Ph. D., Director of the Hospital and
Dispensary Survey;
Josephine Goldbcark, B. A., Director of the Nursing Survey;
Wade Wright, M. D., Director of the Industrial Hygiene Survey;
Donald B. Armstrong, M. D., Director of Tuberculosis Survey;
S. Josephine Baker, M. D., D. P. H., Director of the Infant
and Maternity Survey;
T. W. Salmon, M. D., Director of the Menial Hygiene Survey;
W. F. Snow, M. D., Director of the Venereal Disease Survey;
Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey.
The expenses of the Survey and of the publication of the report have
I met by appropriations received from the Community Chest, through
Welfare Federation, of which the Hospital Council is a member.
rhe report as a whole, or by sections, can be obtained from the Cleveland
pital Council. A list of the parts will be found in the back of this volume,
ther with prices.
TABLE OF CONTENTS
HE Care of the Sick — Page
Resources for Care 819
Some Definitions 822
08PITALS —
Hospital Provisions and Community Needs 828
Organization for Service 838
The Human Problem of the Hospital Patient 849
The Medical Profession and the Hospitals 858
Finances and Administration 868
Some Practical Matters of Administration 877
ispensaries —
Dispensaries in Cleveland 890
The Public Health Dispensaries 901
Policies and Needs ^ 912
The Down-town Dispensary 922
'EciAL Problems —
The Convalescent and the Hospital 926
Community Program for Convalescent Care 938
Chronic Illness and Its Care 944
Social Service in Hospitals and Dispensaries 952
The Ambulance Service of Cleveland 961
08PITAL AND DiSPENSARY PLANNING
Community Planning 966
Individual Hospital Planning 973
Organization to Carry Out Plans: 979
PPENDDC —
1 aDies .a.......... •••..... cio4
piTALS AND Dispensaries 821
ly physician, because she is "afraid of hospitals." A member of a
5 utilizes the services of the official doctor of the organization during a
►r illness, but when he thinks something serious is the matter with him,
alls a **real doctor," meaning one whom he pays. Quacks' offices are
iged with thousands of credulous victims, and the mails are filled with
3y directed toward the coffers of patent medicine vendors. Choices
ag the resources available for the care of sickness are as varied as the
imstances surrounding each case, and as manifold as human nature
. •
L health survey of Cleveland might theoretically arrange the ten resources
he care of illness in the order of their relative efficiency, and then study,
different sections of the population, their usual order of utilization
iifferent kinds of sickness or accident. Such a study cannot practically
lade, but suppK)sing for the sake of argument that it could be made, let
sk this question: would the order of utilization by the people of the ten
urces for the care of illness correspond to their order of relative efficiency?
0 far as it does not, the well-being of the community suffers. Reputable
sicians and the hospitals and dispensaries in which these physicians ren-
service, obviously constitute the primary and fundamental medical re-
ces for the care of illness and the promotion of health. Are they used
1 the degree of fullness and of discrimination with which they should be?
ot, why not? The answer would not be the same for all groups of the
ulation.
\ study of the hos]>itals and dispensaries of Cleveland cannot rightly be
ted to the amoimt and the nature of the work done, the internal adminis-
ion, and other technical problems, important as these are. It needs also
Delude a study of the attitude of different sections of the people — the
lical profession, the well-to-do, the poor, the foreign-born, etc. toward
je institutions. It is on the basis of these attitudes, understandings or
understandings, that the choice among medical resources is made in time
ickness or accident, and upon which the utilization of hospital and dis-
sary for the benefit of tlie public ultimately rests. Financial support of
pitals and dispensaries by the community depends precisely on the same
siderations. In this section of the report of the Cleveland Hospital and
Jth Survey, therefore, an endeavor will be made to review the details
he work of the hospitals and dispensaries of the city, in their medical,
linistrative and financial aspects, and to consider also the relation of
c institutions to the various sections of the public which use them or need
tse them. Hospitals and dispensaries represent or ought to represent
organization of medical services upon a scientific basis, bringing to bear
1 the needs of the individual patient the maximum resources in equip-
t and skill that twentieth century medical science can muster. To pro-
B a better understanding of hospitals and dispensaries by the community
promote at the same time their better and more discriminating utilization,
their more effective and generous support.
^^^ Hospital akd Health Sub?k
We need to approach the study of the hospitals and dispensaries of a
great city from the standpoint of the community rather than of the instiUi-
tion; to see them as the average citizen and the average family sees them,
rather than as the physician or the specialist in hospital administratioii.
Laying aside for the moment the demands which the average family may
make on hospitals and dispensaries for the promotion of health, a real thoogh
slowly growing part of their function, the primary reason for the utilization
of hospitals and dispensaries is the occurrence of sickness or accident. When-
ever illness or accident comes, the individual or the family must reach a
decision as to what is to be done. Choice must be made among passible
resources. It is well to list tliese resources so that all of the elements of the^
picture shall be in mind. A list of ten resources for the care of illness migb
be included:
1. The home remedy,
2. The advice of friend, grandmother, or neighbor of reputed wisdom,
3. The private physician,
4. The drug store,
5. The physician of an organization of which the patient or family is a
member (for instance, lodge doctor, industrial physician, city
physician),
6. The quack doctor or medical institute,
7. The midwife (for obstetrical care),
8. The nurse,
9. The hospital,
10. The dispensary.
The attitude of a community towards its hospitals and dispensaries i
made up of the points of view of its individual citizens. These points o'
view are practically expressed in determining what choice is made amonL,
the resources for the care of sickness. Such choice or decisions are influeiicei^
by considerations of finances, but also by custom, personal connections^-^
prejudices and information or misinformation regarding the availability^
powers and prestige of the various resources for the care of a given caseo^
illness or accident.
It is obvious that the ten resources for the care of illness vary in theiT^
grade of efficiency. It is obvious that the various elements in the popula — '
tion select resources differently. Thus the use of the midwife is largely con —
fined to foreigners; the quack reaps his richest harvest from among theless^
educated; the service of the dis])ensary at the present time is chiefly (or^
those of limited means. One man with a pain in his back goes to a dispen-^
sary. Another equally unblessed with this world's goods hies himself to a
drug store and purchases and applies a widely advertised *'RheumaticV
Ready Relief." One woman goes to a hospital for an operation; her neigh-
hoT two blocks away refuses to go to an institution even on the advice of her
UoapiTALS AND DISPENSARIES 821
family physician, because she is '* afraid of hospitals." A member of a
'odge utilizes the services of the official doctor of the organization during a
minor illness, but when he thinks something serious is the matter with him,
he calls a *'real doctor,'* meaning one whom he pays. Quacks* offices are
thronged with thousands of credulous victims, and the mails are filled with
money directed toward the coflFers of patent medicine vendors. Choices
among the resources available for the care of sickness are as varied as the
ctroi.ijnstances surrounding each case, and as manifold as human nature
-A health survey of Cleveland might theoretically arrange the ten resources
for tJie care of illness in the order of their relative efficiency, and then study,
for different sections of the population, their usual order of utilization
for different kinds of sickness or accident. Such a study cannot practically
be naade, but supposing for the sake of argument that it could be made, let
us ^sk this question : would the order of utilization by the people of the ten
resources for the care of illness correspond to their order of relative efficiency?
In sc) far as it does not, the well-being of the community suffers. Reputable
physicians and the hospitals and dispensaries in which these physicians ren-
der service, obviously constitute the primary and fundamental medical re-
soii^ces for the care of illness and the ])romotion of health. Are they used
^tlx the degree of fullness and of discrimination with which they should be?
If ^^iot, why not? The answer would not be the same for all groups of the
poj>xilation.
-A study of the hospitals and dispensaries of Cleveland cannot rightly be
M'^ited to the amount and the nature of the work done, the internal adminis-
tra,t:ion, and other technical problems, important as these are. It needs also
to include a study of the attitude of different sections of the people — the
ii^dical profession, the well-to-do, the poor, the foreign-born, etc. toward
these institutions. It is on the basis of these attitudes, understandings or
ni^^ijnderstandings, that the choice among medical resources is made in time
of Sickness or accident, and upon which the utilization of hospital and dis-
pc^^sary for the benefit of the public ultimately rests. Financial support of
hosjDitals and dispensaries by the community depends precisely on the same
considerations. In this section of the report of the Cleveland Hospital and
He^.lth Survey, therefore, an endeavor will be made to review the details
^\ Uie work of the hospitals and dispensaries of the city, in their medical,
unistrative and financial aspects, and to consider also the relation of
institutions to the various sections of the public which use them or need
to Mae them. Hospitals and dispensaries represent or ought to represent
th^ organization of medical services upon a scientific basis, bringing to bear
upon the needs of the individual patient the maximum resources in equip-
tJ^^iit and skill that twentieth century medical science can muster. To pro-
iiiote a better understanding of hospitals and dispensaries by the community
1^ ^ promote at the same time their better and more discriminating utilization,
a^d their more eff^tive and generous support.
822 Hospital and Health Survey
SOME DEFINITIONS
The hospital and the dispensary', taken together, comprise what may Ix'
called the organized or institutional practice of medicine. In the private prac-
tice of a physician, some patients are seen in his office, others in bed in their
own homes or in a private room of an institution. In the institutional
practice of medicine the dispensary patients correspond to those who are
seen in the physician's office, and the hospital patients to those whom he
sees in bed.
During the winter of 1919 and spring of I9'20, when the Survey was made,
there were 47 institutions known as hospitals, and 26 dispensaries and health
centers in Cleveland and Lakewood. Under a law of Ohio which became
eflFective in 1919, all hospitals and dispensaries must be registered with the
State Department of Health and render to it an annual report. Eight of the
above 47 ** hospitals" had not registered with the State Department of
Health at the time the field work of the Survey was completed (June, 1940).
Their names were found in the telephone directory. They are not further
referred to in this report, except in relation to the public sup)ervision of hos-
pitals, in the section on ** Organization to Carry Out Plans.*' The definition
of dispensary as thus far interpreted by the State Department of Health
does not appear to include the Health Centers or clinics doing primarily
preventive work.
The medical institutions of Cleveland may l)e further divided according
as they are members of the Cleveland Hospital Council or not. Table I
in the Appendix gives the hospitals and dispensaries of Cleveland, stating
after each the approximate number of beds in the hospital, and the approxi-
mate number of annual visits by patients to the dispensary.
On the accompanying ma]) these institutions are shown in their profHT
location.
It is important to state certain definitions and distinctions which will k
of service in understanding the problems and relations of the hospitals and
dispensaries of Cleveland.
Hospitals may be broadly classified in two ways: first, according to the
character of diseases treated, and, second, according to the relation of the
institution to the conuminitv.
With regard to the character of diseases treated, the distinction is l)etween
general hospitals, such as City or Lakeside Hospitals, and special hospitals
such as Cleveland Maternity or St. Ann's Maternity Hospital. The latter
receive only patients of a designated medical type. It will be observed '^^
once that Cleveland has few of the second group.
On the other basis of classifying hospitals in their relation to the com-
munity, two divisions may be made:
(a) Public-service hospitals.
(b) Proprietary hospitals.
I
3PITALS AND DISPENSARIES • 826
I. The public ought to understand the diflFerence between the *' medical
rding house" and the hospital.
In every large city are found institutions, usually of the proprietary class,
ch have an operating room, a nursing service, and which receive the
\ents of private physicians, put them to bed, nurse and feed them, and
iride for nursing attendance at operation if the case is surgical. The pri-
* physician carries the same individual responsibility that he would if
patient were in bed at home. The difference is merely that there are
lilies for a major operation close by, and that the patient's household is
red the difficulties of adjustment to illness, the introduction of a trained
se, provision for a special diet, etc. These are to all intents and purposes
lical boarding houses.
The modem hospital is as different from a medical boarding house as a
lenger liner is from a tramp steamer. Both float and both will take one
ewhere. But one is just a boat, while the other is a boat \Aus an organ-
ion.
rhe modem hospital provides the physician with certain facilities which
unavailable in the patient's home. Medical practice today requires
e than the physician's individual trained senses. Laboratories for many
s and an X-Ray department are necessary adjuncts to modem medical
!tice. The patient cared for at home can secure these benefits only
lugh expensive and somewhat slow recourse to private laboratories. In
hospital, this equipment and a vast variety of other instruments and
aratus are brought together under a single roof, and organized under a
:le control, so as to be most economically and effectively used. Modem
Fcine also is highly specialized. No one physician can master all the
Qce* Many cases require examination and study by physicians each
"esenting a different branch of medicine, in order that all the necessary'
8 be obtained, and through consultation an accurate diagnosis of the
ase be established. The staff of a modem hospital provides a group of
^ialists working with joint equipment, and under a mutually acceptable
1 of team work, which should render the service of each of maximum
je to the others as well as to himself and to the patient.
Similarly the modem hospital provides assistants to the physician of
cial skill; the medical assistant, the interne; the laboratory assistant,
technician; the nurse, and the social worker. Through the aid of these
.stants the highly special skill of the physician is kept for just that kind
«rork which requires it, and his time is not spent on routine or details,
isequently with a given expenditure of time and energy he can render
rice to a much larger number of patients, and more effective service
that.
A modern hospital may be defined as an institution in which there is
i use of medical equipment and cooperative organization of medical
1 for the diagnosis, treatment and prevention of disease.
A critical study of hospitals makes it clear that some institutions main-
i the principles of the medical boarding house with respect to their private
i
824 Hospital and Health Subvey
The first class receive patients as a public service, whether pay, part-pay
or free patients. The second class are conducted as corporations for the profit
of their owners. It is important to notice that the term "private hospital/'
which is not infrequently used, is decidedly ambiguous. The word ** private"
is sometimes employed to indicate a hospital supported by private funds as
distinguished from a state or a municipal hospital. In another sense, a
private hospital is taken to mean one which receives only private patients of
certain physicians and no ward or "staflF" patients. In still a third sense,
the word ** private" is applied to a hospital which is conducted as a private
business for profit. To use the same word "private" for a hospital whidi
is performing a great amount of public service rendered alike to those who
pay and those who do not pay, as for an institution which is run as a business
enterprise, involves dangerous confusion. The term "proprietary" makes
the proper distinction.
This term, however, is not necessarily one of reproach. It is perfectly
legitimate and proper for an individual or a corporation to maintain a hos-
I)ital for profit, as a business enterprise. Such an institution corresponds to
a "private school" or "academy," and may be as well conducted and as
useful to a limited circle of j)atients as are many well known private schools
to their clientele.
As will appear later, a number of institutions in the above list fall within
the proprietary class. There are some of these hospitals w^hich were incorpo-
rated as business organizations to be run for profit, but which in practice are
conducted as public service institutions, and have been so recognized by the
Cleveland Hospital Council. According to the principles which will be laid
down in this report, the extent to which the public should assist financially
in the maintenance of a hospital should vary in precise degree with the amount
and proportion of public service rendered by the institution. To \ye able tc
measure this accurately and to make the results of this measurement knoi^Ti
to the public or to the agency re])resenting the public, such as the Community
Fund, is one of the important aims which those interested in hospitals must
have in view.
The degree of public service rendered by a hospital does not correspond
with the number of its free patients. Some persons have tlie notion that
doing charity means giving something for nothing. The twentieth century
idea of charity is a service, not a dole. The i)ublic service rendered 'by*
hospital should be measured from a financial standpoint by the amount of
care given at a rate lower than the cost of the service. This in practice means
measured by the number of days of care rendered during the course of a year.
If a patient is treated for a day and pays only half the cost of the senicd
the hospital may be credited with one-half of a day's free care. Such is «
simple method of estimating the financial aspect of the public service of a
hospital.
From the professional standpoint, public service must be estimated id
terms of kind and standard of care, a more technical and difficult matter to
evaluate. Classification of hospitals according to the quality of service, *D
invidious task, can l)e undertaken here only with reference to one distinc-
[OSPITALS AND DISPENSARIES ' 826
on. The public ought to understand the diflFerenoe between the ''medical
oarding house" and the hospital.
In every large city are found institutions, usually of the proprietary class.
hich have an operating room, a nursing service, and which receive the
atients of private physicians, put them to bed, nurse and feed them, and
rovide for nursing attendance at operation if the case is surgical. The pri-
ate physician carries the same individual responsibility that he would if
le patient were in bed at home. The diflFerence is merely that there are
icilities for a major operation close by, and that the patient's household is
>aTed the difficulties of adjustment to illness, the introduction of a trained
UTse, provision for a special diet, etc. These are to all intents and purposes
ledicaJ boarding houses.
The modem hospital is as different from a medical boarding house as a
assenger liner is from a tramp steamer. Both float and both will take one
>inewhere. But one is just a boat, while the other is a boat {)lus an organ -
at ion.
The modem hospital provides the physician with certain facilities which
re unavailable in the patient's home. Medical practice today requires
tore than the physician's individual trained senses. Laboratories for many
«ts and an X-Ray department are necessary adjuncts to modem medical
ractice. The patient cared for at home can secure these benefits only
irough expensive and somewhat slow recourse to private laboratories. In
le hospital, this equipment and a vast variety of other instruments and
pparatus are brou^t together under a single roof, and organized under a
ngle control, so as to be most economically and effectively used. Modem
led'cine also is highly specialized. No one physician can master all the
aence. Many cases require examination and study by physicians each
■presenting a different branch of medicine, in order that all the necessary
lets be obtained, and through consultation an accurate diagnosis of the
iaease be established. The staff of a modem hospital provides a group of
pecialists working with joint equipment, and under a mutually acceptable
ilan of team work, which should render the service of each of maximum
^alue to the others as well as to himself and to the patient.
Similarly the modern hospital provides assistants to the physician of
special skill; the medical assistant, the interne; the laboratory assistant,
the technician; the nurse, and the social worker. Through the aid of these
assistants the highly special skill of the physician is kept for just that kind
of work which requires it, and his time is not spent on routine or details.
Consequently with a given expenditure of time and energy he can render
service to a much larger number of patients, and more effective service
»t that.
A modern hospital may be defined as an institution in which there is
^tt use of medical equipment and cooperative organization of medical
'■^ for the diagnosis, treatment and prevention of disease.
A critical study of hospitals makes it clear that some institutions main-
Wn the principles of the medical boarding house with respect to their private
H26 Hospital and Health Survey
I iitients. while Iriving m well organized system for modem hospital work
V. ith res :cct to their ward eases. Is privacy a substitute for service?
The distinction lK*tween the two types of services will be illustrated in
numerous Doints during the course of this report, and will be of importance
in coT^nection with certain final conclusions. Each hospital trustee and ever>*
hospital patient will do well to see how these principles work out with re-
gard to the hospital which he knows best.
The dispensaries may be classified as are the hospitals. As a matter of
fact, the list of dispensaries on pages 984-986 contains none of the pro-
prietary class. There are indeed some clinics maintained in Cleveland by
individual physicians, whether on their own account or in connection with
industrial establishments. Some of these are reputable enterprises; some of
them are merely quack medical institutes. The latter class will be referred
to only in connection with some general recommendations of the Sur\'ey in
the section otl ** Organization to Carry Out Plans," as are the hospitals not
registered with the State Department of Health.
(.Cleveland -has only one dispensary- treating the sick of the class confined
to special diseases — the Babies' Dispensary. Its clientele is limited to chil-
dren not over three years. A highly important gtoup of special dispensaries,
however, are the public health dispensaries, which aim to prevent rathci
than treat disease, to educate rather than to cure — the Health Centers.
Baby Prophylactic Stations, and Prenatal Clinics. Broadly speaking, a line
for the support of dispensary work is drawn by the municipal authorities on
the border line l>etween preventive and curative medicine; private support
of dispensarj' work being largely though not wholly confined to the dispen-
saries treating the sick, and i)ublic support being almost entirely confined to
the dispensaries w^hose work is primarily preventive atid educational.
The term ''disjx»nsary " originally meant a place where medicine wai^
given out or dispensed to the poor on the prescription of a physician, and the
word has persisted, although at the present day the giving out of medicine
is a minor function of a dispensary-. Medical diagnosis, advice, and treat-
ment other than medicine are the services of primary significance. The
term *'out-[)atient department'' is frequently used as synonymous with dis-
l>ensary when applied to a disj^ensary which is part of the organization of a
liospital — the bed cases l)eing the in-patient department and the dispensar}'
the out-patient department. In this report, the term dispensary will be
generally used except when it is desired to draw a special distinction between
the **in" and the *'()ut" patients.
The unit for measurement of the services rendered by hospitals and dis-
pensaries is important to define. Hospital service is measured in days of
care. A patient who has Ijceii in the hospital for two weeks has in this sense
received fourteen units of service. The unit for measuring dispensary' serv-
ice is the visit paid by the patient to the clinic. It will be observed that the
visits paid hy patients to a disj)ensary in the course of a month or of a year
is much more than the numl)er of individuals treated, just as the number of
(lays' care given patients in a hospital is much larger than the number of
SPITALS AND DISPENSARIES 827
erent patients. In actually studying tlie work of a given institution or
he city as a whole, we are of course interested in the number of individuals
?d for as well as in the bulk of service rendered. Days of hospital care
I visits to dispensary clinics represent the latter element — bulk of work
le. The number of individuals treated is in practice a more difficult
ire to obtain, because of the likelihood of the same individual, in case of
Imission to dispensary or hospital, being counted as a different patient.
One of the fundamental problems of every professional institution today
ow to make a specialized and technical piece of work clear to the average
gon. The problem is to interpret hospitals and dispensaries to the com-
tiity. This means stating facts showing the kind, amount and quality
^rvice rendered, and stating them in such a way that they are easily
lerstood by the average person. It is of relatively little importance
it facts a temporary survey gathers and reports — such facts are at most
V a cross-section, a momentary picture. It is of very great importance
it facts the hospitals and dispensaries gather and present regularly to
public, and how they present them to the unprofessional mind — whether
i vivid and convincing fashion or in dry and technical form. What a
rd of trustees needs to know about their own hospital or dispensary;
it the contributors to the Community Fund need to know about all
pitals and dispensaries; what the general public needs to know about
hospitals as k whole or about its municipal institution in particular —
se are of fundamental importance for the Survey to suggest.
The cost of maintaining medical institutions has been • increasing with
at rapidity, not only because of the general rise in prices, but because of
'ance in medical science, the more elaborate equipment that is necessary,
higher specialization in many branches — in a word, higher standards of
^ice, yielding better results for the cure and prevention of disease. Public
iprehension of these new and higher standards has lagged behind their
iblishment in the strongest institutions. Such comprehension forms the
is on which taxes for municipal institutions must be levied and cam-
gns for community chests or for building funds successfully accomplished,
equate moral and financial support of hospitals and dispensaries depends
m making these standards and needs clear in terms of human interest
[ popular understanding. The defining of units, the assembling of sta-
les and the compilation of professional reports are fundamental prerequi-
«. The statement and interpretation of these data to the community
a necessary sequence.
828 Hospital and Health Survet
II. Hospitals
HOSPITAL PROVISIONS AND COMMUNITY NEEDS
Reserving the study of dispensaries for Chapter HI., we may now com-
pare the hospital facilities of Cleveland with those of other communities
and with the probable needs of the city.
During the winter of 1920, while the Survey was in progress, the number
of hospital beds in the cities of Cleveland and Lakewood was 3,378, including
all the institutions registered with the State Department of Health.
Of these, 3,088 beds were in the 20 hospitals of the Cleveland HospiUl
Council, as follows:
Beds
Cleveland City Hospital ^ 785
Cleveland Maternity Hospital ~ 60
Fairview Park Hospital - 85
GlenviUc Hospital 74
Grace Hospital 35
Huron Road Hospital 84
Lakeside Hospital 289
Lakewood Hospital — 53
Lutheran Hospital 50
Mount Sinai Hospital _. 225
Provident Hospital 29
Rainbow Hospital ~ 85
St. Alexis Hospital 250
St. Ann's Maternity Hospital ~ ~ — 55
St. Clair Hospital -. 43
St. John's Hospital 150
St. Luke's Hospital 139
St. Vincent's Charity Hospital 290
Warrensville Tuberculosis Sanatorium 270
Woman's Hospital 37
Total 3.088
.ND Dispensaries S29
3n-council hos]>itals included 290 beds, as follows:
Beds
id Emergency Hospital „ 22
id Home Hospital 10
:veland Hospital « ^ 31
ty-fifth Street Hospital ^ 60
renty-ninth Street Hospital 22
J Crittenden Home 12
E*rivate Hospital 9
tchcock's Private Hospital 15
k's Hospital 45
n Army Rescue Home.^ 54
{Hospital 1 10
*otal...„ 290
assification it is to be noted that in conformity with the usual
!s (1) for the insane and feeble-minded, (2) for the infirm and
orphanages, and (4) under the control of the United States
, have not been included. The list includes hospitals for general
•ases of an acute or chronic nature, and convalescents, but not
ses mentioned above. This point is important in making com-
1 other communities.
)eds are com])ared with the po])ulation of the cities of Cleveland
3d, taken together, we should find that there are 3,378 beds to
of af)proximately 840,000 in these two cities. However, these
ving more tlian the j)opulation of Cleveland and Lakewood.
ed by what may be called the metropolitan district, and even
: areas depend uT)on them. We may form a definite estimate
)llected by the Survey on the two days, December 3, 1919, and
1920, on each of which was taken a census of the patients in the
)itals and in three others. A tabulation of the patients in these
these two days by location of residence(the average of the two
d that of the 2,651 patients 14.7 per cent., or practically one-
le from outside the city of Cleveland. This number includes of
coming from Lakewood, but it is certain that at least one-eighth
its who were in the hos|>itals on these two days came from out-
id or I^akewood. At least one-eighth therefore should be added
ation served by the hosDitals on our list, which would make a
it 945,000. Dividing this by the number of beds, 3,378, we find
; provision to the extent of about 2.8 beds to one thousand of
This is a fundamental figure, because it is an index of the de-
ision of hospital service for community needs. Its sigiiificance
elucidation.
830 Hospital and Health Surybt
Comparisons must needs be made with other communities. In the 1919
report of the United Hospital Fund of New York City, a classified list is
given of the hospitals in that metropolis. There is shown a total of 28^
beds, which does not include the four classes of mstitutions mentioned
above, or many small private institutions such as appear in the Clevdand
list among the non-council hospitals. The proportion of patients coming
from outside the limits of Greater New York is not known, but most of ftc
suburbs of New York are better provided with hospitals than the outlying
districts of Cleveland. It is assumed that the omissions from the list of hospltak
in New York given by the United Hospital Fund would probably balance in
number the beds required to serve non-residents. On this basis, provisioD
of hospital beds in the metropolis in proportion to population is five per
thousand.
Boston provides another basis of comparison. The legal city of Boston is
a little smaller than Cleveland, according to the 1920 census, 727,000 against
796,836, but Boston is one of some 38 towns and cities within the metro-
politan district, with a total population of approximately 1,500,000. A list
of hospitals in this "Greater Boston" showed, from figures in the Medical
Directory of 1918, 140 hospitals, general and special (excluding those types
above named) witli a total of 7,^47 beds. This is 4.83 beds to 1,000 of popu-
lation.
Taking the city of Boston alone, with a census population in 1920 of
727,000, it was found that there were 108 hospitals, with 6,062 beds. Tlis
is an average of 8.3 beds to 1,000 population, but this figure should not be
used for comparative i)urposes, since so large a proiK)rtion of the Boston beds
are used by the metropolitan district, with double the population of Boston
proper. For pur])oses of comparison with Cleveland, the figure for tic
metropolitan area should be taken. It will be observed that the figures foi
New York and for ** Greater Boston*' are almost exactly the same.
It is apparent that ('leveland falls far below either Boston or New Yoii
iu providing hospital service in ])roportion to its population. On the basis
of five beds per thousand Greater Cleveland needs fully 4,725 beds, or at least
1,350 more than now exist. In view of the fact that even when new beds are
planned for, time is required to build and equip the hospitals to contain theffl
and that population needs continue to grow, it may be conser\'atively esti-
mated that Cleveland needs to add 1,500 beds to its hospital capacity tf
(juickly as possible. Even at the present moment (June, 1920) it must b
recalled that while the 1920 census showed a smaller population for Cle^
land than had been anticipated, yet the growth of the suburbs, which must
depend largely upon the main city for their hospital service, has been pw*
reeding at such a rapid rate that it is fair to estimate that not less than 1.500
rather than 1,300 beds should be stated as the shortage in the year 1920.
Were this merely a conclusion derived from statistics, it would be indeed
(luestionable. The statistics, however, are worked out merely to give tf*
index to well-established facts showing the shortage of hospital beds id
(yleveland and the unfortunate results of this shortage. To depict these
[ospiTAiiS AND Dispensaries
831
ill require a closer analysis of the service offered by the hospitals of the
ty.
The hospitals of Cleveland are predominantly devoted to surgery. On
ic two Survey census days, if the hospitals of the city were taken together
emitting City Hospital, Warrens ville Tuberculosis Sanatorium, and Rainbow
hospital), it was found that 48 per cent, of the patients were surgical,
id that in the majority of the hospitals the ratio was much higher. The
sason that City Hospital is excluded is because in its 785 beds are included
Tge groups of cases such as tuberculous, alcoholic, venereal disease and
intagious disease patients, which do not appear in any other hospital. On
le census days, only 21.5 per cent, of the patients represented general medi-
ae, and only 9.4 per cent. sp>ecial services. 18.7 per cent, were obstetrical,
id 2.4 per cent, not stated. The figures themselves are given in a footnote.*
Cleveland is seriously deficient in provision for sp>ecial classes of cases, f
bstetrical cases are found in the majority of the hospitals. The average
T the two census days was 313, or about one patient in ten, 9.3 per cent, of
le total patients in the Cleveland hospitals on those days. Provision for
>stetrical cases in special hospitals is made only at Cleveland Maternity
ospital and at St. Ann's Maternity Hospital, a total of 115 beds. Recent
*ars have seen a great increase in the demand for care in hospitals at the
me of confinement, particularly by middle-class families, but these cases have
ul in the main to be provided for in the general hospitals, without the de-
>lopinent of special hospitals, special services, or special wards to meet the
articular need.
Regarding cases of eye disease, it was found that only one hospital,
akeside, makes any special reservation of beds, four beds being held in the
lale surgical ward of Lakeside for this service. There is no special ward in
le city for ear, nose and throat cases. In New York 608 beds are provided
I special institutions for eye, ear, nose, and throat cases, aside from such
revision as is made in the general hospitals. In Boston, 219 beds are pro-
ided; in Baltimore, 153; in Philadelphia, 58; in Chicago, 32.
In spiecial provision for children, Cleveland is similarly lacking.
Pediatric services exist at Lakeside, City and Mount Sinai, and beds are set
Aside for children in the following additional hospitals : Children's Fresh Air
Camp* Fairview Park Hospital, Huron Road Hospital, Lakewood Hospital,
Rambow Hospital, St. Alexis Hospital, St. Ann's Hospital, St. John's Hos-
pital, and St. Luke's Hospital, making a total of 302 beds designated as chil-
A«n's beds, for other than contagious or convalescent cases.
Type of Service
jKtfcrf.^
*Cla»»Mcation of Patientt, Centut Dayt (averaged)
25f5!triciL:
Number
361.0
80S.S
312.5
157.5
40.0
"* 1918 Bottoo had beds in special institutions to the number of 2698, as follows:
Percentage
21.5
48.0
18.7
9.4
2.4
Taberculosis.
Bye and ear..
CootagioasL^
792
225
340
25
Children 240
Women (maternity) 436
Women and children together 542
Convalescent 98
832 Hospital and Health Survey
It will be observed that these are all parts of general hospitals. As com-
pared with this, New York has 1,!298 beds for children in special hosritab.
and in addition, at least as many more beds specially set aside for children
in a number of general hospitals; Boston has about 240 beds for children in
special hospitals and more than that in pediatric divisions of a number of
general hospitals.
On the two census days, there were 496 children found in the Cleveland
hospitals, of whom 57 were in the contagious disease service of City Hos-
pital. The vast majority of the remaining 439 were scattered through the
wards and rooms of general hospitals, the greater number being surgical
cases.
In the matter of provision for contagious cases, Cleveland ha^ 100 beds
at City Hospital. Boston has 340 beds in its City Hospital. In connection
with contagious diseases, these figures are comparable, since both institutions
rarely take cases except from within the limits of the legal city. It is stated
by such a national authority as Dr. Charles V. Chapin that for the common
contagious diseases (excluding tul>erculosis, venereal diseases, etc.), a com-
munity should provide at least one l)ed for every 2,000 of population. This
in Cleveland would mean almost 400 beds. Boston it will be observed has
measured up to Doctor Chapin's estimate; New York, with 2,100 l)eds for
contagious cases, almost meets it.
A special report of the Survey dealing with tuberculosis (Part IV.) has
shown that Cleveland has not enough beds for this disease.
The estimates of the specialists in venereal disease are to tlie effec*i that
at least 200 l)eds should be ])rovided in the City Hospital, and that a certain
amount of ])r()vision should he made in general hospitals. (See Part V.'
In the ortho])e(iic service, a branch of medicine of ra[)idly increasing im-
portance, Cleveland has an insignificant provision. The number of reported
ortho])cdic cases in lK)s])ital beds, at the time of the Survey, was not kno^n.
except at Rainbow II()s[)ital, which is chiefly designed for convalescent
orthopedic cases of children. Boston has al)out three times the provision for
orthopedic cases as lias Cleveland, and New York has over 300 beds in
sj)ccial lios])itals alone for acute cases of this type.
These facts go to show where the deficiencies in provision of hospital beds
in Cleveland lie. The reason for the shortage of l)eds is obviously that thf
population has grown more rapidly than has re<*ognition of needs for raorf
liospital service. We find in the Cleveland hospitals the more urgent sur-
gical and some medical cases l)eing treated, but very little development of
services for sj)ccial cases. In general it may be said that the urgent diseases
or emergent cases, j)articularly surgical, which force themselves on the com-
munity's attention and upon the attention of the individual hospitals, and
which cannot be denied admission, have left little room for other types of
work.
The effect of this shortage of 1,500 })eds cannot be measured. We can only
estimate the number of sick persons who have had to be cared for in their
homes with inadequate facilities for diagnosis, for nursing, for diet, and for
loSPlTALiS AND D1SPENSARIE8 833
ire of all kinds. The nuTnl>er of cas^s of disease needing the services of
specialist, the complete and thorough observation necessary to make a
iagno. is, such as is only possible under hospital conditions, we can only
ifer. We can only in imagination picture the suffering that has resulted, the
evelopment of slight illness into serious, the diminution of productive power,
le loss of opportunity to prevent as well as to cure disease. Such shortage
r hospital beds can only mean a waste of the vital resources of the popula-
on.
Against these figures ought to be set others which suggest an almost
intradictory picture. If there were a shortage of beds, it might seem at
rst sight that the 3,400 beds now available should be constantly filled to their
ipacity. Such, however, is not the case. On the first census day, Decem-
er 3, 1919, 2,581 hospital patients were re])orted as in hospitals with a
leoretical capacity at the time of 2,831 beds. On the second census day,
inuary 15, 1920, 2,663 patients were reported in hospitals having 3,001
eds. The percentage of beds filled on the census days for this group of
ospitals, was 95.7 and 88.7, respectively.
A similar comparison can be made on the basis of an entire year, by tak-
ig the number of beds in the hospital and multiplying this number by 365,
lus securing the maximum dftys of care that might be given during the year,
omparison of the actual number of days' care, as reported, with this figure
ives the proportion of utilization of hospital facilities for the year. For the
roup of seventeen hospitals for which figures were obtained for the year
)18, a total of 929,825 days of care was possible but only 686,967 days of
ire were given, or 73.9 per cent. During the year 1919, for a group of six-
jen hospitals, a total of 930,465 days of care was possible, but only 645,280
ays of care were given or 69.3 per cent..
It should be stated at once that we cannot expect a hospital or group of
ospitals to have all beds filled all the time. There are periods of epidemics,
ad in normal times there are occasional days when a hospital may have
irery bed taken, but such conditions are exceptional. A hospital may re-
ise cases when it has vacant beds, because there must be classification of
atients to a greater or less degree, and the ward for which the patient is
lited on account of his sex or disease may be full, while there may be
acancies elsewhere. Inability to receive a given patient is thus compatible
ith some vacancies in the same hospital. Over any considerable period of
ime during the year, there are many reasons why a certain number of beds
umot be completely utilized. Rooms and wards must be renovated and
ccasionally repairs are necessary. In many hospitals a certain number of
eds are set aside for the temporary detention of patients, particularly chil-
ren, during a period of observation so as to eliminate risk of contagious
Such are some of the reasons why hospitals never show the use of their
ed3 during the year up to anything like 100 per cent, of capacity. An
uiiial average of 75 per cent, is a very fair showing. During the winter
nd spring months there is generally greater demand for hospital service
834
Hospital and Health Subvet
than during the summer and the autumn, and consequently a higher ratio of
use of beds is usually found for the six months beginning with January, if
compared with tlie other six months of the year. Hospital administrators
may take advantage of this condition by doing repairs and renovations, so
far as possible, during the less active months.
A tabulation of individual hospitals presents some interesting points,
as shown by Table II in the Appendix.
It should of course be one of the prime aims of hospital administration
to utilize the facilities of the plant to their fullest capacity. Good hospital
administration should show a higher average use of beds than 70 per cent for
a year. Conditions will vary among general hospitals. Conditions in special
institutions, such as hospitals for maternity cases, children, chronic cases,
etc., must be considered on their own merits. Thus, in the Cleveland City
Hospital, certain large units are set aside for tuberculosis, neurology (includ-
ing many alcoholic cases), venereal diseases and contagious cases, and the
demand for these beds is affected by many conditions different from thosf
which affect the general medical and surgical services. It should, how-
ever, be the aim of hospital administration to make its internal arrangement
as flexible as possible.* While contagious and acute surgical cases are not safely
to be mixed in the same wards, there should be a constant effort toward the
utmost flexibility of classification so that prAsure on one division of the
service can be relieved by rearrangements which utilize beds vacant in other
divisions.
A comparison of Cleveland figures with those of a number of leading New
York hospitals shows the majority of Cleveland institutions in a somewhat
unfavorable light. Nineteen hospitals in the United Hospital Fund of New
York showed in 1919 an average of 79 per cent, of their bed capacity filled.
The lowest hospital showed 03 per cent, and four showed 90 per cent, or over.
On the whole it may be said that a general hospital should be so adminis-
tered as to run to an average of at least 75 per cent, of its capacity during
'Figures provided by the City Hospital just before this report goes to |>ress show, for the year 1919
and the fi st nine months of 1920, the details of the use of the different divisions of the hospital. Their
are as follows: (The figure* in the parentheses are for the first nine months of 1920, and the other* for
the year 1919.)
Department Beds
Tuberculosis 100
(100)
Contagious. 100
(100)
Specific... 75
(125)
Observation. .„ 50
(50)
Main and Convalescent _ 400
(380)
Total Days
Treatment
Possible
36,500
(27,400)
36,500
(27.400)
22.500
(35,250
18,250
(13,700)
146,000
(104.120)
Total Days
Treatment
Given
27.447
(16.430)
14,806
(13.859)
13.575
(13.264)
12.077
( 8.938)
105.001
( 74.614)
Percestsr
Occupied
75.7
(59.9>
40.5
(50.5^
60.3
(38.7)
66.2
(6S.0)
72.0
(21.7)
The very wide variations between the degree of use of the different services of the hoqntal "'^^
parent. It will be noted that the small percentage of use, particularly of certain divisions, h&s cootiniieo
throughout a long period of time. ''
piTALS AND Dispensaries 835
,rear as a whole, and that an average of over 80 per cent, should be
!ted during the busier portion of the year. A figure as high as 90 per
ought to be the goal.
a estimating the hospital needs of a large community, however, it would
)e safe to expect a percentage of utilization of hospital beds as a whole
ighout the year to be more than 75 per cent, at the present time, even
e face of a general shortage of beds with consequent increase of pressure.
Survey has sought to point out the necessary inflexibilities of hospital
igements and the irregularity of demand throughout the year to account
bis seeming inconsistency.
►n the map on page 823 are shown the eight "Health Districts" used by
Cleveland Division of Health for administration purposes. The hos-
population of the city on the two census days was tabulated with refer-
to location of residence of the patients according to these health dis-
5. Comparison with the map will assist in interpreting Table III in the
mdix which gives this tabulation. .
. glance at this table and at the map shows that the hospitals of the city
not been located according to any general plan, nor to any great extent
reference to the needs of any particular locality. Thus District II and
•ict VIII show the largest proportion of cases in the hospitals,
this is what one might expect considering the congested residential
icter of District VIII, and also the enormous business and industrial
lation of District II, during the working hours. A large amount of
for hospital attention invariably arises under such conditions, yet the
hospital in District II is Huron Road, and the district has less than
hird the number of beds per thousand of population that are provided
ealth District III, which, with three times the proportion of beds ac-
ng to population, shows less than one-third the number of hospital
per thousand. Com])arison with District VII is also instructive.
number of hospitals are found located near the boundaries of districts,
belong to the one as much as to the other, but the more fundamental
is that the range of service of many hospitals has very little relation to
listrict in which it is located. Table IV in the Appendix shows the
^rtion of cases on the first census day registered in each hospital from
vn health district.
urther study of the individual hospitals on the second census day and
me cases for other periods, showed quite clearly that hospitals can be
ed into two groups, with respect to their range. One type, such as
>n Road, Lakeside, City, Mount Sinai, St. Luke's, and St. Vincent's,
what may be practically called a city -wide range. The proportion of
drawn from their own vicinity is no larger, or is less than one would
rt in proi:ortion to distribution of population. In the other group are
itals such as Fairview Park, St. John's, Glenville, Lutheran, Provident,
e, St. A^'n's, and St. Alexis, which show a large proportion of patients
n from their own vicinity. The difference between the two classes is
more striking when the figures for the individual hospitals in the latter
■836 __^_ Hospital and Health Survei
olass are examinc-d in detail. In some instances from two-thirds to three-
fourtlis of the patients are fonnd to be draw-n from the hospital's owti dis-
trict or a neightwring district, so that the great bulk of the hospital clientele
is local. Generally speaking, the range of the larger hospitals is wider than
the riiiige of the smaller one.i.
TJie facts shown in these tables are of importance in connection with the
locution of future hospital units, and will be referred to later in that connec-
tion in the section on Community Planning.
It is important that each hoard of trustees understand the range of its
own Iios|iital. Adaptation to the special needs of its clientele is a I'erj
different mutter in u hospital which serves primarily its neighborhood from
the ca.se of one which draws from all over the city and from the environ.'.
The most important summary conclusion to which the data in this sec-
tion lead is the shortage of 1,500 hospital beds in Cleveland in 1920. The
work of tlie existing hospitals has been unduly limited, because of this short-
age, to urgent surgical and to maternity cases. Medical and special woik,
particularly for children, has not been pntvided for in any adequate degree.
Study of the Cleveland hospitals reveals these conditions quite clearly, and
they are thrown into relief by comparisons made with New York and Boston.
It is apparent that while the Iwst aclministered hospitals of Cleveland ba«
used their beds to as full capacity as the beat institutions elsewhere with which
comparisons have been made, the hospitals in Cleveland as a whole have fallen
below a desirable (MTcentugc of utilization of their theoretical cajjacity. even
in the face of the community's need for beds. Some of the reason.'^ tor this
have l>cen indicated, and tlic need for flexibility and efficient administration
has lioen pointed nut ms ;i n-incdy.
Fig. 11.
Prtmnmi and Nrfd for Honptla Btnt
loSPITALS AND DISPENSARIES 837
Distribution of hospitals according to sections of the city shows lack
in the past of any general planning and the need for the formulation of prin-
ciples by which the locations and functions of future hospitals can be de-
termined. It is ap])arent tbat there is special need and large demand for
lospital service coming from the central section of the city, and inasmuch as
I considerable part of the need from this section is known to be of an urgent
'haracter, future plans for the location of hospitals must take into con-
ideration local provision for this central section.
It has been sought in this section to point out not only general matters
►f interest to the city as a whole, but to indicate some of the kinds of facts
i^hich hospitals need to know about themselves; which the trustees and
heir representatives should have periodically reported to them. In how
n^ny hospitals do the monthly reports to the trustees show, for instance, the
percentage of beds used in each of the main divisions of the hospital in pro-
portion to the theoretical capacity of each division.^ Shrewd business men
taiow just what facts to demand in regular reports from their o^ti enter-
prises so that they shall be able to determine whether or not the business
IS well run. Trustees should be as discriminating in the selection of the facts
which they ask to have set up as the guideposts for the business and policy
of their hospitals.
838 Hospital and Health Svbtet
ORGANIZATION FOR SERVICE
•
A hos])itaI is much more complex than most business organizations of
equivalent size. Its peculiarity is the inclusion of a number of different pro-
fessions, each highly specialized, which must work together and which must
be kept in effective working relations. The basis of a hospital is its medical
staff, but in addition to this medical element, is the business administration,
represented by the business men of the trustees, by the superintendent, and
by his administrative assistants; the nurses, another highly speciaKzed and
well organized group; social service, representing still another and different
type of work in the hospital; and finally, the housekeeping, mechanical, and
clerical groups, who maintain the essential daily routine of the plant. It
should be added that while the emphasis of the work of most superinten-
dents is on the business side, the superintendent ought to interpret, develop
and represent all phases of a hospital's activity.
Hospital personnel thus includes such widely varying elements and
draws them into such intimate relationship that the successful organization
and administration of a modern hospital is a difficult matter requiring special
training and skill. There are stated at the end of this chapter a series of
recommendations regarding hospital organization to which the discussion of
this chapter aims to lead, and which it endeavors to interpret.
The basis of hospital organization may be one of three types. The
first, which is found only in the proprietary hospital, is a group of stock-
holders or owners of the hospital corporation, who may or may not have an
interest in the professional and welfare activities of the institution. The
second type, as represented by City Hospital, is under the direction of a
single man, the Director of Pub ic Welfare, who appoints the executive
officer and staff of the hospital. The third type, the usual form of organiza-
tion of privately supported hospitals, is that of a board of trustees. Cer-
tain hospitals which are under the control of religious organizations fall
somewhere midway between types two and three.
It is proper enough that there exist proprietary hospitals as a form of
business enterprise meeting an apparent public demand, but no hospital
which aims to be in the public service class can expect to receive public con-
fidence and support unless it has as its governing authority an individual
or group possessing the point of view of j)ublic service, without financial
interest in the operations of the institution.
The conditions found in the City Hospital of Cleveland indicate very
clearly the need for more general public interest in an institution of major
importance, such as this. The most serious administrative deficiency found
at the City Hospital by the Survey was in the nursing service. So great a
shortage of nursing service was found that the conditions amount to a serious
neglect by the city of its solemn responsibility for the humane care of sick
and helpless citizens. It is recognized that the ultimate responsibility rests
with the citizens of Cleveland, who should have appropriated more money for
the maintenance of City Hospital. More immediately, the responsibility rests
06PITAL.S AND DISPENSARIES 839
ith the appropriating authorities of the Cleveland municipal administra-
m* The executive officers of the Department of Public Welfare and the
ity Hospital should be held responsible for voicing the need in a clear,
fective, and persistent way, both to the appropriating authorities and to
ke public. There is not evidence that sufficient attention has been called
► the conditions by the administrative officials who have been aware of
lem.
In the nursing service of City Hospital a decided shortage of students
ists, and in some instances, of the supervising staff also. It is a conserva-
^e estimate that there are only about one-third as many students as are
eded for the number of patients, as 63 students are assigned the 481 beds
ed for training — a ratio of one student to 7 or 8 beds. . The ratio of students
beds was in actual practice lower than this — one student to 10 beds in the
leral services during the day, and one student to 40 beds at night. Due
the shortage of student nurses, ward attendants have had nursing duties
igned to them for which they were entirely unqualified.
The presence of a board of trustees or cf a visiting committee who were
ively interested in the hospital might probably have been of great service
the administrative officers of the hospital and to the Director of Public
^Ifare in making apparent to the municipal administration and to the
leral public the needs of the City Hospital and the gravity of the present
iciency. As the Survey has recommended, an appropriation of $150,000
i^ear for nursing service is necessary for at least the next year or two in
ler to secure a sufficient number of graduate nurses to provide a minimum
satisfactory care for the patients. If, as the Survey has also recommended,
ufficiently capable head of the training school can be secured with an ade-
ate corps of trained assistants, it is probable that the training school
1 be so V)uilt up that the amount just mentioned can be diminished in
ure years, as an increased number of student nurses is received, up to the
LXimum for which the hospital can provide suitable training.
At Warrensville Infirmary the lack of medical and attendant service is
o grave, and here again the institution has been lost si^ht of, even by
*tions of the public which, if they knew the facts, would he interested to
>Use public opinion to better conditions. The need is not only for more
^ical staff and attendants at Warrensville, but also for recreational facili-
s for old people and others who are patients and who need some element
their lives beyond the barest minimum of physical care; also for the em-
>yed help of the institution, who, particularly under present economic
editions, are obtained with difficulty in a place which is relatively isolated
<?omparison with other places in which as good, if not better, wages, can
secured. Much in this direction would gladly be done by volunteer
distance if the right people knew the facts and were interested to be active
thft matter.
•
It has been recommended by the Survey that the Cleveland City Hos-
tal be governed by a board of trustees, which would require a change in the
*It it recognised that legal restrictions upon municipal taxing power have placed considerable
litstions upon Cleveland's expenditures for public services, as in many other cities.
840 ' Hospital and Health Survey
city charter. It may be pointed out that from the standpoint of efficiency,
government by a director need in no way suffer in comparison with
govcrnnr.ent by a board df trustees. The effectiveness of either form of
government depends upon personnel, the recommendation in favor of a board
of trustees being chiefly that of greater stability through changing municipal
administrations. 1 his again may work for good or ill, depending upon per-
sonnel. At some periods it would serve to retard progress, and in others to
prevent disruption following a political overturn. On the whole, however, a
hoard of trustees is desirable.
Even under the most ideal conditions of municipal administration, a city
hospital needs to be brought in contact with its community, and this can
best be secured by attaching to the institution in some way a group of dis-
interested citizens, men and women, who will visit it, be in touch with its
work, help its governing and executive officers by friendly advice, and above
all else, interpret the institution, its work, and its needs to the financial
appropriating authorities and to the public as a whole. The formation of a
strong board of trustees l>est accomplishes these purposes, but if this pro-
posal proves unacceptable, some progress toward the same result may be
accomplished by a properly selected visiting or auxiliary conunittee,
appointed by the Director of Public Welfare; such a committee
of course having only advisory powers. The degree to which such a board
will be of practical service will depend almost entirely upon the Director.
He has it in his power to stimulate the board to activities which will
not interfere with the hospital's activities but be of benefit, or, on the other
hand, he may reduce the group to one on which few capable individuals will
find interest in serving. In the absence of a board of trustees, however, the
presence of some such advisory body is highly advisable.
A hospital which is managed by a religious sisterhood will do well, as
four such hospitals in Cleveland have recently done, to appoint a lay advis-
ory committee which will exercise much the same functions as a board of
trustees though without the legal authority usually vested in them in other
hospitals.
For the typical hospital, privately incorporated, there should unques-
tionably be a board of trustees. Such bodies are usually either self-perpet-
uating or elected by a hospital membership or by church or other organiza-
tions which constitute the hospital corporation. Members of boards shouU
have definite terms, and the })ersonnel should change slowly, a few terms
expiring each year. Many of the chief deficiencies in hospital administration
in Cleveland and elsewhere have arisen because of defects in the make-up
of the board of trustees or in its relationship to other groups in the hospital
organization. The composition of boards of trustees has too frequently
been determined by an historical accident which threw together a group of
doctors and lay business men who together made up the original body, or
on the other hand the board is composed entirely of business men, who are
usually immersed in affairs, and leave to the medical staff or to one or two
of their own number, practically the whole responsibility for administration
of the institution.
TIOSPITALS AND DlSPENaAHIES 841
Perhaps the most frequent cause of diflSeulty in Cleveland has been the
existence of a number of different boards or groups within the same hospital,
without clear definition of their respective powers and duties. Thus there
may be found a board of trustees, a board of managers, and an auxiliary
board in the same institution. The personnel of one of these groups may
be entirely women; of another, entirely men; the third may be also of women,
or of both men and women. The original reason for the formation of these
different bodies was obviously the desire to interest as many persons as jjos-
rible in the hospital for the sake of moral and financial support. Principles
of organization applicable to hospitals as well as to business establishments
require that there shall be one governing authority. The existence of other
boards or committees is not inconsistent with this principle, but the pro-
visions of the by-laws and the actual practice of the hospital should make
it quite clear that a single body which should be known in general as the
"Board of Trustees" has complete authority*, and that all other commit-
tees or groups have advisory powers or delegated powers x)nly; nor should
powers be delegated by the board save to committees which include some of
•- its own membership. Delegation of power to other committees almost
invariably leads to division of authority and confusion in administrLtlon.
In a few hospitals where numbers of different boards and committees
exist, a simple remedy is practical — consolidation. There are usually found
* certain number of active members within each committee, just about
enough altogether to make a single effective governing body.
A board of trustees of a hospital ought to include within itself all the
chief elements with which the hospital is concerned. Boards frequently
suffer from being composed entirely of business men. Boards of trustees
should include other elements which enter deeply into the work of a hospital.
Education is one of a hospital's interests, in relation to nurses, to medical
study, and to the community in general along health lines. Every hospital.
Particularly those connected with medical schools or maintaining training
schools for nurses, should include in their boards one or more persons inter-
ested in or connected with educational activities. Men and women concerneil
>n the philanthropic and social service relations of a hospital likewise repre-
sent an element which ought to be on every hospital board. Selection of
pewonnel from the business, educational, philanthropic, and other elements
which ought together to make up the circle of interests of a hospital is no
easy task, for the group as a whole must not be too large, it must be har-
^nious, and must be capable of prompt and effective action Such mingling
w interests in the personnel of a board is a goal to be sought for. Men
^ experienced in the management of business affairs constitute a necessary and
Suable element, but men and women interested and concerned with other
sctivities need to be sought for and included.
r It is perhaps not quite clear to the average person why the physicians
r ^hodo the medical work of a hospital should not be members of its board of
f «listees. The accumulated experience of hospitals throughout the country
V,
*It » weU to restrict the use of the word "Board" to this one body, and to use the term "com-
'^'ittee" for all other groufM, medical and lay.
842 Hospital and Health Survey
is against such membership. The physician who is on a hospital staff or
who is in active practice will have, if a member of the board of trustees, a
double position and a double interest. The word double is not to be inter-
preted as meaning selfish. As a member of the board, the physician is in a
position of authority over the hospital policies. As a member of the staff,
he is connected with the conduct of a definite piece of work — carrying out
these policies within the hospital. So long as hospital staffs are made up
of practising physicians, each of whom gives a portion of his time to the hos-
pital service, the selection of a few of these men for membership on the board
of trustees is certain to create diflSculties. The medical knowledge and in-
terest of the physician is the professional guide to which the board of trus-
tees must give attention, but this guidance from the medical staff can best
be furnished through the medical staff's own organization, acting as a pro-
fessional body and related to the board through a suitable committee and
through the superintendent.
The nursing work of a hospital is another element of great importance in
the daily administration of the hospital, and one which at the present time
presents especial diflSculties. A special section of the report of the CIe\'eland
Hospital and Health Survey is devoted entirely to nursing (Part IX.) Here it
may be mentioned merely that the relation between the nurse and the hos-
pital administration in the past has been largely through the nurses' train-
ing school. As the nursing report shows, hospitals have been too ready to
utilize their training school for nurses as a means of securing cheap labw.
Part of the young woman's payment for receiving education in nursing has
been rendered by giving manual service. Nurses are too much in demand
to permit these conditions to continue. WTiile part of the education (rf a
nurse lies necessarily in the hospital and dispensary, where practical ex-
perience must be gained, the education of the future nurse and the daily
conduct of the hospital routine cannot be identified so closely in the future
as they have been in the past. The education of nurses must stand in a
greater measure on its oi^ti feet, as an educational enterprise, aflSliated with
the hospital more along the lines of the affiliation between medical school
and hos])ital. The routine work in caring for patients must be conducted
in a larger measure by women who have already had their educational train-
ing for the work, and who do not receive an educational course as part of
their compensation. The varied activities which have been carried out in
the past by the graduate nurse and the pupil nurse must in the future be
<'onducted by an apportionment of tasks among graduate nurses, attendants,
maids, and orderlies.
In its relation to hospital organization, this may mean physical separa-
tion between the training school and hospital in many instances, as out-
lined in the nursing report. The conduct of training schools by hospitals
as part of their own organization requires special knowledge and usually*
special committee, in order that educational policies may be developed, and
educational standards maintained. For these reasons, the special training
school committee recommended in the plan of organization is deemed <fc-
sirable. The relationship pro])osed between the trustees, the training
school committee, the superintendent of the hospital, and the head ol tfc
niirsinfj; service, should be considered carefully.
HofiPITALS AND DISPENSARIES 84S
The social service department represents the newest element to enter
the hospital, and its position as yet has not received universal recognition.
In a number of the best institutions, however, in Cleveland and elsewhere,
the social service department is developed and its place is fairly well defined.
Few boards of trustees and few superintendents have at the present time
fuflScient knowledge concerning the policies and the methods that should
prevail in a social service department to be able to guide it properly. A
special social service committee is therefore thought desirable, to serve with
advisory powers only, and to help in developing the social service of the
hospital so as to be of the maximum assistance to its medical work.
A failure on the part of the board of trustees to give suflScient authority
to their executive officer, the Superintendent, is another source of weakness
in not a few hospitals in Cleveland as elsewhere. More than one executive
head in an organization is an obvious weakness and danger. To manage
a modem hospital with all of its varied interests and all the widely differing
groups within its personnel, requires a man or woman of unusual ability and
tact, and with special training. Everywhere in the country the number of
such qualified persons is at present far below the demand. The board and
its advisory committees need to supplement the superintendent in advisory
« well as in directing ways. It will be observed that according to the plan
for hospital organization outlined in the following, the superintendent stands
in a central position, meeting with the board on the side of hospital adminis-
tration, and with the medical executive committee on the side of the hos-
pital's professional activities.
A third aspect, which is not mentioned in the plan of organization, but
'whidi may be ti^ken for granted, is the superintendent's relation to his
•dministrative departments; the steward, the dietitian, the engineer, as well
«s the head of the nursing and of the social service departments. Periodical
<50irfeTences between the superintendent and the administrative group are
^feiiable. Medical, nursing, social, and administrative interests within the
™pital render it desirable that from time to time representatives of all the
™erent groups be brought together for their better mutual understanding.
Recommendation number 6 points in this direction. It is particularly im-
portant that members of the board of trustees shall understand personally
tne hospital inter-relationships and the different parts of its work, and that
"^€y shall come into contact at first-hand with sources of information,
"urough such conferences held from time to time for the discussion of selected
problems, this can be achieved. There is no stimulus to members of a
jwiaging board like direct contact with facts and with the people who are
doing the work over which they have authority.
'*What is the whole duty of a Trustee?" is perhaps the fundamental
question concerning hospital organization. How is a man or woman living
"?» great city and with business or other definite vocation, to give sufficient
^^ to a hospital really to understand its work and to be able to meet to
f*^full the responsibilities of trusteeship? The question cannot be answered
^ general terms, for the activities of a modern hospital are so varied and so
^•clinical tKat few members can come into sufficient touch with all of them
to have sound judgment upon all questions that may arise regarding any
844 Hospital and Health Survey'
one of them. Yet, by division of labor among the members of a board, and
above all, by a really active sense of responsibility made effective through
the leadership of the president or other 'officers, a reasonable degree of knowl-
edge of the work of the hospital can be gathered by each member, and the
sum total, when the board gatliers together, will be sufficient to render
the trustees a truly responsible governing body.
It is of particular importance that the tnistees understand what facts
they should know of periodically, so that these may be presented in the
monthly and annual reports of the superintendent. The percentage of beds
used in each division of the hospital has already been mentioned as one of
these important facts. The length of stay of cases in the different divisions
of the hospital is another. At the time of the Survey census, it was found
that taking the general hospitals of (>leveland as a whole, 44.6 per cent, of
the patients had at that time been in the hospital from three to fourteen
days, 13.2 per cent, had been in the hospital less than three days, 19.2 per
cent, between fourteen and thirty days, 9.2 per cent, between one month
and two months, and 12.9 per cent, more than two months (9% not stated).
The proportion of cases staying for these longer periods is higher than it
should be in hospitals designed primarily for acute stages of disease. The
reason lies largely in the lack of dispensaries and of facilities for convalescent
and chronic patients in Cleveland, to which attention will be devoted later
in this report. A study of individual hospitals showed wide variations in this
figure, ranging from no patients staying over sixty days to as high as 29.9
per cent. A report showing the length of time that patients have been in
the hospital, and the number in the ivarious divisions of the hospital who
had been there more than a normal period, should be of distinct value to the
trustees as well as to the medical staff and the superintendent.
Statistical record of patients who have been refused admission is another
item of significance. Monthly reports should show the number of refused
cases, classified by the main type of case, i. e., medical, surgical, children's,
etc., and classified also according to whether the applicant was for a pay.
part-pay, or free bed, and with classification according to reasons for re
jection. Not a few hospitals fail to keep any memorandum of cases refused
admission because of lark of room or other reasons. Data as to whether
or not a waiting list is maintained, or whether refused cases are placed on
the waiting list, are also of value, although the maintenance of a waiting list
is not always practicable.
Statistics regarding the results of care have been developed somewhat
through the American College of Surgeons, but their further development
and the regular reporting of the condition of patients at discharge and at
specified periods thereafter should be part of the regular reports of hospitals
in the future. Similarly in dispensaries, the trustees should know what:
proportion of patients pay one visit and never come back to continue needed
treatment.
Those items arc mentioned here merely as illustrations and of course aK*
in addition to the ordinary statistics of the number of patients admitted, th^
77/;mber of units of work done in each of the chief divisions, and the financia'
lOBPTTALS AND DISPENSARIES 845
Sgures showing income and expenditures for the various departments of the
institution. In the section on individual hospital planning we shall return
to this subject and summarize the more essential facts which a hospital or
dispensary should gather and present regularly for the information of its
governing body, its supporters and the public. To substitute guidance by
facts for guidance by impressions and by hearsay is the goal of the best ad-
ministration.
SUAfMARY OF Pi^INCIPLES OF HOSPITAL ORGANIZATION*
1. The final governing authority of the hospital should be a Board of
Trustees. No member of the Board should be a member of the active or
(x>nsultant medical staff of the hospital. Hospitals which are under a re-
ligious or public city or federal organization and which therefore cannot
have Trustees, should appoint an Advisory Committee similarly constituted.
In addition to the men members of the Board of Trustees who represent
diiefiy financial, administrative and broad public interests and experience
it is of much importance that there be included on the Board of Trustees a
representative of some institution of higher education, viz: University, Nor-
mal College and women members whose experience and interest can be relied
upon to contribute constructive ideas and opinions.
2. The appointment of the medical staff should be vested in the Board
<rf Trustees. All members of the staff, chiefs of services, or assistants should
be appointed by the Board for terms of one year renewable by the Board.
The nomination should be made on the initiative of the Board of Trustees
or of the Medical Staff or of an executive committee of the medical staff.
The Board of Trustees should consult with the Superintendent, or Chief
Executive OflScer, before confirming the nomination of a Medical Staff, or of
individual members thereof.
3. The Superintendent of the hospital should be app>ointed by the Board
He should have entire administrative authority over all departments of the
hospital. Under the rules and regulations adopted by the Board of Trus-
*tts, the Superintendent of the hospital should have authority to nominate
o^ appoint all heads of departments and employes. This implies the au-
^ority for discharge or dismissal of any employe for cause. The superin-
tendent should be the representative of the trustees in relation to the staff
0^ outside interests.
4. The medical staff should be definitely organized for the promotion of
*fwn work, common policies and satisfactory relations with the administra-
tis of the hospital. Regular meetings of the medical staff or sections
"hereof should take place for the discussion of professional work. For
^idance in organizing such professional conferences the recommendations of
^« American College of Surgeons are called to the attention of the medical
'ttf s of hospitals. The staff should be organized into divisions or services,
Medical, surgical, etc. It is desirable that there be a recognized chief for
^h division.
* Prepared in collaboration with Haven Emeraon, M. D., Director of the Survey, and W. L. Bab-
^'ock, M. D., oonstiltant on Hospital Administration.
846 Hospital and Health Subvet
(a) Provision should be made in the By-laws of the Hospital for the
recognition of physicians, not members of the staff, whose practice in the
hospital complies with definite hospital standards. It is recommended that
these physicians organize into an auxiliary staff* without service or voting
power, and that a delegate or delegates from this staff be recognized by the
Trustees and Attending Staff as their representative.
5. There should be a Medical Executive Committee composed of mem-
bers of the medical staff, selected by the medical staff or by the Board of
Trustees on the nomination of the medical staff. The Superintendent of
the Hospital should be a member of this Committee. The total member-
ship of the Committee should not be so large as to be unwieldy. Seven
members is generally the maximum desirable.
6. It is recommended that the Board of Trustees of hospitals arrange for
periodical conferences of designated members of the trustees, of the medical
executive committee, the superintendent and administrative oflBcers such as
the heads of the training school or nurses' service, and of the social semce
department. This joint group should meet periodically for the discussion
of hospital policies or administrative matters.
7. The staff of the dispensary or out-patient department should be ap-
pointed according to the principles above laid down and the physicians
serving in the dispensary should receive definite recognition as members of
the hospital organization and staff. For each department of the dispensary
there should be designated a chief of clinic who should be under the general
authority of the chief of the corresponding department of the hospital, but
who should be directly consulted by the superintendent or the assistant
superintendent who is in charge of the dispensary on all matters affecting
the dispensary. The chiefs of the dispensary service should constitute a
Dispensary Medical Committee which with the superintendent, the assistant
executive in charge and such others as may be designated should meet from
time to time on dispensary matters. It is suggested that a representative
of the dispensary staff be a member of the Medical Executive Committee.
8. The medical staff of the hospital acting thru the Medical Executive
Committee and the Superintendent should formulate a definite set of stand-
ards, subject to ratification by the Trustees, for all professional work of phy-
sicians in the hospital touching such matters as attendance, the making
and sii])orvision of records, diagnosis, use of laboratories, X-Ray and other
diagnostic aids, the duties of residents and internes, the inter-relation of
staff physicians and outside physicians, the matter of fee-splitting, etc.
9. Physicians not members of the hospital staff should be entitled to
send to the hospital and to treat therein private cases in rooms or wards,
subject, however, to such limitation as to number of beds to be allotted to
outside physicians as may he formally made by the Trustees, and provideo
that the phvsicians treating such cases conform to all standards made by
the McdicafStaff.
HOBPTTALS AND DISPENSARIES 847
^■^— ^""^^ * ■■ I- ^.ll, ■!!■■ I ■■— ■ »■■ — »l ■■■■I, »■ ■ >■■
10. No physician should receive a fee from patients other than snch fees
as may be permitted to staff physicians nor should any physician receive a
fee from a patient unless the charges for the hospital care have been met
according to the rate established for various rooms or wards for members
of the staff and outside physicians alike.
11. In such hospitals as may still continue to keep a training school as
part of the hospital organization there should be app>ointed by the Board of
Trustees a training school committee composed of both men and women,
to direct educational policies. This committee should include representa-
tives of the Board of Trustees, with other persons known to have had experi-
ence in education, and also members of the alumnae of the nurses' training
school. The superintendent of the hospital and the director of the train-
ing school in the hospital and representatives of the medical staff selected
by the medical executive committee, though not members of the training
school committee should sit with the committee.
^ ^ Among the Catholic hospitals or in hospitals administered under a re-
ligious organization which have no boards of trustees and are subject to the
directionl.ofithe Bishop of the diocese, a committee on the training school,
advisory tto; the Bishop, might with advantage be established at once to
direct thejeducational policies of the training school.
The relationship between schools of nursing and hospitals should be
cMentiaUy the same as that created between medical schools and hospitals.
The School of Nursing, like the medical school, should exist primarily to give
technical education to students who are to obtain part of their training in
^ hospitals.
An ideal organization for a school of nursing which should be realized in
Cleveland as soon as circumstances permit is clearly the University organiza-
tion in which ward training would be given in such hospitals as come up to
the conditions required by the University for educational purposes for its
•Indents.
12. The superintendent of nurses in the hospital should be appointed by
the Board of Trustees of the hospital, on nomination of the superintendent
^ the hospital with the concurrence of the training school committee. She
«^ould have administrative authority, subject to the superintendent of the
hospital, over the entire nursing service and she should be responsible for the
educational standards and policies as laid dowTi by the training school com-
^ttee. It is considered desirable that the superintendent of the hospital
*nould delegate to the superintendent of the training school the appointment
^i dismissal of nursing personnel.
xhe offices of principal of the training school and superintendent of nurses,
•[e educational and athninistrative offices, respectively, and may or may not
^ combined in the same individual. When they are combined the head of
^c training school should be designated ** Superintendent of Nurses and
^^cipal of the Training School."
848 Hospital and Hcalth Subtei
13. The Social Service department of the hospital should be unda the
direction of a head worker who should be responsible to the superintendent
It is recommended that there be a Social Service Conunittee, which among
other members, should include one or more of the trustees, of the medid
staff and the superintendent of the hospital.
>iTALs AND Dispensaries 849
THE HUMAN PROBLEM OF THE HOSPITAL PATIENT
Treat not only the disease, treat also the man. " These words of Ru-
1 Virchow set the standard for the highest form of hospital service,
two or three thousand patients who are in the hospitals of Cleveland
, present the hospitals not only with a variety of bodily ills, but with
lems of personality and environment which are as varied as human
re, and which influence vitally the ultimate success of the hospital's
on to maintain as well as to restore health.
Irchow's words set not only a standard but express a warning, for the
ital's great danger is overspecialization — attending to pathology and
looking personality. Successful work in the operating room may be
Dendent of what the patient is or thinks or feels, but successful restora-
of the patient to health and living eflSciency depends not only on the
*ry but on the patient's state of mind after he goes from the operating
[ to his bed in the hospital and from his bed in the hospital to his home.
•
Q a survey it is necessary to consider persons as well as patients, in
p that a true picture be given of the hospital's services, of theijp relation-
i to the community, and of their values and deficiencies, as judged by
inal results in making people well and humanly eflScient. The Survey
Jierefore endeavored to study the people and their reaction to the hos-
s of Cleveland as well as the hospitals of Cleveland in their relations to
people. Several hundred interviews and conferences were held with
icians, including both members and non-members of hospital stafiFs;
nurses in hospitals and in public health fields; with social workers;
organizations of the foreign-bom; with church workers; and with people
more or less at random in their homes or elsewhere.
hose who are accustomed to hospitals too often fail to recognize how
and strange an experience, to the average patient, is his first contact
a hospital. The admission procedure, the unfamiliar antiseptic odors,
light of many sick people, the precise business-like eflSciency of hurry-
lurses and doctors, fill many a patient with vague and uncertain ideas
hat may be going on behind the many closed doors, and what may
be happening to himself. Courage is easily lost in the strange insti-
nal atmosphere. The educated man who is familiar with hospitals,
ig previously been a patient or a visitor, and who is self-confident and
ise even during sickness, is in quite a dififerent position from the un-
med immigrant who has never had contact with doctors or hospitals
5 life, or the timid woman, or the sensitive child.
t is not that hospitals or their personnel lack kindness in the treatment
e patients. It is their business to be helpful, and hospitals and their
)rs, nurses, and other personnel generally are, but it is rather that hos-
i are helpful in a professional and technical way, while the patient is
ally full of worrying questions he would like to have answered, of fore-
igs which it would be desirable to dispel of states of mind which depress
and which, if maintained, will hinder his recovery. These forebodings
850 Hospital and Health Survey
and these states of mind require not merely a general attitude of kindness,
but sympathetic insight, clear analysis, and definite action to dispel.
The human problem of the hospital patient can be perhaps best illustrated
by the foreign-born. On the two Survey census days, 63.1 per cent, of the
adult patients were American-born, and 36.9 per cent, were foreign-bont
According to the estimates in 1917, of the Cleveland Americanization Com-
mittee, there were 744,728 total population in the city, of whom ^1,939
were of foreign birth, 466,142 native bom of native parents and 281,586
native born of foreign or mixed parentage. Those of the third group ait
largely children. Taking these figures, we find that the 231,939 foreign-
born are 49.7 per cent, of the 466,142 native bom of native parentage. TTiis
figure may be roughly compared with the percentage of foreign-bom adults is
the hospitals of Cleveland, which was just stated as 36.9 per cent. This illus-
trates an important point which studies in other conmiunities have verified
— that the foreign-bom adult generally uses the hospitals less than the
American-born adult. This is largely because of lack of familiarity with an
institution wjtli which many immigrants had little experience, pre%nous to
coming to this country. It must be remembered that a large number of
recent immigrants have come from small towns and many of them think,
"Hospitals are places where you go to die." A considerable proportion of
the foreign-born patients, moreover, speak little or no English.
The attitude of the foreign-born toward the hospital reflects all the lights
and shades of the hospital's own attitude toward its patients of foreign
birth. Frequently the very human and impressionable surface which the
foreign -born presents ready for the hospital's sign and seal, is masked be-
hind an enforced silence because of unintelligible speech. Too often the
phrase ** those ignorant foreigners'' shows merely lack of understanding by
the American -born. A common language is the searchlight most useful in
discovering physical, racial, or temperamental needs, and means of adjust-
ing the hospital regime to treat these. When the hospital has given time and
thought to its task, it has been able through sympathetic interpretation \o
convince the patient of its friendly interest, its ability in diagnosis, its skill
in treatment, and when this conviction is made doubly sure by intelligent
follow-up work in the home, there is every evidence that tlie hospital's work
is worth while, that the ])atient is grateful and appreciative, and that the
experience has been of permanent educational value to him in the matter rf
personal and j)ul)lic health and in the growth of a sense of social and cmf
particii)ation.
The result is different when the hospital has had no spec»ific machiflcry
for gettinj^j at tlie back of the foreign i)atient\s mind, and making tlie some*
wliat inflexible and mysterious hospital routine less a puzzle to him. The
patient's mild skci)ticisni as to wlietlier American hospitals are good pla<^
for the foreigTi-])orn, increases to a large doubt. This is further enlarged by
his friends, wlio have trouble in being understood at the inquiry' desk; ^ho
may he una})le to talk with tlie doctor or to get the diagnosis. If a medical
case, the patient worries through a retarded convalescence and goes boo*
lad to be free- and wondering I If a surgical case, often his climax oi
Hospitals and Dibpensaries
851
protest against the vast unknown of hospital machinery is a refusal to per-
mit operation. He leaves against advice, grateful for the somewhat peremp-
tory discharge of the hospital, which in turn, feels inwardly afiPronted that its
effort to help should be powerless before his unreasoning "stupidity."
In seven hospitals the proportion of foreign-bom adult patients was over
80 per cent., the maximum being as high as 47 per cent. No hospital in
Cleveland has made any definite provision for interpreters, either as a
matter of promoting the ease and comfort of the patient, or of increasing
hospital efficiency. As a rule the hospital is concerned with "making the
patient understand" — "We manage to make them understand somehow."
Some other patient of the same mother tongue who has learned English is
Eressed into service, or an employe or a visitor is called upon. The prob-
5m, however, is not merely "making the patient understand, " but is to render
the i>atient "understood. "
The following table, based on the average of the two Survey census days,
showed an interesting phase, the contrast between the proportion of pay,
part-pay, and free patients among the adult foreign-born and the American-
born patients in the hospitals of Cleveland.
Hospital Patients on Two Survey Census Days, Averaged
American-bom Foreign-bom
Number Percentage Number Percentage
Pay. 989 39 . 2 351 23 . 8
Part-pay. 735 29.1 444 30.1
Free 733 29 .1 631 42 . 8
Information not furnished 66 2.6 48 3.3
Total'. 2 , 523 1 . 474
The table indicates what one would expect, that the foreign-born show a
much larger proportionate use of the free beds. The generally higher eco- *
nomic status of the American-bom is doubtless sufficient explanation.
One important relation of the hospital to the community is the furnishing
^ information about the condition of patients. Patients themselves want to
know how they are getting on, and their relatives and friends likewise wish
"Us information. Hospital staffs and administrators must use their dis-
^tion in what they tell the patients or relatives, just as private physicians
^» yet the hospitals often fail to give elementary and necessary information
^to give it in a way which will be helpful or even useful.
. Many inquiries come by the telephone. A story has been reported of an
'Jnmigrant family, very anxious to secure information as to the condition of
tte father who had been taken to a hospital after an accident. Unable to
SS'i Hospital and Hsalth Svsvet
speak English, the mother and her children had recourse to the neighbor-
hood druggist. He called up the hospital three times, and was unable to
learn anything that would either satisfy himself or relieve the family's
acute anxiety. The error was not inhumanity on the part of the hospital,
for the information was later furnished readily, but was due to the fact that
the telephone operator had not been taught to appreciate the importance of
interpreting the hospital to the public. This incident would not be men-
tioned were it not an illustration of many.
The importance of this duty is often not sufficiently clear to the hospital
administration to make them provide adequate instruction to the person or
persons who are responsible for answering such inquiries, either in person or
over the telephone, or to cause the selection of a sufficiently trained and
tactful person to perform this function.
Sometimes a mother is eager to see her child frequently. There are
often perfectly good reasons why she should not see the child at all or during
certain periods, but not infrequently there is failure to explain to an anxious
family why the privilege is denied.
Interpretation of the hospital's work, rules and results to the public is
part of the hospitafs job. The public includes its own patients, their reli-
tives and friends, and also the broader circle of the hospital's supporters,
and any one in the community, in fact, who has a reason to be interested in
the hospital's activities. This interpretation of the hospital's work, rules
and results, is made partly in the hospital's formal reports and partly throu^
its daily relations with its patients and those interested in them. Too little
attention has been given to such interpretation through the channels of the
hospital's routine contacts.
The patient's lack of understanding of the hospital is too often matched
by the hospital's lack of understanding of the patient. The patient can be
greatly helped to understand the hospital by the right procedure at the time
of admission. Hospitals wdiicli maintain dispensaries should use the dis-
pensary as the means through which patients are admitted to the wards.
The provision of a trained and tactful member of the social service depart-
ment in connection with the admission desk of the dispensary will serve to
start many patients, who will later be referred from the dispensary to the
wards, with some understanding about hospitals in general and this hospiul
in particular. From this standpoint, the two critical points in the patients
hospital career are the day of admission and the time of or just before dis-
charge.
A considerable portion of patients are sent to the hospitals by charitable
societies. On the Survey census days, it appeared that an average total of
201 patients, or 11.8 per cent, of all patients, had been admitted to
hospitals at the request of some charitable agency. In the case of these
patients, the charitable society stands to the hospital as an interested party-
If its work with the patient and w ith the family is to be successful, it m*/
need to know the physical condition of the patient, and the prognosis. 1^
3j08fitals and Dispensaries 853
is the duty of the hospital to cooperate with the charitable society by fur-
nishing the necessary information, consistent with the interests of the in-
dividual patient.
The hospitals have not always met this responsibiUty completely or wisely,
because of the same deficiency just mentioned, lack of a definite sense of
responsibility for interpreting the hospital's work, and failure to assign a
suflSciently trained and responsible person to the task.
A considerable portion of the patients in some institutions come as in-
dustrial accident cases, or are sent through a medical department conducted
at some commercial or manufacturing establishment. The special report
of the Survey on industrial medicine and hygiene (Part VTI), deals with
this matter, but in an industrial community like Cleveland its importance
justifies mention here. The hospitals need to serve industry, and industry
should support the hospitals adequately in return for service.
What can the hospital do in relation to the difficult problem of the foreign-
bom who do not speak English? The calling in of paid interpreters is finan-
cially impossible in most of the smaller hospitals. Moreover, no one inter-
preter can speak every language and almost any language of western Europe
is Dkely to be called for sometime. Few if any hospitals could afford even
one fuU-time interpreter, or could manage to keep such a functionary busy
with the particular patients whose language he could speak. The problem
of hospital interpretation cannot be solved by paid interpreters employed by
the individual hospitals. The chief practical recomimendations to be made
•re these:
If a hospital and its out-patient department are taken together, a sufficient
number of patients speaking a given foreign language or group of related
'^iiguages might come to the institution on an average day to justify and
'ttiuire the entire time of an interpreter, and the work in the two branches
could be adjusted so as not ordinarily to conflict. The use of full-time in-
terpreters, however, doing no other work, must necessarily be limited to
TOy large institutions, such as the new City Hospital will be. Most hos-
pitals which receive patients not speaking English should solve the problem
^ interpretation by depending on specially trained nurses or social workers
^ by calling in the aid of outside organizations interested in the foreign-
"oni or of the foreign-bom themselves. Hospital superintendents in engaging
^ployes for certain positions should consider ability to speak certain for-
^ languages as an asset and a reason for the engaging of a particular
"^dividual. Really good interpretation in securing medical and social his-
tories and in meeting the patient's human needs while in the hospital, cannot
be obtained by calling in an uneducated orderly. The main reliance should
be upon nurses and members of the social service department who have a
^finite professional sense of responsibility for the hospital patients.
In communities having a considerable number of foreign-bom of any one
^ group, cooperation can usually be obtained from immigrant organiza-
^ons themselves. These organizations should be encouraged to serve as
854 Hospital and Health SuRvn iv^
visitors to patients of their own race who have not other friends and in hop-
ing with the more difficult and special cases in which interpretation is neces-
sary and beyond the power of any employe of the hospital. Enough hos-
pitals are now utilizing outside cooperation of this sort sufficiently to show
that it is gladly provided by immigrant organizations (or by Americu
immigrant welfare societies where they exist) without cost to the hospitil
and to the mutual benefit of both sides. Such an arrangement with immi-
grant organizations would go a long way toward promoting general under-
standing of the hospital by the people of that group in the community.
These plans, however, cannot be efiPective unless some department of the
hospital and ultimately some individual is definitely charged with organizing
and keeping up the system of interpretation. Generally speaking, the sociw
service department should be charged with this responsibility and some member
of the stafip of the department should be selected to carry out the responsibility
who is especially qualified and interested. A hospital which has any con-
siderable proportion of foreign-bom patients should make a point of having
in its social service department someone who is able to speak at least one of
the foreign languages common among patients and who has secured special
knowledge and training in the backgrounds and characteristics of seveni
immigrant groups so that she is capable of fulfilling these duties. This will
involve some inside work with various hospital employes, particularly nurses
and other members of the social service department; the use of phrase boob;
the encouragement of various means by which nurses and social workers
may secure knowledge about the backgrounds and characteristics of the
chief immigrant groups. An efiPort should be made to interest internes in
the same, and this should have the support not. only of the hospital superin-
tendent but of the chiefs of the medical staff. It should be made apparent
that thus better histories can be obtained, better cooperation of the patient
secured, and better medical results achieved.
The critical moment for tlie ])atient, from the standpoint of disease, is
often the time of admission to the hospital, but the critical time for the
patient from his standpoint as a person is usually at or a little before dis-
charge. In the discussion of the problem of convalescent care (page 000) ynH
he found statistics indicating that a large majority of hospital p)atients
leave the hospital needing some definite form of medical care, either in their
homes, in a (iisi)ensiiry, or in an institution for convalescents. The
information gathered in Cleveland agrees entirely with the studies and
estimates of Dr. PVederic Brush, the leading national authority on con-
valescent care, that the medical job is not done at the time the patient
leaves the hosj)ital. The hospital's responsibility as a hospital is not always
to do this medical jol), hut it must link the patient with the physician, the
disj)cnsary, the convalescent home, or other organization which will perform
the n(H»ded service.
The beginning of this connecticm is the explanation to the patient (or
to his parents, if tlie j)atient is a chihi) of the patient's condition, in terms
that will he un<lorstoo(i by the lay mind; of what need exists, if any, for
further medical suj)ervision; or of what daily routine of diet, hygiene.
SoBPTTALS AND DISPENSARIES 855
siercise, and occupation is desirable during the period after discharge.
Explanation to the patient or to those responsible for the patient, of the
latient's condition on discharge and what may be called the needed pro-
;ram for after-care, is a definite responsibility which few hospitals in Cleve-
uid have met, save in exceptional instances. It is part of the hospital's
esponsibiUty to have a definite system for meeting this need.
At a few hospitals there has been established a so-called follow-up sys-
em, usually modeled upon that of the American College of Surgeons. This
ims to secure for the medical stafip the results of operations or the condition
f the patient at a certain period after discharge, such as three months,
ix months, or a year. Such information is of medical value to the staff,
nd in the long run will tend to the advancement of medical science and the
mprovement of service to patients. But the term ** fish-up" instead of
follow-up" should be applied to a method which merely secures facts as
o a patient's condition a certain time after he is. discharged, and does not
Q some definite and effective way help to make the conditions during this
leriod what they should be. A follow-up and not a fish-up system is the
tandard which should be set in a progressive community like Cleveland,
rhich wishes to obtain 100 per cent, value from the medical work of the
[istitutions which it supports.
When it is found that six per cent, of 200 patients recently discharged
rom four of the leading hospitals needed continued hospital care — in other
irords, had relapsed since their discharge; when it is found that 1S.5 per
ent., in addition, were living under such home conditions that satisfactory
onvalescence was unlikely (See Table VII., Appendix), it is apparent that
•zpensive hospital service is easily wasted because of the lack of a little fur-
her service which would have made all the preceding work permanently
iirorth while.
"Should the social service department have the responsibility for the
)roblem of after-care?" No! The medical staff of a hospital have the
*esponsibility for the care of its patients, and making a medical program
or after-care is a part of that responsibility which cannot rightly or effec-
tively be delegated. When it comes to carrying out the details of the work,
the social service department has a definite place, as will be brought out
more fully later in discussing this subject. The social service department
2&U assist the staff of the hospital in securing the facts regarding the pa-
tient's personality, family housing, home conditions, neighborhood, and
finances, which in conjunction with the medical facts known regarding the
patient's condition, will enable the responsible member of the staff to for-
mulate a program for after-care. When it conies to assisting in carrying
out the program, the social service department generally has Ijeen and
usually should be called in, either to make explanations to the patient or
to arrange for contact with the Visiting Nurse Association, the Department
of Health nurses or a charitable society which will he able to exercise super-
irision, to assist in improving home conditions or in securing the institu-
tional care that may be required.
As the facts in the section on convalescence bring out, the need for finan-
:^ial aid during after-care is approximately much less frequent than the
856 Hospital and Health Svbyet
need for explanation and advice, given in terms of the patient's d^ree dF
education and understanding, and of the practical conditions of his environ-
ment.
The dispensary attached to the hospital sliould be used as one of themeani
of providing after-care of discharged patients. Reference of the patient
to the dispensary should be made in every instance where further super-
vision is necessary and the patient cannot pay a private physician. The
follow-up system should insure the actual return of the patient to the dis-
pensary in a large majority of instances.
In summary, the patient's lack of understanding of the hospital needs
to be overcome by development of the admission procedure, which shouU
be concerned witJi more than the elementary procedi^e of registration,
assignment to a definite ward or room, and fixation or remission of fees, and
which should include educational and interpretative elements. The special
problem of the non-English speaking foreigner should be met at the time
of admission, and later through some definite provision for interpretation,
both by hospital personnel and through the cooperation of associations
interested in immigrants, as above suggested.
The utilization of the dispensary as the place of admission for ward
patients will, if the dispensary admission system is rightly organized and
its personnel rightly selected, enable the average ward patient to go into
a hospital bed with some previous understanding of the situation.
The hospital has a definite responsibility for interpreting the patient's
condition to him or to those responsible for him, in terms which can be
understood by laymen and which will be a practical help; also of explaining
and of helping (at least in the l>eginning) in the needed program for medical
after-<*are. This is part of the medical responsibility of the hospital, and
while a social sen'ice (le])artment is of great assistance both in securing
facts regarding the patient's jjersonality and environment, and in helping
to carry out the medical after-care or referring the jmtient to an agencj'
which will do so, a hospital which has no social service department should
still be responsible and Ix^ able actually to provide for at least tlie explana-
tion to the imtient or his relatives, and the definite reference of tlie \yaikni
to the needed sources of after-care.
The medical staff of the hospital, through its executive committee,
should l>e exi)e<*ted to define the duty of the hospital in this respect, so the
administrators of the hospital can have medical authority behind tliem for
seeing that tliis rcs]>oiisibility is carried out by visiting and resident staff,
nursing and administrative assistants, and by tlie social service department
if tlierc is one.
Answering inquiries regarding patients is a definite pwirt of the hos-
pital's duty to the community and should be fulfilled according to a defi-
nite coo|>erative policy by carefully instructed members of the hospital's
administrative personnel. Cooi>eration with charitable agencies in behalf of
their p;iticnts is a particularly significant responsibility of the hospital,
affecting no inconsiderable proportion of the ward patients.
HOBPTTAUS AND DISPENSARIES 857
•
In the long nin, the degree of support of the hospitals of Cleveland will
depend upon the degree to which their work is appreciated by the com-
munity. The elaborate facilities, equipment, staff, and organization needed
for the thorough study and treatment of hospital cases require an increas-
ingly high degree of appreciation on the part of the community of just what
Itospital work is, what it requires, and what it costs. The foundation of
appreciation is understanding. Anyone grasps the beneficent service of a
hospital to the emergency accident patient, but understanding of the less
obvious and more typical cases, which constitute the large majority of pa-
tients, is not so easy. The patient's lack of understanding of the hospital is
pardonable at the time of entrance. The patient's lack of understanding of
the hospital at the time of discharge is a misfortune to the patient and to the
hospital as well. Only on the basis of mutual understanding can adequate
support for the bes^ospital work be built up and maintained in Cleveland.
858 Hospital and Health Survey
THE MEDICAL PROFESSION AND THE HOSPITALS
In the City of Cleveland the American Medical Directory of 1918 gives i
list of 1,169 physicians, of whom 1,050 are stated to be in active practkx.
A tabulation of the staff lists of the members of the Hospital Council showed
that 309, or 29 per cent, of the total were on the staff of a hospital or dispoi-
sary, while 71 per cent, had no such connection. Allowing for the small
number of additional physicians on the staffs of the non-council hospitals, it
is certainly true that two-thirds of the medical profession appear to have do
connection with organized medical service.
A similar comparison made about five years ago in Boston indicated that
the proportion of physicians having a hospital or dispensary connection was
about 50 per cent, larger. In New York, figures collected by the Public
Health Committee of the Academy of Medicine indicated that almost
exactly 50 per cent, of the medical profession in New York were on hospital
or dispensary staffs. Cleveland thus has relatively more physicians than
either of these two cities who are not members of any hospital or dispensary
organization.
It is apparent that so far as membership on a hospital staff impUes ad-
vantages for the scientific study of disease, for the use of special equipment,
and for consultation with specialists, the majority of physicians of Clev^
land have not these advantages. So far as membership on hospital staff
gives control in the use of hospital facilities, tabulation of the Cleveland
hospitals by number of beds and size of staff shows that about 25 per cent, of
the medical profession have control of about 80 per cent, of the hospital
beds.
A patient may of course be admitted to a hospital at which his private
physician is not a member of the staff, but if the patient is a ward ease, the
physician then loses the right to treat him. General complaint was made to
the Survey during the first months of its work by physicians who were not
on hospital staffs, that they often could not secure admission of their pa-
tients to hospitals even as private eases, and of course they also complained
of the many instances in which the patients were admitted to wards, when
the care of the patients had to be resigned to the members of the regular
hospital staff.
A study of the sources from which patients were admitted to hospitals
on the two Survey census days showed the following:
Request for Admission Percentage
By staff physician 51 .3%
By non-staff physician ~ 33.2%
By charitable or relief agency 118%
Source not stated - 3 . 7
/c
Note — In this tabulation City Hospital, Warrensville Tuberculosis
Sanatorium, and Rainbow Hospital are omitted, as admissions at these in-
stitutions are on a different basis from those at general hospitals.
BOSPTTAI^ AND DISPENSARIES 859
^ —
These figures appear to indicate that a considerable number of physicians
lot members of the hospital staffs may and do send their patients to the hos-
pitals and treat them as private cases. It is quite evident, however, that a
arge number of the 1,050 practising physicians in Cleveland have little if
iny contact with the hospitals even in this way.
There are wide variations shown in the proportion of patients admitted
lirough non-staff physicians. The variation depends less on the size of the
ospital than on the number and organization of its regular attending staff.
lius some of the small hospitals have relatively large staffs, and physicians
ot members thereof apparently rarely secure admission for their patients.
hoL the other hand, some hospitals of similar size showed on the census days
high percentage of patients admitted by non-staff physicians — proportions
inging up to 83 per cent.
Figures for a group of large general hospitals may be of interest, as show-
ig the wide variation found. These are shown in Table V. in the Appendix.
Part-pay and free cases may be admitted through non-staff physicians,
lit are rarely treated by other than members of the regular staff. In the
roup of pay patients, on the other hand, there are a considerable number of
rivate patients among the cases which are admitted through non-staff
hysicians and who then usually remain under their care.
It must be recalled that these percentages relate only to the two census
ays, but there is reason to believe that the figures are representative of the
sual relationships between the patients admitted through members of the
taff and those admitted through non-staff physicians.
The general attitude of a hospital toward the non-members of the staff
is expressed by its admission policy. Most hospitals receive private patients
■ml most hospitals have a rule that such patients are accepted, when va-
cancies exist, from any reputable physician. In practice, however, it is rea-
BODable and inevitable that the members of the officially appointed attending
■taff have the closest contact with the hospital and are likely to fill a consider-
able proportion of its beds. When such shortage of beds exists as in Cleve-
j«iid, the difficulty felt by many physicians not on hospital staffs in secur-
ing admission of their private patients is not more than may be expected.
■There has been no substantial evidence that the administration of the hos-
pitals, year in and year out, has been unduly inconsiderate of the private
Physician of good standing who sought admission for his patient. Mem-
*^ of the official staff have received reasonable preference but this is only
^tural. Until more beds are available for private patients of physicians
** privately-supported hospitals, present conditions cannot be expected to be
Mically improved.
In a few institutions there has been found a practice, not formally recog-
^Ztd by rule, but real nevertheless — of holding beds vacant twenty-four
^Urs or even more because certain members of the staff were likely to wish
860 Hospital and Health Sub?ei
to send patients in. A practice of this kind is unjustifiable, but is excqh
tional in Cleveland.
A study of the degree to which members of hospital staffs overlap revealed
the fact that, except in the teaching institutions affiliated with Wesitn
Reserve University Medical School, there is no large degree of mult^
membership on hospital staffs. Even in the case of University teadiing
at Lakeside, City, and St. Vincent's Hospitals, there is little actual ovcriap-
ping of the staffs. The number of men holding positions in the staffs in ooe
or more hospitals in Cleveland is shown in the following table:
Multiple Membership on Hospital Staffs
233 physicians, or 22.2% of total number, serve on 1 hospital staff
55
w
«
5.2% "
u
«
tt
tt 2
tt
staffs
15
«
«
1.4% "
«
tt
tt
" 3
tt
«
5
«
«
0.5% "
«
It
tt
" 4
tt
i(
1
«
it
0.9% "
((
11
tt
" 5
tt
u
These memberships, however, include some inactive as well as active
memberships. In general, active membership in more than one hosptel
staff is not wise, except in the case of multiple membership held for teaciiH
purposes or in the case of men who are engaged in restricted specialties oi
medicine or surgery and can render these special services to a number ot
institutions with benefit to all. Of the 42 members of the City HospitJ
staff, 26 are nominally active members of other hospital staffs. This, how-
ever, is a teaching institution. The instances in which a physician is carry-
ing several active memberships in hospital staffs in Cleveland are propor-
tionately small. Some of these individual instances, however, are worthy
of notice, and the Survey, in its reports to the several boards of trusUes,
has called them to the attention of the individual hospitals concerned. A
position involving active service in one hospital ought to be sufficient for i
physician and it is wiser for his attention to be concentrated on this institu-
tion than to be divided among several. Multiple membership, therefoie,
with the exceptions noted, should be discouraged.
In connection with Western Reserve Medical School, the following
figures are of interest. 331 of the 1,169 listed physicians in Cleveland are
graduates of Western Reserve University Medical School — 28.3 per cent, i
the total. Of the 309 staff positions in the hospitals and dispensaries of Cleve-
land, 75, or 24.2 per cent, are held by graduates of Western Reserve Uni-
versity Medical School. It will be seen that the proportionate number o(
positions held by graduates of this medical school is somewhat smaller than
the number of graduates of the school among the medical profession as a
whole. It should be added that in the hospital and dispensary positions
31 in addition to the 75 just named, are held by members of the medical
school faculty who are themselves graduates of other schools. This gives a
total of only 106 out of the 309 hospital and dispensary staff positions whick
are held by graduates or members of the faculty of Western Reserve Medical
School.
)8PITALS AND DISPENSARIES 861
In connection with the so-called "democratizing" of hospital facilities
r the medical profession, it should be pointed out that no hospital can be
tisfactorily managed without a definite official staff. A medical boarding
)use, as previously defined, is merely a nursing home in which physicians
eat private patients. Any hospital which endeavors to maintain a medical
"ganization, equipment, and personnel, for diagnosis and treatment, must'
ive some medical authority appointed, to be responsible to its managing
)dy. A number of the proprietary hospitals are maintained by one or more
liysicians who conduct them as their own enterprises, and who are medically
\ well as financially responsible. The public service hospital with a board
■ trustees or other disinterested governing body, must appoint an official
:tending staff. The functions of this staff are not only the care of patients,
[eluding such patients as are admitted specifically as private patients of
)n-staff physicians. Its functions also include the determination and main-
nance of the standards of medical practice which shall be observed in the
stitution. A medical staff of a hospital should not be merely a group of
dividuals each of whom has a certain ward or number of beds under his
large, for a year or part of a year, but it is or should be an organization —
group of physicians representing different branches of medicine and sur-
ay, organized for the joint practice of medicine with the equipment and
cilities provided by the hospital, defining and maintaining the profes-
onal standards and policies which shall be effective throughout the insti-
ition.
In some hospitals the medical staff does not fulfill these functions ade-
oately. It does not set clearly defined standards which govern the practice
' physicians in the institution. Thus in the matter of record keeping,
lere are a number of hospitals in which fairly accurate and complete records
* kept upon ward patients, showing that physical examination was made,
horatory tests performed, and that careful notes were entered at the time pf
aeration or during the course of the patient's treatment. In the same
istitution, the records of the private patients of physicians may be limited
► identifying or financial data, and have almost no medical information of
gnificance. Such a hospital has not maintained (so far as the records show)
»€ same standard of care for private patients as for part-pay or free pa-
ints, who come under the charge of the hospital's attending staff without
tnuneration. Records are not always a complete index of the degree of
tt« actually provided, yet there can be no doubt that particularly in the
latter of laboratory tests and consultation with specialists, part-pay and
Be cases in many hospitals receive more thorough study than do many
ivate patients. Greater privacy and more intimate i^ersonal relation of
« patient to the family physician are maintained for the private case as a
>ssible counter-balance.
In proportion as the general public and trustees of hospitals appreciate
lat a modern hospital should not be a medical boarding house in whole or
part, but a medical organization in which the best resources which the
»spital has to offer in equipment or personnel should be made available for
try patient in so far as he needs them, hospital organizations and hospital
ocedures will be uniform for all classes of patients, private, part -pay, and
». Patients and physicians alike will profit by such a policy.
862 Hospital and Health Sxjbvbi
With these principles in mind, there have been appended to this chapter
certain details which supplement the general principles of hospital organ-
ization stated in the section on Organization for Service.
The organization of the medical executive committee is for the purpose
(a) of providing the medical staff with a small group which will enable it 1
conduct the routine business of its organization, formulate hospital standan
and policies, and make arrangements for the monthly staff nieetings; ai
(6) of providing a group for regular conferences with the superintendent of tl
hospital, and, from time to time, conferences with representatives of tl
board of trustees, to assist in administering the hospital satisfactorily.
The provision of an auxiliary staff is believed important, particularly
view of conditions such as those of Cleveland. It is highly desirable ti
the number of physicians having some connection with hospital staffs shou
be increased. On the other hand, it is essential that active attending stal
of every hospital be not so large, in proportion to the number of beds, x^
be unwieldy or incoherent. Otherwise standards of service are likely to suff<
The organization of an auxiliary staff provides a means of recognizing in
definite way physicians who are utilizing the institution for their priva
patients or for consultation purposes, and for giving such physicians a defini
channel through their delegates whereby they can express themselves to t
official staff or to the hospital trustees.
Beyond such machinery of organization, other means exist for openi;
the facilities of Cleveland hospitals and dispensaries to a larger proporti'
of the medical profession. It is not only in connection with the surgic
o|>eration upon a patient, hut also in the medical treatment of acute cas<
that physicians need the advantages of the diagnostic equipment of hospiti
and dispensaries, and of the skill of specialists on their staffs. The labon
tory, the X-Ray department and other diagnostic equipment, and theseni
of specialists need to be utilized by the private physician in behalf of hi
patient. To make the sj>lendid equipment and personnel of Cleveland hos
pitals available for diagnostic purposes to the medical profession of Cleve
land on a large scale is one of the chief goals to be sought for. This inustb<
worked out in practice largely through the increase of dispensary sennceii
the form of diagnostic clinics, to be available for consultation purposes foi
non-sta,ff physicians. More detailed reference to this is made in the succeed
ing chapters on dispensaries.
The enlargement of dispensary service which Cleveland so greatly neei
would provide opportunity for a considerable number of physicians to codi<
into close contact with hos])ital work, as dispensary staffs should be org*"
ized in intimate relation with hospital staffs. (See page 846.) Th<
medical advantages of facilities for diagnosis, of consultation, and in general
of intimate contiict and co-working with other progressive physicians couk
be opened to a very large imml>er of physicians not now on the staffs oi
Cleveland medical institutions. The approximate proportion of physician
connected with hospitals and dispensaries in Cleveland ought surely not t(
be less than in New York (about oO per cent.) which would mean the addi
tion of "^OO or ^50 physicians to the staffs. If dispensary service in Clevelan'
OSPITALS AND DISPENSARIES 863
developed as it should be during the next few years, this result may be
leasurably achieved.
There are certain groups in the medical profession who feel that their
opportunities in the medical institutions of the city are specially limited.
Interviews with a number of foreign-born physicians revealed a consider-
ible feeling that they *'hadn^t had a chance." A list of 63 foreign-born
ihysicians in Cleveland, furnished by one of the organizations interested in
mmigrants, is probably considerably less than the actual number. Many
rf these physicians have a large practice among groups of immigrants and
ieir children, who constitute a considerable proportion of the population
rf Cleveland. Only nine of these 63 physicians were found to be on the
ists of any of the hospital staffs. The foreign-born physicians of the more
woent groups of immigrants, such as the Slavic and Italian peoples, are
Jractically unrepresented. It may be felt by many that such a condition
^ tend to take care of itself with time. However, the unstimulated move-
ment of "time" is too slow. A definite effort should be made to give recog-
lition on hospital or dispensary staffs to physicians of good standing who
u« of foreign birth or descent, particularly in institutions which number
unong their patients large numbers of the foreign-bom. As has appeared
p the section discussing *'The Human Problem of the Hospital Patient,"
JMiges 84^857), a number of the hospitals fall into this group. There is
inusual value in dispensary service rendered by well-selected physicians of
lustype.
Physicians of the Negro race constitute a small but definite group whose
opportunities to work in medical institutions of Cleveland have been greatly
restricted. There are said to be 19 Negro physicians in Cleveland. One
•f these men is on the dispensary staff of Lakeside Hospital. Representa-
lons made to the Survey by physicians and laymen of standing among the
lolored people of Cleveland are to the effect that the negro physicians and
he negro people feel the deprivation brought about by lack of member-
kip on the staffs of hospitals and dispensaries. The problem can be dealt
nth only in one way, by determining that appointments shall be based
^lely upon merit. It is a fine testimony to the spirit and policy of the hos-
itals of Cleveland that so far as negro patients are concerned, there has
•een absolutely no complaint by the Negroes about discrimination. The
stablishment of a special hospital for colored people is believed to be unneces-
sary and undesirable.
Perhaps the most important relation of hospital and dispensary to the
iJcdical profession is their educational function. The hospital and dis-
•cnsary represent to the physician an opportunity to raise the practice of
liedieine to a higher power because they bring under his command the use
f equipment, the organized professional skill of specialists, and technical
i^istance such as are very rarely available in private practice, and then
»% to the rich.
The educational function of the hospital and dispensary is only ^ in part
Kercised through medical schools. The teaching of a medical school like
liat of Western Reserve University depends in a large measure upon the
864
Hospital and Health Subyet
hospitals and dispensaries which are affiliated with the school. Under-
graduate teaching is and in general can most advantageously be limited
to a few selected hospitals. The development of post-graduate instruction
under the medical school in the general and special branches should pro-
ceed at a rapid rate in the near future, and should involve the use of a con-
siderable additional number of hospitals and clinics.
The actual value of the hospital as a place of advancing medical science
and of the skill of the local profession depends of course largely upon the
use made of the advantages offered. Decidedly one of the most important
means of self-criticism which a member of a hospital staff can have is the
autopsy. Definite knowledge concerning the disease which caused the death
of a patient can very frequently be obtained by autopsy as in no other way.
It is disappointing to find that according to reports received by the Hospital
Council during the year 1919, only 456 autopsies were performed. Reports
from some hospitals were a little indefinite, and the true number might
have been slightly larger. The figures and details are shown in the following
table.
Autopsies Performed in 1919 in Certain Hospitals
City.„ (approximately) 209
Fairview 0
Glenville._ 1
Grace number unknown
Huron Road 5
Lakeside 110
Lakewood number unknown
Lutheran 0
Maternity 8
Mt. Sinai
50
Provident
0
St. Alexis
..number unknown
St. AnnV„
_ 20
St. Clair
1
St. John's
-... 20.
St. Luke's
- ^ 5
St. Vincent's
. 27
Woman's.^
0
Total 456
Such a low percentage can only mean one of two things — either failure
on the part of the medical staff to appreciate the importance of autopsies*
as a real checking up of results, and setting a real standard of self-criticisiD
and self -improvement, or on the other hand, a lamentable deficienc}' ip
administration, in failing to endeavor, in each case of death, to secure u
possible consent for autopsy from the family of the patient. Experience id
many hosy)itals in other communities shows that it is necessary to fix re-
sponsibility u])on some definite person for each branch of service, usually
on the senior resident or interne, for securing permission. Compliance witB
the sj)irit as well as with the form of the standards of the American Collej?e
of Surgeons demands that the medical profession for its own sake show
better results in the future in securing autopsies in the hospitals of Cleveland.
Tt is recognized that the public needs education to understand the great
value of autopsies, not only for the physician, but in the long run to improve
the treatment of every patient.
iLR AND Dispensaries 865
I particularly interesting to observe that the three teaching hos-
Dity, Lakeside, and St. Vincent's), together with Mount Sinai, show
>psies out of a total of 456. Taking these four hospitals, the number
)sies compared with the number of deaths is shown in the following
It will be observed that the best showing made is of ofily about
d of deaths autopsied, and that the average even of these hospitals
han 25 per cent. .
liUTOPSIES AND DeATHS, COMPARED, 1919, IN FoUR HOSPITALS
ty.
tkeside.
t. SinaL
. Vincent's
Percentage of
itopsics
Deaths
autopsies to deaths
209
861
24.3
110
320
34.4
50
188
27.1
27
331
8.2
Totals. 396 1,700 23.3
3nd the formal courses recognized as such under the medical school,
r, the broader educational function of the hospital and dispensary
o be fulfilled. Monthly staff meetings for the discussion of cases,
3f hospital statistics, and of the result of operation or treatment, are
e means whereby the physician and the hospital are stimulated, and
'ice of the institution is advanced. The participation of an auxiliary
auld be of much educational value. The daily contact of physicians
e another in the clinics of the dispensary and in the wards is a less
but no less effective means for development of knowledge and skill,
the opening of facilities for diagnostic service to the physicians of
lunity on a broad scale, through diagnostic clinics, and larger pro-
or treatment of private patients, should serve to render the medical
onal functions of the hospitals and dispensaries effective over a much
ange and to a more profound degree.
Medical Staff Organization*
(a) The members of the Medical Executive Committee should include
e chiefs or representatives of the division of medicine and surgery, one or
ore representatives of the specialties, and a representative from the assist-
its or junior members of the staff.
(b) The Medical Staff should establish standards of hospital practice
all departments, including laboratories, X-Ray department, etc. AU
[edical Staffs should take official action by resolution or pledge in the
atter of fee splitting. No member of the Medical Staff should hold mem-
srahip on the Board of Trustees. Privately organized hospitals with
W. L. Babcock, M. D. Reference should be made to pages 845-848, to which this is a supple-
866 Hospital and Health Subybi
Boards of Trustees consisting of medical men should reorganize by arrangmg
for the appointment of a lay Board of Trustees, the physicians interested
in the hospital organizing into an Attending Staff. The senior Attending Sta£f
physicians should hold active^staff membership in one hospital only. This
restriction should not apply to members of the staff engaged in university
teaching, or to specialists with limited services, or in small hospitals to
clinical assistants.
(c) The following additional committees will often be found useful:
Library Committee.
Resident House Staff Committee.
Hospital Records or Program Committees.
(d) Provisions should be made for the recognition of non-sta£f physicians
by permitting the use of a limited number of hospital beds under the general
supervision of the Chief of the Medical Staff through Chiefs of Departments.
It should be recognized that the so-called open hospital is a powerful factor
in preventive medicine, a post-graduate school for the general practitioner,
and a great influence towards his professional elevation. The practice of
non-staff physicians in hospitals should be regulated, scrutinized and carefully
supervised by the Executive Committee.
(e) The stand taken by the Cleveland Hospital Council to the effect
that all hospital bills should be paid before the Attending Physician or Sur-
geon collects his bill is to be commended and should be made a rule in every
hospital.
(f) At least ten staff meetings should be held annually, at monthly
intervals, excluding July and August. As many more may be called as are
deemed necessary. The Executive Committee should meet monthly or
oftener. Regular Staff Meetings should be 90 per cent, clinical. Routine
business should be abbreviated and parliamentary discussions avoided,
except on important matters of staff or hospital policies. Provision should
be made by the Record Committee, or otherwise, for review of clinical records.
Reports of unusual or interesting cases should be presented for group dis-
cussion, together with results of original research work carried out by indi-
vidual members of the staff, or the hospital laboratories. It is also desirable
that arrangements be made to serve light refreshments after these staff
meetings, which must, of necessity, be held in the evening. It has been
shown in at least one instance where this program has been carried out for
years that the percentage of staff attendance has averaged 75 to 80 per cent.
N3PITALS AND DISPENSARIES 867
of staff membership and has exceeded, by several hundred per cent., the
attendance at regular meetings of the County Medical Society. Attention
is called to the recommendations of the American College of Surgeons as to
program for staff meetings. The Associate, Auxiliary and Resident Staffs
should meet with the Attending Staff at their monthly clinical meetings.
868 HOSFITAI. AMD HEALTH SUBVCI
\ie
I-"'
FINANCES AND ADMINISTRATION
To maintain the 21 institutions which are members of the Clevehni
Hospital Council cost nearly three million dollars during 1919. About 9^
per cent, of this was for hospital care and 2}^ to 3 per cent, for dispensary
service.* This $3,000,000 represents about 700,000 days of hospital care
given, and 120,000 dispensary visits. It represents service to probably
80,000 different individuals. In other words, these hospitals and dispen-
saries care for one person out of every twelve in the population of greater
Cleveland, and cost about $3.07 for each member of the population. Only
a fraction of this cost, however, is a net charge upon the community, for as
the third column of Table VI. indicates, the operations of the institutions
yielded a very considerable portion of the necessary income.
Over two-thirds, in fact, of the expense of the non-municipal hospitakis
repaid by fees from patients and by other earnings. The other third, or
between $600,000 and $650,000, has to be provided by interest on endow-
ments, by legacies and gifts from the public. Taxation must provide for the
municipal institutions to approximately the same amount. It will be ob-
served that in these figures relating earnings to expenditure, only the non-
municipal hospitals are considered. While there are some earnings in the
mimicipal institutions, they cannot fairly be compared with the other hos-
pitals in this respect.
The non-municipal hospitals bring upon the public an annual charge of
approximately $460,000, after deducting from the total expense the earnings
from patients and the amoimt available from endowments of various sorts.
This figure is the estimate for the year 1920, as presented to the public in the
Community Chest campaign of November, 1919. The City Hospital, to-
gether with Warrensville Tuberculosis Sanatorium, required in 1919 an
appropriation of $625,656.92 from taxation. Adding together the cost for
the municipal and the non-municipal hospitals, we find that $1,086,000 is the
approximate amount required to maintain the hospitals and dispensaries of
Cleveland, in annual contributions by the public or "voluntary" taxation,
taken together with legal or compulsory taxation. This is about $1.30 for
every man, woman, and child in the city of Cleveland, or about $1.10 per
head if the larger metropolitan area which these hospitals serve is taken
into consideration.
Parenthetically, it should be noted that these figures do not include the
cost of the dispensary "Health Centers" maintained by the Division of
Health, the cost of the city physicians who care for the sick in their homes,
or any of the other expenses of the Division of Health. In the main, the
bulk of these vast sums goes for the care of sickness. The total amount
expended for education in hygiene and for the prevention of disease is only
a fraction of this amount, the expenditure for the Division of Health bein^
less than 50 cents per capita. Expenditures for hospitals are necessary
*The cx>st of the dispensaries is not accurately stated in several of the hoapital reports, and the above
figiire is therefore an estimate, merely.
I
SofiPITAIiS AND DiSPENSABIES 869
and desirable under present conditions, but one may look forward to a day
^en the proportion between the expenditure to cure illness and expenditure
for prevention will not be so heavily weighted against the preventive measures.
The cost of hospital service is more accurately expressed in terms of the
mit previously dcmied; namely: average cost per day of care. As will be
leen at the foot of Table VI., tins average cost for a large group of the non-
nunicipal hospitals was approximately $4.39 in 1919.
Hospitals have felt keenly the high cost of living, more heavily in fact
ban most institutions, because of the large proportion of their expenditure
duch goes for food, d^gs, and supplies of all kinds, which have especially
Qcreased in price during the past few years. The public has not appre-
iated how expensive good hospital service must now be.
When individual hospitals are compared, the average cost stated in their
eports for the year 1919 varied from $2.00 to $5.62. This range is doubt-
ess too wide, in that it is not believed the lower rate is a true representation
4 the cost of any hospital. Accounting systems have not always been de-
igned so as to charge to annual D[iaintenance all the items which should
iroperly be so entered. It is not believed at the present time that any mem-
ber of the Hospital Coimcil is maintaining service at a rate less than $3.00
)er diem, and this figure is too low to render adequate siervice under present
»nditions. A general hospital properly equipped should expect a per capita
»st of fully $4.00 -per diem. When a hospital is rendering an imusual grade
if service or is conducting medical teaching or research, a cost of $5.00 a
lay need not excite objection.
In general, the average cost of a day*s care, or the so-called ''hospital per
:apita, " must be used with great caution as a basis for either commendation
>r criticism. It must be known how the per capita cost is made up — whether
'or instance a low per capita is due to undue crowding, whether a high per
*apita has been due to a small number of bed days care given because of tem-
porary lack of demand or enforced closing of certain wards or rooms, or
vrhether a high per capita is due to unusual quality of service, or on the
>ther hand to uneconomical administration, or again whether a low figure
nay be accounted for by careful, economical administration, or else by the
lack of the proper facilities.
As a rule, n^iany different elements must be known and considered before
forming any judgment as to the significance of a given per capita cost. The
average for tiie city as a whole is of considerable general interest, particu-
larly in view of the need to call public attention to the expensiveness of
modern hospital service. The fact that hospitals have been generally
charging ward rates (at least until very recently) as low as $2.00 per diem is
a little misleading. The average person has somehow taken for granted
that if a patient paid the so-called ward rate, the hospital's cost was met.
This is f^r from the truth. Ward rates have generally been put far below
oost, and in recent years, most of the hospitals of Cleveland have failed to
raise ward rates to correspond with the increase in expense. This has been
870 Hospital and Health Susm
due in considerable measure to a desire not to levy a tax upon the sick and
suffering, or to make known rates which might keep needy patients {rom
the hospital doors.
Time was when hospitals were thought of as charities for the destitute,
but at the present time, hospitals are public services receiving ^the well-to^b
and middle classes as well as the poor, in varying proportions. The genenl
public should be brought to the point of understanding that hospital ser-
vice ought to be paid for at its cost by those who are able to pay, and that
room and ward rates should be adjusted with respect to cost of service.
Considering the fact that a hospital of the public service class often has u
endowment, it should be expected that the income from the endowment wiD
go to help make up the difference between the cost of service and the eain-
ings from operation. A deficiency will be due partly to the fact that the
ward rates are put at less than cost, and partly to the fact that many patienti
should be and are accepted who cannot pay even these rates.
As a general principle, ward rates ought to be fixed somewhat below the
cost of service, but not very much below. It is believed wise that at the
present time the hospitals of Cleveland should not announce rates for wtai
service at less than $3.00, and in many hospitals or in some divisions thereof,
ward rates may be $3.50 a day. The naming of these rates in no case should
imply that patients unable to pay them in part or able to pay nothing should
be refused admission. A hospital cannot expect financial support from the
public unless it makes the patient's need and not the patient's means the
basis on which service is offered and rendered.
In the following section of this Chapter (pages 877-889) Dr. W. L. Bab-
cock has outlined a large number of highly practical suggestions and recom-
mendations regarding administration. Many of these relate to finances.
It is only fair to point out that the Cleveland Hospital and Health Survey,
despite evident eagerness on the part of all members of the Hospital Councfl
to coo|>erate, found it no easy matter to secure many of the fundamental
financial and statistical figures from a number of hospitals. There was no-
where lack of willingness, but the accounts had not been kept with a view
to critical self-analysis.
Methods of hospital cost accounting have been pretty thoroughly worked
out during re<'ent years. Many smaller hospitals feel that they cannot
readily maintain the trained book-keeping staff to carry out a cost account-
ing system. The extra time required by such a system and the extra expense
involved seem too much, and the hospital is likely to go without. In the
long run, good cost accounting is a money saving enterprise. It points the
way to more ei^onomies than its own maintenance costs. It also helps in
fixing rates so that they bear pro]>er relation to cost, and tends to increase
income where income needs to be increased.
The needs of the smaller hospitals can be met only by some cooperative
enterprise. The Welfare Federation should establish an expert accountant
service, avaihible to any of the Cleveland Hospital Council members, for
Hospitals and Dispensaries 871
^fcrvice in the administration of proper accounting systems and for advice
periodically or whenever necessary in its maintenance. Such a plan would
m&ke available to all hospitals a grade of accountant service which few if
any could afford to maintain alone. The plan would have the further great
idyantage of enabling uniform financial reports to be periodically rendered
to the individual boards of trustees, to the central budget-making authori-
ses of the Welfare Federation and to the public, which in the long run foots
he bills.
In matters of financial as well as medical service, trustees need to de-
ermine exactly what figures they need to have presented to them in their
jinual or monthly reports, in order that they shall know all they need to
aiow regarding the work of the hospital. The central accounting system
iroposed would be of great constructive value to every board of trustees,
K>t only in furnishing information, but in helping them to see what infor-
oation they need to have furnished. An X-Ray department, for instance,
3 very expensive to maintain in terms of gross expense, but in many hos-
atals a considerable proportion of the X-Ray work is for patients who can
my a fair fee, so that the net expense of maintaining the department is not
urge. In a hospital doing a large proportion of its work for patients who can
my few if any fees, conditions are different, but in any hospital, proper ac-
ounting will show just what the X-Ray department costs, just what ratio
he income derived from it in its different classes of work bears to the expense
hereof, and the trustees will be able to judge at the end of a month or a
•ear how much net charge this service brings according to the character of
^ork and service rendered, and the rates which patients can reasonably be
xpected to pay.
Perhaps the most fundamental need for trustees is to appreciate that hos-
pitals are public services in the broad sense of the word. Two more or less
ipposite conceptions have dominated hospitals: (1) that represented in its
xtreme form by the proprietary hospital treating private patients where
inanc'al return from the patient is largely used in determining his accepta-
rility, (2) the charitable corporation in the old sense of the term, according
o which hospitals are regarded as rendering benefits to the helpless who
leither can or should be expected to make any financial return. At these
;wo extremes we would find hospitals serving private patients only, and
lospitals serving only the poverty stricken and the destitute. The outstand-
ing development in the relation' of hospitals to the community during the
last decade or so has been the increase in hospital demand by persons of
the middle classes, the self-supporting families of moderate means in fairly
comfortable financial condition but with no large property holdings and no
large annual margin of income over expenditure. These so-called middle
classes are more and more finding that it is better to go to the hospital than
to be treated at home in serious illness, surgical operation, or for maternity
care.
Much testimony has been received in Cleveland that there is great de-
tiand for beds for these middle classes. Beds are demanded in private rooms
•f more particularly in two to four-bed rooms or small wards, where fees
872 HoBPiTAii AND He;alth Subvet
will be moderate and service excellent but not of what may be called tlie
exclusive type.
The hospitals of Cleveland face such large financial obligations in view
of the high cost of living that much anxiety has been felt by many trustees
in looking forward to the future. Generous public support for the hospitab
through the Community Fund or in other ways is indeed necessary, but the
enlargement of the hospital facilities of Cleveland, particularly in providing
more fully for the middle classes, will assist the hospitals financially hj
rendering a larger proportion of their services of a self-supfK)rting nature,
and thus help in carrying a general overhead which in itself is a very consider-
able part of modem hospital expenditure.
The Cleveland Hospital Council is to be congratulated for having re-
cently secured from the Industrial Conunission of Ohio, a more satisfactoiy
recognition of the hospital's service to industrial accident cases. In Ohio,
as in many other states, the estabUshment of workmen's compensation took
place without adequate recognition of the large part that hospitals and dis-
pensaries would need to play in its successful administration. Industries
and insiurance companies found that prompt and competent medical assist-
ance to men who had met with industrial accidents was not only humane
but was good business. The promptest possible return of the employe to
his work stops the weekly payments and saves more money than it costs.
There are no theoretical or practical reasons why hospitals which are sup-
ported by the community as public service enterprises should render any
service to industry for less than the service costs, when under the very foun-
dation principles of workmen's compensation, the industry is supposed to be
paying the full amount of the bill for industrial accidents.*
Hospitals supported by the community must necessarily receive and
care for many patients who are prop>erly public charges of the city or county
or of some other county. It is fair and desirable that hospitals be reimbursed
for the care given patients who are prop)er charges upon the public. Since
the city of Cleveland maintains its own hospital, the City Hospital is natur-
ally the first place to which such patients should be sent, but because of
emergency or other reasons, other hospitals will necessarily receive cases
which are charges upon the city or county. The law as recently amended
renders it prop)er for the Commissioners of Cuyahoga County to reimburse
institutions furnishing care to persons who are pubUc charges.f It is be-
lieved that the following principles should govern the administration of this
provision :
1 . A policy of paying privately owned and supported institutions for services such u
the care of the dependent sick, which is a public function and a means of preventing disetr
and dependency, instead of providing adequate, publicly owned and operated hospitals
out of the general tax rate of the city, is essentially unsound and should be condemned tf
'Through the efforts of the Hospital Council the State Commiaakm adopted the principle of *'btctp^
co«t for service rendered" on July 1, 1920.
fThe Hospital Council has already i^gotiated with the County Commiiaiooeta oa tlua salqecC ^
negotiations are encouraging.
loSPITALS AND DISPENSARIES 878
ffering temptations to the political use of public monies, and as contrary to the Sfnrit of
nimicipal government.
2. Notable instances of abuse of the practice of subsidizing private hospitals and other
vivately owned institutions are to be found in the recent history of the state of Pennsyl^
rania. In certain cities, however, notably Detroit, Michigan, and New York City, pay-
nent to private institutions for the care of public charges has served a useful purpose
nd has been honestly administered.
3. Only as a temporary expedient and under strict and exact determination of the
luality and quantity of services rendered for which payment is made can such a practice
le approved for the city of Cleveland.
4. Vnth the city definitely committed to the construction and maintenance of a
Dodem City Hospital, the facilities now under consideration and agreed to by the private
lospitals can confidently be expected, if carried out, to offer relief for approximately the
lext twenty years on the basis of the estimated growth of Cleveland.
•
5. Without urging the point to the extent of asking for any public declaration or
xmmitment by the Hospital Council to a policy, it is thought by the Survey that agree-
nent should be reached by the hospitals in the Hospital Council to apply funds for the
sctension of their facilities for part-pay patients equal in amount to the sums received in
'he year from the County Commissioners. It is particularly the responsibility and privilege
if the privately owned hospitals to meet the need of the patient of modest means who
ixpects to pay part, if not the whole cost of hospital care. County payments for the care
i£ the dependent sick should be a resource for increasing part-pay bed capacity and should
oot be accepted mertly as a relief from the burden of raising funds for meeting current
6. With the understanding that the full influence of the Hospital Council collectively
and through its component institutions will be used to accomplish the two objects men-
tioned in 4 and 5 above, and in the belief that the necessity for County payments to pri-
vate hospitals should cease when adequate provision for the dependent sick is made in
INiblicly owned and operated hospital or hospitals, the Survey endorses the proposed
9item of contracts with the County Commissioners under the following conditions:
aamdy, chat payments by the County Commissioners to hospitals with which they make
^tracts shall be made only for services of an approved quality, provided for a definite
period of time and for specified individual patients who have been shown to be entitled
to public relief after investigation of their home or economic condition by representatives
acting under the orders of the County Commissioners.
7. Inasmuch as the County Commissioners cannot, without amendment of state laws,
^ploy from public funds investigators to ascertain the quality of services given to patients
^ to verify claims of hospitals and patients that such and such individuals are proper
^jtcts of public assistance, it is suggested that the Hospital Council request the Community
'^^d to put at the disposal of the Welfare Federation such amount from the unassigned
^ds as may be needed (tentatively estimated as $5,000) to employ trained social investi-
^tors to be put at the disposal of the County Commissioners for the purpose above de-
■^bed.
874 HospiTAii AND Health Subvet
8. It is suggested that the Hospital Council bind its members by mutual agFeemcot
to enter into contract with the County Commissioners only on the basis of the conditkui
suggested in 6.
The hospitals of Cleveland are in a fortunate position compared with
those of most cities, because of joint financing through the Community Fund.
The needs of many institutions are brought before the public at a single
time in a forceful impressive way. Mutual relationship among hospitals
and a better understanding of the broad needs of the community are cer-
tainly promoted also. None the less does the work of each hospital need
interpretation to the public which supports it financially. There is in-
deed a more definite demand for accurate and comprehensive financial I^
ports under such a system as exists in Cleveland, since the central financial
and appropriating committees of the Welfare Federation are in a position
to scrutinize the financial reports of each hospital much more closely than
the average contributor will in communities wherein each hospital raises its
funds independently. An added stimulus is thus applied toward economy
and toward careful financial and book-keeping systems. All the more do
the hospitals of Cleveland, particularly the smaller ones, need expert ac-
countant service to enable them to work out their book-keeping and their
financial reports in the best way.
The Purchasing Bureau of the Cleveland Hospital Council is a distinct
and notable achievement, indicative of the spirit of cooperation in com-
munity enterprises which is characteristic of Cleveland. Through the Pur-
chasing Bureau more economical and satisfactory buying of standard hos-
pital supplies is made possible. Each member of the Council is thus prO"
vided with the services of an expert in buying, who is devoting his entire
time to studying markets, making contracts and assisting the hospitals to
get the best and the most for their money. It is to be regretted that the
use of the Bureau by a number of hospitals has not been as large as it should
be. If the purchases of the hospital for all kinds of supplies be taken, and
the amount of purchases made in 1919 through the Purchasing Bureau, be
expressed as a percentage of this, we have a certain index of the degree \f^
which the hospital has taken advantage of this measure of economy. It ^
found that the percentages of utilization by the diflFerent hospitals were as
given in the following table:
«piTALS AND Dispensaries 875
OPORTIONATE UsE OF THE CENTRAL PURCHASING BuREAU OF THE CLEVE-
LAND Hospital Council
Proportion of Maximum*
Hospital Purchasing Possibility
Cleveland Maternity „ 2/3
Fairview Park Less than l/s
Glenville „ Approximately 4/7
Grace..™ l/6
Huron Road l/S
Lakeside Maximum
Lakewood l/l3
Lutheran™ l/25
Mount Sinai Xess than l/s
Provident l/l2
St. Alexis 1/20
St. Ann's s/s
St. Clair l/S
St. John's 1/5
St. Luke's About 1/4
St. Vincent's -_ l/l7
Woman's Approximately l/S
Most hospitals find it convenient to make some purchases independently
m time to time, because of the unusual character of the article to be
jght or because of the haste with which it must be secured, but given
ciency on the part of the Purchasing Bureau, these objections should be
luced to a minimum. Furthermore, it is obvious that the more fully the
ireau is utilized, the larger will be its purchasing power and the better
ins it can make. Doctor Babcock's recommendations regarding the
ireau (pages 882-885) are very pertinent and practical.
In this as in helping the hospitals to save money by getting the largest
icounts for cash (page 879— section on ** Practical Matters of Ad-
nistration") the Welfare Federation is in a position to make the money
Qtributed by the public go further than it now does.
Hospitals are likely to benefit by taking advantage of every opportunity
' expert assistance in any of their many special lines of activity. The
liool of Pharmacy of Western Reserve University, for instance, is in a
sition to offer assistance to the hospitals of Cleveland that would be of
at benefit in two ways: enabling the hospital to render a higher type of
*In 1919 Lakeside Hospital made practically all of its purchases, amounting to exactly one-third of
operating expenses, through the Central Purchasing Bureau of the Cleveland Hospital Council. That
re has therefore been adopted as the maximum purchase pe rcentage, and the purchases of other hos-
ts have been figured on this basis.
876 Hospital and Health Suryet
service to the public, and lowering the cost of medicines to the hospitals.
For a description of the proposed service, see the section on Pharmacy, in
Part Vin. Such a plan would take at least a year to perfect, but its value
to hospital service should be self-evident.
Hospital financing and hospital administration have become technical
matters. At best, the average layman is not concerned with or even inter-
ested in their details. It is of the greatest importance, however, that the
hospitals of Cleveland shall not lose their individuality because of joint re-
lations through the Welfare Federation and the Cleveland Hospital Council,
and that the work of each hospital as well as of all hospitals taken together
shall be properly understood by the public. To take technical reports of
income, expenditure, and service rendered, as prepared by the hospital for
the use of its trustees, the Cleveland Hospital Council, and the Wdfare
Federation, and to utilize these reports as the basis of an account of hospital
work in which the whole conununity will be interested, is the duty of a
"publicity man." The publicity men and the Welfare Federation which
provides publicity service, should constantly bear in mind that the public
needs to be helped not only to understand what hospitals do» but that their
work is costly and why this is so. Comparisons of the present cost of hos-
pital care with the cost in former years will be useful if so presented as to
bring home to the reader that the added cost is not only bcK^ause of higher
price levels, but means also a higher quality of service. The business man
who thinks in terms of dollars and cents needs to be made to see why the
medical boarding house type of institution has a lower cost, and why sudi
low cost is not as good a thing for the community as a hospital costing fif^
per cent, more per capita but run as a modem hospital with adequate maiical
nursing, and social service facilities for diagnosis and treatment. The public
must learn that health can be bought at a price and that the price is worth
paying.
loSPTTALS AND DISPENSARIES 877
SOME PRACTICAL MATTERS OF ADMINISTRATION
By W. L. Babcock, M. D.,
Consultant on Hospital Administration for the
Cleveland Hospital and Health Survey.
In making these statements and recommendations on General Adminis-
ration, it is recognized that the Cleveland Hospital Council has had many
f them under consideration and in certain instances has actually had com-
littees at work in standardization of supplies, uniform records, accounting,
niform rates, etc. In its contact with the administrative departmentsjof
he hospitals within the Council, the Cleveland Hospital Council has de-
eloped a working organization of great practical benefit to its members.
lie projects under consideration by its various committees, as well as the
^commendations herein, are practical and logical steps in the develop-
lent of economical administration and eflBciency. The Council wouldlbe
f little benefit to its membership unless it adopted standards that would
end to lift the level of the hospitals to an efficient average. The Council
tm be of the greatest benefit if it leads, plans and organizes in advance^of
he hospitals.
FINANCIAL
1. Financial and Office Records, Bookkeeping, etc. — The Cleve-
ind Hospital Council has unified and standardized the financial and statis-
ical reports of its constituent hospitals. The bookkeeping systems, forming
he basis of these reports, which are rendered monthly, have not been
tandardized in the various hospitals. It is recommended that the book-
Leeping forms and headings used by the various hospitals be made uniform.
This is particularly necessary for cash blotters, and voucher registers, in
order to show similarity in distribution of earnings and expenses.
The records furnished the Cleveland Hospital Council relating to per
capita cost in some of the hospitals have been fallacious from the begin-
ning for the reason that many of the extraordinary expenses of some of
the hospitals have been charged to special funds and not to maintenance
accounts. In several of the smaller hospitals record of receipts and expend-
itures only is maintained. No attempt has been made by these hospitals
to credit or debit the various departments of the hospitals with their earn-
"^ or expenses. The per capita costs reported by Cleveland hospitals
for 1919 varied from $2.00 to $5.62 per day. In order to determme wherein
^is difference may be found, it is necessary to check earnings and expenses
^y departments, such as training school, laundry, housekeeping, building
^'^intenance and current repairs, administration, professional care of
f^tients, etc. The latter should be subdivided into its natural subdivisions,
*^<^h as laboratory, X-Ray dei)artment, surgical department, house staff, etc.
2. Accounting — ^The monthly and annual accounting for all hospitals
**iould be made by an accountant under the direction of the Welfare Federa-
878 Hospital and Health Suryet
lion. It may be feasible for the latter organization to maintain the serv-
ices of a paid accountant staff who could carry on a month-to-month audit
in all hospitals within the Federation and furnish each Board of Trustees
with a monthly and annual accounting statement. K the recommendations
set forth in paragraph 1 are carried out in all of the hospitals, it will sim-
plify the audit and accounting to a great extent. K a uniform system d
financial records and bookkeeping is established for each of the hospitab
in the Council, the time devoted by auditors on the books of some erf the
hospitals could be reduced 50 per cent, or more. It should be stated here
that the Welfare Federation has provided for these audits heretofore through
a firm of auditors. It is understood that the Cleveland Hospital Council
is endeavoring to secure a uniform system of accoimting for all hospitals
in the Council.
3. Statement of Earnings — The monthly and annual statements d
earnings of hospitals should be based on cash receipts only. Unpaid p»-
sonal accounts of hospitals have no place in a statement of earnings. The
present earnings and income reported to the Cleveland Hospital Council
and Welfare Federation from the various hospitals are not comparable
for the reason that some hospitals base their statements on cash receipts
only, while others include unpaid personal accounts in their statement of
earnings. (Note A.)
Note A — The practice of many hospitals in carrying unpaid personal accounts oa
their balance sheet as an asset is misleading, fallacious and wrong in principle. A vaiy*
ing percentage of most of these accounts are uncollectible because they are largely accounti
of part-pay patients. If the statement of earnings includes cash receipts only, such open
accounts as are paid after the patient leaves the hospital will appear in the statement
of the month during which they are paid. It is impossible to estimate the percentage of
unpaid hospital accounts that are uncollectible. The good accounts are usuaUy paid
within a few days, while the great majority of the remainder are luicoUectible.
4. Appraisal of Pkopehty — An appraisal of the physical property, build-
ings and equipment, should be made of all Cleveland hospitals on a basis of
present values. The reproduction cost of hospital buildings at the present
time is in some instances at least 100 per cent, higher than five years ago. A
proper percentage for annual depreciation cannot be established without an
appraisal. It is also necessary in order to determme valuation for fire insur-
ance, etc. It is possible that the exp)ense of an appraisal could be lessened
if the Cleveland Hospital Council made a contract for all the hospitals rep-
resented in the Council. The expense could then be prorated between the
hospitals according to property values.
5. Deprkciation — Depreciation of buildings and equipment should be
charged off annually. The bookkeeping system recommended in paragraph
one should provide for an annual depreciation charge.
6. Per Capita Cost — All expenditures for current repairs, new equip-
ment, replacement of equipment and betterments to existing buildings
0BPITAL8 AND DISPENSARIES 879
diould be charged to maintenance account. The per capita per diem cost
mV maintenance will thereby be placed on a uniform basis for all hospitals.
BSxpenditures for new buildings, and equipment for new buildings, should
DM charged to capital expenditures. (Note B.)
Notm B — ^The per capita cost per diem for maintenance has been reported for Cleve-
■■id hospitals as follows:
(a) For 1918, minimum, $1.69; maximum, $4.60
(b) For 1919, minimum, $2.00; maximum, $5.62
3Mdt including Warrensville Infirmary or the City Hospital). It is believed that the
Bintmum per capitas reported do not actually represent the true per capita cost.
7. Cash Discounts — Cash discounts should be taken on all bills where
pNMsible. Experience in hospital accounting has demonstrated that legiti-
ooate cash discounts will represent one-half of one per cent, of total expendi-
bures of general hospitals, or two-thirds of one per cent, of total expenditures
Ror maintenance, exclusive of salaries. (Note C.)
Notm C — ^The practice of holding bills for approval of committees of the Board of
or Managers is pernicious and accoimts for failure to obtain some cash discounts.
Board of Trustees should put in the hands of hospital superintendents full authority
approving bills for payment of aU current expenses. Extraordinary expenditures
Bonld be authorized by the Boards of Trustees before order is placed by superintendents.
which habitually pay bills after 30, 60 or 90 days cannot purchase to good advan-
m the open market, and have a poor credit rating. It may be necessary for the Cleve-
Hdspital Council to establish a fund to cover the discounting of bills for smaller
■MMpitals.
8. Rate for Wards and Rooms — Ward rates are ridiculously low, aver-
aging $2.00 per day. These rates should be raised to at least $3.00 per day,
^imic^ figure represents only part cost of maintenance. Private room rates
5ii some hospitals are also low and should be advanced. Board bills for ward
■nd room beds should be collected one week in advance for general cases, and
9mo weeks in advance for maternity cases. Therefore, patient's relatives
vbould be billed weekly in advance. Recognition should be given the fact
Vliat wages and salaries are materially higher than when these rates were
originally established. It should be understood that ward and room rates
oover bed, board, pupil nursing, interne service in the larger hospitals, cer-
%un routine and diagnostic services, and for free and some part-pay patients,
gratuitous medical attendance.
9. Rates — Cobipensation — The rate formerly allowed by the Ohio State
^bdustrial Commission for compensation cases was outrageously low. Such
irates should be established on a basis of cost of maintenance. $3.00 to $3.50
day, plus charges for all extras, will represent the approximate cost of
880
Hospital and Health Suivy
ward patients, at present. The Cleveland Hospital Council has taken AeL^
commendable stand that hospital cost for hospital service should formfliBy
basis for the establishing of hospital rates by the State Industrial
and it is gratifying that the Council has recently secured recognition d
principle from the Commission.
10. Rates for Municipal and County Patients — The charge for
care of these patients should be based on the average cost of maini
for the preceding year and be a matter of annual adjustment. It shooldl
based on per capita per diem cost. No hospital should accept a lump
or subsidy from any municipality, state or coimty authorities,
should never be made for the care of the sick on the basis of a lump:
annually.
11. Extra Charge Schedule — A charge schedule for extras shook!
adopted by all hospitals, and charges made for many supplies and mudii
vice that is now rendered free. Few Cleveland hospitals have an
extra charge schedule. Hospital clients think nothing of paying for
vices rendered at a hotel or elsewhere. Extra charges for suppUes or
vices for part-pay patients can be cancelled or reduced at discretion
patients are unable to pay. The following schedule of charges is suggested:
Blood transfusion for private patients. .. $50.00
Blood transfusion for ward patients 25.00
Large surgical dressings ^.. 1 . 00 to $2 . 00 each
X-Ray and stereoscopic examinations 10.00 to $40.00
Board of Special Nurses 1 . 50 per day and up
Plaster casts 2.00 to $10.00
Services of hired anesthetist 5.00
Nitrous oxide gas and oxygen 5.00 per adm. hour
Salvarsan administration 5 . 00 to $10 . 00
Proprietary drugs, patent medicines, serums, ampules
and special prescriptions ^ Cost plus 10%
Splints and surgical appliances Cost plus 10%
Meals for relatives of patients 75 to $1 .00 each
Cots 1 . 00 each
Ambulance service Cost
First-aid services for out -cases, including dressings 5.00 to $10.00
Operating-room fee 10.00
Labor-room fee 5.00 to $10.00
Special nursing Cost
Laboratory fees for Wassermann, blood, stomach, fecal, spinal fluid examina-
tion, etc., for private-room patients.
s AND Dispensaries 881
iEDiT Investigator — (a) Large hospitals should maintain an in-
* or credit man whose duty it shall be to investigate the financial
nces of patients. Many patients are maintained without cost
ble to pay part cost; many ward patients are cared for at part cost
ible to pay full cost. Ability or disability of ward patients to pay
outlined in the preceding paragraph can be established by this in-
The data accumulated by the Social Service department of
pitals should be available for the use of the office investigator,
considered suitable for the social service worker or department to
s financial or credit investigator to protect the business credit of
:al.
is recommended that the Cleveland Hospital Council engage a
estigator to investigate the economic status of undetermined cases
small hospitals. The salary and expense of this investigator can
ed over several hospitals. It is believed that the financial benefit
om the employment of such a man would be productive of a definite
Q income to the hospitals. An alternative would be the working
ne arrangement with the local credit association.
:jlssified Wage and Time Schedule — The project of the Cleve-
)ital Council, through a committee of Council members, to standard-
:al wages and hours of duty covering certain groups of hospital
is commendable and should be carried out. It is probable that
iation in scale will be necessary in order to provide for the diflfer-
^ponsibility, etc., in certain positions in large and small hospitals,
re has shown that wages in hospitals may be standardized in the
departments:
Training School Department — Floor supervisors, ward orderlies,
I maids.
HouMekeeping Department — ^Waitresses, chamber-maids, pantry
, cleaners (by the month), housemen and porters.
Laundry Department — Laundresses, washmen and wringermen.
Repair Department — Carpenters, painters, steamfitters and their
srs, wall washers, window cleaners*
Engineering Department — Engineers and firemen*
Ambulance Department — Chauffeurs.
lid not be advisable to extend this classification as to wages and
o offices, laboratories or professional departments which depend
lists or certain skilled employes.
; to the difference in the size of kitchens and variety of personnel
therein, it is not considered feasible to classify kitchen employes.
882
HOBFTTAL AND HeALTH SuBVH
14. Discounts in Room Rates to Privileged Persons— The mi-
jority of hospitals in Cleveland give special rates to members of the
and their families, to graduate nurses of the hospital and the clergy.
Hospitals with endowments primarily given for the benefit of people ol
lower economic status, should limit their room rate discounts to persons ibo
give gratuitous service to the hospital. Such discount rate should not be
less than the per capita cost of maintenance.
PURCHASING DEPARTMENT
1. Central Purchase Bureau — The majority of Cleveland Hospitak
can utilize the services of the Central Purchase Bureau to greater advantage
Several hospitals especially have neglected their duty and opportunities ill
taking advantage of the Central Purchasing policy. The Board of Trustttl
of every Cleveland hospital should satisfy themselves that the hospitilj
under their control takes advantage of this principle to a maximum dtfffti
Their investigation of the subject should include a comparison of prices piil
by the Bureau during the last year for like commodities purchased by tkj
superintendent of tlie hospital during the same period.
Full advantage of a central purchasing bureau will not be manifestd
until the hospitals standardize supplies.
The replies to questions referring to the eflScacy of the purchasing (k*
partment of the Cleveland Hospital Council, from the standpoint of theiK**
pitals, reveal two chief criticisms:
(a) That delays in the delivery of supplies purchased through the
Bureau are frequent.
(b) That prices obtained by the Bureau are in some instances no better
than quotations made the hospital direct.
In reference to {a): it may he stated that many delays have occun^
during the past year on account of slow freight, insuflScient production aw
causes heyoiui the control of the Bureau. It is often necessary, in order to
obtain the best prices, to purchase supplies out of town that ordinarily
would be puroliase<l by the hospital in the city. It is believed that cnti-
cisnis could be Icssenccl if the hospitals would anticipate their wants furtk*
in advance. To meet this criticism, the Bureau should make prompt ^k*
livery a retiuisitc for the acceptance of orders, and aim to consider proinp^
delivery in conjunction with niininunn prices.
In reference to \h) : it may be stated that the benefits of Bureau purchaf
in^ can be incrt\iseil throui^li larger orders. The nature of many coinfli<^
ties iliKV"^ not enable the central purchasing bureau to obtain a price any lowtf
than might be o})tained by the hospital. This fact of itself should not pr^
vent placing orders through the Bureau for most commodities, inasmuch >5
OBPTTAXS AND DISPENSARIES 883
e Bureau*s chief advantage lies in the placing of large orders. The Bureau
ould keep hospitals informed of pending advance in prices.
The Cleveland Hospital Council Purchasing Bureau should systematize
Quotation Department so as to furnish without delay quotations that
J hospital executive may use in comparison with prices he may have re-
ved. To obviate the lost time element, the following should pertain:
(a) Prompt furnishing of quotations.
(b) Prompt placing of orders.
(c) Prompt delivery of goods.
2. Warehousing by the Bureau — It is not believed that the full benefits
Central Bureau purchasing will be manifest until the Cleveland Hospital
uncil provides warehousing and storage facilities. Investigation shows
it many of the smaller hospitals are buying in small quantities, or from
od to mouth, for two reasons:
(a) Lack of capital requisite for carrying goods in stock.
(b) Lack of storage facilities.
In view of the cooperative relationship of the hospitals to the Cleveland
3spital Council and the Welfare Federation, the remedy does not wholly
within the hospitals. Additional storage space cannot be provided in
any hospital buildings without definite building additions. Limited eam-
? power of small hospitals precludes the establishment of a fund suflBciently
'ge to carry a stock of goods.
Investigation and study of the cooperative purchasing bureau main-
ined under the auspices of the Cincinnati Community Union has thrown
w light on this subject. The Cincinnati Community Union has set aside
revolving fund of $50,000 to provide for the expenses, warehousing and
)ck for the charitable organizations, institutions and hospitals of the city,
though in operation only a few months, the participants in this coopera-
te bureau are enthusiastic over the results. It is recommended that the
eveland Hospital Council investigate the possibilities of warehousing to
imited extent in order to encourage greater use of the purchasing possibili-
s of the bureau. It is believed that if the hospitals of Cleveland can be
nired of immediate delivery from warehouses of many staple supplies,
iir bureau requisitions would be greatly increased. The Cincinnati experi-
int has shown that the capital tied up in stock at certain times has only
)resented a fraction of the amount set aside. In fact, it is believed that
ring certain seasons of the year a part of the money set aside for warehous-
[ stock could be drawing interest or be used for other piir|)oses. In this
inection, attention may be called to the fact that provided with warehouse
)acity, the Purchasing Bureau of the Cleveland Hospital Council
lid take advantage of opportunities for seasonable ])urchases that would
neglected or considered impracticable for hospital executives.
884 Hospital and Health Subtet
3. Authorization of Purchases — ^The purchase of supplies or requisi-
tion on Central Purchasing Bureau should be made only with the approvil
of the superintendent, authorized purchasing agent or steward, the latter of
whom should be subordinate to the superintendent. (Note D.)
Noie D — The practice of direct purchases or Bureau requisitions by heads of depart-
ments or dietitians without the authority of the superintendent is pernicious and not
good business procedure. The superintendents of certain hospitals first become funS&tt
with some purchases when bills are received. Marketing in open markets by dietitiaoi
and heads of departments is good practice when properly authorized and checked bj
the hospital superintendent.
PI 4. Standardization of Supplies — ^The project of the Cleveland Hos-
pital Council to standardize the majority of hospital supplies is absolutely
necessary to the proper development and functioning of the Central Pur-
chasing Bureau. Superintendents of hospitals who have preconceived ideas
as to standards should come to an agreement with the committee on standard-
ization in order that they may participate in the benefits to be derived from
the uniformity of specifications, once standardization is accomplished. It
will not be possible to extend the principles of standardization over all hos-
pital supplies, but it is believed that the same can be extended over most pro-
visions, housekeeping supplies and to a certain extent over furnishings. It
isfalso recommended that an attempt be made to extend it over certain
staple drugs and surgical supplies.
5. Storage Facilities and Advance Purchases — Hospitals should
aim to take advantage of minimum prices that may be obtained through
(a) Quantity purchases.
(b) Purchases in advance of needs.
This plan necessitates increased storage or warehouse capacity for some
hospitals.
Advantage can be taken of tlie markets by the seasonable storage of the
following goods: canned goods, coffee, tea, na\'y beans, sugar, soap, starch,
laundry soda, flour, butter, eggs, dried fruits; and sometimes crockery,
glycerin, lard, narcotics, certain bulk chemicals, manufactured dry goods, et«.
Sufficient eggs should be stored in public warehouses in April, and butter
in June, for hospital consumption during the months of maximum high prices.
(October, November, December and January.)
Egg candling and storage should be carried out only by reputable and
high class firms who will guarantee quality at time of consumption. Egp
should never be stored in anything but new cartons.
6. Inventories — Physical inventories should be taken on the last d*y
of each month, comprising all material stock in storerooms. The practice
of most hospitals of depending on book inventories is fallacious and not
justified in commercial practice, except for the drug department. (Note E.)
SPTTALS AND DISPENSARIES 885
Notm E — ^This recommendatioin comprehends inventory of unissued stock supplies
I as groceries and provisions, household supplies, gauze and cotton, dry goods, laundry
>lie8, in storeroom awaiting issue. Warehouse supplies should, of course, be included.
e the system of monthly inventories is established on standard inventory blanks,
office employe assisting the steward or proper head of department, can take inven-
and complete records in one or two days, depending on the size of the hospital and
amount of goods carried in stock. It is estimated that the hospital which does not
y on inventory a stock of supplies equal to 10 to 15 per cent, of its annual purchases,
ot taking advantage of seasonable purchases or storage possibilities. In this con-
ion, attention is called to the fact that certain suppplies, soaps for example, improve
torage, and that but few supplies deteriorate.
7. Contracts — Annual, limited or quantity contracts should be sought
certain supplies; notably coal, electric lamps and milk from producers,
s strongly recommended that all hospitals make arrangements to obtain
T milk supply from the producer rather than depend on commercial
ributors.
8. Drugs and Surgical Supplies — It is recommended that the Cleve-
i Hospital Council employ or develop a trained drug and surgical supply
1 as buyer. Expert knowledge of drugs and drug markets, and a prac-
1 knowledge of the hospital use of surgical supplies are qualifications nec-
jpy. It is believed that such a man could develop the purchasing in this
artment and prove a decided economy after the department is organized.
The offer of the School of Pharmacy of the Western Reserve University
cooperate with the hospitals of Cleveland in the standardization and
lufacture of certain drug supplies is highly commendable. The hospitals
[Heveland have an opportunity to avail themselves of the use of a drug
lufacturing laboratory and expert supervision of their local drug depart-
its that is not vouchsafed to many hospitals in other cities. It is under-
xi that the Cleveland Hospital Council has already taken steps to take
antage of this splendid proposition.
The venereal clinics of the city should take advantage of the free pro-
on of arsphenamine by the state.
9. Food Service and Directing Personnel — ^The entire food service
he hospital should be under the direction of a trained dietitian. In small
pitals it is possible to combine the service of dietitian and housekeeper,
this connection, it should be remembered that trained dietitians may make
d housekeepers after reasonable experience, but that housekeepers do not
inarily make good dietitians without special training. The service in
ployes' and nurses' dining rooms should be under the direction of the
titian as well as the food service to patients. In large hospitals it is nec-
ury to study carefully and provide for the cooperative relationship of
steward's department, main kitchens, which are usually in charge of a
886 Hospital and Health Subvit
chef, and the dietitian. The details of the hospital food service are too
intricate to be covered by a survey of this character.
10. Stewards or Purchasing Agents — In large hospitals stewards or
purchasing agents are necessary in order to relieve the superintendent of
many of the petty details of purchasing supplies. Where a steward or
purchasing agent is employed he should have assigned to him duties and re-
sponsibilities similar to those of stewards of large hotels.
HOSPITAL ECONOMICS AND SALVAGING
1. Repair Department — ^Hospitals of over 50 beds can economically
support a general repair man for steam fitting, electrical repair and carpenter
work. The painter, or painters, should be employed by the month. The
repair department can be extended in personnel and equipment as the bed
capacity increases. The development of a central surgical instrument
repair shop for the use of all hospitals is desirable. These shops should be
under the control of one or more of the larger hospitals or of the Cleveland
Hospital Council. Experience has demonstrated that surgical instrument
and appliance shops can be made self-sustaining almost from the beguming.
Prompt, uniform and satisfactory production at a lessened cost will be the
inevitable result. Such an activity might well be included among the {un^
tions of the central brace shop as proposed for the orthopedic center. (See
pages «00-!201.)
^. Manufacturing — Manufacturing of certain hospital supplies can be
extended by individual hospitals in accordance with their needs and the
ingenuity of the hospital executives. A central sewing room for manufactur-
ing dry goods should have a place in everj' hospital.
It is only necessary here to call attention to the fact that manufacturing
can l>e extended without limit in hospitals that have the requisite repair
personnel. Some hospitals manufacture fracture beds, bed elevators, wooden
stools, mattresses, cotton waste from recleaned gauze, stretcher canvass,
Bradford frames, extension apparatus, splints, etc., without limit. The
manufacturing of dry gcKxis ada])table to hospital use is limitless, depending
on the facilities ])rovi(led. The economical manufacture of soap from grea5e
is strongly urged, and can be carried out in the laundr>' with ver>' simple
equipment. Soap thus manufactured should he used for household clean-
ing ])urposcs as soft soa]). Liiundry soap should l)e manufactured from soap
chips.
S. Wastk and Salva(;in(» — I^ick of attention to waste in hospitals i;^
uniform all over the country. It is not within the province of this Survey
to discuss it. Attention is callcil to the op|X)rtunity for salvaging and sale
of wa>tc pa|HT. old harrels, waste ruhlHT. old metal, rags, bottles, etc. J^ur*
giral gaii/.o and handagcs should Ik* washed and re-washed until worn out.
It can tlicn he roduccil to cotton waste or sold with rags.
4. LAHi»K Savinc; Okvicks— I^ibor saving devices should be utilized
whenever po»ihle. Electric dish-washing machines are an economy of time
loSPITALS AND DlSPJSNSAiaES 887
nd labor in any hospital. In hospitals of sufficient size, the same may be
aid of electric dough-mizers, meat-cutters and vacuum cleaners.
5. FiBE Protection — ^This subject should be studied carefully by hospital
rustees and executives with the assistance of expert advice. Few hospitals
ave a sufficient number of fire extinguishers, and where these are provided,
bey are not refilled with proper frequency. Only extinguishers approved
y the Underwriters' Association should be used and these should be re-
lied twice annually. At each refilling, they should be labelled or tagged
'ith date of refilling.
Standpipe with hose connections, fire escapes, fire buckets in attic, should
sceive attention. Heads of departments should be drilled or instructed in
deir duties in the event of a fire. Fire drills are desirable, but almost im-
ossible on account of the frequent changing of employes.
6. Insurance (Fire) — It has been ascertained that many of the hos-
itals surveyed are inadequately insured against fire. After appraisal of
uildings, old policies should be cancelled and new policies taken out on the
asis of reappraisal. It is believed that fire insurance rates are due to ad-
ance and it is recommended that appraisals be made, old policies cancelled
nd new policies issued so as to take advantage of present rates. It is
referable that hospital insurance policies be drawn for five-year periods,
rhich provide for lower rates. Co-insurance policies are not reconmiended
xcept for fire-proof buildings. For non-fire-proof buildings a maximum cov-
rage is recommended by means of straight policies. The contents of hospital
uildings should be fully insured .as most hospital fires are small and the
ontents suffer to a greater degree than the buildings. Owing to the recent
apid increase in construction cost, hospitals should examine their fire insur-
nce policies without delay and increase them to a figure approximating
resent values.
Compensation insurance covering employes should be carried by all
ospitals. Elevators and automobiles should also be properly covered.
GENERAI. RECOMMENDATIONS
Professional
1 . It is recommended that standing house orders be established :
(a) For preparation of patients for operation.
(b) For after-care of surgical cases.
(c) For preparation of patients for confinement and after-care (pre-
natal orders); (post-natal orders).
(d) For preparation of patients for operation and after-care in tonsil-
lectomy.
2. That large hospitals sterilize and manufacture prepared catgut from
%w catgut.
888 Hospital and Health Survei
3. That large hospitals manufacture nitrous oxide gas.
4. That arrangements be made to purchase oxygen of local manufac-
turers rather than of jobbers. This will necessitate the hospital owning its
own tanks which can be sent to manufacturers for refilling. All large dtKs
have a number of plants manufacturing oxygen as a by-product. Its cost
under these circumstances should be 50 per cent, less than prices paid job-
bers.
5. That rubber gloves be not issued at the expense of the hospital to
staff members for use on private cases, or to non-staflf physicians.
Visitors and Visiting Hours
Visiting the sick should be limited as much as possible, especially in open
wards. Hospitals where possible, should reduce visiting days to three or
four days per week, including Sundays. Two of these days could have
visiting hours for wards 6 :00 to 7 :00 or 7 :00 to 8 :00 P. M . , and the remaining two
days 2:00 to 3:00 or 3:00 to 4:00 P. M.
Visitors to private rooms are difficult of regulation. They should be
limited if possible to afternoons between 2:00 and 5:00 P. M .
f^ Non-professional visitors in the operating room during operations should
not be permitted. The practice of allowing relatives of patients to witness
operations is dangerous and susceptible of much criticism. It should not
bejpermitted.
HYGIENE OF HOSPITAL AND PERSONNEL
I. Health Tests — All employes handling or preparing food either in
storerooms, kitchens, pantries, dining rooms, diet kitchens, etc., should
have a complete physical examination, including a Wassermann examina-
tion, before being accei)ted for appointment. The medical examination
and tests made should be adequate to exclude typhoid carriers from this
service.
All nurses before admission to the training school, and employes before
assuming duties of their positions should give evidence of a recent vaccina-
tion against smallpox, or b« vaccinated.
In tlie event of development of cases of diphtheria among hospital per-
sonnel, all employes and nurses should have the Schick Test to determine
susceptibility. The making of a Schick Test as a routine procedure prior to
employment or entry to the training school, is unnecessar5% It should not
be neglected, however, in tlie face of an epidemic.
The autliorities of tlie hospital should provide for and encourage medical
exmination of all their employes annually.
'i. Milk Supply — nos])ital laboratories should install apparatus for
testing tlieir milk supply on delivery daily. Determination of quantity of
butter fat, bacteria content, temp)erature and specific gravity will permit
[OBFTTALS AND DlSPJSNSARIES S89
becking of contract which would provide for certain minimum standards,
[ospital milk should be cooled to 50 degrees immediately after milking,
slivered at the hospital before reaching 60 degrees and contain not less than
per cent, of butter fat. The milk contract should call for milk for drink-
ig purposes known as Class "A" grade. Milk should be delivered to hos-
ital raw and provision made at hospital for pasteurization for such milk
i may be desired pasteurized prior to use. (Note G.)
Notm F — Class "A" milk in Cleveland is raw milk from tuberculin-tested herds,
oring 90 per cent, or better, with less than 50,000 bacteria content per c.c. It may be
cessary in some instances to use Class "B" pasteurized milk, which conforms with Divi-
3n of Health standards.
8. Water Supply — ^The hospital laboratory should periodically test the
ater supply. If storage tanks are in use, tests and culture should be made
cm tanks as well as spigots.
4. Ventilation — During the winter months, hospitals with the plenum
rstem should give rigid attention to the details of this system with frequent
camination of air in wards and exposure of culture media. Hospitals using
rect-indirect methods combined with heating, during winter, should make
eekly examinations of air as a check on the mechanical operation of exhaust
ns and the mechanics of the ventilating system.
890 Hospital and Health Subyet
III. Dispensaries
DISPENSARIES IN CLEVELAND
As outlined in the section entitled ''Some Definitions/' and as shown in
Figure HI., Part IL, there are two classes of dispensaries in Cleveland—
those treating the sick and those primarily concerned with preventive work,
orlthe clinical and the public health dispensary, as the two types may be
called. In Cleveland, five dispensaries treating the sick deal with general
diseases; one, the Babies' Dispensary, confines its work to children under
three years. There are also a number of industrial dispensaries supported
by business establishments for the treatment of accident cases. The indus-
trial dispensaries are dealt with in Part VII. of the Survey report, and are
merely mentioned here. The pubhc health dispensaries are dealt with in
the next section of this chapter.
All of the dispensaries treating the sick except the Babies' Dispensaiy
and the industrial clinics are attached to hospitals, and are usually called
the out-patient departments of those hospitals. All of the public health
dispensaries, on the other hand, are distinct from hospitals, with the excep-
tion of a few of the prenatal clinics.
The six dispensaries treating the sick are as follows:
Dispensaries Dispensary Visits, 1919
Lakeside Hospital — Out-patient Department. 59,891
St. Vincent's Charity Hospital — Out-patient Department ^ 21,863
Mount Sinai Hospital — Out-patient Department : 19,324
Babies' Dispensary and Hospital 14,977
St. Luke's Hospital — Out-patient Department 13,313
Huron Road Hospital — Out-patient Department 5,864
It is probable that the number of different individuals treated was about
30,000 in 1919.
From the above table it will be found that the dispensaries of Cleveland
are comj)aratively few in number and small in size as compared with those of
other leading cities. In the section on '* Policies and Needs," such compari-
sons will^be made. In this section the general work of the dispensaries is
reviewed.
Location of Dispensaries
The six out-patient dispensaries are very unevenly distributed — Lakeside
is on the lake at East Twelfth Street; Charity is one mile inland at Twenty-
second Street; and Mount Sinai about one mile and a half inland at 105tli
Street. These three dispensaries treat all kinds of diseases. Huron Road
Dispensary, located in the center of the city, does verj' little except surgical
[TALs AND Dispensaries
891
m^A
Fig. III.
The height of thelblack rectangles represents the percentage of dispensary patients living in
the district and attending the dispensary designated by the letter above.
892 Hospital and Health Survey
emergency work; the same is true of St. Luke's, which is in the. middle of an
industrial district. The Babies' Dispensary, not far from Charity Hospital,
confines itself to sick babies up to the age of three years.*
A study of locations shows that the dispensaries are not so located as to
interfere with one another, but it is obvious that the west and south sides o{
the city are entirely without provision. The range from which patients come
to the dispensaries varies considerably as shown by Fig. III. In Cleveland, as
elsewhere, it is found that a dispensary with medical teaching draws from a
relatively wider area, since consultation cases are sent to its staff for special
study and since the reputation of its staff draws patients. In general the
range of a dispensary varies somewhat in proportion to its reputation.
People will go long distances to secure expert medical care of which they
feel themselves to be greatly in need, but convenience of location and near-
ness of a dispensary are of great assistance in bringing people in the eariy
stages of disease under care and in attaining easy supervision of treatment.
Classes of Disease Treated
Tuberculosis is not cared for in these dispensaries except in so far as diag-
noses are made when patients come into the dispensary with other com-
plaints, but the supervision and control of cases of tuberculosis are carried
on by the Health Centers and the special sanatoria for this disease. The
common ** contagious" diseases are also excluded from dispensaries.
Organization and Executive Control
The management of a dispensary of any size, such as those at Lakeside
and Mount Sinai, involves the handling of a considerable number of patients
and a number of physicians, nurses, social workers, and other assistants, and
needs skilled and executive direction. Rarely, however, has there been pro-
vided by the hospital any officer responsibly charged with full control of the
dispensary and expected to give to it his main attention. At Lakeside and
Mount Sinai, an assistant superintendent of the hospital is director of the dis-
pensary, but at Lakeside until recently the actual conduct of the dispensary
fell entirely upon the head of the social service department. At the smaller
dispensaries — at Huron Road Hospital and at St. Luke's Hospital, and also at
Charity Hospital, tliere have been no executive directors. The hospital
superintendent is responsible for the dispensary as well as for other depart-
ments of tlie hospital, but no official has been assigned to take charge of the
dispensary.
Only at the Babies' Dispensary has there been definite and continued
executive direction and carefully worked out organization, under the pro-
fessor of pediatrics at the University, with a salaried nurse devoting her full
time to the detailed administration. This organization has indeed devoted
too much attention to its own executive detail and administrative system,
*A small number of orthopedic cases receiving special treatment are accepted up to 14 years of sf^
at the Babies' Dispensary.
I
Hospitals and Dispensaries 893
but furnishes on the whole an example of the value of a well-thought-out
and well-worked-out plan of dispensary administration under full-time,
responsible executive direction.
Buildings
The Babies' Dispensary is especiaUy well designed for its purpose. The
other dispensaries are all hampered for want of roiom or from old dark build-
ings. St. Luke's and Charity function in basements; Huron Road in a rather
forlorn annex; Mount Sinai in a small double house; and Lakeside in poorly-
arranged, inconvenient rooms. All of the institutions except Charity are
planning new buildings, and Lakeside is planning certain modifications of the
present plant that will make it much more suitable during the remainder of
the time the building is in use. The unsuitable or inconvenient character of
the plants is typical of the la(;k of attention paid to dispensary work in the
past, while the increasing interest in this form of service is reflected in the
projected developments.
Patients
As shown on the map (Fig. III.), the existing dispensaries draw their pa-
tients largely from the central congested areas of the city. Sufficient num-
bers come from a distance to show that when the work and existing value of
dispensaries is known, distance is not an insuperable obstacle. It would be
interesting and important to ascertain how far the distribution of dispensary
patients by districts agrees with the economic condition of the population in
each section. Obviously, the dispensary draws primarily from the poorer
elements. There are considerable districts in the west and south sides
which appear to contain a large number of people who are financially as much
in need of medical charity as those who are near the existing dispensaries.
Some light is thrown on this point by the study of nationalities. Thirty-
three nationalities were found registered among records studied in the six
dispensaries. The proportion of foreign-born found in the more recent of
these records of races is smaller than the proportion which these races bear
to the total population of Cleveland. Knowledge of dispensaries and willing-
ness to go to a strange institution penetrate only slowly among many groups
of immigrants. At Lakeside Dispensary, American-bom patients consti-
tuted over one-half of the total; Charity draws largely from Italians and
Negroes; Mount Sinai shows over half of its attendance, Jewish; Babies'
Dispensary shows 24 per cent. American-born parents, 18 per cent. Slavic,
16 per cent. Jewish, 14 per cent, colored, and many other nationalities rep-
resented in small percentages. Very little has been done at any of the dis-
pensaries to provide interpretation for patients not speaking English. There
is much complaint from outside charitable agencies that adult patients not
speaking English find it difficult to make themselves understood, or to
understand what the doctor finds to be the matter or what he wants them to
do.
894 Hospital and Hel\lth Suryet
Fees and Finances
It is becoming the general policy of dispensaries throughout the country
to charge admission fees at each visit of a patient, the fee usually being of
nominal amount (except in "pay clinics") and being remitted in whole or
in part where the pajient is not able to pay. In Cleveland, only one of the
five general dispensaries, Lakeside, has adopted a general admission fee in
its daytime clinics. Mount Sinai Dispensary charges ten cents for the
first admission but not thereafter, and Charity makes a nominal charge
when a person loses his admission card. All make charges for medicines at
prices more or less corresponding to cost, and also usually charge for special
treatment or appliances.
In the evening cUnics which are designed for persons who are at work
in the daytime and generally aim to be quite or nearly self-supporting, fifty
cents a visit is charged by Mount Sinai, Charity, and Lakeside — the three
dispensaries which maintain such cHnics. Babies' Dispensary has a grade
system — the highest class pays fifty cents and the lowest grade nothing for
admission.
The charging and collection of fees and the designation of what these
fees should be and when and why they should be remitted, require an adequate
admission system for a dispensary. The present inadequate organization of
most of the institutions would make it difficult to administer satisfactorily an
admission fee system. It is of course essential that if admission fees are
routinely charged, there he a system for receiving and accounting accu-
rately for monies, as well as for deciding what fees should be paid by patients
or be remitted. Having such a system in a dis[>ensary is always stimulating
to better administration and also serves to provide the funds for it. An im-
portant by-product, moreover, is the greater attention given to the economic
and social condition of ])atients, promoting more careful attention to the
social as well as the medical needs of those admitted, and protecting the
medical profession better against those who could properly pay for the ser-
vices of a private physician.
The exact cost of dispensary service in Cleveland is not ascertainable
because no one of the out-patient departments of the hospitals fully sep-
arates its expenses from those of the hospital. Immediate expenses are
usually charged to the dispensary, but the overhead — heating, lighting, super-
vision, and other general expenses — are not usually figured in. It is probable
that tlie average cost per visit does not exceed fifty cents with the exception
of the Babies' Dis]jensary, which is indejjendent of a hospital. The five out-
patient departments of the hospitals, w4th about 115,000 visits, probably
cost altogether about $60,000 a year. Really adequate administration of tie
dispensaries as hereafter recommended would cost more, but the difference
would be met or more than met if adequate admission fees were charged.
Failure to have proper cost accounting is a serious Umitation on dispensary
service. What seems cheap, is held cheaply.
Hospitals and DisPENaA^RiEs 895
Medical Work of Dispensaries
Physicians work in the daytime clinics of the dispensaries without finan-
cial remuneration, except in a few instances of physicians doing special work
at Lakeside and at the Babies' Dispensary. These two dispensaries are
teaching clinics for Western Reserve University, members of the staff being
ilso members of the staff of the medical school. In the evening pay clinics,
til the physicians receive either a regular salary or an amount dependent on
he fees received from patients. A large part of the dispensary work in
Cleveland is connected with the teaching of medical students, all of the staff
it Lakeside and at Babies' Dispensary, and part of the staff of Charity and
f Huron Road, being connected with Western Reserve University Medical
ichool.
The dispensary staffs are only in a few instances organized satisfactorily
Q relation to the staffs of the hospital with which the dispensary is con-
nected. (See section on "Organization for Service.") The practice of
oaking all appointments annually has been taken advantage of only at
ifount Sinai. The Babies' Dispensary is the only one that has an accurate
ind complete enough system of record keeping to afford a basis for clinical
esearch. Most of the opportunity for the student is lost because of inade-
[uate records, and much duplication of work among dispensaries and within
he same dispensary is necessitated for the same reason.
Opportunities for consultation among physicians representing different
pecialties is an important element in good dispensary work, but this oppor-
unity is relatively small in the Cleveland dispensaries owing to loose organ-
Eation and to very lax systems of referring and transferring patients be-
ween dispensaries or clinics. The making of efficiency tests of the medical
Fork and the accumulation of facts on which to base judgment concerning
administrative procedures has yet to be undertaken.
Records
All of the five general dispensaries excepting Charity have a central
iling system — all records concerning each patient being filed together. At
Charity, the filing of the records of each particular clinic separately repre-
ents a serious drawback since the work of the different specialists upon a
ase cannot readily be assembled and the needs of the patient studied as a
rhole. Card record forms for the medical work are in general use, differing
videly in detail. Conference and comparison would lead to improvement
ind standardization. Mount Sinai has a plan for a summary sheet for
liagnosis and laboratory tests, an experiment which is worth pursuing.
Social Service
The too considerable part played by under-staffed social service depart-
kients in the administration of several of the dispensaries is described in
letail in the section on "Social Service". It may be mentioned here that
H relation to cooperation with charitable agencies, the social service de-
896 Hospital and Health Survey
partments have usually made an eflFort to define their attitude toward the
social agencies, particularly in relation to the need of patients for material
relief. All of the social service departments are avowedly opposed to the
giving of material relief, regarding this as the duty of a "family agency** or
relief society. In general an exception is made of certain medical needs
which the social service departments regard as adequate reason for giving
financial aid. Thus at Mount Sinai, it is felt that a patient's inability to
pay for glasses or for dental work is an indication that there are other more
general financial needs and the case is transferred, by the social service
department, to general charitable or relief agency. Lakeside Social Serv-
ice Department will give money to patients for carfare and occasionally
will make small loans. A very small fund is in the possession of this depart-
ment for such purposes. The Babies* Dispensary provides milk at less than
cost or free, if necessary. This is provided for babies up to the age of fifteen
months; after that if the baby is ill, it will be continued up to eighteen months,
but never later. Thid is also done at the Health Centers. The total deficit
for the year 1919 was $18,000, of which the city pays $6,000 and the Babies*
Dispensary $12,000. With these exceptions the social service departments
do not give material relief, but transfer to charitable agencies all cases in
which such needs appear evident or probable. Thus a pretty clear division
of function between the social service department and the non-medical
agencies has been worked out.
On the other hand, there has not been a satisfactory understanding be-
tween the dispensaries and the charitable agencies with reference to the
examination of patients not acutely ill, but concerning whom a charitable
society needs to secure facts as to physical condition, working ability, and
the general health needs of the family. In some instances, notably at Lake-
side, it has been difficult for charitable societies to secure examination of
these cases, who often not being sick, do not interest physicians coming to
the dispensaries primarily to see and treat illness. It has also been difficult,
at Lakeside almost impossible, for charitable societies and agencies, to secure
infonnation regarding the diseases or defects found in patients in whom
they are interested. The families known to charitable societies and receiv-
ing relief from them, can obviously not aflFord to pay for medical care, and
it is particularly for such families that dis[>ensaries should serve as family
physicians. This means providing health examinations and advice concern-
ing occupation, nutrition, etc., as well as diagnosis and treatment during
illness. The dispensaries have given only a very limited degree of service
in this connection, although a real beginning has been made at such places
as the Babies' Dispensary and Mount Sinai. An important field for larger
service lies here.
•
Rkpohts and Tests of Dispensary Service
The annual reports of the dispensaries are most inadequate. The dis-
pensaries probably serve altogether, in a year, as many as 30,000 persons-
hospital beds, .50,000 to 60,000, or twice as many. Yet the attention devoted
to reports of hospital work is not twice as much as that given to dispensary
reports, but ten times as nnich or some such ratio. Even the number of
Hospitals and Dispensaries 897
patients served or treatments given in each of the several clinics — medical,
surgical, etc., were not obtainable from the dispensary reports, (except from
one institution) and had to be specially secured for the Survey. The authori-
ties of the institutions have not provided themselves with the elementary
data with which to judge even the scope and amount of service rendered,
much less its quality. The collection of routine statistics of the work of
each clinic is a matter neither difficult nor costly.
Deficiencies in Certain Branches
•
Like the hospitals, the dispensaries are undeveloped in certain important
specialties in which the public needs service. Clinics for children (over the
age of three) are the most notable example. The children's clinics at Lake-
side and Mount Sinai are very small; tJiere are none at Charity Hospital,
Huron Road, or St. Luke's. The age limit set by the Babies' Dispensary
has been an unfortunate restriction. It has served to limit the development
of clinics for babies elsewhere, and has indirectly tended to diminish the
chance of adequate clinics for older children. Moreover, no one clinic for
sick babies can meet the need for a city as large as Cleveland. All sick
babies needing dispensary care are expected to come to one spot, the Babies'
Dispensary, and even when there they are not treated unless the nurse at
the admission desk agrees with the mother, or with the visiting nurse who
referred the mother, that the baby is too ill to be at a Babies' Prophylactic
Station and that the family is too poor to pay a private physician. A study
by the Survey showed that somewhat more than half of a group of cases
recently applying at the Babies' Dispensary were referred elsewhere. It is
to be strongly recommended that: (1) Babies' Dispensary accept children
up to 14 years, (i) Pediatric Clinics treating children up to this age be
developed at all present and future dispensaries.
Clinic service for cases of heart disease is an undeveloped field in Cleve-
land. Mount Sinai appears to have recognized the problem and to have
begun e£Ports to get cardiac cases under care, at Rainbow Hospital. It is
highly desirable that cardiac clinics be developed as parts of the general
dispensaries which exist or are to be established at City Hospital, Lakeside,
Mount Sinai and the proposed central downtown dispensary.
Relation of Dispensaries and Hospitals
The usefulness of the out-patient department as a means of increasing
the efficiency of the hospital has been but slightly recognized in Cleveland.
The dispensary should be the link whereby most of the hospitals' contacts
with the community are made. Thus the admission of ward patients should
be largely through the dispensary, though of course emergency and some
other cases will enter otherwise. The medical study given in the dispensary
to the patient should be the beginning of the hospital's work with him and
not, as now, be usually wasted because the medical organization and the
records of the out-patient department are not correlated with those of the
hospital.
898
Hospital and Health Su
CARt - CURE
CIRE-PREVENTION
Fig. IV.
luter-rclatioti lidween Hospital and Dispensary.
1TAL8 AND DISPENSARIES 899
f equal if not greater importance, is the function of the dispensary in
action with the discharged patient. This subject is studied in detail
e sections on convalescence.
Clinic Management
he time of doctors, given freely to service in clinics, is much too largely
, in non-medical routine — ^calling in patients, attending to records, etc.
and trained clinical assistants is necessary if the doctor's time in the
is to be of maximum value to himself and to the patient. The details
icient clinic management have been worked out in a number of dispen-
> in other cities.
Relations to the Medical Profession
here has been for some years an apparent feeling on the part of some
bers of the medical profession that dispen.>aries interfere with private
cal practice because they accept patients who could a£Pord to pay a
ician. Much of this feeling has been due to misapprehension of the
; some has been due to the failure on the part of the hospitals to deal
the medical profession on even and open terms. The Survey has found
ndence that cases who are able to pay a private physician have been
)ted by the dispensaries except occasionally, by mistake or honest mis-
nent, and the proportion of such mistakes appears no larger than studies
5W York and Boston have shown to be practically inevitable. The pro-
on of dispensary applicants who/are able to pay private rates for the
cal care which they need is believed not to be larger than three per cent.
IS the records of the Babies' Dispensary, of Lakeside, and of other insti-
Ds show, a number of such applicants are refused treatment. The prin-
5 which it is believed should govern the admission of patients to dis-
iries are stated in the section on ** Policies and Needs."
*
has been unfortunate that this vital matter of relationship between
ispensary and the physician should not have been made the subject of
matic cooperation, conference and study by representatives of both
Had, for instance, a committee of the Hospital Council met with a
iiittee of the Cleveland Academy of Medicine a number of times during
)ast five years, there would probably never have developed any atti-
of disagreement. In the section on ''Policies and Needs" a reconunen-
n is made with the aim of bringing about such cooperative functioning,
of vital importance to remember that the disi)ensary (also the hospital)
entially a cooperative enterprise of the medical profession and the trus-
and administrators, undertaken for the purpose of community service,
idequate development of dispensaries in Cleveland will oflfer to the rank
file of the medical profession opportunities of which it is now largely
ved — for consultation with specialists and for aid from laboratories
)ther facilities in diagnosis and treatment. Physicians may be sure that
900 HOBPTTAL AND HEALTH SUBVET
wlMitever assists the public to give more attention to bodily health and to
understand and utilize the most advanced resources for medical care, will
also stimulate the use of that primary and best loved resource, the family
physician.
ETTALS AND DISPENSARIES 901
THE PUBLIC HEALTH DISPENSARIES
ia previously pointed out, the public health dispensaries di£Per from those
described in that they lay emphasis on preventive work rather than on
nosis and treatment of sickness. They also di£Per in that each public
th dispensary limits itself to a definite area, receiving patients only from
district. Generally speaking, the o£Per of a preventive and educational
ice will draw persons from a much smaller area than in the case of a
c treating sickness. The e£Pective range of an infant welfare clinic is
e smill; that is^ the area from which it will draw many cases L limited
comparatively small region around the dispensary. The same is true
lie prenatal cUnic, while the tuberculosis clinic has a somewhat wider
;e. In practice the district which a public health dispensary does serve
^nds largely upon the extent to which it is advertised or the degree to
ii nurses attached to the dispensary go into homes and interest persons
ome to the clinic. These eflForts, however, are at a disadvantage if an
Dipt is made to bring many persons from considerable distances.
The public health dispensary has a militant purpose. It aims to combat
finite disease like tuberculosis or a group of diseases such as cause infant
tality. It should make no restriction- in receiving patients because of
icial status. Properly conducted, a public health dispensary should in
ivay interfere with the work of private physicians, but tends to send
ents to them since disease or difficulties are discovered which dispensaries
not treat and for which patients will be advised to seek treatment. The
of a public health dispensary is, or ought to be, the reaching of all of the
s within a certain district needing its care. It must measure its work
I population basis and see how far it is able to reach 100 per cent, of the
s of actual or probable tuberculosis in its district, or all the babies or
ictant mothers. This in practice would require that a public health
ensary, with a certain staff, must serve only so large a district as it can
:?tively reach. The time has not yet come when a general statement
be made as to the area which a given type of public health dispensary
cover, and this must be the subject of further study in Cleveland and
svhere.
Reference to Table I. shows that twenty-rtwo different sites are utilized
public health dispensaries or clinics with a public health purpose, and
; the purposes served include four types of work: tuberculosis, infant
are, prenatal care, and dental service. It should be added that the
e clinics treating the venereal diseases (at Lakeside, Mount Sinai and
rity Hospitals) fall on the border line between the public health dispen-
' and the dispensary treating the sick. They have or should have the
tant purpose of the public health dispensary, but they are largely con-
led with the diagnosis and treatment of definite disease. Since Part V.
he Survey report is devoted to venereal diseases only this mention is
le here.
Further reference to Table I. indicates that the first two of the four
ices, tuberculosis and infant welfare, are under the charge of the Division
902 Hospital and Health Sxtsvet
of Health, while the other two, prenatal and dental service, are under private
agencies. The Survey reports on Child Hygiene (Part HI.) and on Nursing
(Part IX.) have given considerable attention to prenatal as well as to tlie
other public health services which involve the nurses' work in the home aa
well as in the clinics, and the report on TuberciJosis (Part IV.) has covered
that field. Certain administrative aspects may properly be discussed here
Prenatal Clinics
In prenatal service the function of the clinic is essentially ^diagnosis. ITic
examining physician should, so far as possible, be able to decide what spedal
care, if any, each expectant mother requires during pregnancy and at delivery,
and to advise her accordingly. The diagnostic and administrative work of
the clinic are of relatively limited value without the home work of the nurse.
The prenatal clinics also play a certain part in medical and nursing education.
It should be apparent, however, that the amount of clinical service or the
number of obstetrical cases, needed for such purposes of education, is only
a small fraction of the amount of prenatal service needed for the community
as a whole. In 1919 there were 19,123 registered births in Cleveland, and
of these 1,251 were delivered in their homes by out-patient teaching services
connected with the prenatal clinics of Maternity Hospital. This is 6J^ per
cent, of the total. It is certainly true that not over lOpercent. of the olitet-
rical cases of Cleveland are required, or could even be directly utilized, for
teaching purposes in connection with prenatal clinics. Practically every
expectant mother would benefit by such service as is rendered at a wdi
managed prenatal clinic. The need of prenatal care is far broader than the
need for ** educational material." The two purposes are not at all inconsis-
tent. The one fits into the other.
The point is of practical importance because of the failure of those res|)on-
sible for the University teaching of obstetrics and for the maintenance of
the prenatal clinics connected therewith, to recognize the community need
as broader than their own special interest. Four different agencies main-
tain eight prenatal clinics. There is room for many more than eight prenatal
clinics and for more than four agencies, provided all were working as part of
an agreed general program. At present the University agency appears to
take the attitude of urging the cessation of the activities of such prenatal
clinics as those of Mount Sinai and the University District. The feeling
produced on the other side is what may be expected. The effectiveness as
well as the extent of the work is substantially diminished by such a situation.
As a reduciio ad absurdum we find two prenatal clinics, next door to one
another, at 2509 and 2511 East Thirty-fifth Street, one conducted by Mi-
temity Hospital, the other by the University District, for the training of its
students.
The recommendations made by the Survey in the reports on Child Hygiene
(Part III.) and Nursing (Part IX.) will remedy this condition if put into effect.
It may he added here, as one detail, that there is no justification for two
Hospitals and Dispensaries 903
clinics side by side on Thirty-fifth Street. Although the University District
prenatal clinic is actually under the auspices of the Division of Health, it, as
well as the Maternity Hospital prenatal clinic, is used as a teaching field
by the University, and it is largely the responsibility of the University to
see that its agents and officers dealing respectively with medical and with
nursing education, work in harmony. The two clinics should be combined.
It is a matter of indifference which plant is retained and which given up.
The University should, as now, appoint the medical and nursing heads of
the service; the internal administration of the clinic, for reasons of economy
and convenience, should continue under Maternity Hospital; the nursing
teaching should be part of the University District plan and be coordinated
with the community plan for prenatal and obstetrical nursing service pro-
posed by the Survey. (See Part IH.)
It is generally helpful for a hospital which has a considerable maternity
service in its wards, to maintain a prenatal clinic (which should be used also
for the supervision of post-partum conditions and be administered as part of
the general dispensary attached to the hospital) . Such hospital clinics should,
however, work as cooperative parts of the city-wide plan for maternity care.
There is need for many more prenatal clinics, however, than are or can be
connected with hospitals. Wherever possible the prenatal clinics should be
in the same buildings as the Health Centers of the Division of Health. By
the bringing together of a variety of diflferent health activities within one
building, each service tends to strengthen the others by increasing the con-
tact of the neighborhood with the Center, its purposes and personnel; and
to correlate many details of work by the medical, nursing and clerical sta£Ps.
Such combinations also bring administrative economies in management and
save such present wastes as renting rooms for prenatal clinics which are used
only V few hours each week. In advance of the assumption by the city of
prenatal work as a regular servi 'c in its Health Centers, cooperation between
the city and the private agencie;3 may usefully proceed in this manner.
Dental Clinics
Dental service as a branch of public health dispensaries is a recognized
activity in which Cleveland is singularly deficient.
The three mouth hygiene dispensaries operated by the Cleveland Mouth
Hygiene Association at three of the health centers are operated for fifty weeks
of the year, five days a week, and three hours at each session. Each unit in-
cludes a dentist and an assistant. The cost of these is met from the Com-
munity Fund as a part of the budget presented by the Welfare Federation.
These three Mouth Hygiene dispensaries, operated five half days per
week, are the only available and acceptable service (except the private dental
practitioner) for thirty to thirty-five thousand parochial school children. It
is estimated that fifteen Mouth Hygiene Units operated eleven half days per
week would serve this group of children quite well; i. e., would provide the
prophylactic service necessary' for eighty-five or ninety per cent, of these
904 HCNSPITAL AND HeALTH SuBYET
children and would provide for from one-third to one-half of the repair
service necessary.
The grave deficiency of dental service in Cleveland is illustrated by the
fact that the total clinic provision in the city includes onlv that at the three
health centers, the six clinics at public schools and the dental clinic at the
City Hospital, a total of ten dental chairs running 156 hours a week. In
Boston five institutions oflFer either free, at or below cost, dental service
with a total of 247 chairs used for 5,956 hours a week. The present policy
of the College of Dentistry of Western Reserve University renders it hardly
possible to class it with public service clinics for dental purposes. (See
Part VIII. of Survey Report, page 685.)
Dental care for the poor in Cleveland is limited largely to extractioD
and remedy of gross pathological conditions causing obvious inconvenience
or pain. Lack of knowledge of the needs and possibilities of oral hygiene is
responsible for the neglected teeth of most dispensary patients. Dental
clinics where a small fee is charged are badly needed in the congested dis-
tricts.
It is strongly recommended that dental service be developed as an activity
of all the health centers, including the central downtown dispensary, and
that each dispensary connected with a hospital should include a dental
clinic for both adults and children. The Survey has recommended to eacJi
of the major hospitals that a dental surgeon be a member of its staff, with
rank as head of a department; and that under his direction a dental clinic
be conducted, with the necessary dental assistance. Pay dental clinics for
persons of moderate means would be a great public benefit.
The "Health Centers"
The tuberculosis and infant welfare work of the Division of Health may
be studied from the standpoint of the management of its clinics as well as
from that of the specialist in the medico-social problems of the diseases
concerned. Of the eight "Health Centers," seven include tuberculosui
clinics; all have infant welfare clinics, and there are in addition, six "baby
prophylactic stations," subsidiary centers for the better covering of more
neighborhoods.
As to buildings, three of the Health Centers are located in stores, occu-
pying the entire ground floor in each case. Two of the stores have light from
one side only ; one of these two has good light from the rear. The third store
stands on a lot aloae and has excellent light and ventilation on all sides. .\1I
three have the advantage of unusually good front light. These three cen-
ters are the ones selected by the Mouth Hygiene Association for the install-
ment of the dental work. Three other centers, Nos. 1, 3 and 4, are located
in single dwelling houses. No. 4 has the entire house (allowing a man and
wife to occupy the upper floor in exchange for the care of the store fronts);
all the rooms have some dayliglit, making the total result better than in the
stores. Health Center No. 5 is the most fortunately located of all, being
Hospitals and Dispensaries 905
in a public bath-house, which is also a gymnasium and social club-house;
there are here ample space and a fortunate arrangement of rooms. No. 8, the
University District center, is in half of a double house. It is neither very light
nor roomy and arrangements are poor for the work. The six auxiliary sta-
tions are: one in a library — an excellent room designed for a kindergarten
room; one in a Y. W. C. A. building; one in a conmiunity center; two in
public bath-houses; and one in a settlement house. One of the public
schools in the downtown section is used in the summer for an extra station.
All the clinics are limited to essential equipment. They are all supplied
with imported scales for weighing the babies in grams. A new dental equip-
ment was being installed in Center 7 at the time of the visit of the Survey
investigator. The buildings were not adequately heated in the cases of
Nos. 7 and 3, where dependence had to be placed on stoves, with no suitable
place to store coal. Nos. 1 and 4 were heated by gas stoves which markedly
affected the air.
There are 35 tuberculosis clinics a week held in the seven main centers.
University District does the home visiting on tuberculosis cases in its area,
but gets the cases from the clinics held at Center 2. These clinics are held
Monday, Wednesday, Friday and Saturday afternoons from 2 to 4 p. m.,
and Thursday evenings between 6:30 and 7 p. m.
In the Child Hygiene Department 46 clinics a week are held. Centers
6 and 7 each hold six clinics a week. Center 2 and the auxiliary station at
Alta House hold two each a week. The other ten stations each hold clinics
weekly. These clinics are held between 9:30 and 10:30 a.m. The nurses
reported that Saturday was always the least crowded day.
Two other types of clinics are held in the Health Centers, but are under
auspices somewhat different from those of the two above mentioned. The
district doctors hold visiting hours in three of the clinics from 9 to 10 a. m.
each day. An average of about six patients come to these clinics daily for
dressings, or to get advice for minor ills. The number is frequently two to
three and it is not infrequent for the doctor to have not a single caller.
The three dental clinics maintained by the Mouth Hygiene Association
in Center 2, 6 and 7 meet five times a week from 1 to 4 p. m., and are largely
used by parochial school children and the families of patients with tuber-
culosis.
^ It can be easily seen that these clinics do not use nearly all the available
daily hours. With the exception of Station 5 the rooms are idle during the
other hours. Stations 6 and 7, both of which have infant clinics six morn-
ings a week, and dental clinics every afternoon but Saturday, do not waste
much time, but the other buildings could serve useful purposes at other
hours. This is true of the evening hours for all stations.
The patients attending the clinics are derived from different sources. In
a study made of a series of cases attending the Infant Hygiene Clinics, 57
906 Hospital and Health Subvet
per cent, were found to be referred by neighbors, friends or relatives; 37
per cent, referred by the Health Division and clinic nurses; 2 per cent, by the
Visiting Nurse Association; and 4 per cent, by physicians. The practical
value of the work is rather well illustrated by the large number of cases
sent by apparently satisfied clients. In considering this, the use of the clinic
in providing an inspected milk at lower than market prices must be borne in
mind. It is not purely the desire for a health inspection for their children
that brings the mothers.
In the tuberculosis clinics the largest percentage came in as a result of
efforts of the Division of Health nurses, 46 per cent, having come in this way.
14 per cent, were referred by physicians and by friends or relatives; 11 per
cent, by dispensaries and hospitals, 7 per cent, by the Board of Education
(referred when there is a health problem in relation to the issue of working
papers), 3 per cent, by the Associated Charities, and 1 per cent, each from the
Red Cross, the Juvenile Court and the Visiting Nurse Association. The
source of reference for the other cases was not stated. These figures do not
refer to active or positive cases only, but to all patients tliat came to the
clinic for purposes of examination.
There were about three times as many visits to the Infant Hygiene
clinics as to the tuberculosis clinics in 1918, the last year for which the figures
have been calculated. This attendance is out of proportion to the number of
active cases, for there are nearly twice as many active cases of tuberculosis
under care, as cases in the Infant Hygiene Clinics. This generous attendance
in the Infant Hygiene Clinics is doubtless due to the insistence on the part
of the clinic that the baby come in every two weeks in order that its milk
be continued.
In the Infant Hygiene work the nurses give much assistance in the clinics.
They weigh each baby, suggest to the mother regarding clothing and visit
the cases at home to instruct in milk modification when this seems desirable.
They also keep the milk book. This is a big job as well as a very large book.
Each patient has to be graded as to the amount he shall pay for milk. There
are five grades similar to those adopted at the Babies' Dispensary. The
nurses have not established quite such hard and fast regulations as at the
Babies' Disp)ensary, but are free to exercise some judgment. A milk that
would retail at 30 cents a quart is sold at the various rates according to the
family grade:
Rate 1...
Rate 2 ..
Rate 3a.
Rate 36
Rate 4 ...
Cost per
Qt.
Cost
perPt.
Cost S. M.
22c
15c
30c
17c
lie
17c
10c
5c
10c
5c
5c
5c
0
0
0
*S3mthetic Milk adapted.
Hospitals and Dispensaries 907
Any families claiming to be in grade 4 who are not referred by the Asso-
ciated Charities are cleared through the Social Service Clearing House while
Jie patient is still present. Then if the family is known to some relief agency
:he agency is consulted to see if the family should receive free milk. The
majority of families are in rate 3a or 3b. S, M. A. costs 40 cents a quart
retail. It is a special preparation of fats and oils devised by Doctor Ger-
rtenberger and prepared in the milk laboratories of the Babies' Dispensary.
The doctors prescribe the milk for two-week periods. It is delivered by
the Belle Vernon Farm Company. The child must return in two weeks
)r the milk will be discontinued.
Work and Personnel
The work of the Health Centers may be divided into medical and nursing
^ork. The type of work for each group must be divided into the four de-
kartments or activities of the clinics.
Medical Work
The medical work is under the supervision of the Commissioner of Health
ith a department head in charge of each branch. At present the Bureau of
'uberculosis has no chief. The Commissioner of Health is therefore respon-
ble for its activities. He is not able to give the health centers much de-
iiled supervision. This is especially unfortunate because there are no spe-
ial requirements for the doctors working in the clinics regarding experience
ith tuberculosis. There are eight physicians in the Bureau, each receiving
salary of $780 per year for attending five clinic sessions weekly. All the
sises requiring sanatorium care or hospital admission are passed upon by
ae clinic doctors. The medical records- would indicate that the physicians
lade a careful lung examination in each case. Re-examinations are seldom
Bcorded. Sputum analysis, though not absolutely routine, is fairly fre-
uent. Many records showed that the patients neglected to return the
K>ttles given out for collecting sputum specimens. The doctors seemed
nterested in the work and there was comparatively little complaint among
he nurses that the doctors were not punctual. Tonics, cathartics and cod
iver oil are occasionally prescribed at the clinics.
The Chief of the Bureau of Child Hygiene takes an active part in the
RTork. He personally conducts one clinic a week at Center 5. He visits
the other centers rarely, stating that all the doctors on duty have served in
the Babies* Dispensary for at least one year and do not need supervision.
Much of the rest of his time is spent in the drawing of charts and collecting
statistics, work which might better be undertaken in the Bureau of Vital
Statistics. His salary is $3,300 a year and he devotes his full time to the
work. The Chief of this Bureau is also responsible for the infant eye work
and the inspection of boarding homes for children. These two functions
have been so far systematized as to require practically nothing of his atten-
tion. He is also responsible for the licensing of midwives, but this is not
associated with the clinic work.
908 Hospital and Health Subtet
The work of the physicians in this bureau is excellent in certain respects,
yet lacks much that would make it of vastly greater value. The babies come
to the clinic and are undressed and weighed — they are then dressed before
they go to the physician. He discusses food with the mother, writes a pre-
scription for the milk the child will need for the next two weeks and fills in
its formula on a printed detailed slip. If the mother complains that the
child has a cough, she is advised to take it to the Babies' Dispensary where
it can receive a chest examination. The Survey investigator noted the fol-
lowing case. A mother brought in a two-year-old child, very thin and under-
nourished and unable to sleep. A private doctor had told the mother that
it had worms and had prescribed medicine. At the cUnic the mother was
advised to return to the private doctor, although assured that the child did
not have worms, and no directions were given regarding diet or general habits,
which were admittedly bad. The ability to prescribe diet for infants up to
15 months is highly developed in the clinic physicians, but the giving of
other health directions and the diagnosing of cases adequately enough to
relieve the mother from trips to the Babies' Dispensary are not usual. Tlie
nurses complained of the diflSculty in interesting the doctors in the child be-
tween 3 and 6 year^. These little ones are allowed to come to the clinic for
weighing and health directions, but not much information appears to be
gained from the doctors which is of aid to the mothers.
The only other medical work done in the stations is the work of the dis-
trict physicians who make their headquarters at the. dispensaries. They
are called by the nurses to visit various cases in the district, including con-
tagious or tuberculosis cases, as occasion may require. They report to the
center each evening for calls that have been left there during the day.
Administrative Work
This is all in the hands of the supervising nurses. There are two clerical
assistants in each center, but the nurses complained that few of them were
able to take any responsibility. The nurses do not even trust the care of
the milk book and the collection and accounting of the money paid for milk
in the clinics to these helpers, but nurses have to be assigned to these duties.
Social Work
There is no social work as such. All cases coming to the tuberculosis
cliiic are cleared through the Social Service Clearing House. All rate S
and 4 cases coming to the child health clinics are cleared. Referring and
consulting about cases depend on the interest and understanding of the nurse
carrying the case. All the rating for milk is done by the nurses. The judg-
ment used varies in wisdom, depending on the nurse doing the work. The
nurses frequently attempt to make social adjustments in a distinctly amateur
way. I
Records and Filing |
A system of filing by families has been adopted and has a certain distinct
advantage. One number is given to the family and each additional member
08PITALS AND DISPENSARIES 909
lo comes for any cause gets the same number with an additional letter.
lus there are found in the same folder cases for the tuberculosis clinic, for
fant hygiene^ for acute eye conditions, and possibly for a contag'ous condi-
)n. But keeping families in groups this way makes necessary a rather
iboi'ate daily attendance book and careful cross indices. It is convenient
len the nurse writes up the record and keeps all the records of each family
gether. Where genenl home visiting is so vital a part of the clinic work
seems an advisable plan. There is a social family history card filled out
r each family at the time of the first visit; this is a form with d^tiiled
adings. There are various forms for the different departments. The
fant hygiene card has a weight chart on the b ick and is similar in every way
the card used at the Babies' Dispensary. There ai*e special formo on which
et is prescribed which are worthy of notice. There are forms for city hos-
tal admission as well as admission to Warrensville. All the records seemed
be well filled out for the first visit. The routine recording of weight
uses the dates of all subsequent visits to be noted, but the facts observed
the doctors were not always recorded. Each nurse keeps a daily record
her work and detailed monthly reports are filed at the Division of Health.
Financial
It has not been possible to obtain from the Division of Health an itemized
)ense account of the Health Centers for 1919. It is known that the
>enses for the year from the three departments using the health centers
s in 1919 as follows:
Total Salaries
Communicable Diseases $ 53,526.97 $ 31,171.84
Tuberculosis 72,883.22 60,697.99
Infant Hygiene 65,330.05 53,352.09
$191,740.24 $145,221.92
The rates of salaries are as follows :
Physicians
Chiefs of Bureaus $3,300. Full time (2)
District Physicians 3,300. Full time (7)
Tuberculosis clinic — physicians 780. 5 clifiics (8)
Infant Hygiene clinic — physicians 800. 6 clinics (6)
Infant Hygiene clinic — physicians 450. 3 clinics (9)
Nurses
Director of field nurses $2,400 Fulltime (1)
Assistant director 1 .980 " " (1)
Supervising nurses 1,660 " " I
Field nurses— 2nd year 1 ,440 " " KW
1st year 1.320 *' '* J
910 Hospital and Health Subyh
Clerical Workers
Senior Typists. $990 or $1056 Full tim* (10)
Junior Typists 792 Full time (7)
Almost 76 per cent, of the cost of the work goes to salaries. There is
some income from the work, and there is another large item of expense not
included in the foregoing — that is the milk, as mentioned above. The nulk
report for one month showed that Rate No. 1 overpaid exact cost $106.
Rate No. 2, by buying of pints instead of quarts, overpaid $1.88. The other
grades all underpaid, making the deficit for the month somewhat over $700.
This is a small deficit; it is usually about twice that. The nurses charge $1
or 50 cents to teach milk modification at home. The dental work is charged
for — Rate 1 pays 50 cents each time; Rate 2 pays 50 cents at first and 25
cents thereafter; Rate 3a pays 25 cents first and 25 cents thereafter; Rate
8b pays 25 cents at first and 15 cents thereafter; and Rate 4 gets free treat-
ment. These dental collections go to the Mouth Hygiene Association.
Conclusions
In summary, Cleveland has made a real beginning in a publio health dis-
pensary program. Its health centers meet real needs, and their medical and
nursing organization provides in the main a sound foundation both for im-
provement in details of service and for future advances in policy and scope.
Aside from such general recommendations regarding dispensaries as appear
in the next section of this chapter, the following may be made here:
1. There should be coordination between the publicly and privately
supported public health clinics; notably by the utilization of publicly main-
tained plants (Health Centers) for prenatal clinics (see page 903). This
would aid in utilizing the Health Centers to their capacity.
2. The infanc hygiene work should include children up to six years.
The present limitation of work to infants and children under three years
of age is a great misfortune. With little additional expense better care
and supervision could be extended to the children up to six. The supply-
ing of milk, a daily necessity which makes return to the clinic vital, has
swelled the attendance rather than improved the excellence of the medical
work or the pertinence of the health directions. This milk plan is doubtless
wise has surely resulted in preventing much illness among infants, and
should be continued; but it should be a relatively smaller part of the clinic
service. The doctors should develop keener and more intelligent interest
in the children over 15 months, and should be prepared to write out as accu-
rate a diet for them as for the younger children.
3. The division line between the sick and the well child should be ex-
tended a little in favor of the sick child. That is, the doctors should more
freely make examinations and give at least health directions to children with
colds. Skin conditions are another bone of contention, the prophylactic
center doctor feeling they are "diseases" and should go to the Babies* Dis-
[OfiPITALS AND DISPENSARIES 911
pensaiy, and the Dispensary feeling that the mild forms belong in the Health
Centers*
4. The Health Centers should utilize clerical service more freely for
business management and executive details, and require less of these duties '
from the nurses. The recommendations of the Nursing Report should be
followed in this matter.
5. The Centers should as sbon as possible include in their services the
examination of the supposedly well, both adults and children. The offer-
ing of such periodical "health examinations" may perhaps best begin in
the proposed central dispensary (see discussion of that subject), but is a
proper function, ultimately, of all health centers.
6. Increase in the number of dental clinics is urgently needed as recom-
mende 1 in Part VIII. of the Survey Report.
7. The Health Centers should include administrative and sanitary activi-
ties, such as properly belong to a local office of a Health Division under a
district form of organization. This, as well as the much-needed improve-
ment in supervision, will be possible only with an advance in efficiency of
the Division of Health, its better organization, and larger financial sup-
9H Hospital and Health St:rve\
POLICIES AND NEEDS
A comparison between the amount of dis|)ensary service in New York.
Boston and Cleveland shows a startling contrast. The 115,000 dispensary
visits made during last year in Cleveland to the dispensaries treating the sid
must he compared with some 3,600,000 in New York City and with some
750,000 in (ireater Boston. In proportion to population, Greater Cleveland
has about 14 dispensary visits per 100 population. New York about 60 per
100, and (jreater Boston about 50 per 100. A further comparison may be
made with Chicago, which in 1918 had 835,000 dispensary visits recorded,
or al)out 35 per 100 of population. It will be seen that Cleveland's provision
is extremely low. As brought out in the early part of this report, this de
ficiency is reflected in many ways in liospital service, and this will be empha-
sized in the following? sections of this chapter; but the shortage of dispensary
service also means for the community as a whole, deprivation of adequate
medical care to many needy groups in the population, lack of specialist
service to many more, failure to diagnose and treat many diseases during
the early stages, and dei)rivation of consultant and diagnostic facilities to
many members of the medical profession.
Preceding a statement of recommendations for improvements or increase
of service to meet these deficiencies, a statement is made of certain policie!^
regarding dispensary management and administration.
DISPENSARY POLICIES
Admission of Patients
(a) Policy— In determining admission to a dis[)ensary, the needs of the
patients and the protection of the community must be the primary considera-
tions. The medical profession has a right to be protected against imposi-
tion by persons who seek in clinics the unpaid service of physicians, when
they could afford to pay for the medical care which they need. The public
has a right to service.
(6) Standards— In determining the admission of individual cases to a
dispensiiry, three points need to l)c considered: namely, the income of the
patient or family, the size and responsibilities of the family according to a
reasonable standard of living, and the character and probable cost of ade
quatc medical treatment for the disease or condition found. It should be
added that under certain circumstances public health considerations must be
the determining factor, for example, a case of infectious syphilis may demand
immediate treatment, irrespective of what later disposition of the case u'
made. When a difficult or obscure condition must be diagnosed, or when
treatment by a specialist is rccjuired, patients might be accepted whose cir-
cumstances would enable them to pay for the services of a family physician,
though not for consultation with or care by specialists.
(r) PKocFDrHK — The social service department should be responsible
for the admission of new patients. Certain practical points connected ^^^th
tliis inatt(T will l)c founri in the discussion of social servi?e.
loSPITALS AND DISPENSARIES 913
Medical Relations
(a) Policy — The medical staflF of the dispensary and also the organized
ledical profession of the community have a right to be consulted about
olicies or problems affectirg their interests. In the case of the general
•rofession, this should be possible through conference between represent i-
ives of the dispensary and representatives of the Academy of Medicine.
.'he Central Dispensary Committee hereinafter proposed (page 920) would
irgely accomplish this purpose.
(6) Compensation — ^Hospitals and dispensaries cannot expect to secure
DOUgh of prompt, regular and ^flScient medical service unless compensation
I given to the physicians of the staff either in opportunities for study and
Kperieoce, or in financial remuneration, or in both. The generous willing-
ess of physicians to render humanitarian service is traditional and unques-
ioned, and should not be unduly exploited. Each dispensary or out-patient
epartment, consideri/ig its own type of work and the medical facilities
ffered, must determine for itself the manner in which it can best attract
nd retain an adequate medical staff. The advice of central bodies such as
de proposed dispensary committee and of the Cleveland Academy of Medi-
ine would be of value in this connection from time to time.
(c) Consultation — A definite function of the dispensary, particularly
t the major institutions, is to provide consultation facilities for physicians.
(d) DivGNOSTic Facilities — In addition to opportunities for consulta^
on, dispensaries should make the services of their laboratories and X-Ray
epartments available to the private patients of physicians (when referred
y them) when such patients cannot afford the rates charged by private
iboratories or by X-Ray specialists.
Fees from Patients
(a) Policy — It is a good policy to charge admission fees and also treat-
lent and medicine fees; no patient being denied a needed service because of
lability to pay the stated fee in whole or in part.
The presence of medical teaching need in no way affect this policy.
(6) Rates — For clinics receiving the gratuitous services of physicians,
n admission fee of 25 cents per visit is reasonable at the present time. It
I desirable that through the proposed Central Dispensary Committee, fees
e made uniform for similar classes of service.
For clinics which aim to be self-supporting and which'^fumish a more than
lominal remuneration for the physicians, the fee should be not less than
iO cents a visit, and may be higher for certain classes of services. The basis
►n which such fees should be adjusted is the cost of service.
914 Hospital and Health Susvet
Fees for special treatments, apparatus, eye-glasses and medicines, should
be fixed at or somewhat above the cost of the materials and immediate
service provided.
Definite schedules of all the admission and the more usual treatment and
medicine fees should be posted in suitable places in every dispensary.
(c) Pay Clinics — Clinics charging fees of 50 cents or more a visit should
be regarded as pay clinics and should provide financial remuneration for their
medical staff. In determining the rates of such remuneration, conferaxse
with representatives of the Cleveland Academy of Medicine is suggested,
or the proposed Central Dispensary Conunittee would serve this purpose.
Such pay clinics should aim to serve self-supporting families of limited
means, particularly in the specialties. There is much need for the further
development of such clinics in Cleveland.
The admission system in connection with pay clinics should protect the
interests of the medical profession as well as of the patient by adopting and
carrying out the standards above outlined.
((f) Remission of Fees — The admission desk in the smaller dispensaries
should be responsible for the remission of all fees. In large dispensaries the
admission desk may be unable to attend to all remissions in the case of old
patients, and social workers in one or more clinics should be authorized to
pass on remissions for the appropriate group of cases.
Adaptation of Clinics to Clientele
(a) Hours — Evening clinics for working people are desirable in all or
almost all dispensaries. These clinics may well be pay clinics.
(6) Foreign-Speaking Patients — Special efforts, as outlined in the
discussion of the foreign -born, in the section on the "Human Problem of the
Hospital Patient," should be made to enable persons not speaking English
to receive effective treatment.
(c) One important group of the clientele of nearly all dispensaries is that
of the beneficiaries of other charitable or medical agencies. It is part of the
duty of a dispensary to serve as the family physician for these. This re-
quires: (1) examination of patients and families and full reporting of condi-
tions found to the society interested; (2) treatment of those needing care,
usually without fee; (3) special arrangement whereby the social service de-
partment of the dispensary has charge of "steering" these cases and insuring
that the work is done and the reports are rendered with a minimum of admin-
istrative demand upon the clinic physician.
(d) The dispensary should be a main agent in the admission of hospital
patients to the wards and in the follow-up of those discharged. (See sec-
tions on Convalescent Care.)
lOBPTTALS AND DISPENSARIES 915
Inter-relations of Dispensaries
(a) Duplication — The pursuance of treatment by a patient or the
oembers of a family at more than one dispensary at the same time should
te discouraged and prevented as far as possible by careful admission systems,
rhe inquiry at the admission desk should include question as to place or
tgency of previous L-eatment.
(6) Reference of Patients — Patients recently under treatment at
>nc dispensary and not specifically referred to another for consultation,
bould be referred back to their former place of treatment, except when satis-
actory reason is found to exist for the transfer. The same policy should of
ourse be pursued when a patient has been under treatment by a private
ihjTsician.
The use of printed or written slips of reference is of practical service.
(c) Districting — The limitation of the work of each dispensary treat-
Qg the sick to a definite area is not practicable, but patients should be en-
ouraged to seek treatment in the section of the city in which they reside or
Lave their place of business. Well administered admission systems at each
lispensary and a common understanding of policy, worked out by the pro-
posed central committee, should reduce to a minimum problems of dupli-
ation and of overlapping of areas.
Dispensary Administration
Essential points of organization are presented in the sections on '"Organ-
sation for Service" and "The Medical Profession and the Hospitals," and
rill be merely recapitulated here:
An ezecixtive head for the dispensary.
A medical organization which is integrated with that of the hospital.
A dispensary medical committee.
A dispensary committee of the board of trustees or, if the board has
not a sub>committee system, one or more members of the executive com-
mittee who have special responsibility to be in touch with the dispensary.
The dispensaries of Cleveland would do well to develop carefully worked
►ut systems of referring patients from clinic to clinic within the dispensary,
or consultation purposes; and for transferring patients for treatment from
►ne clinic to another, with due report back to the referring or transferring
clinic.
The important place of the social service dei)artment in dispensaries is
mtlined in the section devoted to social service.
^^^ Hospital and Health Subvw
Medical Care of Children in Foster Homes
ri<i
1 his has received little attention from the medical agencies of Cleve-
land, and the Humane Society itself has not dealt adequately with its re-
sponsibility in this matter. As Dr. Mac Adam's report shows, in another
portion of the Survey (Part II.), the physical condition of the children
boarded out by the Humane Society is far from satisfactory. Moreover, the
Society's records do not show adequate medical supervision of its children,
and indeed the system which it pursues would render adequate medical work
quite unlikely. Even in the case of the children under three years of ajje,
which are within the sj>ecial province of the Babies' Dispensary and which
are supervised thereby in behalf of the Society, results are not satisfactory'.
This is largely because of the lack of a really intimate affiliation, which is
required for the successful conduct of any such piece of work. It is essential
that the physicians of any dispensary \\hich is served in such a capacity
shall think of the spe<'ial problems of a placing-out society, as well as of the
physical needs of each individual baby. The social workers and nurses who
are in touch with the foster home need special explanation of the child's
needs in terms that they can understand, and the foster mothers need in-
struction not only from the field workers but also, from time to time, from
the physicrian himself. Moreover, the administrative system of the dispen-
sary must be specially adapted to this work for the placing-out society.
Delays must be minimized and records and information be readily and
promptly secured.
In the case of the older children, present conditions are still less satisfac-
tory than with the babies.
Satisfactory results cannot be expected unless the Society has a Medical
Director, who should be a specialist in T.ediatrics, and be responsible for the
medical standards and policies of all children under the care of the Society.
This director should be a member of the staff of the children's clinic of a dis-
pensary with which the Society makes a working arrangement for the initial
examination, re-examination and nmch of the interim supervision of the
children's hcaltli. Preferably he should be also on the staff of a hospital
with a pediatric service so that sick children requiring hospitalization could
be still under his care. There are substantial advantages in utilizing for
examination and supervision the equipment, organization and the group
of specialists of a well managed dispensary, instead of a number of doctors
in seT)arate ]>rivate offices. The systems worked out in Boston, by coopera-
tion between the Children's Aid Society and the Boston Dispensary, and in
Philadelphia by the Seybert Institution, could be studied to advantage as
illustration.^' of method.
It is important that there shall be not only intimate coordination between
the medical authority of the Humane Society and the medical agents and
agencies doing the actual work, but also that the nursing and social service
staffs be in similarly close touch. Without this, satisfactory results cannot
be cx])ected. The medical workers and the field workers must understand
one another and the system under which each group works must be mutually
adapted to achieve the needed degree of mutual understanding.
losPITALS AND DISPENSARIES 917
It is recommended that:
1. A medical director, a pediatrician, be appointed by the Humane
Society, with a financial honorarium, as the authoritative guide and super-
visor of the physical condition and development of all its children
2. This director be a member of the staff of either the Babies' Dispensary
or of the proposed central downtown dispensary (Pediatric Clinic), whichever
the Humane Society decides to be the better organization for such affiliation.
3. Routine medical examination, re-examination, advice and super-
vision of health be carried out through the selected clinic, a special salaried
medical assistant being requisite for the purpose. The Humane Society
should provide this salary.
4. Standards for medical examination, hygienic directions, diet, re-visits,
home care in emergencies, etc., be outlined by the medical director.
5. Consultation by the specialists in other departments of the selected
dispensary (eye, dental, throat, ear, skin, orthopedic, etc.) be provided as
requested by the medical director; treatment also as necessary.
6. The use of the local doctors and of specialists in private offices be
reduced to a minimum; that reports from such physicians be required and
made part of the central medical record.
7. A special worker be in the selected pediatric clinic, under the adminis-
trative direction of the clinic, but with salary wholly or largely from the
Humane Society, to attend to the detail^ of assisting in securing examinations
and consultations; in effecting transfers; keeping track of needed re- visits;
and seeing that the necessary information is furnished by the Society to the
clinic doctors and workers on the one hand, and by the clinic to the field
workers and foster-mothers on the other.
8. Periodic conferences between the medical director and his assistant
or assistants, be held with the clinic worker and the field nurses and social
workers who deal with the Society's cases.
9. The records of the clinic concerning each child be regularly furnished
the Society and the clinic be provided by the Society with such history of
each case as the medical interests require. Record forms should be espe-
cially prepared for this purpose.
10. The present system of utilizing public health nurses for home visit-
ing of placed-out children be continued and made much more effective through
(a) the centralized medical direction contemplated in the plan (b) the closer
medical supervision provided for in recommendations 3, 7 and 8.
If the Babies' Dispensary will increase its age limit and render its organ-
ation suflSciently flexible and adaptable to meet the requirements of eflB-
ent service to this group of children, it would be desirable that the plan be
orked out by the Society in cooperation therewith. The establishment
918 Hospital and Health Sukvet
of some special clinics as well as the general pediatric clinic would be neces-
sary, as the Survey has recommended in its special report to the trustees of
this institution. If the requisite conditions cannot be met at the Babies'
Dispensary, it is recommended that the central downtown dispensary be
utihzed.
It should be pointed out, in conclusion, that while the proposed plan
for adequate medical supervision of placed-out children will cost more than
the present admittedly inadequate system, the expense of the medical work
is after all only a small fraction of the total cost of boarding and general super-
vision of such children. Very little permanent result for the present or the
future generation can follow from any system of children's aid which does
not make the thorough and efficient care of health a primary consideration.
DISPENSARY NEEDS OF CLEVELAND
Aside from the public health dispensaries for which recommendatioDs
were made in the previous section of the report, the dispensaries for the
treating the sick of Cleveland universally need improvement in various
respects. Recommendations regarding each institution have been presented
to its governing body by the Survey. In general, the needs may be sum-
marized as: (1) more work to be done; (2) better executive direction through
the assignment of a definite officer to be in charge of the dispensary, under
the superintendent; (8) representation of the out-patient department so as
to secure better recognition of it by the hospital authorities; (4) paid assist-
ants for the medical staff (social workers, nurses, clerks) so as to relieve the
physicians of non-medical drudgery and improve the grade of service to
patients; (5) better records which, would largely be accomplished by the
assistants just mentioned; (6) better plants and equipment.
The expense involved in the improvement of services lies chiefly in the
salary of th^ paid assistants mentioned, and would be largely met by the
admission fees recommended.
An increase in the amount of dispensary service for the p)eople of Cleve-
land is as greatly needed as is an improvement in the quality of service now
offered. It may be expected that the work of existing dispensaries will in-
crease considerably as more attention is paid to their needs, and better sup-
port is provided. But no increase in the work of the six present institutions
can obviate the necessity of at least the following additional dispensaries:
The City Hospital out-patient department is already provided for in
the tentative plans for the enlarged City Hospital. It should be one of the
major dispensaries of the city. (See section on "Community Planning").
St. John's Hospital should, as soon as possible, develop a good-sized
out-patient department for the benefit both of the* hospital and of the west
side area which it especially serves and which now has no dispensary.
When the re-organization and development at St. Alexis Hospital have
been worked out under the new advisory committee, the establishment of a
SOSPITALS AND DISPENSARIES 919
well-equipped out-patient department should be undertaken and this need
should be borne in mind by the committee even in the formulation of its
plans for the immediate future.
The establishment of an out-patient department, now being built by
Fairview Park Hospital is approved, although this dispensary will prob-
ably remain small and its work restricted largely to certain types of cases,
particularly surgical, corresponding to the work of the hospital.
The same would probably be true of similar out-patient departments that
might well grow up in connection with other hospitals of the same type in
the same section of the city, such as Grace Hospital or Lutheran.
The plans for the re-location of Lakeside Hospital imply a new dis-
pensary, attached to its new plant. This should be another of the few
major dispensaries, as described in the community plan, in the section on
that subject.
The proposed new plant of St. Luke's Hospital will require a dispen-
sary, unless the present buildings or parts thereof, are retained as an indus-
trial hospital, and a dispensary be operated in connection therewith. The
latter plan is recommended.
It is not believed that the proposed new plant of Huron Road Hospital
on Ambler Heights will require a dispensary for some years to come; but
Huron Road might with advantage have at least a medical affiliation with
the proposed central downtown dispensary. (See section on downtown
dispensary.)
A new dispensary will be needed downtown, at least as soon as Lake-
side and Huron Road move out, and meanwhile, certain services for the
downtown area need immediate development.
Cleveland, like most other cities, suffers from lack of any general plan
for dispensary service. The different clinics are not coordinated with one
another or with the public health and charitable agencies. It is essential to
have a plan and effective organization whereby the work of existing dispen-
asries shall be improved and the new dispensaries be established in sections
of the city now unprovided for. But above all, the aim must be to furnish a
basis upon which dispensary service should be better understood by the com-
munity and better serve the community. The points of view of the prac-
titioner of medicine, of business, and of charitable agencies, of the men,
Women and children who need adequate service and cannot pay for it, and
<rf the public as a whole, represented by the city government and organized
Agencies for expression, all need to be considered in framing any forward-
Jooking project of this character. The preventive and educational work of
the health centers must be adjusted in conjunction with the curative medical
^ork of the hospital out-patient departments, so as to be mutually helpful
**id to serve as parts of a developing city plan.
9180 Hospital and Health Survey
It is necessary —
(a) To create some group of people or machinery whereby the dis-
pensary problems of the city can be viewed as a whole, each particular dis-
pensary or related agency be brought into touch with the larger problems,
and the larger problems themselves directly and adequately dealt with.
(6) To have dispensary work rest upon its own financial basis — the
financial support of dispensary service being provided in terms of and in pro-
portion to such service, and not merely as a part of hospital or medical work
in general.
It is therefore proposed:
1. That there be a Dispensary Section or Committee of the Hospita
Coimcil — this committee or section to include representatives from each of
the existing out-patient departments of those hospitals which are mem-
bers of the Council; and also representatives from the Department of Public
Welfare, the Cleveland Academy of Medicine, and persons interested in
visiting nursing and charitable agencies.
2. That there be a salaried executive officer for this Dispensary Sec-
tion or Committee of the Hospital Council. Such officer at first might be
required only for part time and in that case had best be selected from some
organization other than one of the privately operated out-patient depart-
ments.
3. That the Cleveland Welfare Federation require the presentation of
request for support for the out-patient departments of hospitals to be made
separately from the request for support for hospital work proi>er; such re-
quests to show the work done by the dispensary, the cost thereof (includ-
ing a fair allowance for overhead) and the income of the dispensary from
fees paid by patients or from other sources.
In view of the general iniportance of dispensaries to the community,
and of their special service as the ** family physicians" of tlie non-medical
charities, the Welfare Federation should appropriate monies to dis]>ensaries
(the out-patient departments of hospitals) on the basis of reports of (1) work
done, (^) gross expenses incurred, (3) net expense after deducting all dispen-
sary income from fees, s])ecial endowment, etc. This would nieun a con-
sideration of the annual dispensary budgets as separate parts of the budgeb
of the liospitiils to which the dis])ensaries are attached. It would cause ap-
propriating, supervisory and administrative bodies to give much more atten-
tion to tlie dis])ensiiries, which have too often been regarded as merely inci-
dental elements in a hospital.
Cleveland ought to have at least tliree times as much dispensary service
as it now has. In from three to five years this goal can be attained, through
the enlargement and improvement of existing dispensaries and the addition
of new ones at the City Hos])ital and on the west and south sides. The
gross cost of ade(iuate dispensary service to Cleveland, at present costs of
loSPITALS AND DiSPENSAKIES 921
maintenance, would probably be over $300,000 annually. The present gross
>st is not over $75,000 (charging in all overhead). The difference is due
artly to the limited amount of work and partly to low standards. It should
e expected that when proper fee systems are developed, 50 per cent, of the
•OSS cost should be met by fees from patients.
It is thus contemplated that the Dispensary Committee or Section of
e Hospital Council should be an expert advisory and planning body, serv-
g to improve dispensary standards and administration of the several insti-
tion*^; to work out the larger problems of policy and inter-relation, and to
rve also as an advisory body for the Welfare Federation, as the Hospital
)uncil now does. The financial standing given to dispensary work by the
oposed action of the Welfare Federition would be essential if dispensary'
rvice is to stand on its own feet.
No such Dispensary Section or Committee could be effective Uiiless some
finite salaried executive assistance is provided.
More and better dispensary service is one of the impoxlmt medical needs
Cleveland. The Hospital Council and the Welfare Federation should
rognize it as such.
922 Hospital and Health Stjsvet
THE CENTRAL DOWNTOWN DISPENSARY
The central downtown district of the city presents needs for medical
and health service which are now not met, and offers certain unique oppo^
tunities for rendering many forms of service. Huron Road Dispensary b
excellently located, but the present dispensary is very small, and is in cramped
quarters which permit but slight expansion, while the hospital continues as
at present. Lakeside Dispensary, while not as well located, though still
fairly accessible to the central downtown area, has far more possibilities, but
as yet has not measured up to its opportunities. The moving out of both of
these institutions will require either the retention of one plant is a central
downtown dispensary, and the maintenance in this plant of needed forms of
service not now provided, or the establishment of a new plant.
In the firtit place, it is d'?sirable to state the needs to be met. The centrJ
downtown distc*ict of the city requires dispensary service within its own
irea for at least four reasons:
(a) Emergency and industrial surgical work arising from the large day-
time commercial and industrial population of the central area of the city.
(6) Many special forms of medical services which for the public wel-
fare should reach as many persons as possible, and which in the downtown
area can be brought to the attention of the large daytime and evening popu-
lation which throngs this district for business or recreational purposes.
Clinics in this district held at certain hours of the day, for instance at luncheon
time and in the evenings, would reach large numbers of persons who are prac-
tically inaccessible otherwise. Tuberculosis Clinics, Venereal Clinics, or
Mental Hygiene Clinics, are examples.
(c) General medical and also special services such as are provided by
general dispensaries, ought to be available to this transient population of
the central area (as well as to its residents) at hours and under conditions
which would make it possible to have these services most effectively used by
those who most need them.
(d) This dispensary would serve charitable agencies, providing medical
examination and supervision for the families under care in the central dis-
trict, or who have to be brought to this district to the society's offices. Cases
requiring elaborate study or special treatment would be referred to one of
the major out-i>atient dep)artments.
The downtown disi)ensary is required for a larger reason. If propCTly
organized and made a real center of a variety of health and medical activities
such a downtown dis[)ensary would serve as an important educational centw
along general health lines, assisting the work of many other agencies, not
only as a point from which patients would be referred but also as a center
of public healtli educatioii.
Hospitals and Dispensabies 9^
Such a dispensary would include:
(a) A clinic for industrial surgery operated throughout the twenty-
four hours. Such a clinic would require special arrangements for its pro-
fessional services and be administered so that patients could be admitted
without delay, although the clinic might be closely related to the other
dispensary services in the same building. The need for such an industrial
clinic has been brought out in Part VII. of the Survey Report.
(6) A Health Center of the City Division of Health maintaining (1) a
tuberculosis clinic, with a special consultation service at periodical inter-
vals, (2) venereal clinics, and (3) a division for health education, which should
include among its activities the conduct of a clinic for the examination of
well people — children and adults. It might perhaps be best to maintcun
the venereal clinics under private auspices. (See Part V.)
(c) ^ mental hygiene clinic.
(<0 A general medical clinic for the examination and treatment of sick
persons.
(e) Special clinics, such as eye, ear, nose and throat, and surgery, (other
than industrial siu^ery).
(/) The "Orthopedic base" or "center" recommended in the orthopedic
plan, (Part II of the Survey Report), should be in the same building. Its
work would assist all the other branches in the downtown dispensary and
would be assisted by them. This orthopedic center would include, besides
certain administrative functions relating to the orthopedic plan of the city
as a whole, a physical treatment center which would be of city-wide value
and would be especially advantageous if located in this central district.
(g) The affiliation of this downtown health center with the University
is highly desirable.
It has been pointed out elsewhere that there is needed a certain small
number of hospital beds (20 to 50) in the central downtown area, largely for
emergency purposes. This emergency hospital or ** relief station " could with
advantage be combined with the central downtown dispensary.
If both Huron Road and Lakeside Hospitals move to their new sites
within a few years the proposed dispensary and the emergency beds will be
the more urgently required. The plant of Huron Road Hospital appears to
be suitable, with relatively slight modifications, for the combined purposes
of emergency beds (30 to 40 in number) and the downtown dispensary. The
location is almost ideal. It might be well for Huron Road Hospital, as well
as for the public good, that there be a medical affiliation between the Huron
Road staff and the dispensary staff; but the problem of staff for the down-
town dispensary might be solved in other ways.
The industrial surgical clinic should be fully self-supporting, from the in-
dustries which it serves and from the workmen's compensation cases. The
924 Hospital and Health Survey
staff of this division should be salaried. The senior visiting staff would pnj-
vide certain supervisory and consultant advantages.
The public health clinics of the dispensary would constitute an additional
Health Center of the city Division of Health, and would require the neces-
sary addition to its budget. The mental disease and mental hygiene clinic
should be maintained, at least at the start, by the organization especially
concerned with this interest. The orthopedic clinics and physical treatment
center should be sui)ported likewise by the orthopedic group referred to ebe-
where in the Survey report (Part II.)
The Community Fund would properly be called on for the financial sup-
port of the general medical clinics for adults and for children, and for the
special clinics which are required. Not only as meeting a general public
need and a broad purpose in health education, but also as assisting charitable
societies to secure better medical examination, advice and supervision for
their beneficiaries, the central downtown <iisf)ensary has a peculiar demand
upon the Welfare Federation. This dispensary, among other benefits,
would make money spent for many otlier charitable agencies count for more.
In estimating the cost of this dispensary, it must be borne in mind that
the medical staff in all clinics should receive financial com|)ensation, except
for merely consultant or infrequent visiting services. The gross maintenance
expense of conducting the industrial surgical clinic, public health clinics,
general medical, pediatric and special clinics, with a used capacity of 50,OOC»
visits a year, should not exceed $60,000. Deducting the cost of the industrial
and the public health clinics supported by industry and by the city, respec-
tively, tlie gross charge upon private funds would be about $35,000, of which
some $15,000 might be ex])ected to be returned through fees from patients.
The net charge should not exceed $*^0,000 a year.
It is apj)arent that the initiative in putting this dispensary unilcr way
must come from some privately organized group having a special interest in
the matter. It is recommended that shortly after the proposed Ontral
Dispensary Committee has been organized, this committee initiate discus-
sion of the matter and call together a conference of such individuals and
interests as may be necessary. Some one committee or organization would
have to assume definite responsibility for the plant. This committee might
be a joint body of the organizations providing various services, or a nion*
specialized IxkIv which tnade arrangements with the other groups to use the
plant for certain pur])oscs at specified times. The plan will be restricted in
its service in proportion as few activities are included, and will be broad ami
far-reaching as the number of activities and interests is increased, al\vay>
assuming their harmonious coordination. The combination of the public
health and preventive clinics with the curative clinics, for instance. \^ <>^
vital importance.
It would not be unnatural that Lakeside or Huron Road, particularly if
their moving i)lans are delayed, should suggest that their present disf>ensaO
be the basis of the {)r{)[)ose(i central dispensary'. Such a plan is not imprac-
tical, ])rovi(lc(l there be sufficient flexibility and readiness for (X)openitiv<'
Hospitals and DisPENaAniEs 925
adaptation in the existing organization which is made the basis. It \^dll be
well to remember that such a central dispensary represents a Health Center
in a somewhat advanced sense of the term; that it might ideally contain
administrative offices of public and private health agencies, meeting rooms
and auditoria for public health education; and stand before the people of
the city as a visible expression of the communal interest in health. Through
its own activities, in which curative and preventive functions should be cor-
ielated» and through its connections with the Central Dispensary Committee,
the municipal health work, the business, educational and philanthropic
interests, the proposed dispensary might be a constructive force as well as a
service to many individual lives. Only by grasping the possibilities of the
project in the future can any institution or any committee justify an assump-
tion of responsibility for its leadership in the present.
926 Hospital and Health Survey
IV. Special Problems
THE CONVALESCENT AND THE HOSPITAL
By Maby Stbong Burns, R. N.
INTRODUCTORY NOTE
Mrs. Bums, as a member of the staff of the Survey, presents in this chapter a study
of convalescent patients recently dischcu'ged from 'the hospital. Few if any cities have
as yet met adequately the need for convalescent ccu'e. The most notable work in the
country is that of the Winifred Masterson Burke Foundation at White Plains, New YoHl.
under the direction of Dr. Frederic Brush, whose significant contribution as collaborator
in the Cleveland Hospital and Health Survey will be found in the next chapter. The bulk
and general bearing of the convalescent problem in Cleveland is discussed in that place.
Mrs. Bums' contribution is a series of vivid pictures of what may happen to patioits
after they leave the hospital doors, and drives home the point that a sick man's sojoon
in the hospital is only one stage in the journey between illness and health. Too tagSts
does the hospital forget this truth. Too often do hospitals in Cleveland c» elsewhere
feel or at least act as though they felt that their resi)onsibility ended when ''discharged"
is written on the record and the patient is no longer within the building.
The care of convalescents is a much larger problem than that of a hospital or insti-
tution for convalescents. The bulk of convalescence takes place in the home, and parti-
ticularly in medical cases, the whole course of the illness, from onset through acute stage,
convalescent stage, and final restoration to health and vigor, may take place within the
home. From this broader standpoint of the community, the convalescent problem is
approached in the following chapters.
•
In Mrs. Bums' study emphasis is laid upon the hospital patient and his need aftc
discharge. Her very practical recommendations should be compared with what has
been said in the chapter on the Human Problem of the Hospital Patient, with reference to
hospital provision at the time of discharge and the use of the dispensary therewith.
A STUDY OF HOSPITAL CONVALESCENTS IN THEIR HOMES
In atteinptiiifr tliis study two things were very quickly apparent: (li
that convalescence is as nnich a state of mind as of body, and that environ-
ment which does not provide for the needs of both is inadecpiate; C^) that
the back^^round of convalescence is laid, the texture of it stretched and
woven, while the patient is still lying abed in hospitaL His mind is a
sensitive shuttle threading with tireless insistence everj' impression of the
hospital ward, whether grave, radiant, trivial, or profound, and coloring
each with his mood of the moment. On the **date of discharge'' (when
shall wc find a more gracious |;]irase?) the patient takes this mental ** sam-
pler'' and during the time that lie must **remain inactive" as the house
i)]ivsician savs, he wonders over it all. If left to himself he makes few
alterations in this plan of return to healtli which the hospital has spread
Hospitals and Dispensaries 927
out for his interpretative copying. Every impression is traced and retraced
and his conception of health and of his part in holding it is framed in his
idea of hospital service and remains pictured as a never-to-be-forgotten
experience.
In seeing over two hundred such "pictures" one could often exult that
the hospital had been interpreted favorably and with gratitude. When the
interpretation had been distorted through mutual distrust and misunder-
standing, regret was always followed by the conviction that a broader con-
ception of the hospital's responsibility was possible, indeed necessary, and
liat it would more and more make the way straight for patient and hos-
rital alike. Two points of view will illustrate: (1) A Polish woman, after
liree weeks in a hospital ward, thus voiced her opinion on the Hospital
Send Issue, "She is like a great and wonderful mother who cares for many
ick children, this City Hospital. If more money she needs let us say yes
ind give." (2) A man sensitive at being temporarily without money bitterly
esented the hospital's attitude that he should pay his bill there because he
lad hitherto paid his private doctor, "Why would they think I should go
o that place if I could any longer pay a doctor? Would anyone go who did
lot have to? I burn with shame when J think what questions they ask."
Thus convalescence is the state of mind and body on which the hos-
>ital may set its stamp as a friend and helper or as an autocrat without
ympathy. The real service to the patient is but half done on the date
)f discharge. The test then comes, to decide whether the final stage of
»nvalescence shall be to each of its patients a stimulating, worth-while
sxperience or a lonely and difficult task to be faced against great odds.
The cases studied were two hundred discharged patients from four of
iie principal hospitals of Cleveland: Charity, City, Lakeside, and Mount
Sinai. They were nearly all classified as free or part-pay patients. A few
lad apparently paid the full charge for treatment. They included a variety
>f foreign nationalities, of which Cleveland offers many: Armenian, Aus-
jalian, Bohemian, Chinese, Greek, Italian, Lithuanian, PoKsh, Slovenian,
Swedish, etc., a number of native American whites and a fair proportion
>f Negroes. The environment of patients seen ranged from that of wretched,
lousing and extreme poverty to the completely comfortable house of the
j^U- to-do.
The types of illness from which these patients were convalescing were
I'ontagious and general diseases, surgical operations and accidents. There
were also a few maternity cases. Their length of stay in hospital varied
From five days to two months.
Half of the cases were seen within three to four days after discharge.
rhe others were seen within ten days after discharge with the exception
rf six surgical cases who had been told not to resume work for four weeks.
In the homes the reaction of the hospital upon the patient was noted:
(1) whether the diagnosis and medical advice had been understood, and was
beinfj followed with satisfactory results; (^-Z) whether assistance of any sort
928 Hospital and Health Subyet
■ ■ — .^■^— >
would more certainly assure the result for which the hospital had woAed.
In a word, was the best sort of convalescence possible for that particultf
patient in that particular home?
The convalescents seen were classified as follows:
Cases with Home Environment Total Cases Total Per cent.
1. Favorable and adequate 25 12.5
2. Favorable with minor adjustments, eco>
nomic or personal 71
3. Unfavorable but remediable by economic
or other assistance 48
4. Unfavorable and not remediable, needing (^87^%
institutional ccu'e in convalescent homes 44
5. Acutely needing further hospital care —
relapse after return from hospitaL 12
200 100.0%
Thus, with only 1S.5 per cent, in suroundings favorable and adequate
for convalescence, the remainmg 87.5 per cent, of these cases returned to
homes which were unfit in varying degrees for their convalescence. Wilk
proper advice or assistance, conditions could have been remedied in about
two-thirds of these cases (59.5 per cent, of the total number) while with the
other third (28 per cent, of the total number) conditions were irremediable
and the patients required institutional care in convalescent homes or stiD
longer care in hospitals.
Charity Hospital
Considering the convalescent cases of each individual hospital as 'a
group, those of Charity Hospital presented the following distinctive char-
acteristics:
Cases with Home Environment Total Cases Total Per ceot.
Favorable and adequate ^ 15 30.0
Favorable with adjustments ^ 21 42.0
Unfavorable but remediable 6 12.0
Unfavorable and not remediable 6 12.0
Acutely needing further hospital ccu'e 2 4.0
50 100.0%
As permission was given to choose the patients from the complete fite
of those discharged there were by chance mOre pay or part-pay patients
and among these were people of intelligence and personal capability who
ALS AND Dispensaries 9£9
sn able to adjust their homes to provide adequately for convalescence,
ad sometimes been accomplished by pre-arrangement, before going
hospital, with some competent friend of the family who possessed
jcial mental or moral force needed for the situation. (It was notice-
lat this force was as often absent in the more prosperous homes as
je of otherwise discouraging surroundings.) Practically no form of
jervice had been offered to this prosperous type of patient, but the
's evident appreciation of the idea as a possibility was impressive.
J prevalent feeling among the 82 per cent, of operative cases among
was that they had had the benefit of wonderful surgery, but were
er than before the operation as to what had been the matter with
)r what was to be done to prevent further diflSculty. The ''head
i" or attending surgeons were described with awe, yet regret, as
nportant to be bothered"; '*he's so busy he can't listen"; "it seems
t the kind of a man to give you much talk."
ynecological case returned to her home without instruction from the
1, and within two weeks had housecleaned her tenement, painted
re, papered two rooms, and was doing the cooking under a sloping
too low to allow her to stand upright at the stove. The doctor having
e was "all right," she did not understand how she felt worse than
the operation. Concluding it was all a failure, she had begun treat-
•self with Lydia Pinkham's remedy because the newspapers said it
help anyone who felt as she did and she didn't want to waste any
aoney on the hospital.
>ther operative case returned weak and wondering why the old pain
jt as bad, while all she "could get out of the nurses and doctors was
ey had gotten what caused the trouble." Still another, in a wretched
thetically neat tenement, lay abed, mystified at feeling worse than
;fore, while the family questioned her, "What happened? Have we
56 for this?" The cost in money loomed larger than any visible
in health.
the women who were uninformed as to their condition only one had
:ed to know. At seventy years she was tranquil and not inquisitive.
; men also had doubts. A neurasthenic, aggrieved at the little atten-
tstowed upon him at the hospital, had gone home to a combination
ck electrical treatments and doses of No. 99 at Doctor Simpson's
J Institute. His protest was, "Why didn't the doctor say what
io me some good?"
»ther came home to wretched lodgings from a long siege of lead-
ng, pneumonia, and an operation for empyema. While he was ex-
g that the incision had been allowed to close too soon because the
J was short of beds, the doctor who had sent him to Charity Hos-
ime to take him to St. Alexis, there being a vacant bed where the
I who had operated first would open up the incision.
930 Hospital and Hi<i\lth Survey
A man, whose money was low after seven weeks in the hospital, was
travelling a distance of seven miles for dressings because he knew a doctor
who would not charge much.
A sturdy Irishman with facial paralysis after a mastoid operation was
embittering his days with thoughts of sueing the hospital, while his wife
wailed, **Sure, they have destroyed him entirely. 'Twould draw tears from
a stone."
The White Motor employes who after leaving the hospital were cared
for at the dispensary of their works, seemed- well informed except in the
case of one man. A dressing of his foot had not been changed for four
days. Having been told that he was **all right now," he had taken this
literally, until the pain and swelling led him to doubt. He had recently
been burned out of his home, and as the only support of a wife, mother,
and five children under twelve years, had gone on a ten-hour night shift
to get the extra pay of $11.85 a day. He was slowly coming to the conclu-
sion that his foot, by its delayed recovery, was costing more than his hospital
biU.
Summary of Charity Hospital Convalescents — Since hospital seniof
dominates convalescence to such a degree that it has no present but only a
past, these cases have indicated: (1) That more nursing care, if only for its
educational value, ard better night service, particularly for men, should be
offered. (!2) That more tin:e should be given to instructing all types of pa-
tients as to their part in carrying on convalescence, returning to dispensaries!
or physicians, etc. (3) That after-care in the homes is often indispensable.
(4) That there should be more real interpretation through Social Service of
the problems of foreign-born patients, so that **Tony'' would not have felt it
possible to get out of bed and walk off without saying, **By your leave.'
(5) That the cash value of health should be explained to those patients who
reluctantly offer their fees. With the help of Social Service every patient
should be made proud to contribute his charity to the common good.
City Hospital
City Hospital presents the following showing:
Cases with Home Environment T<
Favorable and adequate
Favorable with minor adjustments
Unfavorable but remediable
Unfavorable and not remediable
Acutely needing further hospital care
71 100. 0
The large ])()rtion of those having unfavorable and irremediable >ur*
round!ngs corroborated the suj erintendent's statement that almost half ^^
otal Cases
Total Per cent
5
7.0
19
26.8
21
29.6
20
28.2
6
8.4
Hospitals and Dispensaries 981
their patients have no homes and must be kept in hospital until ready for
work, the only alternative being the Warrensville Infirmary.
Even a superficial contact with the various types of lodgings, rooming-
houses, and rooming hotels, with their forlorn attempts at light housekeep-
ing, brings swift conviction that they can never offer a fair chance to con-
valescents. The atmosphere of isolation, the indifference as to what hap-
pens to the lodger after he pays for his room, the long flights of stairs to be
reckoned with whenever a meal is needed — these, aside from the unwhole-
some living conditions, proclaim the lodging system as **fatiguingly futile"
for convalescent use. The patients themselves evidently realize this fact
and many did not return to their given address. Others had never lived at
the given address, but had been known to the owner of the lodging house or
to some of the lodgers. A few gave an impossible street number selected
with evident care. The Salvation Army, the City Mission, a corner store,
or a former saloon will sometimes be given as an address where nothing
definite could be remembered of the patient. One man was found on the
corner near the restaurant which he had given as his address and explained
there was "generally some one round that corner who knew where he hung
out." Such were the frail links to home and the greater reasons for con-
valescent care in institutions or at least for continued hospital supervision.
Another tremendous claim for convalescent supervision of the most far-
iea€!hing and eflScient sort was made by the fact that many other patients
came from homes which were totally unfit for convalescence or continued
health, unfit for the minimum requirements of normal living — on the edge
of the dump, in gullies thick set with smoke, in leaky shacks — the cracks
stuffed with newspaper and the room reeking with kerosene fumes, in dark
tenements, four or five of which would open on a court filled with the ac-
cumulated refuse and garbage of the winter, where the convalescent child
^ was left to "play."
The hopeful note in many instances was the persistence of the family in
keeping its tenement clean within in spite of the disheartening mess without.
In several such homes on Orange Avenue there was as keen an interest
and sense of personal concern in the Survey of the Hospital Council as at a
Chamber of Commerce meeting, thus bearing out the idea of Doctor Frederic
Brush on convalescence that "health service should be offered where people
live and work and play.* * * Of abiding value in this period of convalescence
is the process of normalizing, in all ways which may hold throughout life."
It is hard to prove which will finally claim the most patients, the influence
of the hospital or that of the home on the edge of the dump beset by every
health hazard and bereft of every help to sanitation, but it is only when
Social Service shall present overwhelming evidence of the limitation of hos-
pital skill before such handicaps that these entirely eradicable conditions will
1 be swept away.
The surgeon, who has conscientiously given his intelligence and skill to
'^Cnew life, should realize that the condition of the home to which he is send-
932 Hospital and Health Subyet
ing his patient, will play a vital part in the final success of his work. To have
a mind to insist that dwellings and their surroundings should be fit for the
minimum requirements of ordinary living would be to open up many possi-
bilities in home convalescent care which, as yet, are untried, and the import-
ance of gain in the general health of the community and in health education,
should not be overlooked.
Still other types bespeak the follow-up work of the hospital. The drug
addict, returning to lodgings with little moral support; the child with chom
celebrating her home-coming with a '* regular meal" of coflFee, sausage and
pie; the heart case who has spent most of his small life in hospitals and
pleaded, '*0h, Muz, my business is always hospitals! Can't I stay home
and get well?"; the fourteen-year-old runaway with mumps whose pride
had thus resented his being put in the **kids ' ward " where his feet stuck out
through the bed-bars; the child of five whose mother had never been abk
to find out from the hospital what its illness had been — these and many
others proclaimed their necessity for further care without which a large part
of the hospital's work goes for naught. ,
Summary of City Hospital Convalescents — ^These cases present the
following well-defined needs: (1) Increased institutional convalescent care;
(2) Instruction of patient at discharge; (3) Social Service, to adapt the homes
of patients for convalescence therein.
Lakeside Hospital
Lakeside Hospital showed :
Cases with Home Environment
Favorable and adequate
Favorable with minor adjustments _
Unfavorable but remediable.^
Unfavorable and not remediable
Acutely needing further hospital care
57 100.0
The cases were offered with ample records and in the spirit of the fullest
cooperation. Probably because of this it was more noticeable that the
instructions to patients by the doctor were most often "none in particular*'
or "return to dispensary."
The "none in particular" probably indicated that to the doctor the case
did not stand out in his mind as needing any instructions other than those of
routine convalescent care after a pneumonia, a laparotomy, or whatever
else the disease or operation might be. The patient, however, assuming
this role for the first time, finds everything strange about being " a pneumonia"
and things stranger still as "a laparotomy. " He is full of interest in himself.
He wants to make a success of getting well and there are many questions to
otal Cases
Total Per cent
4
7.0
21
36.8
14
24.6
16
28.1
2
3.5
Hospitals and Dispensaries 933
wliich he wants to know the answers. He is hoping there will be time for
one of the doctors to have a talk with him about it all before he leaves the
hospital. But often the last day comes unexpectedly, his bed being needed
for a more urgent case, and he finds himself at home several miles from the
hospital, wondering why he managed to find out so little of what the hos-
pital knew so well. When special instruction had been given the patient
on discharge, the effect was almost magical. To have been instructed to carry
on what the nurses have begun, to have responsibility for one's own treat-
ment, gave a new zest and importance to convalescence. Particularly was
this noticeable in patients who were returned to the dispensary for the treat-
ment of syphilis. Alert and intelligent, they were too much in earnest to
be self-conscious and presented convincing evidence of wise and inspired
teaching. With the exception of these cases there was little evidence of hos-
pital Social Service other than visiting nursing among the patients seen from
Lakeside.
The ambulance experiences of many held a large share in their convales-
cent thoughts. The negro who, after an automobile accident, regained
consciousness in "Hogan's dead wagon," "don't never expect to get over
that wake up. " He thought he was being taken to the undertaker's estab-
lishment as dead. Often neighbors have "chipped in" to collect the money
for an invalid carriage so that the police emergency need not be called, and
with a naive idea of gradual descent to the mundane, some announced that
in leaving the hospital, they took a taxi to the nearest car-Une and transferred
to the trolley for the rest of the way home.
Another impression noted among the women was remembering the fa-
tigue of that first complete dressing to leave the hospital. Apparently this
was often done without assistance as the nurses had other duties and the
friends of the patient were not allowed to come to the ward. (This was also
noted in patients from other hospitals. An old negro woman with an aortic
aneurism was being sent home from the City Hospital on the ambulance
stretcher. She described the fatigue of preparation and added "The head
lady nurse told them, 'Don't bother if it is a hospital gown — let her go while
the spirit is in her.* I sure was grateful. She certainly had wisdom, that
lady nurse. ")
Two other shadows of convalescence were: (1) the long uncertainty and
final disappointment over the amount of the hospital bill, and (2) the fact
that patients sometimes came away resentful because they had been the
•* interesting case" used to teach others. They felt that they were being
detained in hospital for this purpose.
These may seem minor details in the immense and complex scheme of
administration which the hospital must embrace, but with the sensitive
unagination of one half sick — "behol^, a little cloud ariseth" and the whole
of his eonvalescent sky is darkened.
The amount of the bill could be approximately decided before the day of
discharge and preferably nearer the day of admission so that this "indeter-
minate sentence" might be cleared up. If the patient has not been able to
J>34 Hospital and Health Survey
pay, it is perhaps not the happiest sort of envoi to have "the last one you
see at the front door saying, *I hope you will be able to work soon and pay your
bill.' " Social service at the front door might perhaps have given the deft
touch to incentive which would have brought the patient to say as much for
himself, with gratitude and courage.
Again, in the matter of the resentful ** interesting case" the house phy-
sician who is a vital influence for energizing convalescence, could in a few
words, with perhaps a touch of cameraderie, present the idea of an imper-
sonal yet chivalrous appeal for humanity, and the patient might becomf at
once the ** interested case," ready and a littte grateful to contribute to the
advancement of clinical medicine and scientific research.
The foreign-born patients who had had bedside lessons in English in
the hospital and who had heard their own language understood and trans-
lated by a sympathetic interpreter, beamed with appreciation at the re-
membrance. This happy cooperation with the Board of Education can be
developed so that the often empty hours of convalescence will be briraminn
with interest.
Summary of Lakeside Hospital Convalescents — Almost without ex-
ception the Lakeside cases showed that the completion of the hospitaFs
work can only be accomplished outside of the hospital and through the ex-
tension service of social work.
Whether this is rendered in the guise of institutional convalescent care
or of home service, there is every indication that the expense would be less
than a protracted stay in the hospital. The patients are quick to testify
that after the first urgent need of acute illness the hospital atmosphere is
not helpful. Its ceaseless movement is too intense and vivid for rest.
To the patient with a problem waiting at home, institutional convaie>-
cence, however luxurious, has little charm — **For what good should I go
away. The worry for the kids would go with me," said a mother amid a
clutter of babies, washtubs and general disorder. "This is tlie best forme
here/' Her peace of mind arose triumj)liant over the scene of distraction,
for her problem was within her grasp.
The unanimous opinion aTnong such convalescents was that any help in
household administration would he welcomed.
Mt. Sinai Hospital
The <ascs referred from \It Sinai came to the investigator slowly and
were ])ossi})ly a more or loss expurgated edition, as there seemed some appre-
hension lest the lios])itars social work should \ye duplicated. Maternity
cases were excluded. For this reason the number of cases for consideration
was smaller than from the other hospitals, only thirty-five being offered. Of
loSPITALS AND DISPENSARIES 985
hese thirteen were not seen, leaving the following percentage compiled on a
asis of the twenty-two cases seen:
Cases with Home Environment Total Cases Total Per cent
Favorable and adequate 1 4.5
Favorable with minor adjustments. 10 45.5
Unfavorable but remediable.- 7 31.8
Unfavorable and not remediable 2 9.1
Acutely needing further hospital care 2 9.1
22 100.0
One characteristic of this group as a whole was that the patients seemed
o have achieved a definite idea of the hospital's plan for them and their
epeated trips to the dispensary were playing an important part in their
onvalescence. The majority were looking upon the situation as a business
proposition without imagination. The evident system and eflScient working
>f the ward routine had impressed them and they were ready to do what
ras required. They seemed less susceptible to untoward surroundings at
lome because of the definite goal toward which they were working. Pos-
ibly this unanimity may have been more evident because of the smaller
lumber, but it was too marked to escape notice.
The Collected Groups
Among the patients of all four groups were some who had been treated at
wo or more different hospitals for the same or different causes — the patient,
lot having mentioned this in giving her medical history at the hospital be-
muse she did not know, or "was not sure how to tell it," and thought "the
lext doctor would find out." In large families the hospital affiliation was
ividespread, several hospitals having been used by three or four members,
ind experience meetings when all talked at once brought out a variety of
lospital lights and shades. This suggested the possibility of extending the
icope of the Social Service Clearing House to include on its registry cards a
lote of any dispensary or hospital care which the patient had received — the
technical details to be furnished by each medical agency as the occasion
irose, as the patient is often unable to give an accurate account of past
Ilness or surgical operations.
The very prevalent protest of the women patients against being kept in
ignorance of the nature of their surgical operations deserves a word. The
patient wants to know how she stands physically, even if she faces a serious
handicap, and she can the better adjust herself to meet it if informed. The
hospital service which shirks, evades, or refuses this after-treatment so neces-
sary to the peace of mind and progress of convalescence has put the hardest
part of the operation and its results on the patient, and has missed its best
chance of rehabilitation.
Why bother at all if the game is not worth the candle — if the work is not
to be carried through to completion and the seal set upon restored health
936 Hospital and Health Survey
and higher spirit? If the patient is well enough to worry herself about her
condition she is well enough to know what she has to worry about. She wiD
then be more willmg to put aside imaginings and prepare to recuperate in
earnest.
Those who have had the fertile experience of a perfect convalescence
have realized that there is much to be learned from contact with pjain and
weakness and returning strength. The convalescent patient should be
helped to find these values, to lay aside a few worries and to take on a few
new aspirations for the future. Inspiriting companionship may often be
found in one's nearest neighbor with a wholesome philosophy to share.
In becoming acquainted with the convalescent in his own home we must
let him state the difficulty of convalescence as he sees it, along with his own
idea of rehabilitation before blocking the way with too many suggestions.
Often the patient must either resign himself to a reduced "health bank
account" or remonstrate at untoward conditions; again, the uncertainty as
to what his depleted strength is equal to, makes any definite undertaking
precarious. This is no time for platitudes in words or actions. No "re-
turn to dispensary" slip will fill the need. Advice to "rest and take it
easy" will not answer. Reinstatement into the type of life to which the
patient is equal must be wisely planned and the very present helps of com-
munity life pressed into service, so that the thrill of ambition, the impetus
to new life which rightfully belong to convalescence may not be entirely
lost.
SUMMARY
Visits to two hundred patients discharged from the wards of Cleveland
hospitals showed eighty-seven and one-half per cent, in home environment
unfavorable for convalescence.
In two-thirds of these homes, conditions were remediable if adequate
and adaptable Social Service could be supplied. This service is almost
entirely lacking at present.
In one-third, conditions were not remediable, and care in a convalescent
home was needed. With present resources it is impossible to meet this need.
The hospital faces a choice of evils — it must either retain the jjatient, using a
bed needed for a case of acute illness, or return the patient to a home un-
fitted to complete the cure.
Possible means by which the hospital may assist convalescence in the
home :
1. Treatment and instruction in hospital towards securing the patient's
confidence and cooperation — the instruction to include understanding of
present illness and means of preventing recurrence.
2. Making with the patient a definite plan for his after-care and rein-
statement into active life, and enlisting his best effort to carry out such a plan.
>8PITALS AND DISPENSARIES 987
3. The function of the Social Service Clearing House might be broad-
ened so as to include a record of dispensary and hospital treatment received
by the patient, with names of institutions and dates. This record could
be used by medical agencies concerned as occasion requires.
4. The function and value of the Convalescent Home, when suitable
and available, should be explained to the patient as an opportunity.
5. Social Service (if a Convalescent Home is not available or desirable)
should create the same essential values of convalescence in the patient's
own home.
6. Teaching the patient while most receptive to suggestions — ^because
of recent contact with the hospital technic of sanitation — how he may fur-
ther the hospital's work to insure permanent good health. This would
include the use of dispensary and other hospital resources, as well as of the
family physician.
A patient thus successfuly involved becomes a valuable field ageat who
[I set forth the work of the hospital in terms of appreciation which his
i^borhood will not fail to imderstand.
938 Hospital and Health Survey
A COMMUNITY PROGRAM FOR CONVALESCENT CARE
An institution is not the ideal place for convalescence from disease. The
home, when conditions are satisfactory, is the ideal place. The possibilities
of home convalescence are only beginning to be dealt with. In the pre-
ceding chapter home convalescence was touched upon m relation to the hos-
pitals, with reference to planning the after-care for the patient, instnictiiig
him or his family properly at the time of discharge, using the dispensary to
provide medical after-care, and social service. The last-named function
served either by the social service department of the hospital, or by cooperat-
ing agencies such as the Visiting Nurse Association or the Associated Chari-
ties, is a necessity. It should further be borne in mind that the aid of social
service is not called for merely in homes of poverty. Much work needs to
be done in middle class homes by the Visiting Nurse Association or by a
representative of the social service department to give the necessary' instruc-
tion and friendly advice about the details of home management, diet, hy-
giene, etc., without which the family will usually not carry out the necessary
routine outlined by the physician. Cooperation with the employer or the
industrial physician, is not infrequently of great importance. The vast num-
ber of medical cases which are cared for in their homes by private phy-
sicians, and which convalesce at home need such advice no less than do
hospital cases.
In a word, the broad i)roblem of convalescence involves private medical
practice, the hospital, the dispensary, the Visiting Nurse Association, and
social service in many branchej?. Many individuals and many agencies
must share in creating better opportunities for both home and institutional
convalescence than now exist in Cleveland. An essential element to any
real advance is an ade(inately maintained convalescent institution. Such an
institution does much more than provide care for the jjarticular ]}atient5
who can he admitted to it. It would serve to stimulate medical study of
(convalescence, now a field nuicli neglected, and would promote throughout
the community, interest in the problem of convalescence whicli will add to
the efficiency of all kinds of medical care in hospitals, dis])ensaries and in
the home.
For an authoritative picture of the need for convalescent care in a com-
munity such as Cleveland, and a program for a central representative in-
stitution for convalescents, the Survey turned to Dr. Frederic Brush, Medical
Director of the liurke Foundation at White Plains, New York, the leading'
institution in the l.'nited States for the efficient treatment and scientific
study of convahvsccncc. The following memorandum was prepared h\
Doctor Brush :
CO\VALES( EXT (ARE
FoH w Amkkk AN City of One Million Population
Ihf Fkkderic Brush, M. D.
The Need
rhcre is a convalescent jXTiod in illness, with fairly distinct medical and
social borders, aTid now reco^niztMl as a particularly favorable time for skilH
loSPITALS AND DISPENSARIES 939
id in rehabilitation. The patient's home is the desired, the cheapest, and
•est place for most convalescence, but institutional convalescence is needed
JT a certain percentage, in large cities.
Such an institution in its modem conception functions widely beyond mere
*cui)erative rest — in prevention, education, refinement, and Americaniza-
:on, occupational adjustment, vocational direction, encouragement, and all-
>und set-up for better living. It complements home care, and notably
>inpletes and fortifies social service. It shortens the hospital stay, with
trge increase of product, and with inspiration to the stafip. It saves money
irectly (convalescent cost being but little over one-half hospital cost per
ay,) and makes large long term returns to the community in bettered per-
>nTieI.
Numbers Needing Country Convalescence •
Various estimates have been attempted based upon the number of hospital
atients in the community, plus a small percentage from dispensaries, pri-
ate physicians, employers, etc. These may be summarized into an ideal
•quirement of convalescent beds for ten per cent, of all hospital patients —
arying greatly, of course, depending upon each city's conditions. To this
hould be added about one-fifth for dispensaries and other sources (as at
resent organized; but this ratio should be increased). Thus a city discharg-
ig 100,000 hospital patients yearly should provide institutional care for
^,000 convalescents.
Number of Beds and Apportionment of Patients
Assuming that the city in question presents the better living conditions,
we may well take 5,000 hospital patients, plus 1,000 from other sources, as
a planning basis. About twenty-one days proves to \ye the average stay in
convalescent homes. The requirement for the 6,000 patients is accordingly
tm beds.
We may base an estimate upon the long and abundant ex)>erienc^s in
f>ur jarreater cities, and apportion them as follows:
1. The Main Institution, for adults — 120 beds; men and women — ages,
from fifteenth birthday upwards to old age, including 15 per cent, plus of
heart disease, with standcu'd surgical (with dressings), preventive and hold-
ing (chronic handicapped) convalescence.
2. Children's Home — 100 beds, taking girls from 6 to 15 and boys
from 6 to 10 years, receiving surgical dressing and orthopedic cases, and
heart disease up to 20 per cent, of total, along with the standard lines as
above outlined.
3. Boys* Place — 30 beds, ages 10 to 15; disease classification as in the
Children's Home (Very important but not to be large).
940 Hospital, and Health Survey
4. Mothers with infants and young children — 30 beds, averasing 60
patients.
5. Special Heart Institution— 40 beds, for the seriously ill, giving bed
care at first, etc. Age and sex as in Number 2.
The Plants
New or expensive buildings are not essential. An old mansion, a large
farmhouse with its many outbuildings, or a disused hotel adapt readily.
Tents serve well at times; extensions are happily made; much equipment
may be improvised. Five acres of land is minimum; the larger areas giving
considerable advantages. These Homes might be conducted upon one
large plot of 100 acres if the topography, etc., gave essential separation of
patient's activities. A location well within 20 miles of the city's center shoold
be chosen, if possible.
Costs
A per day capita cost of $1.75 may be expected, even under post-war
conditions, giving $225,000.00 yearly operating expense for the 350 beds, as
approximate. This includes transportation, and maintenance of a City
Admission OflBce.
Selection of Patients, Follow-up, etc.
Careful selection of patients by one City Officer, given authority and
support, is of first importance. This officer may be on part-time only. Tie
necessary follow-up, including occupational and vocational direction, b
usually well done by the city organization which sends patients, and the back-
to-health-and-to-normal-life cycle is only thus completed.
Convalescent home planning, organization, and procedure are becoming
fairly well standardized, with detailed information readily available.
Those of the Staff of the Survey who have been engaged in the local
study of convalescent institutions and the convalescent problem can only
add to Doctor Brush's statement some suggestions relating his program more
in detail to present conditions and probable future development in Cleve-
land.
In most cities the convalescent problem, so far as it has been dealt with,
has been taken up by bits and snatches. Here a group of kindly people
have taken a large dwelling house and made it into a ** convalescent home
for some twenty-five men ; another committee of the charitable maintain a
building donated by one of their number, in which sickly and tired mothers
may recu])crate after illness or operation ; still another group has under its
wing a small institution for children; and yet another a small ** preventorium"
for the j)re-tuberrulous child.
loSPITALS AND DISPENSARIES 941
One of the great lessons which the Burke Foundation has taught is the
:reater efficiency gained through the use of a large institution instead of a
lumber of little ones. The small independentJy managed convalescent
lome, accepting ten to fifty patients, secures with difficulty expert medical
ervice of physicians who are particularly interested in the convalescent
•roblem and scientific study of convalescent cases; it cannot possibly pro-
ide elaborate therapeutic-equipment or a staff of special workers and teachers.
a the large institution, therapeutic equipment, personnel and continuous
•rvice of a medical staff whose members are selected especially because
icy are interested in convalescence are all possible within reasonable limits
f expanse.
In a letter transmitting his outline. Doctor Brush remarks: *'It may be
ell to bring to the attention of those becoming interested in this branch,
>ine of the important points of this proposal: that preventative tubercu-
iilosis comes in under numbers 1, 2, and 8; convalescent orthopedics, bone
iseases, etc., likewise in these three places; that cardiac children well enough
>r reconstructive treatment enter under numbers 2 and 3; that adolescents
Jie group most successfully dealt with and most neglected in convales-
*iice) are especially well planned for. * * *
V Perhaps the most characteristic and radical part of my conclusions is
le recommendation, based upon definite experience, for tlie care of many
ifferent classes and ages, etc., in one Institution (see nimibers 1 and 2.)"
The recommendation to be made regarding the convalescent problem of
Cleveland is that it be dealt with not by bits and snatches, but by one central
nd representative group of persons who will study the whole problem and,
rith a long range program in mind, will take each practical step as funds
re made available. So far as institutions are concerned, there should be one,
sither than many, or rather, as Doctor Brush's outline indicates, a group
f related institutions managed as one.
At present Cleveland has :
Rainbow Hotpital, with 85 beds, taking children between 2}^ and
14 ye€u^ of age, mostly orthopedic cases.
The Children'M Freth Air Camp, with 60 beds (225 in summer),
receiving weak, anaemic children and some convalescent mothers.
Holy Croat Houae, with a capacity of 50 beds, receiving crippled and
invalid children (chronic rather than convalescent cases).
For adults a small number of chronic cases are held at City Hospital,
►ut no convalescent cases are supposed to be there. At Warrensville In-
irmary are numbers of chronic and incurable cases, but little provision for
onvalescents. In a few of the private institutions of the proprietary type
onvalescent cases are treated, but the number of beds available for such is
'ery small.
942 Hospital and Health Suhvet
Taken as a whole, institutional provision for convalescents in Clevdand
is practically confined to children, and even for them is limited to cerUin
types of cases. The main resources throughout the year are Rainbow Hos-
pital, and in summer time, the Children's JVesh Air Camp.
The major need is that some one central and representative group should
assume the responsibility of developing convalescent provisions which will
be adequate for the needs of the city. It is recommended that the Trustees
of Rainbow Hospital either assume this respK)nsibility, or at least act as the
agent through which some larger group might ultimately be organised.
Rainbow Hospital now provides an excellent service to a liniited range U
patients, but appears to furnish a basis upon which a much more compre-
hensive and satisfactory development might be made.
With this in view, it is desirable that Rainbow Hospital should enlarge
immediately the scope of its work. It should have no exclusive affiliation
with any one hospital with respect to its medical staff or with respect to the
reception of patients. It should aim to develop a staff which is especiaUy
interested in the scientific medical study of convalescence. It should at
once undertake to receive a considerable group of cardiac cases from the chil-
dren's services of the Cleveland hospitals, as well as convalescent orthopedic
and surgical cases. It should institute studies of the convalescent problem
in Cleveland, supplementing those made by the Survey, and through its
members or representatives the Board should study notable developments
in other cities, particularly the Burke Foundation, as a basis for the formu-
lation of a program and of the definite steps which should be taken year
by year towards its execution. Publication of these studies and reports of
the case work with convalescents of various types are important phases of
such a program, and are essential to the growth of ap})reciation of the con-
valescent ])robl^m by the medical profession and the public. Cooperative
affiliation with related agencies, such as some of those above mentioned,
would be desirable in the formulation and execution of any such ])rogram.
Provision of a convalescent institution for adults, sliould be made as soon
as possible, as a part of this plan, either by Rainbow Hospital or by a group
of persons organized in cooperation therewith.
The outline presented by Doctor Brush gives a program which for finan-
cial reasons alone cannot be realized in a day, yet nothing less than this
should be accepted as wortliy of a progressive city.
The cost of maintenance of a convalescent institution is about half that
of a hospital receiving the same number of persons with acute diseases. A
convalescent home is an institution which no city can afford to omit in
providing for its sick. Its absence means burdens upon the hospitals, which
involve undue expense, and burdens upon the community which are less
easily traced, but which are no less real, being a financial drain upon the
charitable public and a definite loss to wage earners and to employing in-
terests.
When serious illness befalls, the care of the patient in home or hospital
equires, as it were, an investment on the part of the community in order
piTALS AND Dispensaries 948
the sick man shall be restored to health and living efficiency. From
Bnancial as well as from the humanitarian standpoint it is to the com-
ity's interest that this restoration shall be complete and shall be as
ipt as possible. A period of stay in a hospital for acute diseases repre-
$ a part, often the most expensive part of the investment, but the subse-
it period of convalescence, either at home or in an institution, requires a
tin investment of time, skill, and money, also. Unless this subsidiary
important investment in convalescence is made, the value of the whole
stment may be nil. It is difficult to put such an argimient in financial
s of actual cases, but it should not be difficult to appreciate the tragedy
the waste of insufficient convalescence, and to strike the imagination of
;ns of Cleveland who have the means, to support a program and develop
jstitution which shall be worthy of their city.
944 Hospital and Health Suryet
CHRONIC ILLNESS AND ITS CARE
Through the courtesy of the Visiting Nurse Association and the Divisi(»
of Health, a Kst was secured by the Survey of all patients who were treated
in their homes during the month of November, 1919, by the nurses of these
organizations, who were regarded as chronic, incurable or convalescent
cases. A list of 2,078 persons was furnished. In the absence of an oppor
tunity to make intimate medical study of each case, it was not possible to
draw a sharp line between the chronic and the convalescent, but only about
ten per cent, were believed to be of the convalescent class. The remaining
cases, some 1,800 in number, were chiefly people suffering from chronic
disorders, living at home, but needing more or less regular nursing or medical
attention.
A tabulation of these cases, classified by age and groups of diseases is
given in the following table :
Chronic and Convalescent Cases Under Nursing Care
Diagnoses Cases
General 142
Respiratoxy (except tuberculosis) 63
Circiilatory 37
Digestive 127
Nervous System _ 174
Mental ^ 17
Total (not including tuberculosis) 560
Tuberculosis 1 , 518
Grand Total 2,078
Adults Children
Total cases (not including tuberculosis) 382 178
Tuberculosis 1,322 196
Grand Total 1 , 704 374
Opinions secured from tlie visiting nurses and checked by conferences
with tlieir supervisors, lead to the conchision that such medical attention
as was needed for these ])atients in their homes was generally secured by the
family or on the initiative of the visiting nurse. The medical attention was
either ])aiil for or wJien necessary was obtained without charge from an
interested ])hysician or a district physician. Medical attention in many
instances was or sJiouki have been secured through a dispensary, since many
patients were able CK-casionally to go out of the house.
)6PITALB AND DISPENSARIES . 945
Each nurse stated her judgment regarding each patient, as to whether
□tie care was practicable or whether institutional care was necessary. In
r, or 42.66 per cent, of the cases, institutional care was believed desirable.
the remaining 1,191 cases, or 57.33 per cent., it was believed that home care
uld be adequate. If we omit for a moment the tuberculosis cases, and con-
er the 560 patients with other diseases, we may estimate that less than half
these, or about 250, needed institutional care, and that the remaining
mber, or about 300, could be cared for in their homes.
In the special report of the Survey on tuberculosis, much attention is
•ren to the shortage of sanatorium facilities, and the need for additional
ovision in order that at least all active cases of tuberculosis shall receive
ompt and adequate institutional care.
This census of the chronic and convalescent cases in their homes is of
>urse only a very imperfect picture. Only a fraction of the total number of
ises would be known to any one agency, even to the visiting nurses, yet,
long these figures simply as they stand, it is apparent there were as many
two hundred persons, actually known to a responsible medical organiza-
>n like the Visiting Nurse Association, who it is believed needed care in an
ititution for chronic patients, and who could not be properly attended to
their homes.
It would be highly desirable that at least once a year the Visiting Nurse
sociation should make a similar canvass and classification of its patients
order that the directors, and through them the whole public, shall be
'ormed of these needs.
The problem of chronic illness must be clearly distinguished from that
convalescence. The convalescent patient is in the process of restoration to
alth. If institutional care is needed, the period of stay in a convalescent
►me is as a rule comparatively short. Two to four weeks after the usual
ute illness or surgical operation is generally sufficient. The medical atten-
>n required is of quite a different nature from that needed in a case of
tronic illness, where a definite disease process exists or there is a definite
sturbance of bodily function which ought to receive close medical super-
sion and systematic treatment. Another important practical diflFerence
ises from the fact that the chronic case is usually a man or woman in middle
' late life. To provide convalescent care for children is an important prob-
tii, whereas chronic illness among young persons is comparatively rare,
irthermore, cases of chronic disease which cannot be cared for at home are
fgely among the poor or those of very limited means, and with very unsatis-
:^tory home conditions.
946 Hospital and Health Sukvet
Considering all these points, it may be said that a very large proportion
of the cases of chronic illness which require institutional care should be the re-
sponsibility of the city, rather than of a private agency. There is, indeed,
room for a si>ecial hospital to care for the chronic and incurable which would
devote particular attention to the interesting but as yet comparatively un-
studied medical problems of these cases and which should provide for part-
pay and pay patients, though having a certain number of low priced or free
beds. The need for such an institution is at present met in Cleveland only
by the inconsiderable provision of a few sanatoria or **homes"and hospitab
of the proprietary type.
Eloquent testimony to the lack of present provision in Cleveland for
the chronic case is derived from many of the leading hospitals of the city in
which the Survey found large numbers of patients w^ho had been in the hos-
pitals a long period of time. On the two days, December 3, 1919, and Jan-
uary 15, 1920, on which a census was taken in the institutions of the Cleve-
land Hospital Council, a tabulation was made of the length of time the pa-
tients had been in the hospitals. For this tabulation, Warrensville Tuber-
culosis Sanatoriiun, Rainbow Hospital, St. Ann's Maternity Hospital, and
Cleveland Maternity Hospital were omitted. The first two of these make
special provision for long term cases and cannot be compared with a general
hospital, while the latter two accept maternity cases only and for this reason
should be omitted.
On December 3rd, there were 2,016 hospital patients in the group con-
sidered, and of these 243, or 12.5 per cent, had been in the hospital for over
two months. On January 15th the number of cases in these hospitals was
2,029, and the number who had been in the hospital over two months was
286, giving again a proportion of 14.1 per cent.
The wide variation among the individual hospitals is shown in Table
VIII, in the Appendix in which the figures for the tw^o census days have
been averaged for the sake of simplicity
It is not necessarily true that a patient who is in a hospital over sixty
days is a chronic case, l>ecause some patients with obscure diseases or who
are slowly recovering from illness or operation, may properly remain in a
hospital for several months, but the great bulk of these long-term patients
are cases of chronic illness. Some of these patients are private cases and are
paying tlieir way, but tJie great majority do not pay even the cost of their
care. Aside from the matter of payment^ it is a' serious waste of serv'ice in a
hospitiil designed for acute diseases to have to care for chronic patients.
It must also l)e remembered that the cost of giving adequate care for chronic
patients in a suitable institution is only from one-half to two-thirds of the
average cost of maintenance in a hospital for acute diseases.
36PITAL.S AND DISPENSARIES 947
From the figures secured in the hospitals and presented in the table, it is
obable that 250 chronic eases are usually in Cleveland hospitals, in beds
dch are designed for acute cases and for which there is great demand.
The individual hospital is only in part to blame for these conditions,
is important to see just where the responsibility lies and what steps can be
ten toward remedy. A few long term cases are retained in acute hospitals
cause they pay for the privilege, but these are not the majority. No hos-
:al however should permit such patients to stay if there is demand, as there
tquently is, for beds for acute cases. There is a much larger proportion of the
ig term cases who could be sent to their homes and suitably cared for
erein if sufficient trouble were taken to make the necessary arrangements
• medical supervision and for attention at home. Adequate home care
such chronic cases w^ould require the hospital to have a social service de-
rtment. An active social service department in a hospital would study
t the home problems of the long term patients, finding just what would be
cessary in the way of home provision, securing financial aid where this
>uld be required and where the cost would be within reason, and enlist-
5 the cooperation of the Visiting Nurse Association, the district physician*
other agencies.
When it is recognized that the cost of maintaining a chronic case in the
d of an acute hospital for a year is almost equivalent at present to the
lary of a social worker during the year, and that a social worker would be
le to work out the problems of a large number of such chronic patients
they could be cared for at home, it is seen that the present hospital policy
"penny wise and pound foolish." From the standpoint of individual
•spitals, this statement may be controverted, since the hospital would have
maintain the bed anyway, and add the salary of the social worker in ad-
tion. But from the standpoint of the community and of the Welfare
deration as representing the community, it would be an actual saving to
troduce a social worker and let the bed occupied by one or two chronic
ses in the course of a year be occupied by twenty or more acute cases.
There are also a very large number of chronic patients who do not require
e amount of care given in a hospital and who are not ill enough to be in
d all the time. These patients are suitable for treatment in a doctor's
Bee, or, in the case of many, dispensary care is all that is necessary. The
iportance of dispensary care in chronic illness requires emphasis for the
ason that a great many chronic patients are suffering from disorders which
«d very careful medical study to arrive at an accurate diagnosis, and there-
re successful treatment; and such medical study often involves the services
one or more specialists, laboratory tests, the use of the X-Ray, etc. The
pense of such diagnosis is beyond the resources of many people who can
'ord to pay a doctor and who usually have a family physician. The develop-
int of dispensary service in Cleveland is an important means of providing
tisultant and diagnostic aid. These patients, generally through their family
948 Hospital and Health Suryet
physician, could thus secure the special study and diagnosis necessary. An
enormous amount of physical distress and suffering and of habitual living it
fifty per cent, efficiency, exists because of the failure to study out conditions
of a chronic nature, to arrive at a definite medical analysis of the character
of the disorder and to outline a plan of treatment, hygiene and living con-
ditions which will restore the patient to health or will maintain him at the
highest physical grade possible for him. This class of ambulatory chronic
patients represents a very large number, of which no census anywhere has
yet been made.
After putting aside (1) the ambulatory chronic cases, (i) patients who are
entirely able to pay for whatever care they need in an institution or elsewhere,
(8) the patients who could be cared for in their homes with social service
supervision, and (4) the tuberculosis cases whose needs are studied elsewhere,
there remain those who definitely must receive care in a special institution
for the chronic or the incurable, and who can pay little or nothing for what
they receive.
To meet this need is the responsibility of the municipality. Warrens-
ville Infirmary is the obvious institution which should play this part in behalf
of the city.
The Infirmary occupies a well-constructed building, built in 1906, and
placed in an excellent location. It operates a car to meet the Chagrin Falls
street car line. About one hour is required to reach Warrenville from the
Cleveland Public Square. Unfortunately, however, no other provision than
street cars is made for transporting patients; there is no ambulance serNice.
If a case of contagious disease develops at Warrenville, the patient must be
taken to City Hospital in a truck.
The capacity of the Infirmary is approximately 900 beds. In March.
1920, there were 634 inmates. Of these 147 were insane. A further report
stated that there were 46 cripples, 41 paralyzed, and 25 blind, who had been
in the institution two or more years. Hardly more than half of the inmates
in 1918 were American -horn. There are no interpreters.
The personnel in charge of the institution consists of a Superintendent,
non-resident, appointed by the Director of Public Welfare; a Medical Di-
rector (also in charge of the Workhouse and the Girls' Home), appointed by
the Director of Public Welfare and responsible to the Superintendent; a
Matron, appointed by the Mayor; and, at the time of the study, twenty-two
attendants, not all trained — inmates being used where possible. The General
Superintendent of the City Farms has some administrative control over the
Infirmary.
Hospitals and Dispensaries 949
From this account it is obvious that the Infirmary has not recently used
its capacity, and that there has not been sufficient service to provide satis-
factory care for even those who are there. On one day on which the institu-
tion was visited, there was but one attendant for three women's wards on
three different floors, in which there were 120 patients, 40 of whom were
semi-invalid. One nurse is assigned to make dressings, fifteen or twenty
bring the daily average. The Medical Director is so crowded with work,
as he also has charge of the medical service at the Workhouse and the Girls'
Home, that he can attend to only the most urgent needs. He is unable to
follow up complaints or to answer letters which come to him complaining of
the care of patients.
It was stated by the Outdoor Relief Department that a physical examina-
tion was part of the admission routine, the applicants being sent to district
doctors or hospital dispensaries. There is no provision for a record of exam-
ination on the card, unless the diagnosis and condition should be mentioned
in the investigator's report on the reverse of the card. No medical examina-
tion is made on entry to the institution, either for venereal diseases or for
any other complaint; neither is a physical examination made afterwards.
It is decidedly unfortunate that in spite of the urgent need for more f aciU-
ties for the care of chronic cases in Cleveland, only those patients who are
physically able to care for themselves are considered suitable for Warrens-
ville Infirmary. Bed-ridden cases and those which require more or less
medical and nursing care appear to be regarded as undesirable.
With the present shortage of help and attendants this point of view on
the part of the officials can readily be understood, but such a condition is not
permanently tolerable. Here is a well located plant with 900 beds. In
Cleveland are large numbers of chronic patients who are cared for in acute
hospitals at undue expense, and with serious deprivation of service to the
acutely sick. The city of Cleveland should meet its elementary respon-
sibility in providing enough money to pay for medical, nursing and house-
hold service required to run Warrensville Infirmary to its capacity, so far as
there is really demand for it.
In extenuation of the present policy it is fair to state that conditions dur-
ing and since the war have made it difficult to secure sufficient personnel,
yet the officials in charge do not appear to have made any such determined
effort as the situation requires, to impress upon the city administration and
also upon the public at large, the need of providing more funds for Warrens-
ville, so that it could care for its inmates properly and so that it could be
open to all the classes of patients who urgently require such care as this
institution ought to render.
The institution provides practically no therapeutic facilities , such as
massage, mechanical exercisers, electro-therapy or hydro-therapy. On the
advice of a committee of the Cleveland Welfare Federation studying the
950 Hospital and Health Survey
welfare of cripples, a trained occupational worker was employed, and in
October, 1918, a workshop was opened for the men. Work for the womoi
consists mainly of sewing and knitting. The provision of therapeutic facili-
ties would be a great contort to a large number of patients. Further develop-
ment of the occupational work is highly desirable.
It is apparent that particularly under present conditions, the problem of
securing sufficient nursing and attendant service is a difficult one, as is the
related problem of household help. The distance of Warrensville from the
city renders it less desirable from the standpoint of many employes than i
more accessible institution. Higher wages will be generally necessary as i
result, but even higher wages will not themselves usually prove a sufficient
inducement, particularly when employment can be secured readily by people
who are even moderately trained at any definite occupation. The living
conditions must be made not only comfortable but pleasurable. The d^
velopment of recreational facilities for those residing at WarrensviDe is a
practical step which would be of much service and which would justify the
necessary expenditure by the city. It would render possible the retention of
a larger and certainly of a more stable staff, and would save more money
than it would cost.
From the standpoint of the patients, entertainment and recreation are i
very obvious measure of humanity, while from the standpoint of the attend-
ants and the help, they are a practical measure of economical and efficient
administration. The management of the Infirmary could doubtless secure
considerable assistance from various Cleveland agencies interested in recre-
ation.
A certain amount of music and other entertainment can be secured on
special occasions with little or no expense. There is need for some person
who will be definitely in charge of the recreation and social life of the insti-
tution, both for the patients and for the staff of nurses, attendants and help.
Such a person would develop nuiny resources within the personnel itself, and
would organize social and recreational activities. With a little cooperation
from the administration and some expenditure for equipment, music, etc.,
a great deal could be done.
Steps should he taken in making up the next annual budget for utilizing
the Infirmary to a larger percentage of its capacity, in order to provide for
the large number of persons in (^leveland who now need institutional care
as chronic patients. There are at least two hundred such patients now
occupying beds in acute hospitals in Cleveland, to the detriment of these
hosj)itals' service, while really acute cases must moreover be turned away
for lack of beds. If Warrensville can be provided with sufficient staff to
make care siiti.sfactory for the inmates, it would undoubtedly be possible to
kcc]) it full u)) to nearly if not quite all its capacity of nine hundred l)eds.
To sum u]) the situation in Cleveland regarding chronic illness and its
care, it mav he stated that:
[08PITAL.S AND DISPENSARIES 951
1. There are at present at all times several hundred patients in the hospitals of Cleve-
ad, designed for acute cases, who are chronic cases and should not be in these hospitals
: aU.
2. As a result, hospital service is rendered less available, and the acutely sick must
ten be denied needed care because beds are taken.
3. There are very large numbers of ambulatory chronic cases who require study by
»ecialists, the aid of laboratories and of other diagnostic apparatus in order that they may
ceive sufficient medical study to be properly treated. The shortage of dispensary and
nsultant service for the physicians of Cleveland at present renders it impracticable for
any of these patients to secure what they need.
4. The lack of a sufficient number of privately supported institutions furnishing a
igb grade of care for chronic cases who can pay, forces the acute hospitals to retain a
tixnber of such patients and leaves the remainder to be inadequately cared for at home
r in the few small proprietary institutions who seek such work. There is undoubtedly
lace for a well-managed institution for chronics, which could be largely or wholly self-
tpporting.
5. Adequate social service departments would enable a considerable number of chronic
eises now in acute hospitals to be cared for properly in their homes. A definite economy
> the conununity would result. This is an additional reason for the increase of hospital
3cial service in Cleveland, the need for which is more fully discussed in the next chapter.
6. Provision for those chronically ill who cannot be cared for at home and who cannot
ay their way in an institution, is a primary responsibility of the municipaltiy. War-
ensville Infirmary has the space and needs the additional personnel with which to meet
bis responsibility. There should be unremitting effort by the Department of Public
(Tdfare until funds are provided for this purpose. Such chronic cases should not be
etalned in any considerable numbers at City Hospital, whereas as many as 300 beds
ould well be used at Warrensville, not including in this number those who are crippled
r merely infirm from age.
7. The large number of tuberculosis patients found in their homes by the Survey
onphasizes the need, brought out in the special report on tuberculosis, for increase in
matorium provision.
952 Hospital and Health Suryet
SOCIAL SERVICE IN HOSPITALS AND DISPENSARIES
It is only fourteen years since the first hospital social service department
in the United States was established in Boston. Today over three hundred
hospitals have taken on this new and important adjunct to their medical
service. It is curious that a community so advanced as is Cleveland in many
respects should have made only a slight development in the social service
activities of its hospitals and dispensaries.
Three hospitals in Cleveland have organized social service departments.
Four other institutions have each one person who is devoting some atten-
tion to social and financial relationships connected with patients. The
Lakeside Hospital Social Service Department has been in existence sevoi
years, that at Mt. Sinai three years, and that at St. Vincent's Charity Hos-
pital one year. Each of these social service departments began with one
worker. Lakeside had six workers at the beginning of 1920; Mt. Sinai four
and Charity five. These departments have developed independently and
there has been no uniformity in poUcy.
At Lakeside, the social service department appears to be an outgrowth of
the visiting nursing service. For a number of years its activities have been
almost entirely confined to the dispensary, and its head worker was prac-
tically responsible for admission of patients and for many details of dispen-
sary administration. It is unfortunate that for a niunber of years this de-
partment has maintained a policy of medical secrecy which has prevented
its meeting the needs of agencies such as the Associated Charities or making
a contribution to the community health problem. To furnish to a charitable
agency information regarding the medical condition and the health needs of
patients in whom the agency is interested is part of the responsibility of a
hospital or dispensary. To effectuate this relationship between the hos-
pital and the outside non-medical charity is part of the duty of the social
service department. Lack of records in the social service department at
Lakeside has rendered it impossible to study the social conditions which
cause disease or which render its successful treatment impracticable unless
they are altered. Although Lakeside Dispensary is a teaching clinic of
Western Reserve University Medical School, the social work is not so con-
nected with the organization as to bring the medical students in contact
with it and enable them to learn something of the relationship between the
medical and social problems. This has been done in a number of other
leading medical schools, notably in tliat of Indiana University.
At Mt. Sinai Hospital, the social service department was organized as a
definite part of the dispensary, and has been much more intimately related
to the medical service on the one side, and to the social and charitable agencies
on the other. As at Lakeside, a considerable part of the time of the social
service staff has been sj)ent in assisting in the administration of the dis-
pensary. As at lakeside, a lack of clerical assistance has made adequate
records impracticable, so that much of the research value of the work has
been lost.
»iTALs AND Dispensaries * 958
he recently developed department at St. Vincent's Hospital is like the
•s, largely concerned with the dispensary rather than with the hospital
. Lack of clearly defined policy other than to do kindly and friendly
;s for patients is apparent here as often elsewhere in this new branch of
ce.
1 the prenatal clinic at St. Luke*s Hospital a nurse spends half her time
tting dispensary patients and in making financial investigations for the
ital, and this is called social service.
t the Babies' Dispensary a graduate nurse, called a "social service
J, " is responsible for the admitting of new patients, and classifies them
"ding to their abiUty to pay the various grades of fees in this institu-
— admitting them or referring them elsewhere according to her judg-
t City Hospital there has been a single worker, who without any definite
y or guidance, has endeavored to mitigate personal or other problems
lose few patients she could reach among the thousands passing through
institution yearly.
t Rainbow Hospital is a "social service nurse," who does follow-up
for the children who are discharged.
1 addition to the activities of these seven institutions, the Association
le Crippled and Disabled maintains a social service department of a dis-
ive and efficient sort. While not properly speaking a hospital social
ce department, its work is of very simila character. A description and
lation of this will be found in the portir, i of Part H. which deals with
are of cripples.
he most striking fact about hospital and dispensary social service in
sland is the lack of any definite conception of the policy which a social
ce department should pursue and of its relationship to the organization
e institution in which it works. In no department does there appear
J a clear recognition that the prime basis of social service in a hospital
spensary is the assistance of medical treatment. Social service is not
ther should not be in a medical institution for the sake of being kind to
nts, or for the sake of finding out what patients can pay the hospital
or for the sake of helping to run the dispensary.
[indness is a general function of a hospital organization — not an attri-
of social service in particular. The fixing of fees or finding out whether
nts can pay is an administrative function, to be performed by a financial
itigator. It is a serious interference to any really constructive social
ce to patients if the worker who is supposed to render such service is
d in the position of an inquisitor into the details of personal income.
954 Hospitals and Dispensabies
Helping to admit patients to a hospital or dispensar^*^ or to administer a
dispensary is a useful and necessary service which social workers have often
been called upon to do since no other trained persons have been available,
particularly in a dispensary. Social workers have been rendering such ad-
ministrative assistance in several dispensaries of Cleveland as in other cities,
and have been of substantial value to their institution and to the patients
by doing so. It is quite true that assistance in many phases of administra-
tive work in hospitals and dispensaries falls naturally to social ser\nce. When
these pieces of administration involve personal dealings with patients (as in
admissions or in the management of clinics) the training and practical ex-
perience of the social worker is of distinct value.
Physicians in a hospital do various things which a layman might do,
such as making records or assisting in administration; so also nurses do
many things for which their special trainmg as nurses is not a pre-requisite,
but the essential reason which brings a doctor to a hospital is the activity
which he alone is trained to perform — medical diagnosis and treatment.
The reason why nurses are in hospitals is because there are certain duties
which only trained nurses can perform — the bodily care of patients and
assistance of physicians during operations and in therapy. The distinctive
function of social service which brings the social worker in the hospital and
dispensary is the contribution which she can make to medical treatment,
assisting the physician in securing those facts about the patient's personality
and environment which will bear upon the cause and characteristics of hw
disease, and aiding the pliysician in planning and carrying out the details of
treatment which under the conditions of the patient's character, family, and
finances, are necessary to secure the best results.
In the hospitals and dispensaries of Cleveland, social service has been
largely introduced as a measure of kindness and as a helpful agent in adminis-
tration. There has nowhere been recognition of any definite policy or of the
essential relationships between hospital social service and medical treat-
ment.
A trained social worker is one who has learned to make critical but
sympathetic judgments of the human problems usually presented, and who
has also learned how these can be dealt with effectively in practice. As an
example of the questions which face medical and social workers and which
need trained social judgment for their answer, we may cite:
Shall material relief be obtained for a family for the three or four
months during which the father will be in cui institution because of sick-
ness, or shall the five children and mother be placed in four different homes
of willing relatives during that period — a course to which the mother strenu-
ously objects?
Shall a delicate child with kind-hearted but quarrelsome and unedu-
cated parents, be placed in a country home for six months; or shall an at-
tempt be made, through the parents' love for the child, to reconstitute
family life sufficiently to enable the girl to get well at home?
3PITALS AND DISPENSARIES 955
Shall an unmarried pregnant girl of 21 be urged to marry the father
of her child if the man is willing, although the girl has lost her confidence in
him, or shall she be helped to fight her battle of life alone?*
The answer to such questions requires in the first instance, careful study
the social worker of the patient's personality and family circumstances,
orting to the physician and deciding in conjunction with him the proper
irse to pursue, having both medical and social facts in mind.
There is very little indication from the studies made of the work of the
ial service departments in Cleveland that this type of analysis is prac-
jd in its definite relations to the medical problem of each case. The
iracter of the disease is of vital influence in determining what treatment
necessary, but how the treatment shall be applied depends in a large
asure upon the patient's personality and environment.
In addition to the study and analysis of the case necessary to form judg-
nt as to the social causes of the disease and of the conditions which will
*ct its treatment, the social worker in the hospital or dispensary must also
leavor to help in the accomplishment of the treatment, as by finding a
> for a man with a damaged heart, getting food or money for an under-
irished family with three sickly children, or by securing a vacation, a
mdly visitor, or the help of a relative so that a woman will consent to have
operation in the hospital, knowing that her children are properly cared
meanwhile. In these types of practical service, where the problem is
her obvious, persistence and resourcefulness are often shown among the cases
died in the Cleveland social service departments, but because of the com-
lation of lack of definite policy and of pressure of administrative work,
ire has been little real study of cases so as to bring out relationships be-
een disease and social conditions, thus enabling a really definite and well
mded plan to be made for combined medical and social treatment.
It must be apparent that in many cases where the personality of pa-
nts or family difficulties or lack of funds are involved, medical treatment
largely or wholly wasted unless adequate social service goes with it. The
mary and fundamental recommendation therefore for the social service
>artments of Cleveland is a definite aim — a clear-cut policy.
The need for sufficient medical social service in the Cleveland City Hos-
al is the outstanding requirement when individual institutions are con-
ered. In a large municipal institution of this sort the great majority of
J patients come from home conditions which render convalescence difficult
has been shown in the section on **The Convalescent and the Hospital")
the hospital's care is of greatly diminished value in restoring the individual
family to health unless something more is done than simply to provide
^ surgical operation or bed care during an acute illness. '
* Davis 6l Warner, "DiapeiiMries." 1918. Page 114.
056 Hospital and Hel\lth Subvet
Waste of human energy, increase of human suffering, and fruitless ex-
penditure of public fimds goes on at any large municipal hospital without
social service — the institution can merely render medical attention during
the acute stage of an individuars illness, and passes by related conditions in
the man or in his home or his occupation.
Re-occurrence of illness, re-admission to the hospital, lowered efficiency of
the patient and family, further illness, and family deterioration, make a
vicious circle which the most skilled surgeon and finest diagnostic equipment
cannot break alone.
In New York, Bellevue Hospital, with 1,300 beds, has a social service <fc-
partment with 30 workers. In Boston, the City Hospital, an institution
only a little larger than the City Hospital of Cleveland, and much smaller
than the enlarged City Hospital which Cleveland will soon possess, has 17
social workers. At the Cook County Hospital, Chicago, there is a socUl
service department with 8 workers, and in the social service department d
Cincinnati General Hospital, there are 4 workers.
The larger the institution, moreover, the greater is the need that the head
worker be a i)erson of unusual personality and previous definite experioioe
in hospital social service. The Cleveland City Hospital needs an adequate
social service department with a strong, well-trained woman at its head.
She should be responsible to the superintendent of the hospital, but theie
should be a social service advisor^' committee appointed by the Director of
Public Welfare (or by the board of trustees if such a board is formed for the
City Hospital). The duties of such social serv^ice committees are touched
upon later in this chapter. This committee would be of particular impor-
tance to City Hospital during the first years of development of adequate
social service there.
It may he mentioned that some years ago a scK*ial service department
was started in the Boston City Hospital on the initiative of a number of
private citizens, including some of those closely associated with the institu-
tion by medical interests. Private funds supported the original staff, but
the city soon entered and paid a share as the department enlarged. While
at present some of the staff of workers are still supported by private funds,
the outcome will undoubtedly he complete municipal support. At no time,
however, has tliere been any cjuestion of division of responsibility for im-
mediate control })y the hospital. In a municipality with the active civic
spirit of Cleveland such initial sharing of the burden of hospital social se^^•ice
by ))rivatc funds ought not to be necessary; but it is not at all undesirable.
TJie Welfare Federation has certain special reasons for supporting social
service* in h()s])itals and dispensaries. A very large proportion of })overty is
caused by sickness or is acconi])anied by sickness, making it useless to attempt
to restore the family to sclf-sup])ort imtil the illness has been successfully
treated. Studies in a number of cities indicate that sickness is one of the
conditions accompanying poverty in from 60 to 80 }>er cent, of the families
known to such an agency as an Associated Charities. Since the members of
such families obviously cannot afford a private doctor, it may be said that
Hospitals and Dispensaries 957
the hospital and dispensary must be their family physician. The charitable
agency must look to the hospital and dispensary for medical diagnosis,
advice and treatment, and the agency requires the constant cooperation of
the hospital and dispensary. Without the social service department this
cooi>eration generally proceeds with halting steps. The social service de-
partment is the link between the highly organized, specialized medical insti-
tution and the community agency which deals with the family in its home.
Without such a link, much money and much time are wasted by these agen-
cies. Thus it is not only in behalf of the intrinsic service to the patients of
hospitals and dispensaries that social service has a claim to support, but also
because the work of other charitable agencies which are members of the
Welfare Federation will be very substantially assisted tliereby.
The special need of hospital social service in connection with the con-
valescent and the chronic case has been brought out in the preceding chapters.
The section dealing with the plan of hospital organization includes a brief
statement concerning social service. A social service department should be
part of the hospital organization, not maintained by any outside agency.
Social service needs to work intimately within the hospitnl and hence to be
an integral part of its administration. The head worker of the social
service department should, like the heads of other departments, be respon-
sible to the superintendent, but it is advisable, particularly during the
formative stages of social service, to have a social service committee, includ-
ing a few members of the board of trustees, one or more members of the
medical staff, the superintendent ex-oflScio and other persons who are
familiar with general philanthropic work and whose advice regarding the
policy and problems of the department will be of value. Such a committee
should be advisory, like others suggested in the scheme of organization.
The personality of the head worker and the quality of her training and
experience are of vital importance to a social service department. There
hajs been in Cleveland, as in a few other cities, much discussion as to the
training necessary for a hospital social worker, and in particular of her rela-
tion to nursing. A nurse's training does not provide one of the essential
elements for a hospital social worker, nor can this be gained by a brief period
of observation of social service or by a two or three months' "course." Not
less than one year's study of social work and an additional year of practical
experience under educational supervision is necessary to render any person
a competent worker in so difficult and complex a field as this. The training
of a nurse provides important knowledge of medical matters and a familiar-
ity with the point of view of physicians and patients, and with the conduct
and administration of hospitals and dispensaries. Actual experience in many
social service departments throughout the country has proved thai, as a
matter of fact, some successful workers are nurses and that some of them
are not nurses, and that to debate as to whether a hospital social service
worker must be a nurse or must not be a nurse is merely a waste of time.
Personality implying effectiveness in dealing with people, a certain degree
of administrative and executive ability, and a definite training in the analysis
of social problems and familiarity with the methods of dealing with them.
958 Hospital and Health Survey
are essential elements, as well as certain subject-matter concerning partk;-
ular diseases or medical problems to be dealt with. During the present form-
ative period of social service, too much care cannot be taken in selecting
the right quality of head worker, and then leaving it largely to her to nomi-
nate and appoint her assistants.
Social service in the hospital and dispensary must be viewed priniarilj
asjan adjunct of medical treatment. It is usually desirable that social serv-
ice shall assist in various administrative activities, as in connection with the
admission of hospital patients, the admissions to th^ dispensary' or the
management of dispensary clinics.
It is not desirable, however, that a member of the social service depart-
ment should be used as the financial investigator of the hospital. The utiliza
tion of social workers at the admission desk of a dispensary is desirable, bu!
the financial grading of patients should not be her primary responsibility,
nor should financial grading be of such rigidity as exists at the Babies' D^
pensary, or existed until recently, at Mount Sinai. Such rigid grading tends
to develop arbitrary standards of dealing with patients, on an entirely super-
ficial basis, establishing a wrong relationship with a patient by emphasizing
hisjfinancial rather than his physical need. It is well that Mount Sinai has
discarded the custom.
It may be added that it is not desirable to have any person kept continu-
ously at the desk admitting patients to hospital or dispensary without being
assigned a portion of her time to other phases of social service, particularly
the study of families in their homes. The admission of patients requires a
series of **snap judgments,*' based necessarily on slight information. In
order to keep any person from becoming "routinized,'' losing freshness and
flexibility, the effect of making necessarily hasty judgments in the admission
of patients must be counteracted by giving the worker some, even if only a
small amount, of time for intensive observation and service with a few jw-
tients in their homes.
In a dispensary' the social worker can be of value not only at the adniiv
sion desk, })ut in various phases of dispensary administration, notably in
the detailed executive management of clinics. The routine of the clinic
needs adaptation to the needs of each patient. The doctors' time shouW
not he taken up with executive detail but should be given to medical work.
The social worker, as clinic executive, is a great aid alike to physician and
patient.
The Social Ser\'ice Clearing House supported by the Associated Charities
[)rovides (a) registration of families known to charitable agencies. By means
of this there is at the office of the Clearing House a list of families or **cases"
known to any agency using tlie Clearing House, and with tlie name of each
case or family is a list of the agencies which have been interested in this case.
The Clearing House also provides for (b) answering inquiries from agencies
about families and telling them whether any other charitable agencies are
interested in the family, and if so, what agencies. By this means a charit-
loaPITALS AND DISPENSARIES 959
ble agency may find out the names of those who have previously known
. family and then, by calling these agencies, learn what has been or is being
bne for the family.
The Clearing House is very largely used by hospitals and dispensaries of
yleveland. During 1919 a total of 89,569 inquiries were made, and of this
otal of 25,966 or 43 per cent, were from medical agencies, chiefly dispensaries.
»uch registration takes place largely through the social service departments of
he dispensaries and through the nurses in the health centers.
Registration of dispensary cases in the Social Service Clearing House,
lowever, is not accompanied by full use of the information thus secured.
Vhen the dispensary registers a case it learns automatically by the reply
lip, sent from the Clearing House, the names of the agencies who have
ormerly known the family. If the social service department of the dis-
lensary does nothing further the time spent in registering the family is prac-
if!ally wasted. It is found that in a large number of cases no use of the in-
ormiition secured from the Clearing House is made.
The Social Service Clearing House is a most important means of promot-
ng team work among agencies and of avoiding overlapping in deahng with
amilies. Its use should be increased in every way, but it is a question how
BT mere registration without making use of the information is worth while.
It is recommended that a conference be held of representatives of the
Lssociated Charities maintaining the Clearing House and of a number of
epresentatives from medical agencies, particularly the large dispensaries
nd health centers, and that the following questions of policy be discussed
nd, if possible, decided.
• 1. Shall it be the policy of the agency to register all cases, or only cases
in which it is likely that they will make use of the information secured from
the Clearing House?
2. If the latter, decision should be reached by each agency as to what
types of cases, classified in medical or in other ways, they will register, and
the Clearing House should be informed of this policy and of changes from
time to time.
It is desirable that as large a number of cases be registered as possible,
>ut mere waste of eflFort in futile registration should be avoided. It is neces-
ary to draw the hne at the right point, given a certain sized social service
md clerical staff in each medical organization.
• It is not deemed advisable that a routine social history be taken of every
latient, as is done in some clinics, notably at Mount Sinai. Many facts of
rmlue are found through conference between social worker and patient, but
inless there are enough social workers to take up these cases and deal with
he needs found, the time taken in getting a thorough social history is largely
960 Hospital and Health Subvet
or wholly wasted in many instances. Unless a dispensary has a very unusual
number of social workers, such as no dispensary in Cleveland has at the
present time or is likely to have in the near future, it is advisable that detailed
social histories be taken only on selected cases, the social worker at the
admission desk or in the clinic determining (on necessarily brief judgment)
which cases shall be selected.
Social service departments have generally suffered from lack of suffident
clerical assistance to keep adequate records which are required in social serv-
ice as in medicine, for good work. Furthermore, it is not economical to
take a large part of the time of a social worker for clerical tasks.
Finally, it is urged that a definite portion of the time of the head social
worker or of one of her best assistants be devoted to the constant study of
the social problems of the hospital and dispensary, and their interpretation
to the staff and the administrative authorities of the institution. Periodicil
studies of the social problems of selected groups of patients are practicable
even in a small social service department, if tiie groups selected are smaB,
but judiciously chosen so as to be medically and otherwise significant. Sud
studies and reports on the social problems of these patients outline to the
staff and the administration the social conditions influencing some of the
chief diseases treated in the hospital and dispensary. Only in that way can
the policy of the social service department be expected to grow, and the
hospital and dispensary steadily advance in a broad policy of prevention as
well as cure, and of widening service to the community.
\\
EICN3PITAL8 AND DiSPENBAHIES 961
AMBULANCE SERVICE
To understand what the ambulance system of Cleveland ought to be it
s necessary first to outline the present situation.
There are three different agencies in Cleveland which may be called
ipon for ambulance service. The Police Department has "Pohce Emer-
gency" cars, used for the sick or for the law-breaker, as the need may be.
City Hospital owns three ambulances (two Atlas cars and one Ford) but
lias only one in commission.* The Survey was informed that each of the
ocal undertakers, of which there are over 100, has one or more " combination-
w-agons" (combination "dead-wagon" and invalid carriage).
From January to November, 1919, the police answered a total of 3,290
imbulance calls. The City Hospital ambulance was out of repair for five
nonths of 1919, but during the other seven months made 937 calls. The
lumber of calls answered by the undertakers could not be estimated.
In contrast with these provisions may be cited the provisions found in
severaj other leading cities. In New York City the ten public hospitals
operate 31 ambulances, and in addition, 35 private hospitals provide a total
of 70 ambulances. The City Hospital in Providence, Rhode Island, has
tliree ambulances. In Jersey City the City Hospital has six ambulances.
In Philadelphia about 35 private hospitals own ambulances and their serv-
ices for emergency work are recognized by an annual appropriation of $300
to each hospital from the city.
The distribution of ambulances has an important bearing upon their
availability and promptness in answering calls. A police ambulance is sta-
tioned at each of the fifteen police precinct stations of Cleveland except at
Ptecincts 4, 10 and 15. The City Hospital ambulance is expected to serve
the entire city, and the service of the ambulances provided by the undertakers
is not districted. Calls for the Police Emergency are supposed always to be
sent to the Police Information Bureau, and then to be relaved to the nearest
Pr^inct station, although they may be received directly at the precinct sta-
*^^on itself. If the emergency patrol at the nearest precinct station is not
^vailable, the call is transferred to another district ofiice. So far as could
*^ ascertained, there is nothing to prevent a person from calling the poUce
^D[iergency, City Hospital ambulance and an undertaker's car, for the same
^D[iergency case.
In a matter where a few minutes time may be of such vital significance,
^^ promptness with which ambulance calls are answered is of decided im-
^^tance. The consensus of local opinion seemed to be that the police
^^ergency cars were prompt in arriving, but there was universal criticism
^ the utter unreliability of the City Hospital ambulance in answering calls,
"^^lays of many hours often occur and it has not been at all unusual for the
^^bulance not to arrive until the next day after the call, was sent in. One of
* Note — It it understood that a new ambulance has recently been purcnaied for City Kotpital.
962 Hospital and Health Subtet
the hospitals reported a case of pneumonia, for which the City Hospital was
asked to send an ambulance on the 18th of the month. The ambulance
was promised for the 20th but never came at all. In the case of contagious
diseases, which can only be received at City Hospital, and for which the City
Hospital ambulance is the only logical and suitable means of transportation
available, such a delay means unnecessary exposure of other persons, espe-
cially dangerous in the crowded homes and lodging houses from w^ch the
City Hospital patients arc apt to come. It is our opinion that at least two
more ambulances should be provided for transporting contagious cases, so
that all these cases may be cared for by the City Hospital's own ambulances.
It is also felt that twenty-four hour service should be provided by the City
Hospital for contagious cases. With the transportation of contagious pa-
tients concentrated under the control of City Hospital, the hazard of pocily
disinfected ambulances, such as at present exists, could be obviated.
Inasmuch as a patient for whom an ambulance is called is often seriously
ill or injured, ambulance service must mean more than mere transportatioD
from one place to another. An injured man may have to be carried from
his house to the ambulance. A person hurt in a street accident may need
some form of first aid in order to save his life. A case of acute illness, needs
to be made comfortable for the ride to the hospital, and in winter needs to
be sheltered adequately from the cold. In case of contagious disease, the
ambulance must be disinfected in order to protect the next patient using^
These requisites of eflScient ambulance service are met, when met at all
in Cleveland, in varying degrees.
The Police Emergency cars carry the driver and one other policeman*
The City Hospital ambulance sends someone with the driver, if the patient
must be carried. One undertaking firm which cares for many of this class
of cases sends only tlie driver of the car.
Training of the amimlance crews of the police force in first aid and the
pr()j)cr care of y)atients on their way to the hospital, has not been so com-
plete Mild adequate as is desirable. A lecture on first aid is given by a physi-
<'ian at each district, and instruction is given in the use of the pulmotor. A
f(*w years ago lectures and demonstrations were given by a representative of
tin* Life Saving Corps of the Red Cross. Comment has come to the Sur\*ey
of tli(* kindness of the police who serve with the ambulances, but more than
kindiKvss is iKHnicd to give first aid treatment in case of sun-stroke or suffo-
catioiK Skill and definite truining are necessary. The policemen assigned
to ainhulancc service should he recjuired to pass a thorough course in first
aid. consisting of both theory and ])ractice. The provision of an adequate
ctntTgency kit for each anihulaiu'e would seem imperative, yet the police
patrols are ])rovi(led with only tourniquets, rubber gloves and handcuffs,
and the City Hospital ambulance had no first aid equipment at all. This
ul)s«'n<<' of first aid cciuipment is not. excusable, and should be remedied with-
out «lelav.
3PITAL8 AND DlSP£NSARI£S 968
At present there is no continuous assignment of members of the police
!e to the ambulance service, so that a man with proficiency gained by
erience (in lieu of training) may be replaced by one to whom the simplest
Iters of emergency treatment are unlaiown.
No matter what the ailment of the patient may be, the ride to the hos-
il needs to be made as corafortable as possible. The following incident,
ilar to many which have come to the attention of the Survey, was reported
n the personal observation of a member of the Survey staff, on one day
ing the winter. The Police Emergency was drawn up in front of a store
lower Euclid Avenue, and a shivering, pallid woman in a semi-conscious
be was carried out and placed on the hard, unpillowed leather shelf of the
bulance. There was no blanket to protect the woman from the cold
theast wind, and her husband covered her with his coat.
The type of ambulance used by the police department is uncovered at
end and the cars are very unsuitable for cases of serious illness, especially
patients with respiratory disease. The City Hospital ambulance, how-
r, is a closed car with a stretcher.
The Animal Protective League operates two ambulance trucks for the
tisportation of dogs, and was at the time of the study having another
! made. Their ambulances are fitted with adjustable cages. The
triors of the cars are painted, and the cars are washed out with hot
ter to keep them in a clean and sanitary condition. In winter the exterior
e sides are covered with regulation side curtains. The humane care
logs is a matter which should be of concern to every person, but it is eer-
ily only reasonable to insist that at least the same degree of humane care
rendered to human patients who through illness or accident are forced to
an ambulance.
The matter of disinfecting an ambulance which has carried a patient suf-
ing from contagious disease, is one of importance. Some provision is
de for disinfecting the police emergency cars by formaldehyde spray, but
iference with the policemen in charge of these oars convinced the investi-
jOT that very little real disinfection was done. Disinfection of the City
ispital ambulance by wiping out with cloths moistened in creolin solution,
1 change of pillow case and blankets, is carried out on return from trans-
rting a case of contagious disease only when the case next to be called for
)ne of a different contagious disease. From numerous complaints by phy-
ians it would seem that undertakers often fail to make any provision for
infection, although no data on this matter were obtained.
One thing which has impressed itself most forcibly upon the Survey staff
the general unwillingness of the dependent sick to use the Police Emer-
ncy ambulance. Well-to-do patients can of course, afford to pay the fee
arged for the use of undertakers' cars. Innumerable cases were found
wever, where patients who could ill afford the five or ten dollars, summoned
' private ambulance rather than endure the stigma of riding in the police
urgency. It must be remembered that to all practical appearances there
964 Hospital and Health Subyet
is no distinction between the sick man in the police emergency and the mm
who has been engaged in a street fight or some less conmiendable pursuit
Natural pride and self-respect resent such a method of transportation in
case of sickness or injury, and this feeUng of resentment is justifiable. Cer-
tainly a more dignified and considerate method of conveying a patient to
the hospital needs to be provided. On the other hand, it seems just as
unfortunate that an undertaker's wagon should be used for carrying patients.
No ambulance service is provided for taking patients to Wanensvillc
Infirmary or, in case a contagious disease develops there, for removing the
patient to City Hospital. In the latter case a delivery truck is used, an
arrangement hardly to the credit of the city of Cleveland.
It is believed by the Survey that at least the Cleveland hospitals main-
taining over 200 beds should provide their own ambulances, and that the
smaller hospitals might combine in some manner under the Hospital Coun-
cil. In order to maintain such a system of ambulance service in a satisfac-
tory manner, it is necessary to have some central organization. In Cleve-
land, so long as the present police emergency ambulances will doubtless
remain in use for some time, even though individual hospital ambulances are
provided, it would doubtless be best to retain the present central call bureau
under the jurisdiction of the police department, assigning an emergency dis-
trict to each hospital providing such service. The method of handling ambu-
lance calls used in New York City may be taken as the basis of a system for
Cleveland. In New York the city is districted for emergency ambulance
service and there is a central bureau to which all emergency calls are made.
This central bureau is at all times informed of the movements of each ambu-
lance, whether it has gone ff)r a patient, or whetlier it is available for use on
a call. When an emergency call is received it is relayed to the proper district
oflSce. With a little modification the present central call bureau of the
Cleveland Police Department could be adapted for the use of an efficient
city-wide ambulance system.
The following recommendations are considered essential to the improve-
ment of the ambulance service of Cleveland :
RECOMMENDA TIONS
The poUce patrol wagons should be replaced by ambulances for use in emergency
work, and the use of police patrol wagons for ambulance transportation should be dis-
continued as rapidly as possible.
Each ambulance should be provided with a stretcher, blankets and ordinary first aid
equipment, including a Thomas splint.
At least four such cars should be provided and stationed in appropriate sections of
the city.
The policemen assigned to ambulance service should be required to pass a thorough
course in first aid, consisting of both theory and practice. This instruction should be
[OSPITALS AND DlSPENSABIfiS 965
Elder the direction of the Division of Health. Aangnment to the ambulance branch
r the police service should be continuous.
At least two more ambulances should be provided at the City Hospital to be used
tr transportation of contagious cases from all parts of the city to the City Hospital, and
ir transferring cases to and from Warrensville Infirmaiy and Sanatorium.
Twenty-four hour service should be provided by the City Hospital for the trans-
ortation of contagious cases.
Hospitals of over 200 beds should provide their own ambulance service, smaller hos-
itals combining with one another under the Hospital Council to provide such service,
lie larger hospitals also might find it advantageous to come into some such joint scheme.
As ambulance service is provided by individual hospitals, an agreement should be
»ched with the Chief of Police by which an emergency district would be assigned to each
ospital providing such service.
The existing centralized system of calling for ambulances at the Police Information
tureau should be continued for all emergency work.
The hospitals and public health agencies should discontinue the use of undertakers'
ivalid carriages for ambulance service.
966 Hospital and Health Sukvet
V. Hospital and Dispensary Planning
COMMUNITY PLANNING
From the standpoint of the community, hospitals and dispensaries in
Cleveland have been planted, rather than planned — ^planted each by itadf
instead of being planned as part of a community scheme for organized medi-
cal service.
The hospitals thus planted have grown, but have not grown fast enou^
to keep pace with the development of the city. This is even more true oJ
the dispensaries, the starved children of the hospitals. The outstanding,
almost tragic, fact in the situation of Cleveland is the shortage of 1,500 beds
below present community needs, and the deficiency in dispensary service,
which at present is not more than one-third of the needed amount.
These major needs are a challenge to the courage and resources <^ a pro-
gressive, self-confident city such as Cleveland. The passage of the City
Hospital Bond Issue during the spring of 1920 for $3,500,000 gives assurance
that when the necessary steps of making plans, selUng bonds and putting up
buildings have been taken, at least one-third, or possibly half, of the needed
1,500 beds will be provided.
It was originally expected that the $3,500,000 would be sufficient to ccm-
struct 900 beds and a dispensary, tearing down the present psychopathic
building of 200 beds, which is unfit for hospital use; and thus making a net
addition of 700 beds. The City Hospital would then have practically 1,500
beds, and it should have this number as soon as possible. Since the figure
$3,500,000 was decided upon by the autliorities, building costs have continued
to rise, and (while the future course of prices cannot safely l>e predicted) it
is probable that the sum will be insufficient to build any such number as 900
beds, besides a dispensary and necessary enlargements or improvements in
nurses' home, power plant, kitchen, etc. The present city administration
should proceed as ra])idly as possible with plans and construction, making
the $3,500,0()() go as far as it can, and all public officials and private persous
who have tJic iiospital interest of the city at heart should continue their efforts
until the City H()sj)ital has reached the needed size.
Privately su])ported liosj)itals must expect to provide 750 to 900 beds of
the needed 1, ,>()(), as soon as possible, and also the dispensaries, as outlined
in the (liscussioti of that subject. An expenditure of probably $H, 000,000
for buildings must he faced by the pe()))le of greater Cleveland during the next
few years.* This figure does not include such special provisions for research
<ind medical tcaciiin^ as may be provided in connection witli the University
Hos])itaI. Of the Ji?b2,()()(),()()() it may be expected that two-thirds, or a little
less, will have to he y)rovided by ])rivate gifts, and about one-thir<i, or some-
what more, by the iiiunici])ality.
*Thi8 sum includes $3,500,000 bond issue. At the time of concluding the Survey the bonds had bees
authorized but not marketed.
loSPITALS AND DISPENSARIES 967
In one of the striking financial *' campaigns'* of recent years, the Jewish
Community of New York City, with a population only slightly more than
he total population of Greater Cleveland, raised more than $7,000,000 for
»uilding funds for its various institutions. Cleveland has let its population
;row faster than it has permitted its hospitals to grow. Atonement for the
Sleet of yesterday can only be made by dipping more deeply into the pocket
ay. Delay means only the incurring of still heavier future obligations.
It is greatly to be desired that in securing these building funds Cleveland
hall pursue Uie policy already so finely established through the Welfare
(federation in raising annual expenses. Joint campaigns for hospital building
unds are the desirable method. Otherwise Cleveland will|be weary with
»iie hospital ''campaign" following another, with the almost inevitable
esult that those which happen to have been unable to make campaigns first
^11 suffer, and the response will be influenced more largely by chance than
>y relative need or merit. What is of even more importance is that balanced
tevelopment will be less likely, because joint campaigning implies in) a con-
iderable measure joint planning, the mutual adjustment of plans^to the
>Toader needs of the community.
It is true that the present year, 19S0, does not seem a propitious one for
i large financial ''drive" such as this building fund campaign would have
o be. There are just two practical recommendations for those who ought
x> voice the need and lead the campaign to meet it: conviction and courage.
There must be profound belief in the urgency of the need for more hospital
leds and more dispensaries, and firm determination to meet this need at
he earliest possible date.
Projected Enlargement
The Survey found that a number of Cleveland hospitals had made, plans
or expansion. Three notable examples are the following:
The project of Lakeside Hospital to move from its present site near
East Twelfth Street and Lakeside Avenue, to Wade Park, enlarging its
capacity from 289 beds to 500 beds. In connection with this is to be men-
tioned the desire tomove Maternity Hospital to the same area, and to enlarge
it to 100 beds, as a part of the University Hospital group; and, the building
of a hospital of 150 beds for babies and children, as part of the same group.
The total for the group is 750 beds, making a net increase over present pro-
visions in the same group of institutions of 400 beds.
The project of St. Luke's, to move from its present site on Carnegie
Avenue to Ambler Heights, and to enlarge from its present capacity of 139
beds to 300 beds, a net addition of 161 beds, or, if the present hospital were
retained and used for an enlarged dispensary and an industrial hospital of
perhaps 100 beds, a net addition of about 250 beds.
The project of Huron Road Hospital to move from its present site on
Huron Road, to Ansel Road and Wade Park, enlarging its present capacity
of 84 beds to 250 beds, a net addition of 166 beds.
968 Hospital and Hsalth Subyet
The plan of Lutheran Hospital to enlarge from 50 to 100 beds has already
been put before the public in a campaign for the needed funds.
A number of other hospitals have stated to the Survey in more or less
specific form their desires or projects for expansion. It will be observed
that on the minimum basis of calculation the projects of Lakeside, Maternity,
the new Babies' and Children's Hospital, Huron Road and St. Luke's would
together bring a net increase of 727 beds minimum, or 816 beds mitTininni
In other words, these projects alone, if carried out, would provide most of
the 900 beds which must come from private funds. It is to be desired, how-
ever, if a joint campaign for building can be organized and successfully
accomplished, that the legitimate desires of some of the small institutions be
recognized. It is particularly important that if funds cannot be asked for or
secured sufficient to provide for the total amount required for the needs d
all the institutions, that some of the smaller hospitals whose present buildings
and equipment are now notably inadequate, shall be allotted sufficient amounts
to enable them to make needed changes or improvements of a permanent or
semi-permanent nature, even if their substantial program of enlargement
must be postponed, and if the plans for the three largest hospitals have to
be somewhat, curtailed. For example, the improvement of the nurses' home
at St. Vincent's or the provision of a dispensary at St. John's, are urgently
required by present needs for better service, irrespective of increase in the
number of beds.
In the rounding out of Cleveland's hospital facilities through the develop-
ment of specialties, the increase of service to children is the most urgent
need in both hospitals and dispensaries. The building of the proposed Babies*
and Children's Hospital is perhaps the most greatly needed of Cleveland's
hospital facilities, after the enlargement of the City Hospital.
There is need of enlargement of facilities for maternity care, and the pro-
gram of Maternity Hospital to increase its size from 60 to 100 beds is approved.
This, however, is not so urgent as a number of other needs, such as for chil-
dren's beds, for an eye and ear hospital, or for tlie improvement in the plants
and nurses' homes of several other institutions, such as St. Vincent's, St.
Alexis, etc.
In the case of diseases of the eye, ear, nose, and throat, the deficiencies
in Cleveland, as pointed out in the early part of this Report, are imusually
serious. Many other cities have found it desirable to establish eye and ear
hospitals. New York provides 608 beds; Boston, 219; Baltunore, 158;
Portland, Maine, 100; Washington, 94; Philadelphia, 58; Pittsburgh, 40; and
Chicago, S2. In Cleveland one hospital only (Lakeside) makes any special
reservation of beds for eye cases. Six hospitals maintain an ear, nose, and
throat service. There is no throat ward in the city. There are cared for in
hospitals and dispensaries a relatively small portion of the eye, ear, nose,
and throat work required by a population as large as that of Cleveland and
its vicinity. No center exists for the training of physicians and nurses in
these specialties. There are exceedingly numerous industrial eye injuries.
All but one of the twelve oculists who responded to the Survev's letter of
Hospitals and Dispensaries 969
inquiry stated that industrial eye injuries came to them with evidences of
having been mishandled.
Of the 545 persons in the city known as totally blind, 306 cases may be
considered as due to preventable diseases or injuries. In addition to this
number, 121 cases are to be classed as curable.
It is therefore recommended that beds to the number of 100 be established
for eye, ear, nose, and throat cases; these beds to be maintained preferably
as a branch of an existing general hospital, or, if established as a separate
hospital, to be in close cooperation with a general hospital, in order to secure
the most economical administration and the mutual advantages of coopera-
tion between the staff of the general hospital and the specialists in eye, ear,
nose, and throat. It is essential that there be such freedom and independ-
ence for the eye, ear, nose, and throat staff sls to enable the fullest develop-
ment of the special facilities, technic, and educational opportunities, and if
these conditions cannot be met were the beds to be part of a general hospital,
the beds should be established as a separate hospital, with the affiliation
indicated.
It is desirable that the hundred beds be divided between the ear, nose,
and throat service, and the eye service, in the proportion of three to two;
and that there be maintained a dispensary eye clinic and a dispensary ear,
nose, and throat chnic, in connection with these beds. The clinics had best
be parts of a general dispensary, but in any case the hospital staff should
have direct medical control. It is of course highly important that the eye,
ear, nose, and throat beds and clinics be used for medical teaching purposes,
under-graduate and post-graduate, and for nurses. It would be well that
there be provision among the institutions affiliated with these special beds
for an exchange of visiting physicians and surgeons, and of nurses in training.
Provision for all other specialties, such as orthopedics, and laryngology,
should be made by the development of services in general hospitals, with an
assigned number of beds and with possibly the addition of more beds or
pavilions at a future date, rather than by the construction of new important
specialized hospitals. The special hospital has a place during the period of
development of the technic of a specialty; but the permanent provision of
hospital faciUties in special branches is better and more economically made
by divisions of general hospitals.
Locations and Re-Locations
The study made by the Survey of the locations and inter-relations of
hospitals in Cleveland has led to approval of the plans of Lakeside, Huron
Road, and St. Luke's hospitals to move from downtown locations to sites
in the eastern part of the city, in or near Wade Park. Prevailing winds in
Cleveland are from the west, and sites in the eastern part of the city will
continue to be dirtier than locations on the western edge, until Cleveland
deals effectively with its obnoxious coal smoke. It must be pointed out,
however, that the moving-out of these hospitals and the closing of St. Clair
970 Hospital and Health Subvet
Hospital, which the Survey has recommended, will leave the central portion
of the city practically unprovided with local hospital facilities. With ade-
quate ambulance service, such as Cleveland should demand and secure (see
discussion of this subject), location will be rendered a secondary factor in a
large proportion of hospital cases, yet the tremendous volume of hospital
eases arising out of the downtown area cannot but require some local pro-
vision.
It will be necessary to retain either at Huron Road or at Lakeside, or in
perhaps a new hospital, from thirty to fifty beds, preferably affiliated with a
larger out-lying institution so as to secure the advantages of lowered cost
and better medical service. It would be more economical if the present
site and part of the present buildings of Lakeside or Huron Road were utilised
for this purpose instead of requiring new construction.
As outlined in the section on the downtown dispensary*, this downtown
hospital should be part of the same plant as the new proposed downtown
dispensary.
In the chapter on dispensaries and in the chapters just preceding, the
need for the development of several additional dispensaries, particularly on
the west and south sides was pointed out, and the particular institutions
named.
All of these points regarding the location of hospitals and dispensaries
and their inter-rejation need to be thought out as part of a comppehensi\'e
plan for providing general service to the city as a whole, and also local facili-
ties of various kinds, readily accessible to each district. In previous sections
of the report it has been brought out that certain of the larger hospitals have
a wide range, drawing patients from all over the city and from outside the
limits of Cleveland; that other hospitals are largely local in their clientele.
The same is true of dispensaries, some being city-wide in their range, others
serving few patients outside of one general section of the city, while the heaJlh
centers are definitely restricted to a certain comparatively small area, as
preventive work must be in order to be effective. Certain principles under-
lying community planning of the number and location of hospitals and dis-
pensaries may be formulated as follows, as the conclusion of this section.
PiuxciPLEs OF Community Plan
There should be a small number of what may be called major hospitals
and dispensaries, equipped with everything in the way of modern diagnostic
and therapeutic equi])nient. These major hospitals and dispensaries are
expected to be city- wide in their range, and to serve particularly for receiving
difficult cases from within and outside the city, for consultation purposes
and for diagnosis. In Cleveland the new City Hospital with its dispensary
should serve as such an institution for the west side. Lakeside, in its present
location or in its enlargement as part of the University group, would ser\'e
in this capacity also. Mount Sinai and St. Vincent's may be mentioned
also, utkI a few other hospitals, such as St. Luke's, may develop on a similar
Hospitals and Dispensaries 971
grade, although the teaching hospitals and dispensaries should be the dis-
tinctive institutions of this ciass and every eflFort should be made to render
them capable of measuring up to this responsibility fully.
What may be called the district hospital, with its district dispensary or
out-patient department, may next be mentioned. In this group may be in-
cluded the bulk of the hospitals of Cleveland, the range of which is not strictly
confined to a given district but which are more local in character and which
may not usually expect any large consultant or diagnostic service such as
would go with the teaching institutions. Somewhat less elaborate and ex-
pensive equipment and a less high degree of specialization in medical organi-
sation may be expected in this group of institutions. It may be pointed out
that such institutions fill a necessary and most worthy place in the scheme
of hospital and dispensary care to the people of large cities.
Finally come the health centers, primarily preventive in their activities.
More and more as the years go on, various therapeutic services of the simpler
kind need to be located in as many neighborhoods as possible, because the
more localized is their range, the more intensively and eflFectively can they
reach 100 per cent, of the population with a message of hygiene, with period-
ical examinations for the detection and prevention of disease, with service
for the prevention of infant and maternal mortality, the discovery and
control of tuberculosis, and the detection of remediable physical defects of
school children.
The health center should aim to reach the entire population of its district
for preventive purposes, sending cases in which defect or disease is discovered,
either to the family physician or to an appropriate dispensary or hospital, or
in the case of difficult problems, directly to the major institutions for diag-
nosis. The combination of some of the simpler forms of curative work with
* the educational and preventive services is a necessary development of the
health centers of the future. It may be pointed out that the proposed down-
town dispensary and emergency hospital which will be permanently needed
in the downtown section after Lakeside and Huron Road move, will be largely
a reference center for preventive as well as for diagnostic and curative pur-
poses. Particularly in a city like Cleveland, with its important medical
school, the institutions doing the teaching must bear the primary responsi-
bility, in hospitals and in out-patient clinics, for diagnostic service for the
patients of private physicians as well as for the patients who cannot afford to
pay a physician. The medical profession should reap the benefit of the de-
velopment of more extensive services in the health centers and in the dis-
trict hospitals and dispensaries. Appointments therein as staff or auxiliary
members and the benefits of their facilities for consultation and diagnosis,
should supply the most serious present deficiencies in what the local prac-
titioner has to oflFer his patients.
It is evident that the danger of a "community plan" is that it leads us
to glittering generalities merely. But it ought to be obvious that the ab-
sence of a community plan leads to anarchy. Cleveland has taken a long
step away from the state of anarchy which characterizes the medical institu-
972 Hospital and Health Subtet
tions.of most large cities, through its Hospital Council and its Welfare Federa-
tion. Any community plan which exists not merely on paper but which b
a Uving thing with muscles and teeth, requires that individual institutions
must adapt their policies and programs accordingly.
SacriiSces of policies or programs which seem desirable and Intimate
from the standpoint of an individual institution may be called for by its
proper adjustment to larger community needs. It seems hard, at times,
to expect a worthy institution to say **no" to the eager desire of its staff for
a program of expansion which a community Survey shows is more than is
required by the institution's district or by the particular kind of need which it
serves; yet at times such negative prescriptions are wise and necessary, and
should be self-imposed. It is not too much to expect of the hospitals and
dispensaries of Cleveland that they have a community plan. It is not too
much to expect that they abide by it, living not as bachelors and spinsten
who have only themselves to consider, but as members of a family each d
whom shares, nourishes, and is nourished by the life of the whole.
TAis AND Dispensaries 973
INDIVIDUAL HOSPITAL PLANNING
^ wise planning of a hospital's policy involves at least four elements:
idaptation of the work, as to kinds of service offered, rates charged, etc.,
ommunity, the district and the hospital's special clientele.
s adaptation should be based on knowledge, perhaps requiring special
)f the social as well as the medical character of the hospital clientele,
ined in the section on **The Human Problem of the Hospital Pa-
The Cleveland Hospital and Health Survey has rendered to the
ing authority of each hospital in the Council a report, the recom-
tions of which, as to policy and administration, are the result of such
f. Each hospital has thus had a cross section of the situation and
is of 1920, as judged by the Survey.
Periodical Self-Surveys, based on continuotis critical observation of the
ion's iDork, by its trustees, staff and executive officers, and fortified by
reports and special studies. As urged below, annual reports should
the basis for annual self -contemplation, but for a critical review and
ous eflFort toward better service.
^jong-range planning of program. Each hospital should look as far
IS possible, studying out its present and future needs, (a) as to kinds of
which it should render and (6) as to the building, equipment, organiza-
id personnel which it needs to have in order to render these services.
; a few hospitals of Cleveland are suffering today because no com-
Jive plan was made in the past, and additions have been made to hos-
iildings which now make a badly balanced plant. Often the service
gs, the nurses' home, or the power plant were not provided for suflS-
when additions were made to bed capacity, or were not planned
view to easy enlargement when the number of beds should be in-
A comprehensive plan which may be many years in realization
ivent one-sided and ill-judged extensions either in plant or in branches
ice. Expert advice and assistance could be provided for many in-
ns by the Hospital Council or the Welfare Federation in connection
lis long range planning of each hospital, although of course in case of
istitutions, or where extensive future building plans are involved, the
aid of a hospital architect or consultant may b6 desirable.
innual Reports to the Welfare Federation and to the Public.
il recently, each hospital in Cleveland as elsewhere, depended on its
rticidar list of financial supporters. Each hospital usually prepared
ual report more or less especially designed to express that quality of
le which has been described as a ** lively expectation of favors yet to
The situation was radically changed when there came about joint
ig through the Community Fund. The individual hospital no longer
a direct public appeal for its own support. Such joint financing is
desirable on the whole but certain minor defects or difficulties must
974 Hospital and Health Surtkt
be guarded against. One of these is . diminished incentive t^ prepare an
annual report. It is true that under such a system as that of the Welfait
Federation, each institution must present its budget and the financial and
service data required by the Welfare Federation so that the appropriating
committee shall be in a position to reach a wise decision. Neverthelesi,
there is no longer the same sense of direct relationship with the public, and a
more or less definite public at that. After all, one of the great values of
periodical reports ought to be the stimulus to the people who make them
(which mere compilations of financial and statistical data do not provide).
Preparation of a report ought to mean the formulation of fairly definite
ideas about the work and needs of the matter reported on. It wiU mean
this if the basal scheme of the report is properly designed.'
Recognizing this, the Welfare Federation and the Hospital CoudcO
should expect their member institutions to render not only the necessary
statistical and financial data but also real reports to the public. The future
of joint financing depends upon maintaining active public interest in the
work to be financed. There must be meat upon which this interest may
feed. Concrete facts are the basis.
. The.*e should be three types of reports furnished to the public either di-
rectly or through the Welfare Federation or the Hospital Council :
i. Summary report of hospital and dispensary work in Clevelandy taken at
a whole, including the elementary data showing b\dk and general types of semce
rendered, income and expenses.
This should be prepared under the auspices of the Hospital Council and
published by the Welfare Federation. A form for such a report is suggested
and may be found in the appendix. Table IX. This may well be compared
with the Summary Annual Report of the United Hospital Fund of New York
City, the pioneer undertaking of its kin! in this country.
2. A report from each hospital to the Hospital Council and the Welfare
Federation, giving the technical figures not only of bulk and general types of work
but the details of service and results; of cost in relation to units of sertic^: and
of income and its various sources.
The monthly and annual re[)ort forms prepared by the Hospital Council
for the use of its members have served a highly useful purpose. They may
}>e slightly developed further to advantage, and should be made unifonn
with the reports recjuired by the Welfare Federation. The Hospital Coundl
annual report form is heHeved to furnish so desirable a basis that no other
form will he outlined here. It is suggested that the form might be somewhat
smaller and easier to use if some of the items which are extended over many
lines were ])ut into more condensed and tabular form. These and other de-
tails should he adjusted so far as ])ossible in order that this fonn shall be
oomparahle with that required )>y the State Department of Health. Thus
the labor of filling out two forms will he reduced to a minimum.
Hospitals and Dispensaries 975
■
It is recommended that the following items be included in the report
form:
Percentage of bed days care given in comparison with -total possible
number of clays care in each division of the hospital, and for the hospital as
m whole (monthly and annual.) The extent to which it is poLsib^e to sub-
divide the di£Ferent sections of the hospital wiU depend on the degree to
which the hospital is itself sub-divided into buildings or separate units, and
tbe degree to which groups of wards or rooms are definitely <issigned to p ir-
ticular services or classes of patients.
The number of visits ^and number of new patients in each clinic or
division of the dispensary should be shown as well as the figures for the dis-
pensary as a whole; the average number of visits per patient for each, and
the average attendance per clinic day. Thus in tabular form:
Clinic Report for Month (or Year) for Dispensary op.
NafDC of No. of No. of New Av. No. of Visits No. of Av. No. of
Clinic Visits PatienU per Patient Clinic Dasrs Visits per Day
Medical
Total.
It evening clinics are- conducted on a diflFerent financial basis (pay clinics)
from the corresponding day clinic these should be shown separately.
The cost of the dispensary and the income from its operation in relation
to'cost should be shown. Income from operation may well be classified into
admission fees, treatment fees, fees for medicines.
As soon as the accountant service of the Welfare Federation (as recom-
mended in the sections on administration) is in effective operation, all hos-
pitals would be in a position to show the costs for the main divisions of
their work, as well as for the hospital as a whole (average daily per capita)
and for the average daily cost for provisions per capita. In so far as it is pos-
sible to state relative costs for private room and for ward service, this should
be done.
As soon as possible a report on results of service should be developed.
The usual report of "condition on discharge" as **cured, " ** improved",
** unimproved", "died", is definite only in the last item; has practically no
medical or social value and is not worth including in hospital reports. Real
976 Hospital an^} Health Subvbt
reports of results of care of patients can develop only as the outcome d a
real follow-up system. As individual hospitals develop these, a smomvj
report of results of care should be included in the annual report form. It
would be well at once to include the following items in the form under the
heading :
** Disposition of Patients at Discharge."
Total patients discharged .-. :
Of these, patients died to the number of.
Remainder.
Disposition of these as follows:
Private Ward or Staff
Patients Patknts
No. Percent. No. Percent
1. Referred to home under care of private physician
2. Referred to another hospital
3. Referred to convalescent home
4. Referred to dispensary supervision ^
5. Referred to patient's home without arrangement as to care
6. Other reference
7. Left against advice
8. Unknown or no record
Total.
The use of such data showing administrative action at the time of dis-
charge will be a definite stimulus toward better follow-up and convalescent
care.
3. The third farm of report from the hospitals should be not statistical but
interpretative: a statement of progress and of problemSn of accomplishment and
of needs.
The traditional annual report has done this in a measure but has often
been written by committee members who had little first-hand contact with
the facts, or very slight conception of what should be said except thanks to
other committee members and to staff and supporters, so tliat it largelj*
failed to accomplish any real purpose. An annual report should be built
from the ground up. The medical executive committee and the head (rf
each main administrative department should be asked to turn in a report
kKTALS AND Dispensaries 977
•
their several fields six weeks before the report is to be issued. It should
;xx)ected that besides certain statistical or other facts relative to the
k of the department, these reports shall contain a summary of (a) accom-
iments of the year — items felt to be indications of progress; (6) present
>lems and needs; (c) definite requests and recommendations for action,
lome hospitals, each chief of a medical, surgical, or special division, the
i of the laboratory, and the head of the X-Ray department will be asked
ender reports as well as the medical executive committee.
The reports from the head of the nursing, and from the head of social
ice, should pass through the training school committee or the social ser-
committee, respectively, before coming to the superintendent and to
trustees. The committee may write its own report if desired, but in any
: should state its comment upon the recommendations presented by the
mtive.
[t is recognized that securing reports from many medical and depart-
ital heads is not always easy and that the reports are not always well
>ared or to the point. Much of this difficulty has been due to failure on
part of the Superintendent or trustees to give to those writing reports a
lite idea as to what was expected.
The superintendent's report to the trustees should be a real survey of
hospital, its accomplishments, problems and needs, and should include
»mmendations. Trustees who do not receive that type of report either
lot know how to get, or do not get, the best out of the man or woman
►m they employ as superintendent.
•
On the basis of such reports from their executive officer and their depart-
its, and of conference with them, the trustees should be in a position to
w what they need to know to plan the coming year's policy and program,
the amount of money they need to secure. The reports should be the
3 of the presentation of the hospital's needs to the Welfare Federation
should be accessible to those having a basis for definite interest therein.
rhe trustees ought not to have to prepare a detailed report, but merely
rief statement of decisions or recommendations for which the other re-
ts are the foundation. A group of reports thus prepared should con-
ite a real annual self-survey. This need rarely be printed as a whole.
!re is required something less technical for a published report.
Interpreting Hospital to Public
[t is essential from the standpoint of maintaining the interest of the pub-
n a hospital and dispensary and of stimulating boards of trustees of the
itution itself, that technical facts of such reports be interpreted in terms
ordinary items of interest and of every-day human standards of health
well-being. This is not usually within the capacity of the hospital ad-
istrator or trustee.
978 Hospital and Health Susvet
The hospital needs, and the Welfare Federation should furnish each hos-
pital, the service of a publicity expert, just as it provides the service of u
accountant for the technical data. The publicity man would help the hos-
pital to put its technical facts in common terms, to connect them with idets
and interests which the average man readily understands and appreciates.
The use of such a statement, put into form with the advice of the pub-
licity man, would be partly for those particularly interested in the hospitaL
and partly for other hospitals and the general public, reached through tk
Welfare Federation and the press. The custom of presenting reports at as
annual public meeting of the trustees or members of the hospital corporatioii
is useful if only that it gives to reports a certain news value.
Under present conditions in Cleveland, the trustees of hospitals uv
freed from the necessity of the continuous pursuit of the vocation of hoiMV^
able begging, the most characteristic occupation of trustees in most com-
munities. They may ordinarily concentrate their financial efforts within t
brief period of the year, and be free at other times to give their attention to
administration, and planning for the hospital. It is above all, important
that in working out and planning the present and future policy of individual
hospitals, the trustees, the staffs, and the executive officers keep always be-
fore them the conception that the hospital is an agent for service to the com-
munity, and not an institution with all its roots in its own soil. There is
marked danger that those who work within the four walls of an institution
lose touch with outside interests and agencies, and develop the ingrowing
rather than the outlooking mind. This danger is particularly apparent in
such a highly specialized technical service as that of a hospital. A weD-
managed dispensary tends to assist hospital trustees, staffs, and adminis-
trators to keep in touch with the community, because a dispensary is less
rigid, less walled-in than a hospital proper, and helps in achieving a prac-
tical combination of administrative efficiency with human adaptability.
Hospitals closely connected with a church organization appear in some cities
particularly prone to be over-institutionalized. The public spirit and com-
munity interest manifested by such hospitals as St. Vincent's and St. Johns
should be mentioned as notable illustrations of a different point of view in
Cleveland. Such a cooperative organization as the Cleveland Hospital
Council has undoubtedly assisted all hospitals to think in terms of larger
units than themselves.
I
I
OBPITAI.8 AND DiSPENSABIES 979
ORGANIZATION TO CARRY OUT PLANS
Planning for individual hospitals and planning for the hospitals'^and
spensaries of a community as a whole will yield little practical result unless
ere is community organization of the right sort. In Cleveland we may
ftssify the community functions and organization in two groups, those
ider public auspices (municipal or state) and those under private auspices,
iliated as members of the Welfare Federation and the Cleveland Hospital
>uiicil.
An institution dealing with so serious a matter as treatment of iUness
s a responsibility to the public which should be recognized by a certain
gree of public supervision. By a recent law, the Department of Health
the State of Ohio was empowered to register, define, and classify all hos-
:als and dispensaries, to require hospital reports, and to license maternity
spitals. It is deemed desirable that these public supervisory powers be
tended as follows:
«
(a) Every hospital and dispensary should be required to obtain a license
to operate from the State Department of Health.*
(b) Such license should be issued for a term of one year, renewable by
the Department.
(c) Licenses should be revocable for cause, provided that notice of
reasons shall be given in advance to the institution and also an opportimity
for a public hearing when requested.
(d) Hospitals and dispensaries incorporated as charities should be
licensed without fee and a smaU license fee should be charged to institutions
^x^ch are incorporated for profit.
(e) Inspection by the State Department of Health should be provided
for and appropriation made for a staff to perform this work.
The State Department of Health should be empowered to outline and
rescribe requirements or standards under which licenses should be issued
Dd under which hospitals and dispensaries may operate.
The administrative powers of the State Department of Health should be
ercised by this Department throughout the State, except in chartered
'ies. Such cities should be authorized to pass laws or ordinances (the con-
tution provides that they shall not be inconsistent with the existing state
^s) and to administer the licensing and inspecting powers above provided
' under its own local authority.
*Mt is the opinion of Doctor Babcock, who hat collaborated on this study, that this is an undeairablc
^^xuatrattve lopunaibiiity to place on state authorities.
980 Hospital and Health Subvxt
The State Department should administer the law directly in those cities
or other political subdivisions which do not maintain their Ic^cal administii-
tion under their own auspices. The State Department of Health should in
all cases continue to receive annual reports from hospitals and dispensaries
and to maintain a register of all licensed institutions. No chartered city
should be permitted to prescribe or tolerate standards for the mainteDaDce
or licensing of hospitals or dispensaries which fall below those prescribed by
the State Department of Health.
If there were no other reason than the existence in Cleveland of a num-
ber of commercial hospitals, this would be sufficient for the extension of the
powers of the state and the administration of these powers in Cleveland
by the municipal government. The inspection made by the Survey of the
sixteen institutions not members of the Cleveland Hospital Council revealed
the fact that while a few are of the public-service class and a few others are
well-conducted proprietary institutions giving a fair standard of care to their
patients, the remainder are utterly unworthy of existence. In six cases oo
graduate nursing service whatever was provided for the sick patients. In
more than one instance, the buildings were dirty and the patients appeared
to be physically uncared for.
Proprietary hospitals have a legitimate place, but making a profitable
business out of the improper care of the sick is intolerable, and can be p^^
vented only by public authority. The State, utilizing as proposed the ma-
chinery of the city government in the larger communities, has the right and
duty to set minimum standards to which every institution treating the sick
shall conform, and to enforce such standards through appropriate agents.
Such a policy does not mean interference in hospital management by the
state or city, or public regulation of hospitals in any detailed sense of the
term. It means the securing of such facts as shall enable the public to be
protected against an unworthy and improper class of institution — leaving the
majority, which are far above this class, free to conduct themselves as thev
will.
It is important in a community program for dealing with hospitals and
dispensaries, that the municipal agencies caring for the sick shall be properly
related to the private agencies, and this has been notably achieved in Cleve-
land through the Hospital Council. The City Hospital is a member, as wdl
as the privately supported institutions.
The broader interests of the city in public health (in which the hospitals
are also concerned) should be brought into closer touch with private agencies
interested in such subjects, through some such means as the proposed CIev^
land Public Health Association (see Part II.). In the opinion of the Survey,
the relations between the Welfare Federation, the Cleveland Hospital Coun-
cil, and the individual institutions should be somewhat as follows:
Outlines of Community Organization
1. It is the function of the Welfare Federation to deal with questions of
general policies in relation to large groups of welfare agencies and in particn-
BtoBPITALS AND DISPENSARIES 981
Iftr to provide machinery for joint financing and suitable apportionment of
funds raised.
It is highly desirable and has been elsewhere recommended by the Survey
(Part II.) that the Welfare Federation have on its executive staff an assistant
to its general director, who will be. an expert in the health field, and who
will be able to advise the director on the many problems in this field to which
the Federation devotes over one million of the four million dollars raised
annually by the Community Fund.
2. Within the hospital and dispensary field, the Hospital Council should
outline standards for hospitab and dispensaries, covering minimum require-
ments in:
(a) Organization (board of trustees, superintendent, staff, nursing, etc.)
for hospitals and dispensaries.
(b) Medical work (examinations, use of laboratories, records, internes,
private and ward patients).
(c) Finance and accounting.
3.. Only hospitals complying with these standards should be admitted or
retained as members of the Council.
4. Only hospitals in the Council should be assisted by the Federation.
5. Financial support by the Federation should be on the basis of chari-
% table work, which should be taken to include free service an(f also part-pay
service, rendered in hospital beds or in dispensary clinics.
6. Appropriations for the support of dispensary work should be separated
from those of hospital work, since the units of service are different.
7. Municipal hospitals, and also hospitals not doing charitable work as
above defined but complying with the standards, may be members of the
Council and the Federation, and receive the benefits of such membership
(they will not of course need financial aid).
Place of Hospital Council
The Cleveland Hospital Council has been of such great value to Cleve-
land and indeed to the state and the country that too much emphasis cannot
be laid upon the importance of its adequate maintenance and development.
It has brought the hospitals of the city together for cooperative work, and
for mutual improvement in many respects. Advantageous legislation in
connection with hospital service and public health work has been promoted
by the influence of the Council and by the activities of its executive secre-
tary. Certain of the technical standards, forms of report, etc., as outlined
by the Council have been made use of by institutions and by official bodies
in other parts of the United States. *
982 Hospital and Hsalth Subyet
The Central Purchasing Department of the Council has been and b i
valuable contribution to the economv of hospital administration. Tie
amount of purchasing done (for hospitals alone) for the first half of the year
1919 was $90,890.89; for the entire year of 1919, $268,503.07; and for the
first six months of 1920, $222,278.97. It will be noticed that the purchases
for the first half of 1920 almost equal the purchases for the entire year of
1919. It is estimated by the Department that there has been a saving on
the large purchases for the first half of 1920 to the amount of $10,000.00,
and that there was also considerable saving on the small purchases, althou^
no definite estimate can be furnished of this.
Consideration should be given to the transfer of the Purchasing Depart-
ment from the auspices of the Hospital Council to those of the Welfare Fed-
eration, in order that the range of service of the Department may be widened;
or the Council might oflFer the services of the Department to Federation
organizations which are not members of the Council.
The opportunities for service by the Council to the hospitals of Cleve-
land are increasing steadily in proportion as the hospitals appreciate more
and more the advantages of cooperative activity in administrative direc-
tions, for the sake of economy and efficiency, and of conferences and discus-
sion for more eflFective formulation of policies concerning hospital service.
The development of a dispensary section of the Hospital Council for
purposes of improvement of dispensary service which is recognized as an
urgent need throughout the city, is now an important activity which natur-
ally belongs within the general scope of the Cleveland Hospital Council.
Almost endless opportunities exist for service to hospitals through the
expert services of the executive staff of the Council, which should assist the
members in an advisory way through their own efforts and through as-
sembling information, arranging conferences, securing expert advice from other
sources, etc. Many of the recommendations made by the Survey to indi-
vidual hospitals, particularly those of moderate or small size, will doubtless
cause these hospitals to appeal to the Hospital Council for advice in helping
them to work out details of such recommendations as are approved in gen-
eral by the hospital trustees. The interest of the hospitals in legislation
will continue to call for some activity in this direction on their part each
season.
The organization and staff of the Hospital Council does not appear ade-
quate at present to meet these demands, but it is of the highest importance
to the best advancement of hospital and dispensary service in Cleveland
that the Council equip itself to carry its increasing responsibilities. It may
be noted that the time has probably arrived when a substantial share of the
work in initiating and promoting legislation, in which the Courcil ha^
achieved so much success, may be taken over by the Ohio State Hospital
Association. This would seem a logical development.
It is recommended that the proposed Central Disi>ensary Committee be
made part of the activities of the Hospital Council as soon as the Council
^taff is able to carry the additional work.
PTTALS AND DISPENSARIES 988
Hospital Standards
Membership in the Hospital Council should mean to other hospitals and
le public, the acceptability of the hospital according to standards of good
jiization and management. The chief present deficiency of the Council
le to the fact that hospitals have been accepted as members whose stand-
1 have been too far below those of the average maintained by the Council,
not as high, in one or two institutions, as a few hospitals not members
le Council. It is recognized, however, that in the initial formation of the
reland Hospital Council, it was not practicable to define or enforce
dards very definitely. The time has now come, however, when definite
imum standards of admission should be publicly known as well as pro-
onally enforced. The Council, through its committees, oflScers, and
rutive staff, should be the democratic professional agent of the hospitals
dispensaries, themselves, for their own improvement; and should be the
isor of the Welfare Federation on technical questions concerning hos-
1 and dispensary functions and standards.
The state and city governments, through the regulative acts proposed,
jld set minimum standards and an institution which does not comply
1 these should not be allowed to operate at all. Between the minimum
idards and the desirable hospital standards is a considerable zone. The
^ital Council should not take in this twilight zone, but should always
3urage and assist institutions which are within its shadow to move as
idly as possible up into the light.
With such relations between the state and city governments, the
nicipal hospital, the Welfare Federation, and the Cleveland Hospital
incU with its hospital and dispensary experts, it is believed there will
\t in Cleveland the machinery for the continued advance of hospital and
>easary standards of administration. If such progress is suitably reported
the public through the individual hospitals and through the general ac-
ties of the Council and Federation, growing interest and backing for hos-
il and dispensary work should be annually manifested, expressing itself
more intelligent policies, fuller cooperation, and larger funds for main-
ance and for permanent improvement.
But organization after all is only machinery. It is the ideals and spirit
individuals and of small coherent groups working together, which pro-
le the motive power that drives institutions and communities onward,
e schemes of organizers, publicity men, and financiers, can make the path
lier and lessen friction during the forward movement, but the goal-posts,
ides, and impelling forces, for community and institution alike, depend
on the intangible elements of the individual soul and the civic spLit.
jveland impresses every investigator with its eager readiness for cooper-
ve activity. With such a community spirit, there is indeed the danger
tt attainment shall be measured too easily in terms of ratch-words and
:emals, and not enough by the more abstract but more fundamental tests
984
Hospital and Health Subyi
of technic. It is for the development of a high degree of weU-founded pn
fessional achievement with no loss of its present splendid tradition of con
muaity endeavor that every lover of Cleveland must hope.
TABLE I
HOSPITALS AND DISPENSARIES IN CLEVELAND
Institutions Members of Cleveland Hospital Council
Dis-
pensary
Hospital Visiu,
Beds 1919
Babies' Dispensary and
Hospital— 2500 East
Thirty-fifth Street 34* 14,977
Cleveland City Hospital —
Scranton Road 785
Cleveland Maternity Hos-
pital— 3735 Cedar Ave 60 3 , 688
Fairview Park Hospital —
3305 Franklin Avenue 85
Glenville Hospital— 701
Parkwood Drive 74
Grace Hospital— 2307 W.
Fourteenth Street- 35
Huron Road Hospital — 748
Huron Road 84 5 , 864
Lakeside Hospital — East
Twelfth and Lakeside Av. 289 59,891
Lakewood Hospital — 14519
Detroit Avenue „ 53
Lutheran Hospital — 2605
Franklin Avenue 50
Mount Sinai Hospital —
1800 East 105th Street... 225 19,324
*In mimmer only.
Da-
Hospital
Beds
Provident Hospital — 624
East 103rd Street, 29
Rcdnbow Hospital — South
Euclid, Ohio 85
St. Alexis Hospital — 5163
Broadway 250
St. Ann's Maternity Hos-
pital—3409 Woodland Av. 55
St. Clair Hospital— 4422
St. Clair Avenue 43
St. John's Hospital— 7911
Detroit Avenue 150
St. Luke's Hospital — 6606
Carnegie Avenue 139
St. Vincent's Charity Hos-
pital— Central and East
Twenty-second Street 290
WarrensviUe Tuberculosis
Sanitarium, WarrensviUe,
Ohio ^ 270
Woman's Hospital— 1948
East 101st Street. 37
Vatk
1919
13.313
21.863
TALS AND Dispensaries
9S6
Institutions Not Members of the Cleveland Hospital Council
Dis-
pensary
Hospital Visits,
Beds 1919
;ie Avenue Hospital
4 Carnegie Avenue..Unknown
lAineral Fumes Treat-
t — 8101 Hough Ave..Unknown
md Emergency Hos-
-1780 East Fifty-
Street. 22
uid Home Hospital
7 Prospect Avenue.. 10
nt Hospital and Sana
um — 1770 Delmont
lie ^ Unknown
I Invalids' Home —
Addison Road 46
'leveland Hospital —
I Euclid Avenue 31
ifty-fifth Street Hos-
-2415 East Fifty-
jtreet. 60
^venty-ninth Street
ital — 1873 East Sev-
ttinth Streets- 24
Jennings Home for
ables — 10603 Detroit
tie 26
Avenue Hospital and
orium — 9810 Euclid
lie. Unknown
cc Crittenden Home
Eddy Road 12
Hitchcock's Private
ital — 5013 Prospect
lie 15
Dis-
Hospital
Beds
Visits.
1919
Holy Cross House — 9014
Cedar Avenue 50
Joanna Private Hospital —
933 East Seventy-eighth
Street 9
Kate Castle Rhodes Babies'
Dispensary — 12611 Madi-
son Avenue, Lakewood
fNeal Institute Company —
3920 Euclid Avenue ^..Unknown
fOhio Sanitariums Com-
pany— 14822 Terrace
Road ^ .Unknown
tOrthopcdic In .titute— 1936
East Sixty-sixth Street Unknown
fReliable Invalid Home —
2222 East Eighty-ninth
Street...^ Unknown
Rest-Cure Hospital and
Sanatorium — 2453 East
Fifty-fifth Street 16 (in use)
St. Mark's Hospital— 629
Eddy Road 45
Salvation Army Rescue
Home — 5905 Kinsman
Road 54
U. S Marine Hospital —
1041 Lakeside Avenue 86 4«493
Windsor Sanatorium— 44 15
Windsor Avenue 38
Wright's Hospital— 18902
Nottingham Road 10
Y. W. C. A. Retreat— 4916
St. Clair Avenue Temporarily
Closed
titutions not reported as registered with the State Department of Health up to June, 1920.
1186
Hospital and Health Subiit
Public Health
Health Center No. 1—1510 Bast Forty-
ninth Street.
Health Center No. 2 — 502 Central Ave.
Health Center No. 3 — 2810 Seymour
Avenue.
Health Center No. 4 — 5825 Cable Ave.
Health Center No. 5—9206 Woodland
Avenue.
Health Center No. 6—10126 St. Clair
Avenue.
Health Cent^ No 7 — 6100 Pear Avenue.
University Health Center — 2739 Orange
Avenue.
Frophylaciie Baby SiaiiotiM —
5706 Clark Avenue.
7654 Broadway.
12S10 Mayfidd Road.
Dispensaries
4247 Pearl Road.
833 East 152d Street.
3008 Bridge Avenue.
2511 Bast Thirty-fifth Street.
Prenatal Cliniee —
Maternity Hospital Dispensary— 2SI9
Bast Thirty-fifth Street.
(Sub-stations)
2749 Woodhill Road.
Alta House, 12510 Mayfidd Road.
2317 Lorain Avenue.
Goodrich House, 1420 East Tbiitr-
first Street.
Bast Forty-ninth and Fleet Street
Mount Sinai Hospital— 1800 East lOSth
Street
St. Luke's Hospital— 6606 CaneKk
Avenue.
TABLE II
PERCENTAGE OF OCCUPANCY OF HOSPITAL BEDS
HOSPITAL
City
Fairview Park..
QlenviUe
Grace—
Huron Road
Lakeside
Lakewood
Lutheran *
Maternity
Mount Sinai
Provident
St. Alexis
St. Ann's
St. Clair
St. John's
St. Luke's
St. Vincent's
Woman's
)eda*
1919
Per Cent.
OccuDied
1919
Per Cent.
Occuined
1918
Occn^
CemusDir
AvcrafEd
785tt
60.3
82.2
70.0
85
60.4
62.3
67.6
74
66.3
72.3
69.0
35
66.8
52.7
94.3
84
75.0
68.2
86.9
289
90.8
82.6
72.9
53
45.9
40.7
68.0
50
80.9
70.5
93 0
60*
79 9
70.3
71.7
225t
72.4
81.7
84.2
29
40.5
49.4
65. 5t
250
78.1
78.0
97.8
55**
Unknown
75.0
93.7
43
40.2
58 6
33.7
150
Unknown
79.0
90.1
139
75.8
71.6
95.3
290
66.9
58.1
73.0
37
76.0
Unknown tt Unknown
*For maternity cases, adult beds only were included, except for Maternity Hospital for 1919, «rtu^
was figured on a basis of 60 mothers and 33 cribs, as the bed days reported included both mothen tsA
babies.
tMt. Sinai for 1918 was figured on a 155-bed basis; for 1919 on a basis of 155 beds for Febrttsr?
and March, and 225 for the remaining ten months.
tProvident furnished data for the first Survey Census day only.
••St. Ann's figures for 1919 were not furnished.
+ tNo definite information was available regarding" beds at Woman's for 1918.
tJCity was figured on basis of 650 beds until December, 1918, and 785 beds thereafter. Siax the
tield work of the Survey was completed, figures were furnished by the City Hospital Adminiitratioa
based on 725 beds which were available for 1919, instead of 785. This gives the i>ercentage occupied W
the year in the hospital as a whole, as 66.5 per cent. Further details of importance regarding City Hos-
pital will be found in the foot-note, page 834.
PITAI^ AND D18FENSARIE8
987
TABLE III
HOSPITAL BEDS ACCORDING TO HEALTH DISTRICTS*
let Type of Dittrict
Factory
Popula-
tion
of
DUtrict
82,185
Hospitals
in
District
Total
>ital
in
Dittrict
Hotpil
Beda
Beds to Hospital
1000 of tolOOOofPbp.
Population ulation of
. J'actory , Congested 42 , 1 59
.l^ear Congested 130,775
.J^actory, Congested 164,094
.Part Congested 136 , 294
Part Residential ....
.Jndustrial 176,836
Residential
Congested
..Semi-congested 90,766
Residential
Congested 72.168
of Dittrict
(Cenmit I)
5.2
Dittrict
(Cenmit I)
2.7
Lakeside... 429
St. Clair
Cleveland
Rmergency
Huron Road 84 2.0 3.5
City 820 6.3 1.2
Grace
St. Alexis 293 1.8 1.2
East 79th
Florence Critten- «
den
Joanna Private
St. Luke's 280 2M 1.9
Holy Cross
Salvation Army
Rescue Home
Woman's
GlenviUe 373 2.1 2.1
Mount Sinai
Provident
St. Mark's
FcurviewPark 285 3.1 2.1
Lutheran
St. John's
Maternity 490 6.8 4.1
St. Ann's
St. Vincent's
East 55th Street
Cleveland Home
Mrs. Hitchcock's
Private
de Lakewood 53
Rainbow 85
3 .. Warrensville Tu-
berculosis Sana-
torium 270
Wright's 10
East Cleveland .... 31
It will be observed that the population figures are those which were furnished the Survey from loca
ites, and are higher than those g<ven 'n tn- 1920 census. For the sake of uniformity, these esti-
population figures have been used throughout this table since its puri>ose is primarily the com-
3 of different districts, and census figures for anything except the city as a whole were not available
time of writing this report.
088
Hospital and Hbalth Subvet
TABLE IV
, PERCENTAGE OF HOSPITAL PATIENTS COMING FROM HEALTH
DISTRICT IN WHICH HOSPITAL IS LOCATED
(First Survey Census Day)
Cleveland City 4.6
Cleveland Maternity 13 . 7
Fairview Park.^ ^ 36 . 7
GlenviUe 46 . 7
Grace 3 2 . 3
Huron Road 6 . 6
Lakeside*...^
Lakewoodf...^
Lutheran 44 . 2
Mount Sinai — J1.2
Provident 78.9
St. Alexia. 35J
St. Ann's. J.. 59.8
St Clair ^^ 23.6
St John'st
St. Luke's.^.. 15.6
St. Vincent's - 0.1
Woman's -26.0
^Address not furnished for 52 per cent, of patients.
fHospttal outside city limits of Cleveland.
lAddress not furnished for 59 i>er cent, of patients.
TABLE V
PERCENTAGE OF CASES, CLASSIFIED ACCORDING TO COMPENSATION
FOR CARE, ADMITTED THROUGH VARIOUS SOURCES TO
THREE LARGE GENERAL HOSPITALS
Patients Admitted to Hospital No. I., Classified According to Compensation for
Care, and Source of Reference
Patients paying full cost of
care
Patients paying part of
cost of care
Patients paying nothing
for care
Patients not classified
100%
Percentage of total admis-
sions
(excepting patients not
classified as to compen-
sation)
Percentage
of total
admissions
Percentage
referred by
staff
physicians
Percentage
referred by
non-staff
physicians
Percentage
referred by
by charitable
agencies
Percentar
not
classified
41.9
53.0
43.2
2 2
16 w;
20.8
39.3
40.5
20.2
0.0 lOO^c
30.1
14.8
45.8
35.7
3.7 loos;
7.2
0.4
34.4
65.2
0 0 100^.
37.9
44.3
15.6 2 1 lOO'r
Hospitals and Dispenbabies
989
TABLE V— Continued
PERCENTAGE OF CASES, CLASSIFIED ACCORDING TO COMPENSATION,
FOR CARE, ADMITTED THROUGH VARIOUS SOURCES TO
THREE LARGE GENERAL HOSPITALS
Patients Admitted to Hospital No. II, Classified According to Compensation for
Care, and Source of Reference
Patients psytng full cost
of care
Patients paying part of
cost of care
Patients pasring nothing
for care
Patients not cla9sified
100%
Percentage of total admis-
sions.
(excepting patients not
classified as to compen-
sation)
Percentage
of total
admiasions
Percentage
referred
by staff
physicians
Percentage
referred by
non-staff
physicians
Percentage
referred by
charitable
agencies
Percentage
not
classified
27.9
67.5
32.5
0.0
0.0 100%
40.9
68.0
30.9
1.1
0.0 100%
15.5
47.7
29.2
20.0
3.1 100%
15.7
77.3
22.7
0.0
0.0 100%
59.0
35.5
4.2 1.3 100%
l^tients Admitted to Hospital No. HI, Classified According to Compensation for
Care, and Source o( Reference
Patients paying full cost
of care ...^^^^^^.. — ..^.
Patients paying pert of
cost of care ^
Patients paying nothing
for care
Patients not classified.
Percentage of total admis-
sions ■
(excepting patients not
classified as to compen-
sation)
Percentage
of total
admissions
30.5
49.3
20.2
0.0
100%
Percentage
referred
by staff
physicians
56.4
50.0
73.5
0.0
68.9
Percentage
referred by
non-staff
phsrsicians
43.6
50.0
26.5
0.0
31.1
referred by
charitable
Percentage
not
classified
0.0 0.0 100%
0.0 0.0 100%
0.0 0.0 100%
0.0 0.0 0.0
0.0 0.0
990 Hospital and Health Sukvi
TABLE VI
FINANCES OF HOSPITALS IN CLEVELAND HOSPITAL COUNCIL, 19W
Municipal
Total Kxpetae Total Baminss Peroentafe Es
for Hospital from Operation penaet are of To(
Cleveland City Hospital $428 , 636 . 77
Waxrensville Tuberculosis Sanatorium 197 , 020 . 1 5
Total Municipal ^.. $625 , 656: 92
Non-Municipal
•Babies' Dispensary
•Cleveland Maternity
•Fairview Park
tGlenviUe
♦Grace
♦Huron Road „
♦Lakeside
♦Lakewood-;.„»
{Lutheran
fMount Sinai
♦Provident...^
♦Rainbow
♦St. Alexis -
♦St. Ann's
♦St. Clair
♦St. John's
♦St. Luke's
♦St. Vincent's
♦Woman's
67,305
$ 7,000
104%
90,435
58 . 802
65.0
85,000
65,000
76.5
33 » 000
33.000
100.0
117.600
83,800
71.3
480 , 000
264 , 000
55.0
58,000
52,000
200,000
89 7
332,000
60.4
14,000
13,000
92.9
63,445
12,910
20.4
108,800
70,000
64.3
107,125
84,888
79 2
36,975
28.390
76 7
169,342
120,200
70 9
207.120
176,820
85 4
249,350
204 , 800
82.1
50.083
39 , 600
79 2
$2,269,580.00
$2,895,236.92
$1,514,210
Summary for Non-Municipal Hospitals (so far as calculable^
Subtotal, Expense for Hospitals $1,927,993.00
Subtotal, Earnings from Operation 1 . 296 , 214 . 00
Bed Days Care, 1919.. 439,700
Average Cost per Day of Care $4.39
Average Earnings per Day of Care $2.95
Percentage of Average Cost per Day of Care Earned from
^Budget for these institutions covers the year from October 1, 1919, to September 30, 1920.
tBudget for this institution covers the year from January 1, 1920, to December 31, 1920.
tin order to estimate the average cost and average earnings per day of care for non-municip«l "^
pitals, it is necessary to omit the following hospitals from the calculation: Qlenville and Lutheran, >*v
the time of preparing the table, the total cost and total earnings of these institutions for 1919 could oot ti>
ascertained; and also Rainbow, St. Ann's, and St. John's, as at the time of preparing the table, the 000
ber of bed days care for the year 1919 could not be ascertained. The figures in the summary theref<tf«°
not make a total as large as in the non-municipal group in the table.
AND Dispensaries 991
TABLE VII
SUMMARY OF CONVALESCENT GASES
Charity City Lakeside Mt. Sinai
ith Home Enviroxunent Cases. Per ct. Cases. Per ct. Cases. Per ct. Cases Per ct.
id Adequate 15 30.0 5 7.0 4 7.0 1 4.5
ith minor adjustments. 21 42.0 19 26.8 21 36.8 10 45.5
but remediable. 6 12.0 21 29.6 14 24.6 7 31.8
and not remediable 6 12.0 20 28.2 16 28.1 2 9.1
ling further hospital care.... 2 4.0 6 8.4 2 3.5 2 9.1
50 100.0 71 100.0 57 100.0 22 100.0
Cases with Home Enviromnent Total cases Total Per ct.
id Adequate.. _ 25 12.5
ith minor adjustments 71 35.5
but remediable... 48 24.0
and not remediable : _ 44 22.0
ling further hospital care ^ 12 6.0
200 100.0
TABLE VIII
iTIENTS REMAINING IN HOSPITAL OVER TWO MONTHS
Number of patients Percentage of patients
Number of patients remaitiing over two remaining over two
>SPITAL on Survey census months on census months on census
days, averaged S |^ days, averaged JBi \ days, averaged
ty 549 .5 162 . 5 29 . 6%
atemity 43.0 0.0 0.0
k 57.5 2.5 4.3
'51.0 1.0 2.0 .
33.0 2.0 0.6
73.0 6.5 8.9
215.5 26.0 12.1
36.0 3.0 8.3
46.5 0.5 0.1
160.0 8.0 5.0
19.0* 0.0 0.0
244.5 22.5 9.2
51.5 0.5 0.9
14.5 1.0 6.9
137.0 9.5 6.9
132.5 4.5 3.4
210.0 15.0 7.1
43.0 0.0 0.0
2,117.0 265.0 7.9
9n was received from Provident Hospital for the first Survey census day only.
992
Hospital and Health Survey
TABLE IX.
PROPOSED FORM FOR SHOWING
HOSPITAL AND DISPENSARY SERVICE pF CLEVELAND
«m.^ A-m «>&■«•«>• «««• *fj &■■«> AVA«»aaaBX«r« ^ v^a »■■«> -^^a^T^a
••«>«• aA^^«>^a»s»j
L ^.#^#<p ■■m>«» m^^»i
.
Name of
Hotpitfti
Name of
Hospital
Total for
Cleveland
Hospital
Council
HtMpital—
Numbo' of Beds
Percentage of Poanble Days Care
,
•
Classes of Patients
Pay Patients
\
Number
Days Care
Part-pay Patients
Number
Days Care
,
Free Patients
Number
^ Days Care j
«
Metliod of Survey
Bibliography of Surveys
Index
Part Eleven
Cleveland Hospital and
Health Survey
Method of Survey
Bibliography of Surveys
Index
Part Eleven
Cleveland Hospital and
Health Survey
Copyright. 1920
The Cleveland Hospital Council
CleveUind, Ohio
Publiibed by
The Cleveland Hospital Council
308 Anisfield Bldg
Cleveland - Ohio
Pref
^he Hospital and Health Survey of Cleveland was made at the request
le Cleveland Hospital Council.
The Survey Committee appointed to be directly responsible for the
c and through whose hands this report has been received for publiea-
consisted of the following:
MAiiCOLM L. McBride, Chairman;
Mrs. Alfred A. Brewster»
Thoaias Coughlin,
Richard F. Grant,
Samuel H. Halle,
Otto Miller,
Dr. H. L. Rockwood,
Howell Wright, Secretary
The staflF responsible for the work were:
Haven Emerson, M. D., Director,
and the following collaborators:
Gertrude £• Sturges, M. D., Assistant Director;
Michael M. Davis, Jr., Ph. D., Director of the Hospital and
Dispensary Survey;
Josephine Goldbiiark, B. A., Director of the [Nursing Survey;
Wade Wright, M. D., Director\of the Industrial Hygiene Survey;
Donald B. Armstrong, M. D., Director of Tuberculosis Survey;
S. Josephine Baker, M. D., D. P. H., Director of the Infant
and Maternity Survey;
T. W. Salmon, M. D., Director of the Mental Hygiene Survey;
W. F. Snow, M. D., Director of the Venereal Disease Survey;
Louis I. Dublin, Ph. D., Director of the Vital Statistics Survey.
rhe expenses of the Survey and of the publication of the report have
I met by appropriations received from the Community Chest, through
Welfare Federation, of which the Hospital Council is a member.
rhe report as a whole, or by sections, can be obtained from the Cleveland
pital Council. A list of the parts will be found in the back of this volume,
ther with prices.
TABLE OF CONTENTS
[OD OF Making a Cobibiunity Diagnosis
Page
ion — Why a Survey is Necessary 1003
ry Steps:
ization of the Need 1004
to be Considered : 1004
•sing the Group of Diagnosticians 1005
>ry of Survey 1005
>rs Influencing Scope 1007
Methods :
pretation of Results 1009
ation of the Patient 1009
tnunity History Taking 1010
ititative Estintiate of Needs 1010
and Law Enforcement 1010
dination and Functional Control 1011
Associated Health Professions and Their Training 1012
ititative Determinations of Functions 1012
ty of Function 1013
urces for Prevention 1015
king up the facts for Diagnosis 1015
n:
tment and Follow-up 1016
I Letters and Questionnaires 1018
JLIOGRAPHY OF SuRVKYS
Lh Administration Surveys 1038
tal Hygiene Surveys 1044
it Mortality Surveys 1049
.1 Surveys 1052
strial Hygiene Surveys 1054
Tculosis Surveys 1057
less Surveys 1059
issified 1060
EX ^ 1061
*■
It*
letKod of Making a Comniunity Diagnosis
By Haven Emerson, M. D., and Gertrude E. Sturges, M . D.
INTRODUCTION: WHY A SURVEY IS NECESSARY
X THAT is a survey, and why does Cleveland or any other city need the
J^ luxury of a diagnosis? A diagnosis implies the presence of ill health.
Is Cleveland sick? Even as the careful and thrifty owner has his car
erhauled to prevent delay upon the road or accident under strain, and as
e young husband looks far into the future and insures his life, so a city
ay well indulge in community insurance by a periodical searching for weak
ints in its organization, loose bolts, missing parts, proof of wear and tear,
ed of replacement and reinforcement of its structure.
While all the world is clamoring for production, it is worthy of great praise
at a community should determine that, in one place at least, the producer
all rank ahead of the produce in their thoughts and plans.
Property will always have its protectors and promoters. It is persons
lo are chiefly neglected, and for these the community health diagnosis
kes thought. How may their sickness be prevented, their lives made
iger and happier and if sickness overtakes them, how may skill and gentle-
ss be put quickly at their service?
To survey is to view with attention as from a height — to prospect, to
amine, and in so doing to make a review and retrospect, to use history
d present exx)erience as a basis for programs for the future to insure prog-
iS.
The community physician should detect the presence of all factors aflFect-
5 health and formulate all practical and economical measures to decrease
►ease and increase comfort.
The public, as investors in the Comihunity Fund, are stockholders in the
rious institutions supported by this fund, and as stockholders, are entitled .
a statement of results — as to the per capita costs as well as the quality
d quantity of the output. The contributing public and more particularly
^ boards of trustees of the various institutions, have a definite respon-
►ility also in seeing that the funds which are provided are made to serve
^ best interests of the community. They should make sure that the high-
: degree of professional service is rendered through the institutions for
tich they are responsible and that the same principles of organization
d efficiency are carried out as in up-to-date business enterprises. To this
d it is essential that both the character of professional service and the type
business administration receive the thorough investigation of experts from
cie to time.
It is also pertinent for the investors to know whether there is any over-
>ping of effort or duplication of function by existing institutions that could
1004 Hospital and Health SuBYiH
be obviated by more clearly defined policies or by a division of the territaiy
to be covered by each institution. What preventive or curative needs are
not being provided for adequately: t «., measured by the estimated service
required for prenatal care, for dispensary service, for hospitalization, etc.,
what failures to meet the need are apparent? What services are not being
rendered at all? In an extensive view of all the city's activities for preven-
tion and treatment of disease, for education of physicians and members of
the allied professions, what distinct gaps exist in the service? Is there an
understanding of the precise problems to be solved and of the ways and
means by which they may be solved? Are all modem information and experi-
ence in the prevention as well as the treatment of sickness, sufficiently under-
stood by each agency serving the public? Until every doctor, nurse and
health visitor working among the sick is aware of the resources and applica-
tion of preventive medicine to health protection, no possible increase in
hospitaUzation of the sick will meet the needs of the city. Each case of sick-
ness presents a problem of prevention as well as of relief, of education as
well as of treatment, of the family and the home as well as of the individual
patient. And, finally, is there adequate provision made for coordinating
the activities of the private health agencies to the end that they may provide
the maximum service with the minimum of eflFort and of overhead expense?
PRELIMINARY STEPS
With some of the problems in mind to be answered by the community
diagnostician, what are the preliminary steps to be taken?
Realization of the Need
First the patient must realize that he needs the services of a physician
and must be prepared to render him every assistance. Without not only the
patient's consent but his eager and willing assistance, no physician can get
all the facts needed before prescribing. A community differs in this respect
chiefly in quantity, not in elements for diagnosis, from the individual patient.
Cost to be Considebed
SuflBcient financial support must be assured to **pay the doctor's bill."
In Cleveland adequate provision for financing the Survey was made from the
Community Fund, at the request of the Cleveland Hospital Council through
the medium of the Welfare Federation. A sum of $53,000 was appropriated
for this purj)ose of which $52,668.98 was spent.* It is interesting to note
in this connection that service, conservatively estimated to be worth over
$10,000, has been given to the Cleveland Survey by cooperating national
and local organizations.
The Committee in Charge
The organization or committee under whose auspices the communit}'
study is to be conducted is another matter for preliminary consideration. In
^hit amount was estimated at the time of going to press.
Method 1005
Older that every institution may feel itself an integral part of the group con-
ducting the Survey, the committee should be as representative as possible
and, that good feeling may be assured, men and women known to be broad
in their judgments should be chosen.
In Cleveland the Survey has been conducted under the direct supervision
of a special committee of the Hospital Council, consisting of public-spirited
business men, a woman representing the nursing interests, the Commissioner
of Health and the secretary of the Hospital Coimcil. The Hospital Coun-
cS itself is a cooperative organization consisting of representatives of the
boards of trustees and superintendents of the public and private hospitals
in the city. The conmiittee must be able, as this one was, to open all the
doors of the city. By the position, character, professional, business and
social standing of its members, it must be able to give access for the sur-
veyors to all important public and private groups who can give information
or spread it. The editorial offices of the daily papers, the offices of city gov-
ernment, the clubs, churches, professional, business and social groups must
be readily accessible and hospitable to the inquiries that lead into the in-
timacies of community history, and willing to take trouble to see that needs
and recommendations are frankly discussed and acknowledged.
The Group of Diagnosticxajis
Choosing the doctor and his colleagues is the first problem with which
the committee is confronted. The group of diagnosticians should possess
not only knowledge of the field to be studied, but wide experience with
conditions in other cities, in order that they may have a background for
guaging local problems. Impartiality will generally be better assured by
selecting the entire Survey staflF from outside the city.
The Cleveland Hospital and Health Survey has been particularly fortu-
nate in securing the cooperation of many national agencies which, because of
the wealth of their experience, are in an ideal position to survey any locality.
SCOPE
Hie scope of a survey may be either intensive or extensive; either an
analysis of one phase or agency of health service or a general health survey;
i. e.9 the examination of a single part of the body, one of the special senses
or a general medical examination.
Historical
It is interesting in this connection to study briefly the range of previous
surveys. A study of available literature at the Russell Sage and medical
libraries brought out the fact that surveys of health administration and allied
subjects are numerous. (See bibliography of surveys). These are the case
histories of community patients. Eighty such surveys have been made in
thirty different states (several covering more than one state) and also in
1006 Hospital and Health Survey
two foreign countries. New York, Illinois, Ohio, Pennsylvania and Min-
nesota ranked in that order in the number of public health studies that had
been made upon various of their communities. These investigations have
been conducted chiefly by the United States Public Health Service, by state
or local health departments, by the New York or local bureaus of municipal
research, by the Russell Sage Foundation and by local Chambers of Com-
merce.
Mental hygiene was the subject next in order of attractiveness to the
surveying mind. Results of sixty-three studies of this subject were found.
Many of these have been made by the National Committee for Mental
Hygiene and several by state or local charitable organizations.
Search brought to light thirty-eight infant mortality and child health
studies. The largest number of these had been prepared by the United
States Children's Bureau, although the Russell Sage Foundation and the
National Child Labor Committee had each conducted several studies of this
type.
Thirty-four social surveys were found, made by a wide variety of groups.
This number includes only the most important contributions along this line.
The list could be greatly increased, no doubt, by the addition of all the
local social studies that have been made, reports of which were not sought
for particularly in this review of the litarature.
There were records of twenty-nine industrial hygiene investigations, half
of which were made in New York City, six by the New York City Depart-
ment of Health. Many studies of industrial hazards have also been made
by the United States Public Health Service and by the United States De-
partment of Labor.
There were records of twenty-five tuberculosis surveys, many of them
made nnder the auspices of the national or local anti-tuberculosis societies.
The cffiM't of industry on the incidence of tuberculosis is the subject of many
of these investigations. The influence of housing and economic conditions,
nationality and race were some other main points covered in these studies,
The amount and character of sickness in various communities have been
the object of twelve investigations — most of them conducted by the Metro-
politan Life Insurance Company.
Hie most comprehensive surveys that have been made are: the Pittshurph
Survey, the record of which is published in six volumes, embracing the fol-
lowing: among its major topics — civic improvements, industrial hygiene,
housin^^ schools, playgrounds, libraries, social agencies — and The Spring-
field, Illinois, Survey which in(;ludes studies of schools, mental hygiene, rec-
reation, housing, charities, industrial conditions, city and county ad-
ministration, i)ublic health and the correctional system. *
One hundred and eighty-four authors were responsible for the two hun-
dred and eighty-one investigations above summarized. There are many
Method 1007
authors of several surveys — L. K. Frankel and L. I. Dublin, studies of sick-
ness incidence; C.-E. A. Winslow, Carrol Fox and Franz Schneider, Jr.,
health administration and sanitation; Thomas W. Salmon, T. H. Haines,
E. O. Lumberg, W. L. Treadway and S. D. Wilgus, studies in the field of
mental hygiene; J. W. Schereschewsky and L. I. Hanes, surveys of industrial
hygiene; Shelby M. Harrison, social surveys; W. H. Slingerland, studies in
prevention of infant mortality.
The report of a study made by the Northeastern Hospital Association, of
the hospital facilities in an area of about 4,000 square miles with a population
of 2,500,000 in the North of England, comes nearer to including many of
the points upon which the Cleveland Hospital Council wished information
than any survey reported in the United States. This English study which
was summarized in the Edinburgh Medical Journal in December, 1919, did
not, however, enter the field of health administration or deal with the social
and medical problems of a large industrial city such as Cleveland. This
study is well worth reading by hospital associations in this country, especially
such as have to do with rural and small town community services for the sick.
Factoks Determining Sc6pe
The scope of a survey will be decided by many factors, particularly by
the extent of previous surveys. Cleveland, for instance, had adequate cur-
rent information on recreation, education and housing and it was unneces-
sary to elaborate upon these accessory features of a health survey. Sick-
ness surveys had been made in other cities by the Metropolitan Liife Insur-
ance Company, the results of which were applicable to Cleveland, and so it
was not thought necessary to collect duplicate data in this field. The scope
of a survey will also be determined to some extent by the aims of the group
conducting it, by the special problems that are immediately facing the
community, and by the financial resources of the sponsors of the investi-
gation.
In general, it may be said that, since many separate agencies both pri-
vate and public are involved in protecting or serving the city's health, all
must be coordinated in an attack upon disease. As many of them as pos-
sible must be analyzed and described in order to arrive at a community
picture. The general scope of the Cleveland Hospital and Health Survey,
as outlined in the letter of authorization, included:
1. Study of education in medicine and in the allied professions.
2. Study of the facilities for the treatment of the sick.
3. Study of measures for the prevention of disease.
The scope of the individual parts of the survey will be decided again by
the special community problems involved, as well as by the nature of the
institution or service. As the chief problems brought to the attention of
1008 Hospital and Health Surtet
the present sursrey lay along the line of hospital and dispensary treatment
these services received a large share of attention.
Detailed plans of the ground to be covered and the character of the re-
port should, as far as possible, be worked out before the survey is far ad-
vanced— for the sake of economy in time and money.
Method 1009
AIMS AND METHODS OF DIAGNOSIS AND TREATMENT
The aim of the community physician should be not only to arrive at a
diagnosis and prescribe a course of treatment but to explain thoroughly both
diagnosis and treatment to the patient, and where possible to assure* avoid-
ance of repetition of the diflSculty. In general, the Cleveland survey has
been undertaken in a spirit of practical application rather than as a tech-
nical, statistical or research problem. That is, every effort was made to ex-
plain all criticisms and recommendations to the governing bodies and execu-
tives of each institution concerned, as by personal conference with these
^oups the community physician had his best opportunity for influencing the
'amily of the patient to assist in carrying out the treatment prescribed.
Jften the executives themselves were able to point out deficiencies that were
lot apparent to our investigators. On the other hand, they frequently
nade situations clear that might, without interpretation, have given rise to
mdeserved criticism. Besides numerous more or less informal and in-
omplete conferences on details of the work during the year, a week was
levoted to formal conferences with groups of trustees of hospitals, to present
nd discuss the survey findings after they had been formulated and ma-
ured. The preliminary recommendations and constructive criticisms were
o ^vell received that many recommendations of the survey had already been
>ut into eflFect before the findings were published.
The diagnostic procedures employed by the community physician are
imilar to those used by the regular medical practitioner, i. e., history tak-
ig, physical examination, laboratory analysis.
Education of the Patient
It will be necessary to make use of educational methods, first, last and
Iw^ays, to win the confidence of the patient's family and friends. The
aethods employed in community education are those of publicity, i. e.,
le^v^spaper and magazine articles, circular letters and addresses and lectures
>y members of the stafiF. It is essential that the public recognize the pur-
K>se and scope of the investigation and by personal contact with the diag-
Lostic group develop confidence in those who are conducting it, so that
irhen the findings are ready, an educated and receptive public opinion will
lave been prepared.
The Cleveland Hospital and Health Survey was fortunate in obtaining
lie services of the publicity experts on the staflF of the Welfare Federation,
irho have been most useful in making contacts with the public through the
ocal press.
During the first month, the Survey sent form letters to various groups
medical practitioners, social agencies, hospitals, labor unioas, industries,
nen's and women's clubs, and fraternal organizations), to obtain their in-
erest and cooperation. In some cases, specific infommtion was asked for
o that the letters served two purposes. (For two typical letters, one [to
physicians and one to social agencies, see Appendix 1 and 2.)
1010 Hospital and Health Subvet
During the course of the Survey members of the staflF addressed over
sixty meetings of various sizes, including the Academy of Medicine, the
Men's and Women's City Clubs, the Chamber of Commerce, church congre-
gations and groups of physicians, nurses and dentists.
CoBiMUNiTY History Taking
In order that the community diagnosis may be based on all the facts,
and present problems understood in the light of the past, the personal his-
tory of the patient must be secured. Facts as to the history of public health
in Cleveland were obtained by conferences with those who have been inter-
ested in this work for many years.
A conception of the special problems of the community which rel ite to
public health, or a knowledge of the history of the present illness, must be
formulated from rather intangible material obtained in personal conferences,
or questionnaires which ask specifically for criticisms of institutions which
are not serving the public in a satisfactory manner. The information so
obtained, although inconclusive, will often serve to suggest avenues of study
that might otherwise be overlooked. Also an institution's relations with
the public are an important index of the eflFectiveness of its service. In
analyzing such information it is important to diflPerentiate criticism stimu-
lated by personal animosity, from that which is confirmed by similar obser-
vations from other and varied sources, pointing towards a real undermining
of health or at least a defective structure or function.
Quantitative Estimate of Needs
It is necessary- to gauge tlie extent as well as the quality of service needed
along various lines. That is, an estimate must be made, based on local figures
compared with those from otlier cities, of the number of women who need
prenatal care, out-])atient delivery or institutional confinement, the nunihei"
of children of |)re-school age who need free medical supervision, the number
of tuberculous who should be under observation at health centers, the num-
ber and cliaracter of those who need dispensary service, the proper propor-
tion of hospital beds to the population, and so forth. It is obvious that no
final answers to these questions can be made, but in order to decide the need
for extension of the various preventive and treatment facilities the extent of
the problem must be measured and recorded.
Laws and Law Enforcement
Study of the adequacy of state and local laws relating to the professions
and dealing with i)ul)lic health agencies, and the efficacy of their enforce-
ment, is essential. In connection with the mental hygiene and social hy-
giene studies investigations were made also of the provisions for detention
Method 1011
of individuals and their treatment in the courts. Does the sanitary code of
the city contain all modern provisions for health protection? Are the laws
adequate which regulate conditions in industry afiFecting health? Compar-
ing the existing laws with model laws in other states and cities, it will be
possible to recommend additions to or changes in the existing statutes.
Some of the questions of law enforcement that are fundamental to health
protection follow: Are physicians and midwives practising without a license;
do they report births, deaths, contagious and infectious disease as the law
requires; are housing and sanitary regulations upheld; are children allowed to
work on streets and in factories in violation of the Child Labor laws; is the
ordinance against dense smoke commonly observed?
A birth registration check was made at the Division of Health covering
about 800 children under two years of age, who had been bom in Cleveland,
to see if their births had been recorded. The form on which the information
for checking was collected will be found in the Appendix (3).
Coordination and Functional Control
The actual analysis of the organization and accomplishments of the
different institutions may well be compared to the physical examination of
the patient. It is quite obvious that it is impossible to diflPerentiate sharply
the various methods of procedure, as they often overlap or are combined.
In studying any institution attention must first be given to its type of or-
ganization and functional control (the nervous system). Of whom is the
board of trustees composed? Do the trustees take a personal, interest in the
details of hospital administration? Do they see that the same principles of
efficiency on which they pride themselves in tlieir private enterprises are
carried out in the public institutions under their supervision? Is the execu-
tive authority of the institution divided?
The organization of the medical staflFs of hospitals and dispensaries also
was studied in detail. How is the medical staflF nominated? How are the
members appointed? How often are staflF meetings held and what is the
purpose of these meetings? Has the staflF an executive committee? Is there
an auxiliary staflF? These and similar questions were put, and special recom-
mendations as to hospital organization were made when the answers were
obtained.
The administrative procedure of private philanthropic institutions is
very often their weakest spot. Methods of efficiency and practical economy
are often lost sight of in well meaning attempts to render service.
Are purchases made in large quantities? Are storage facilities ample?
Are cash discounts taken? Are accounting and bookkeeping methods
standardized? Are all reasonable time-saving devices in use? These are
1012 Hospital and Hualth Subvei
some of the questions which interest the investigator. Questionnaires U8cd
in
1. Study of organization and administration of private and public heaitfa
nursing agencies
and
2. Study of hospital administration
are reproduced in the Appendix (4 and 5).
The Associated Health Professions and Their Training
The brain needs here as in the case of the individual patient the most
delicate and tactful approach, and the psychology of professional groups
must be studied, as well as the crude facts of their numbers and accompM-
ments. As the entire undertaking of preventive medicine and all the caie
of the sick depend upon the quality of licensed practitioners of medicine,
nursing, dentistry and pharmacy, full knowledge of the limitations in the
education of students both before and after graduation must be sought and
described. If one element rather than another in the examination of the
community has been incomplete, it is the study of professional training of
physicians, dentists and pharmacists. For the nurses the information is
quite complete.
Quantitative Determinations of Functions
It is necessary to ascertain the number and the size of the different types
of institutions and to decide whether the available service is suiEcient to
meet the actual and potential demand. Are there enough hospital beds to
care for the community sick? The answer to this question was sought in
various ways. The hospitals were asked to keep for two months a record
of the cases to which they refused admission. Printed pads were furnished
the hospitals on which to record this information (Appendix 6). The re-
sults of this investigation were tabulated as follows:
Type of service — medical, surgical, etc.
Economic status of patient — pay, part-pay, or free.
By whom request for hospitalization was made — self, agency, doctor or family.
Whether or not patient was placed on waiting list.
The public health agencies were asked to furnish statistics as to the
number of patients under their care during a certain month, who were
properly hos])ital cases. Social agencies and district physicians were asked
whether they were able to obtain hospital care for their patients promptly.
Questionnaires, sent to i)hysicians, inquired whether they found it difficult
to obtain hospitalization and if so for what class of patients. The number of
available beds was compared with the estimated population to be served,
and comparison was made also with the ratio of hospital beds to population
Method 1013
in other cities. The number of existing beds for various special services,
e. g.» orthopedics, tuberculosis and maternity was ascertained and a compari-
son made with the estimated need in Cleveland and with the number of
beds available for similar services elsewhere.
A special investigation to determine the need, if any, for an institution
to care for convalescents, was made by visiting the homes of 200 patients
recently discharged from four leading hospitals to see if conditions were proper
for their prompt convalescence.
Is there enough social service work provided by hospitals and dispen-
saries to make the medical service most effective? Is the ambulance service
ample so that the location of hospitals in the outskirts of the city is feasible?
Are there enough dispensaries and are they properly located? Are the
special dispensary services, i. e., prenatal, prophylactic, babies', orthopedic,
industrial, tuberculosis, venereal, and so forth, adequate? Is sufficient
medical service provided by child-caring institutions, by schools and by
industrial plants? Are there enough diagnostic laboratory facilities, both
public and private?
The method of investigation to determine the answers to these questions
was in each case somewhat similar to that described above for determining
the needs in hospitalization. That is, a study was made of the number,
location and amount of service of the existing institutions. The question-
naire that was used in determining the amount and character of medical
service in industry is given in the Appendix (7). All reasonable avenues of
inquiry were followed to learn whether the local need was being adequately
met. The amoimt of service was compared with the estimated number of
people to be cared for and with the extent of similar service provided by
cities of approximately the same size. Hospital superintendents, physicians,
representatives of nursing and social agencies were asked by questionnaire
and in conference, whether their needs for ambulance transportation were
being promptly and satisfactorily met. Inquiries were sent to other cities
for facts as to the number of ambulances provided by the city hospital, by
the police and by private hospitals; as to the number of dental chairs for
free service and the hours they were in use; as to the number of hours of
medical service provided weekly in free clinics for the treatment of tuber-
culosis; and so forth. The amount of potential dispensary service and of
medical service in schools and industry is obviously determined not by the
number of dispensaries but by the number of physicians and nurses and the
amount of time devoted by each to this service. The actual amount of
service rendered is shown by such records as the number of patients cared
for annually and the number of difiFerent treatments given. Again the
value of the service is not measured by the amount but rather by its charac-
ter which is a less tangible factor to analyze.
Quality of Function
The output of a hospital or dispensary cannot be measured by exact
standards, but there are certain recognized methods by which medical and
1014 Hospital and Health Subyei
nursing procedure may be analyzed as to quality. These are: a study of
personnel and equipment, an analysis of the records of patients, a personal
observation of technic and a statistical analysis of results.
Upon the character as well as the training and experience of the personnel
in charge of any service depends the quality of the product. Personahty is,
of course, an intangible factor to evaluate, but the training and experience
of the workers are or should be a matter of record, available to the investi-
gator. In the nursing survey, and the study of the health department
especially, particular attention was given to these factors (Appendix 8).
The employment of trained persons is essential to assure standard service in
the professional lines. Inquiry was therefore made as to whether anaes-
thetist, dietitian and laboratory techniciiMis were employed in hospitals.
In some instances the character of service must depend largely upon the
adequacy of equipment. Laboratory and hospital nursing technic, for in-
stance, require certain minimum equipment to produce a high grade d
service. In measuring these services observation was made to see if standard
equipment was available. (Appendix 9.)
In order to determine whether the physical defects of children in insti-
tutions were being detected and corrected, several hundred children, some
taken from each institution, received both physical examinations and mental
tests. For the form used for recording physical examinations see Appendix
10.
As the records of patients constitute the only means by which an ob-
jective presentation of medical work can be accomplished, the analysis of a
considerable number of the records of an institution gives a fairly accurate
picture of the clinical procedure obtaining there. Therefore, in evaluating
the quality of various professional services, the study of records received
considerable attention. Fifty records from each of twenty hospitals were
analyzed to find whether they contained the following items: personal his-
tory, physical examination, working diagnosis, laboratory findings, ojjeration
or treatment, progress notes, final diagnosis and condition on discharge. One
hundred records were studied in each of the disi>ensaries with the above
points in mind and also to ascertain the nationality of the patients, the
number of revisits, ancf so forth. Several hundred health records of school
children were analyzed to find the proportion of corrections that had been
made to the number of defects found, and the average number of nurses'
home visits and parents' consultations on each case. Health center records
were analyzed to find the average number of patients' visits to the clinic and
of nursing visits to the home; the records of nurses' time were studied to
find the relative proportion spent in clerical and other duties. Prenatal
records were analyzed to find the month of pregnancy during which the
patient w^as brought under care, as well as the number of patients' visits to
the dispensary, and of nurses' visits to the home. A comparative analysis
of the records of the school census, of the work certificate office and of the
state industrial commission to learn the number of children employed in
industry, was made. Data were secured from a census of 100 newsboj'S
1 E T H O D 1015
ttending a down-town school as to their age, health, mental capacity^ — as
tated by their teachers — and the number of hours they worked atfnight.
Ln investigation was made of the content of industrial health records and
he method of compiling and analyzing the data recorded. The method of
ling and indexing hospital and dispensary records was also|investigated,
nd inquiry made as to the means of assuring compliance with the^hospital
ules for the completion of histories.
Extensive personal observation was made of nursing service both in hos-
litals, dispensaries and in public liealth nursing districts, and of the work
f school medical inspectors.
In the Division of Health also the method of evaluating the quality of
ervice by personal observations was found useful. Members of the Survey
taflF accompanied sanitary and dairy inspectors and collectors of laboratory
amples in their trips, and made observation of routine laboratory examina-
ions and other functions at the central office.
Resources For Prevention
In studying the adequacy of health protection and the prevention of
lisease the following questions must be faced. Are sanitary conditions in
hild-caring institutions, schools and industrial establishments such that the
lealth of children and employes is safeguarded? Is the city water supply
rom a safe source and protected from contamination.^ Are sewage and gar-
bage disposal satisfactory? Does the method of control of communicable
liseases minimize the danger of their spread? Does the inspection of food
iroducts and drugs protect the public against adulterated or contaminated
iroducts? Are nuisances controlled and the contamination of the air pre-
sented? Is the community being constantly educated in the methods of
lealth protection, both public and private?
The methods of ventilation and cleaning, of adjustment of blackboards
nd seats, the general construction, lighting, cubic air capacity and toilets
f public school buildings were investigated. The temperature was read in
I series of rooms and the force of the drinking fountains in many buildings
VBS noted by the investigator. Investigation of working conditions was
oade in several hundred industrial establishments. (For the questionnaire
tsed in studying working conditions for women, see Appendix 11.)
A study offthe amount and character of health education was made
for questionnaire,^see Appendix 12.)
Checking Up the Facts for Diagnosis
Statistical study may well be compared with the laboratory method of
liagnosis — the methods of investigation are more exact and the finding^
acre definite. If the processes are accurate the results permit certain de-
luctions to be drawn with precision.
1016 Hospital and Hkaxth Subtet
Some of the statistical studies made by .the Survey were as follows: A
study of data regarding age and sex distribution and nationality of the popu-
lation; a study of general mortahty and mortality from the chief causes {«
a period of years; a comparison of mortality and morbidity rates, as wdl
as hospital and dispensary attendance, by health districts; a study of tube^
culosis mortality by age, sex, form and occupation; a comparison of the
death rate under one month, the maternal death rate and the stiUbirth rate
of a series of cases under prenatal care with that for the city as a whole; a
study of the records of The Industrial Commission of Ohio relating to
accident frequency and accident severity rates in industry and to the em-
ployment of women and children in industry; the preparation of pin maps
locating the various types and sizes of industrial establishments; a study of
milk consumption in connection with the tuberculosis survey (for the form
used in collecting the material, see Appendix 13). The records of 1,000
families were tabulated as to types of illness, amount of milk consumed, the
kind of milk purchased and how milk is cared for.
In order to obtain statistical information, a census was taken on Decem-
ber 3, 1919, and again on January 15, 1920, of the patients in the hospitals
of the Cleveland Hospital Council and in four other institutions which woe
willing to furnish the necessary information. These results were averaged
and tabulated as follows: (Census blank. Appendix 14).
Percentage of beds in use.
Type of service, i. e., medical, surgical, etc.
Length of stay of patients in hospital.
Location of residence of patients.
Economic itatus of patients.
Percentage of cases admitted by staff and non-staff physicians.
Percentage of free, part-pay and pay cases admitted by staff and non-
staff physicians.
Age of patients.
Nativity of patients.
Economic status of patients according to nativity.
CONCLUSION
. Treatment and Follow-up
When the community diagnosis has been made and, after a consultation
of specialists, the method of treatment is outlined, how shall the prescrip-
tion be prei)ared, by whom the operation be performed, and who shall be
the victim? A detailed report of a survey is of much more than local interest.
Communities of comparable size have much the same problems to face as
has Cleveland. Study of the results of a survey in one city will often sen'e
to suggest the answer to problems in another community.
M £ T H O D 1017
It was thought useful to have the Cleveland Survey printed in the present
inopeosive form in order that copies might, at small expense, be made
available to state and local health departments, to medical and general
'libraries, to hospitals and nursing organizations, to medical and other prac-
titioners in the allied professions, to public health societies and others.
The final action of the survey staflF is to prepare their report for publi-
cation. It is left to the patient — the public — to do the rest. The survey
will prove of no avail imless the commimity is ready to carry out the plan
proposed. If , as in Cleveland, there is no permanent organization extant to
which a follow-up of the community's case may be left, it will be necessary
to recommend, as the Cleveland Survey has done, the formation of a cooper-
ative group composed of representatives of all organizations interested in
public health, to which — with their other duties — will be left the task of
seeing that the community takes its medicine. The proposed Cleveland
Public Health Association must provide follow-up and convalescent care for
the community patient, the great city of Cleveland!
1018 Hospital and Health SuBvn
APPENDIX
FORM LETTERS AND QUESTIONNAIRES
November 28, 1919.
Dear Doctor:
We are at your service and we need your counsel and support.
Take a moment to answer the queries below and we can assist your patients throoib
you to better service.
1. Have you found difficulty in obtaining hospital care for your own
patients?
2. If so, for what kinds of patients, i. e,:
Surgical or medical.
Pediatric or orthopedic.
Neurological or mental.
Obstetrical or gynecological.
3. What solution have you to suggest for remedying the hospital sit-
uation from the point of view of the patients or of the medical profession?
4. During the past 12 months, approximately how many patients with
venereal disease have you had, under your private care (syphilis — gonorriiea
— chancroid)?
5. How many of these patients discontinued the treatment you advised
without your consent, and why?
These reports will be kept confidential and no names quoted in reporting the totab
received in the answers.
Come in and watch the process of taking the family and personal history of Clev^
land, making the physical examination of the city and trjring out laboratory methods for
a Community Diagnosis. It is your community and the treatment will be in your hands
in any event. #
Give us the "once-over". It does us good to be criticized.
Yours cordially,
Director.
(2.)
November 20, 1919.
Dear Sir:
The Hospital and Health Survey wants to look at the medical and health service of
Cleveland from the outside as well as the inside. We need very much to have the infof-
mation and opinion of the Social Agencies. As you call upon the hospitals, dispensaries
and Health Department for medical aid in behalf of your people, you can therefore give
us many practical points which are most important.
On a separate sheet we have put a few questions or topics. We should like very much
to have your answers or comments on any or all of these.
Method 1019
In case you prefer to go over the matter personally with a member of the staff of the
Survey, will you kindly cal^ us so we can arrange for a conference?
Any information given by you as to names, quotations, etc., will be treated as con-
fidential by the Survey.
Very truly yours,
QS-JHS Assistant Director.
1. Patients refused admission to hospital. Do you find many patients in whom you
are interested who cannot be admitted to hospitals? Among what classes are these the
tnore frequent? We would be glad to have comments, reasons, etc., for refusal or other
ixmditions, which might help to bring out the nature or extent of the shortage of hospital
beds if such exists.
2. Have you felt there is inadequate dispensary service? If so, along what lines of
ivork or in what parts of the city?
3. Do your agents find it difficult to secure answers to inquiries for medical informa-
tion concerning hospital and dispensary cases in which you are interested? Are the diffi-
milties uniform among different hospitals or dispensaries?
4. The work of the City District Doctors. Are they prompt in answering calls?
Do they give continuous care on your cases? Can you secure medical information from
khem when needed? Do you distinguish between the type of patient you refer to City
Physicians and to the other medical relief agencies, such as dispensaries and private doc-
tors, as to whether they are ambulatory or bed ridden, contagious or non-contagious, etc.?
Do you think that patients who can afford to pay anything for medical care should be
referred to City Physicians?
5. What patients feel or say about hospitals. Any ''stories" or examples of experi-
ences that patients in hospitals have had which would serve to bring out the rv'al difficul-
ties, needs or deficiencies, would be welcome.
6. What policy exists between the Social Service Department of the hospitals and
your agency with regard to furnishing material relief? What points do the Social Service
Departments turn over to your agency for general work with the family or how far do they
carry this themselves or do you both handle this phase of the work at the same time?
(3.)
BIRTH REGISTRATION SURVEY
Fill out only for children under 2 years of age bom in Cleveland.
Name of child (Family name) (Given name) ,
Date of birth: Month..^ Day Year
Place of birth (address of residence or institution).
Name and address of attending physician or midwife,
Signed by person making report
1020 Hospital and Health Subyet
(4.)
COMMITTEE FOR PUBLIC HEALTH NURSING EDUCATION
OFFICE REPORT: PRIVATE AGENCIES
A. I. Name of Association
Address Year founded..
B. Organization
I. Types of work.
1. ^General visiting nursing.
(a) Specify what kinds of work are included
(b) What types of sickness are refused or referred to another organixatkn
for nursing care? ^
2. Specialized Services
(a) Infant or child welfare; up to what age?.
Specify what kinds of work are included..
(b) Anti-tuberculosis work ^Supervision Instruction
Placement Bedside care—
(c) Industrial nursing _
II. 1. Total number of visits made during last fiscal year
2. Total number of cases
3. Cost of a visit -
4. Average number of visits per day per nurse
5. Number of patients paying:
(a) Full cost.
(b) Part cost-
(c) Nothing
III. Personnel
1. Board of Managers: Title
(a) How many are men?
(b) How many are women?
(c) How often does the board meet?
(d) Does the nurse superintendent meet with the board?
2. Nursing Committee
(a) How many members?
(b) How often does it meet? -
S T H O D 1021
3. What committee determines policies?
4. What committee controls the budget?
5. Staff:
(a) Superintendent: Name and title.
(b) Assistant superintendents, how many?
(c) Supervisors, ** "
(d) Staff nurses, " "
(e) Student nurses, (graduate) ** *'
(f) " " (undergraduate) " " .
(g) Attendants or practical nurses, '* **
(h) Nurses employed in clerical
work (full time), " " .
(i) Dietitians. ^
6. By whom are the following engaged and dismissed?
(a) Supervisors
(b) Staff nurses ^......^..^.^ — ....^...............~^..
7. What are the minimum professional and educational requirements for a Staff
8. Are staff nurses assigned to special services?
Administration
I. Supervision
1. Number of staff nurses to a field supervisor: minimum.... maximum
2. How often do staff nurses report to the supervisor in the main or branch office
or station?
3. Do£8 the supervisor visit in homes, (i|i) with the staff nurse?
(b) without " " "
4. Are printed or written standard practice instructions used?
II. Conferences
1. Are meetings of entire staff held regularly? (a) How often?
(b) Who calls the meeting? (c) Who presides?.
2. Are case conferences held regularly? (a) How often?
(b) Who presides? (c) Who attends?
3. What conference of other organizations are regxilarly attended by members
of the staff?
1022 IJOSPITAL AND HdALTH SUBTET
III. Efficiency
1. What methods are used to judge efficiency of nuraes?^^
2. (a) Are efficiency records kept? (b) Has the nurse access to her
record?
(c) If not, how is the nurse informed of her standard? _
IV Salaries
1. Staff nurses: Minimum Jidaximimi Rate of increase
2. Supervisors: " " " " " i
3. What is the length of vacation on salary?
I
4. Are the following furnished in addition to salary?:
(a) Uniforms (b) BoanL. ^ (c) Lodging i
(d) Other Allowance.
V. Hours of work
1. What are the hours of work daily? (a) Sunday?
2. Is time spent in record keeping included in working day? .
3. Is there one complete day of rest in seven?
4. Is there a weekly half-holiday in addition?
5. Overtime work: average per week per individual during last month
6. Is night work expected? (a) For what cases?
(b) Is time off allowed for night work?.
VI. Recording
1. How many hours weekly are spent in recording, (a) by supervisor?
(b) by staff nurse?
2. How many clerical workers (not nurses) arc employed?
D. What is the superintendent's conception of the function of the Association in regard
to the education of
(a) Patients and families? „ -
(b) Nurses? ^ ^
£. Comment by superintendent on education, training, and personalty of staff nurses?
F. Obtain two copies of the following:
1. All record forms.
2. Practice instructions.
3. Efficiency record.
4. Annual repwrt for last two years.
5. Publicity material published within the last year.
Method 1023
I. Remarks:
Name of Investigator.
Date
5.)
VRVEY OF ADMINISTRATIVE DEPARTMENTS OF CLEVELAND GENERAL
HOSPITALS
FINANCIAL ADMINISTRATION
0 Per capita per diem cost of administration — 1918? 1919?
Do you charge all expenditures for current repairs, new equipment and betterments
to expense accoimt so that it will appear in your per capita per diem cost of main-
tenance? ~ «
Do you charge off annually a percentage for depreciation?
>) Do you discoimt certain bills for cash?
Total earnings from cash discounts for 1919?.
:) Have you an income from endowments?
i) What rate charged for private rooms? Ward beds?
t) Do you charge extra for the following?
Blood transfusion? ! Rate?
Large surgical dressings? Rate?
X-Ray plates and stereoscopic examinations? J^ate?
Nurses' board? Rate?
Surgical dressings, such as perineal, abdominal and prostatic pads, plaster
bandages, etc.?.. Rate?
Plaster casts? J^ate?
Services of anesthetist? J^ate?
AU laboratory examinations? Rate?
Fancy foods, such as squabs, broilers, frog legs, etc.? Rate?...
First aid services in emergency cases? Rate?
Salvarsan administration?.... Rate?...
Drugs and prescriptions? Rate?
Splints and surgical appliances? Rate?
Ambulance services? Rate?
Meals and cots for relatives and friends of patient? Rate?
f) Do you collect board and room accounts one week in advance?
Do you bill patient's responsible relative weekly thereafter?
g) Have you an office clerk, investigator or credit man for investigating financial stand-
ing of patients?
1024 Hospital and Health Subyet
(h) Do you admit county or city patients at regxilar rate8?_
(i) Do you use a budget system in estimating srour expenses for the ^giMimg year?
(j) Do you have an annual accounting by a firm of accountants?
Have you installed a modem bookkeeping system adapted to hospitals?.
If a standardized system of hospital bookkeeping and financial reports were recom-
mended, would you endeavor to have same carried out in your hospital?
Have you an accoimting system in use in your hospital?.
PURCHASES AND SUPPLIES
(a) Are all purchases made by or with the personal approval of the superintendent?.
Have you a steward who makes purchases? „
Are heads of departments permitted to make purchases?
(b)2Have you saved money through the purchasing bureau of the Cleveland Hoipita
(c) Do you obtain quotations or ask assistance of the purchasing bureau of the Clevdand
Hospital Council when about to make purchases of any size?
Can you increase the amount of your purchases through the bureau to advsntage?
(d) Have you sufiicient store room capacity for
One year supply of canned gbods?
Three to six months of gauze and cotton?
Three to six months soap supply? ^
Three to six months supply of dry goods?
(e) Do you store fresh eggs or fresh butter in public refrigerator storage house in April or
May for use during the period of maximum high prices? (November, December,
January)
(f ) Have you contracts for the purchase of coal? .Electric lamps? -
^ Milk from producers? —
(g) Would you cooperate with the Cleveland Hospital Council and the American Hospital
Association in a standardization of hospital supplies? -
HOSPITAL ECONOMICS, SALVAGING, ETC.
(a) Have you a house carpenter? Steamfitter?.
Painter?
(b) Have you a surgical appliance or instrument repair shop?.
Do you salvage, wash, and reclaim, gauze and bandages?
Do you bail and sell waste paper?
Grease? Garbage? 3arrels? Old Rubber?.
Old metal? Rags? Bottles?
Method 1025
(c) Do you make soft soap from grease? JFrom soap chips?
(d) Do you utilize labor-saving devices?
Vacuum cleaner? .« ^^-. ^ ^
Electric floor scrubber?
Electric dough mixers, meat cutters, etc.?
Dish washing machines?
(e) Do you maintain a sewing room and manufacture part of your dry goods?
DEPARTMENTAL EXPENSES
Engineering Department
(a) Do you manufacture your own electric ciurent?
(b) Is yo\2T boiler plant and machinery up-to-date?
(c) Do you maintain a refrigerating plant?
And are your ward and corridor ice boxes refrigerated therefrom?.
(d) Do you manufacture ice?
Laundry
(a) Is your laundry machinery in gbod order and modem in type?
Cb) Have you a steam tumbler? Steam presses?
(c) Have you a trained laundry man or woman in charge?
(d) Do you manufacture your laimdry soap from soap chips or grease and alkali?.
Ambulance
(a) Do you maintain a hospital ambulance service?
If not, what ambulance do you utilize?
0>) Do you consider the Cleveland ambulance service satisfactory?
(c) Should a central ambulance service be managed
By the mimicipality? ^
By private ownership? ~ ^
By the Cleveland Hospital Council?
Dietetic Department
(a) Have you a dietitian?
(b) Does she arrange all menus for patients, nurses and employes?..
(c) Does she have general supervision of all cooking and food service in the hospital?.
1026 Hospital and Health SuRvn
(d) Does your dietitian purchase food supplies?.
Professional and Staff Service
(a) Have you an organized Attending Staff?
(b) Has the Attending Staff an Executive Committee with authority in professiooal mat-
(c) Is the Superintendent a member of the Executive Committee? —
(d)_Do you furnish rubber gloves for your attending surgeons for use on private caies?
Jf so, why?
(e)^Do you purchase manufactured catgut, or do you prepare your plain and chroouc
catgut from raw gut?
(f ) Has any member of your Attending Staff authority to purchase equipment or sup-
phes? „
(6.)
APPLICANTS FOR HOSPITAL CARE NOT ADMITTED
Name of Hospital ^
Date
Sex.. Age
Nature of disease (or diEignosis)
Address (or location in city)
Was applicant for Free Part Pay Pay.
(Check)
Was request for admission made^by Patient's self.
Family of patient
Agency in behalf of patient..
(Check)
If request by agency, please state name of agency.
Was applicant put on waiting list
Name of organization giving information ^
(7.)
MEDICAL SERVICE IN INDUSTRIAL ESTABLISHMENTS
1. Firm name Date
2. Address ~
S T H O D 1027
Nature of product *
Total number of employes Male Jemale Children, 15-18 _
Medical Service
Dispensary Location in plant No. rooms Size
Plant hospital No. beds Personnel
Physicians, full time, during service Part time
Names and addresses
Nurses, trained, male, female
No on dressings, visiting, other, mixed
Type of medical service
First aid Kits where?
Average no. dispensary visits daily
Total no. accident cases per month Surgical, n. o. s Medical
Accessibility of disp. Verbal, written permission of foreman
Noon visits? After working hours. On company time?
Physical examination, required, optional, applicants, employes, periodic, transfers?
Causes and percentage rejections _ -
No. handicapped employed Own employes?
Medical records, day sheet
Permanent individual record
Daily individual record _
Special services
Dental service Limits Cost
Laboratory X-Ray
Visiting nursing
Absence follow-up Sickness _
Dressing assistants Clerks _..
Interpreters
Ambulance service, own equipment, personnel , „
Hospital for severe cases
Service satisfactory? Why?
Contract? Supplementary compensation?
Complaints?
Do you favor establishment of industrial wards?
Of industrial clinics? ^
Care of eye injuries? ^
No. cases tuberculosis yearly Disposal
Disposal communicable diseases
Venereal disease program „ a
1028 Hospital and Health SuRvrr
6. Relations of medical department.
To whom is chief surgeon responsible?.
To whom are nurses responsible?
Relation to employment
Relation to safety
Relation to other employes' services.
7. Personal Service Activities
Mutual benefit fund Control
Self insurance. Sick benefit...
Sick absences Accident absences...
Rest rooms .Equipment..
JL<oc^cc^^ft.. ...»-«...».«-««.»»..«>.».«......»...»«.»«.«»»»«»-»«...... ...»«^ocation.»»«.««-».........
Lunch room JFood sold, heated....
Recreation ^ . —
Education, health, general
8. Health hazards of operation
9. Labor imions
Shop committees ~
10. Cost of medical service Salaries .Equipment
Maintenance
Does it pay? How?.....
11. Information from Position — •
12. Statistical reports.
Record forms
Photographs
Blue prints
Method
1029
:8.)
COMMITTEE ON PUBLIC HEALTH NURSING EDUCATION; INDUSTRIAL
NURSING SERIES
PERSONAL HISTORY
\. 1 . Name and Address of Employer.
2 Name of Nurse 3. Age.
4. M. S. W..
5. Are you registered? 6. If so,- give state and year.
7. Name of present position (specify staff nurse, supervisor, head nurse, assistant, etc.)
8. Length of service in present position years.
.months.
3. 1. Did you hold a pcud position before beginning nurses' training?.
(Describe last two positions only)
Nature of Work*
Length of Service
Years Months
^Specify exact position held, e. g., teaching, clerical work; employment in store or factory other than
clerical; personal service, such as caring for children, social work, etc.
2. Paid positions held after completing nurses' training —
Have you done private nursing? If so, for how long?.
.years
months.
Positions other than private nursing —
lOSO
Hospital and Health Surtet
Name of Employer
Place
Nature of Work*
Length of Service
Association, Company
or Individual
City or Town
and State
Yrs.
Mos.
•
(a) „
(b)
(c)
^'V^.. ........... ......... ...............
(d)
\ /
(e)
(0 ^
•
\ /*••***-'""•— ""-•"•■--•"•"-••■■-•••••
i
H>ive name of position and kind of work , e. g., head nurse; operating room; staff norse; infant wel-
fare work, etc .
C. 1. General Education
NAME
Grammar or Par-
ochial School
High School
College
Other Schools Not
Nurses* Training
Schools
City or Town
and State
Year of If not gr»d-
graduation uate No. <A
yn. attended
2. Hospital Training (Undergraduate):
Name and Address of Nurses' Training School.
Year of Graduation Length of Course.
Numb.r of Hospital beds at time you graduated
ET H OD
lOSl
Were pupils sent out of hoepital to do private nursing?..
If so, for how long were you thus employed?
Did your training include work with the following:
(a) Men (b) Women (c) Children.....
(d) Sick Infants under 2 yrs. (e) Medical Cases.
(f) Surgical Cases . (g) Obstetrical Cases
(h) Nervous and Mental Cases. (i) Venereal Diseases
(j) Tuberculosis (k) Other Communicable Diseases (specify
Postgraduate Courses:
School or College
City and State
Length of
Time
Attended
Year
Subjects Studied
ses' organizations of which you are a member:.
Date.
10S2
Hospital, and Health Si
(9.)
WARD EQUIPMENT
Service Rooms —
1. Bathroom: (a) Is it clean? (b) Adequate facilities?.
2. Utility Room: Are the following present and adequate?
Slop hopper.
Instnmient steriliser.
Utensil sterilizer.
If not, what is done in usual cases!
Bedpan and stool sterilizer.
If not, what is done in usual cases?.
In infectious cases?.
In infectious cases?.
Gas burner.
Cans for rubbish.
Sink.^
Linen hampers Chests.
Bedpan hopper.
Table.
Shelf
Care of infectious linen.
3. Portable Equipment — Is it adequate?
Basins: Cleaning.
Thermometers.
Bathing.
Tray treatment system.
Hot water bags.
Ice caps.
Provision for medication.
Rubber rings.
4. Diet Kitchen:
Sink.
Gas or electric plate.
Ice chest.
Dish sterilizer.
Steam table.
Trays and equipment of same:
Excellent Good Fair Poor
5. Linen Closet:
Supply of linen Arrangement Cleanliness
6. Broom or Maids' Closet: Hopper Condition of brooms and mops
kf £ T H O D 1033
■I ■ ■ ■ ■■ ■ ■ ■ ■ ■ ■■■ I ■■! ^■■.- ■ ■ I I ■ ■ ■ ■ ■ — ^^^ ■ - ■■■■■!■
10.)
MEDICAL EXAMINATION OF CHILDREN IN INSTITUTIONS
astitution - .—
kdidress ...^...i^..^..^..^^ —
Tame J^c.
>ate of Admission ^
>atc.-— _. Height. Weight.
1. \n8ion: OD ^
2. Hearing. «
3. Defective Teeth : PrimAry
Permanent ,
4. Defective Nasal Breathing.
5. Hypertrophied Tonsils
6. Defective Nutrition
7. Cardiac Disease: Functional.^ ~
Organic
8. Pulmonary
9. Orthopedic Defect.
O. Nervous
Ll. Miscellaneous.
:ii.)
INDUSTRIAL DIVISION
Women and Induttry Queationnaire
'oTtx Address
''^>ciuct
• I^umber Employes (on production) —
Male
Female
Boys 15 to 16
Girls 16 to 18
•• Regularity of employment
»- Transportation „
^- Hours: to Lunch to Saturday to.
1034
Hospital and Health Subvey
Maximum daily Total weekly Overtime.
5. Night work.._ „ _
6. Women first employed _
7. Operations found unsuitable for women and why .!
8. List of operations now performed by women. Check those on which women replace
men.
Operation
No. Bmployet
Wage rate
Piece or Time Work
WUy. eamiafi
9. Comparison with men or boys on same work as to wage and efficiency.
10. Minimum or guaranteed wage ^
11. Work, how learned — Training school, fordady, other workers^
12. Opportunities for advancement
13. Types of women workers — ^nationality, color, age, civil state
Educational requirement
Male Female
14. Absences
Lates
15. Length of service
Transfers
16. Accident incidence
Sickness incidence
17. Medical service
Hospital used
Home visits
18. Supervision of women by Extent
Employment woman
Doctor (M. F. full, part time) Hoursi.
Nurse
Service worker —
Forelady
19. Working conditions
(a) Type of building
(b) Ventilation
(c) Cleanliness ,
(d) Sanitation
(e) Light
(f) Distribution of women Crowding
(g) Standing Chairs
Method 1035
(h) Lifting
(i) Fatiguing movements ^
(j) Special health hazards *
(k) Lockers, dressing room ^
(1) Uniforms, optional, required, provided. Jaundered. type-
Cm) Couches
(n) Lunch room Food sold, heated
(Rest Periods)
20. Physical examination, partial, complete, applicants, employes, periodic, transfers
Care of pregnant V. D
21. Health education vs. special hazards
Safety instruction
22. Vacations
23. Recreation — . .. .....^ — . .. .......^.
24. Benefit association
25. Shop committee. Union ...
Information from •. By Date
y W**« •• •^r***
(12.)
PUBLIC HEALTH EDUCATION
Name of Organization
Type of education given — ^Anti-tuberculosis
Social Hygiene
Etc
Way information given —
Literature
Lectures
Etc.
How many people reached?
What age and sex reached?
Any racial adaptation?
Consistent or spasmodic effort?
Conception of future activity along this line?
Samples of literature „
(13.)
MILK CONSUMPTION SURVEY
Date of visit
Nationality (7) No Street Agency visiting (1).
Family receiving relief (2) yes no Kind of relief (3)
No. in family: (4) Adults (15 and over) Lodgers ^
Children (6-14 incl.) Children under 6.
Illness in family at time of visit (8)
1036 Hospital and Health Subyet
Members (6) Nature of Illness
Milk: Daily amount (qts.) Bottle ^ Bulk Canned (5) .Otherwise—
Check
Kept cold. Covered
Is it pasteurized: by dealer _or at home is it certified?.
Check
Remarks:
Investigator.
L Initials only-
2. Other than home nursing care.
3. Financial, clothixig» food, medical care, etc.
4. Indtide any relative living in family as adults or children as case may be.
5. Condensed — evaporated, etc
6. Mother, lodger, etc., call all persons 14 and under, children.
7. Be particular to specify negroes.
8. Include — (a) Sickness requiring the attention of pl^sician, (b) Sickness requiring treatmeot it
hospital or dispensary, (c) Sickness preventing work, (d) Sickness preventing attendance at Kbool.
TH OD
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it.
I-
1087
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1038 HoBPiTAi. AND Health Subtet
Bibliography of Surveys
By Julia T. Emerson
HEALTH ADMINISTRATION SURVEYS
UNITED STATES
Harmon, G. E. A compariaon of the relative healthfulness of certain cities in the
United States based upon the study of their vital statistics. American Statistical
Association, Quarterly Publication v. 15 no.ll4 pl57-174 June 1916.
Lumsden, L. L. Rural sanitation; a report made in 15 counties in 1914, 1915, 1916.
Treasury Department, U. S. Public Health Service, Public Health Bulletin na94,
1918. 336p.
Schneider, Franz, jr. A survey of the activities of municipal health departments in
the United States. (Begun August 1913) Russell Sage Foundation. Reprinted
American Journal Public Health v.o no.l January 1916.
Warren, B. S. and Sydenstricker, Edgar. Statistics of disability; a compilation of
some of the data available in the United States. U. S. Public Health Service
Public Health Reports v. 31 no.l6 p989-999 April 1916.
ALASKA
Haines — Craig, H. M. and Lambie, J. M. Medical survey of an Indian village.
Military Surgeon, July 1914 pi 1-16.
COLORADO
Fox, Carrol. Public health administration in Colorado. Reprint 383, U. S.
Public Health Service, Public Health Reports, December 1916, p3485-3520.
CONNECTICUT
Middletown — Greenberg, David and Joel, I. D. Health survey, under direction of
C-E. A. Winslow, 1918. 73p.
New Haven — Fisher, Irving. Health of New Haven. New Haven Civic Federation,
1913. 8p.
FLORIDA
Fox, Carrol. Public Health administration in Florida. Reprint 340, U. S. Public
Health Service, Public Health Reports, June 2, 1916, pl359-1407.
GEORGIA
Atlanta-^Umdholm, S. G. Report of survey of the Department of Health. New
York Bureau of Municipal Research, 1912. 44p.
Atlanta — Schneider, Franz, jr. Survey of the public health situation. Atlanta
Chamber of Commerce, 1913. 22p.
JiBLIOGRAPHY 1039
ILLINOIS
Grubbs, S. B. Public health administration in Illinois. Reprint 275, U. S.
Public Health Service, Public Health Reports, May 21, 1912.
Mathews, J. M. Report on public health administration. State Efficiency and
Economy Committee, Springfield, Illinois, 1914. 54p.
Chicago— Perry, J. C. Public health administration in Chicago. U. S. Public
Health Service, Public Health Reports v30 p2536-2561 August 27, 1915.
Freepori — Sanitary and health survey of the city of Freeport; conducted by Depart-
ment of Public Health in cooperation with civic organixations of Freeport. Super-
vised by P. L. Skoog. Illinois Health News v.4 n. s. no.5 p75-106 May 1918.
Quiney — Fox, Carrol Public health administration in Quincy.' Reprint 428, U. S.
Public Health Service, Public Health Reports, October 5, 1917, pl665~1679.
Springfield — ^Palmer, G. T. Sanitary and health survey. Reprint from Academy
of Political Science Publications v.2 no.4 1912. 50p.
Springfield — Schneider, Franz, jr. Public health in Springfield. Russell Sage
Foimdation, Department of Surveys and Exhibits, 1915. 159p.
White County — Foster, I. A. and Fulmer, Harriet Health survey of White County;
made imder auspices of Illinois State Board of Health and Illinois State Associa-
tion for the Prevention of Tuberculosis. Springfield Board of Health, 1915. 23p.
INDIANA
Eaet Chicago — Hendrich, A. W. Public health in East Chicago. East Chicago
Departmentof Health, 1916. 42p.
South Bend — Fox, Carrol Public health administration in South Bend. U. S.
Public Health Service, Public Health Reports v.32 p776-805 March 25, 1917.
KANSAS
Sumner County — Sumner Coimty sanitary and social survey. Kansas State
Board of Health Bulletin v.9 no.5 May 1915.
Topeka — Schneider, Franz, jr. Public health survey of Topeka. Russell Sage Foim-
dation, Department of Surveys and Exhibits, 1914. 98p.
KENTUCKY
Crane, Mrs. C. J. (B) Sanitary conditions and needs of Kentucky. Kentucky
Medical Journal v.7 no. 13 August 1, 1909. 44p.
MAINE
LewiMton and Auburn — Pratt, A. P. Public health administration in Licwiston
and Auburn ; a report of a survey made under direction of the State Department
of Health for Public Health District Health Officer, Augusta. State Department of
Health Bulletin v.l n. s. nos. 10-11 pi 5 1-1 70 October-November.
1040 Hospital, and Health Sxjbtet
Portland — ^Pratt, A. P. Public health administration in Portland; a report of a
survey made under the direction of the State Department of Health. State D^
partment of Health Bulletin, v.l n. s. no.3 p58--75 March 1918.
MAR YLAND
Fox, Carrol Public health administration in Maryland. Reprint 166, U. S.
Public Health Service, Public Health Reports, January 30, 1914. 80p.
Baltimore — Fox, Carrol Public health administration in Baltimore. Reprint 201,
U. S. Public Health Service, Public Health Reports, June 12, 1914. 80p.
MASSACHUSETTS
Springfield — ^McCombs, C. E. Organization and administration of the health d^
partment of Springfield. Springfield, Bureau of Mimicipal Research, 1914. 48p.
(o. p.)
Taunton and Quiney — Horowitz, M. P. A synoptic report on a comparative
sanitary survey of two Massachusetts cities. Reprint, American Journal of
Public Health v. 7 no.8 p698-711. Sanitary Research Laboratory of Massacho*
setts Institute of Technology, Cambridge, Massachusetts.
MICHIGAN
Ann Arbor — Folin, J. W. Health survey. U. S. Public Health Service, Public Health
Reports v.4 n. s. p536-539 October 1916.
SaginaW' — Crane, Mrs. C. J. (B) Sanitary survey of Saginaw. 1911. Kalamazoo,
Michigan. The author. 42p.
MINNESOTA
Crane, Mrs. C. J. (B) Report on a campaign to awaken public interest in sani-
tary and sociologic problems in the state of Minnesota. State Board of Health,
1911. 239p.
Fox, Carrol Public health administration in Minnesota. Reprint 223, U. S.
Public Health Service, Public Health Records, October 2, 1914.
Minneapolia — Biggs, H. M. and Winslow, C-E. A. Ideal health department.
Minneapolis, Civic and Commerce Association, 1912. 36p. (o. p.)
St. Paul — Efficiency and next needs of St. Paul's Health Department. New York
Bureau of Mimicipal Research, 1913. 48p.
St, Paul — Flint, E. M. and Aronovici, Carrol Health conditions and health service
in St. Paul. Amherst H. Wilde Charity, 1919. lOp.
St. Paul — Young, G. B. Public health administration in St. Paul. U. S. Public
Health Service, Public Health Reports v.32 no.2 p41-71 January 12, 1917; and
2d U. S. Public Health Service. Public Health Reports v32 no3 p99-138 January
19, 1917.
Bibliography 1041
WISSOURi
5#. Joseph — White, J. H. Report of a sanitary survey of St. Joseph. Reprint 185,
U. S. Public Health Service, Public Health Reports, August 24, 1914.
NEBRASKA
Fox, Carrol Public health administration in Nebraska. Reprint 348, U. S.
Public Health Service, PubUc Health Reports v.31 no.27 pi 750-1 775 July 1916.
NEVADA
Fox, Carrol Public health administration in Nevada. Reprint 317, U. S. Public
Health Service, PubUc Health Reports, December 31, 1915, p3802-3823.
VJ^H^ JERSEY
Glen Ridge — Horowitz, M. P. Sanitary survey of the Borough of Glen Ridge.
Massachusetts Institute of Technology, Department of Biology and Public Health,
1916. 41p.
Hoboken — Sanitary survey of Hoboken. New York Bureau of Municipal Research,
1913. 31p.
VEW MEXICO
Kerr, J. W. Public health administration in New Mexico. U. S. Public Health
Service, Public Health Reports v.33 no.46 pl976-1995 November 15. 1918.
WEW YORK
Report of special public health commission, Albany, New York, 1913. 36p.
Durbea, C. J. Preliminary inquiry into the health needs of rural people of the
state of New York. 36th Annual Report of State Department of Health v3
p79-138 December 31, 1915.
«
Amsterdam — Terry, C. E. and Schneider, Franz, jr. Report of health inventory of
the city of Amsterdam, 1917. lip. (Delineator 7th Baby Campaign)
lihaea — Schneider, Franz, jr. Survey of the public health situation. Russell Sage
Foundation, Department of Surveys and Exhibits, 1914. 34p.
New York City — Baker, S. J. Classroom ventilation and respiratory diseases
among school children. Reprint Series 68, New York City Department of Health,
February 1918. lOp.
New York City — Neal, J. B. Work of the meningitis division of the Bureau Labora-
tories; illness census taken in Health District no.l. New York City Department
of Health B\illetin v.6 no.3, p67-86 March 1916.
Onondaga — Sears, F. W. Study of sanitary conditions on the Onondaga Indian
Reservation. Health News, Indian Conference number v. 14 no.4 April 1919.
Rochester — Crane, Mrs. C. J. (B) Sanitary survey of Rochester, 1911. Kalama-
zoo, Michigan. The author. 119p.
1042 Hospital and Helalth Survey
Syraeute — Shipley, A. E. Report on Syracuse Board of Health. New York Buren
of Municipal Research, 1912. 12p.
NORTH CAROLINA
Brooker, W. H. Teaching health by motion pictures. North Carolina State
Board of Health BuUedn v31 no.2 April 1916. "How public health is bdag
taught in rural districts by means of traveling motion pictures."
Raleigh — Terry, C. E. Health survey of Raleigh. Wake County of National D^
fense. Child Welfare Department, 1918. 29p.
NORTH DAKOTA
Fox, Carrol Public health administration in North Dakota. Reprint 315, U. S.
Public Health Service, Public Health Reports, December 1915, p3658-3688.
OHIO
Dayton — Organization and administration of the Department of Health. DaytoD,
Bureau of Municipal Research, 1913.
Piqua — Fox, Carrol Public health administration m Piqua. U. S. Public Healtii
Service, Public Health Reports v.32 no.25 p974-986. Jime 22, 1917.
PoriMntouih — Southmayd, H. J. Health survey. Ohio Public Health Journal v S
p398-411 September 1917.
Springfield — Fox, Carrol Public health administration in Springfield. Reprint
417, U. S. Public Health Service, Public Health Reports, August 10. 1917, pl255-
1278.
Toledo — Fox, Carrol Public health administration in Toledo. Reprint 284, U. S.
Public Health Service, Public Health Reports, June 25, 1915.
Youngstown — Fox, Carrol Public health administration in Yoimgstown. U. S.
Public Health Service, Public Health Reports v.31 no.39 p2653-2685 Septem-
ber 29, 1916
OKLAHOMA
Norman — Mahr, J. C. and Ellison, Gayfree, comp. Report of the sanitary survey
of the town of Norman, made in September 1914. State Board of Health. 37p.
PENNSYLVANIA
Erie — Crane, Mrs. C. J. (B) General sanitary survey of Erie, 1910. Kalamaaoo,
Michigan. The author. 22p.
Pittsburgh — Report of a survey of the Department of Public Health, Bureau of
Municipal Research. Pittsburgh City Council 1913. 62p. (o.p.)
Reading — -Report on Department of Health. New York Bureau of Municipal Re-
search. Reading Chamber of Commerce, 1913. 46p.
Bibliography 1043
Unioriiown — Crane, Mrs. C. J. (B) Sanitary survey of Uniontown. Women's
Civic League, Uniontown, 1914. 51 p.
RHODE ISLAND
Gilbert, R. W. A study of a typical mill village from the standpoint of health.
Rhode Island Anti-Tuberculosis Association Report, 1910. 15p.
Pawtueket — Gunn, S. M. Report on the public health activities of the city of
Pawtucket, Pawtueket Business Men's Association, 1913. 18p.
TENNESSEE
Nauhville — Crane, Mrs. C. J. (B) General sanitary survey of Nashville, 1910.
Kalamazoo, Michigan. The author. 24p.
TEXAS
El Paao — Rich, J. P. and Arms, B. L. Preliminary report of the health survey of
El Paso; and, Grossman, J. H. Housing health survey. El Paso Chamber of
Commerce, 1915. 8p.
GalveMton — Report of a sanitary survey of Galveston. Galveston Commercial Asso-
ciation, n.d. 30p.
WASHINGTON
Crane, Mrs. C. J. (B) Report of sanitary conditions of cities of Washington.
State Board of Health Quarterly Bulletin v.4 no.l pl-36. January, February,
March 1914, incomplete.
Fox, Carrol Public health administration in the state of Washington. Reprint
255, U. S. Public Health Service, Public Health Reports, February 5, 1915. 56p.
WEST VIRGINIA
Clark, T. Public health administration in West Virginia. Reprint 252, U. S.
Public Health Service, Public Health Reports, January 22, 1915.
Charletion — Tolman, Mayo Survey commission of sanitary survey, 1917. 168p.
WISCONSIN
Milwaukee — Gunn, S. M. Health department, Milwaukee. Milwaukee Bureau of
Economy and Efficiency, 1912. Bulletins 13, 15, 18.
Milwaukee — New York Bureau of Municipal Research. April 1913. 131 p. Health
part 13p.
ITALY
Traveling dispensaries of Italy. The Public Health Nurse. November 1918.
p261-262'. Three illustrations of trucks used for dental and dispensary purposes.
RUSSIA
Winslow, C-E. A. Public health administration in Russia in 1917. Reprint 445,
U. S. Public Health Service, Public Health Reports, December 28, 1917, p2191-
2219.
1044 HospiTAi. AND Health Survey
MENTAL HYGIENE SURVEYS
GENERAL
Femald, W. B. What is a practical way for prevention of mental defect? Na
tional Conference of Social Work. Proceedings, 1915. p289-297.
.Femald, W. B. Standardized fields of inquiry for clinical studies of
defectives. National Committee for Mental Hygiene. Reprint 8, 24p. Mental
Hygiene, April 1917.
Wallin, J. B. W. Scheme for the clinical study of mentally and educatioDally
imusual children. Yale University Press, 1914. 20p. Mental Health of the
School Child, Chapter 19 p429-450.
UNITED STATES
Bowen, A. L. Legislative provision for the feeble-minded; what should it be?
A study made of the plans and ideas of public and private organizatiocis in Mana-
chusetts. New York and Indiana for better provision for the feeble-minded. Spring-
field, Illinois, Public Charity Service of Illinois, Institutional Quarterly v.7 p6fr-
78 December 31, 1916.
Davenport, C. B. Feebly inhibited, violent temper and its inheritance. Bo*
genics Record Office, Bulletin no. 12 September 1915. Reprint, Journal of Nervous
and Mental Disease v.42 no.9 p593-628 1915.
ALABAMA
Haines, T. H. Report, December 1918. (not published)
ARKANSAS
Treadway, W. L. Feeble-minded, their prevalence and needs in the school
population of Arkansas. Reprint 379, U. S. Public Health Service, Public Health
Reports. November 1916, p3 23 1-3247.
CALIFORNIA
Bridgman, Olga Experimental study of abnormal children with special refer-
ence to the problems of dependency and delinquency. Berkeley University, Cali-
fornia. Publication in Psychology v.3 no.l March 30, 1918. 59p.
Terman, L. M., Williams, J. H., Femald, G. M. Surveys in mental deviation in
prisons, public schools and orphanages in California; brief description of local
conditions and need for custodial care and training of dependent, defective and
delinquent classes. California State Board of Charities and Corrections, 1918.
87p.
COLORADO
Hamilton, S. W. Care and treatment of the insane in Colorado. Report to Na-
tional Committee for Mental Hygiene, December 191 6- January 1917. (not
published)
CONNECTICUT
Wilgus, S. D. Survey of Connecticut. Report 4Tiade to National Committee for
Mental Hygiene, (not published)
Bibliography 1045
DELAWARE
Richardaon, C. S. Dependent, delinquent and defective children of Delaware*
Russell Sage Foundation, 1918. 88p.
New Caatle County — Lundberg, E. O. Social study of mental defectives in New
Castle County. U. S. Children's Bureau, Dependent, Defective and Delinquent
Classes Series no.3 Bureau Publication no.24, 1917. 38p.
New Caatle County — ^Mullan, E. H. Mental status of rural school children. Re-
print 377, U. S. Public Health Service, Public Health Reports, November 1916,
p3174-3187.
Suaaex County — Treadway, W. L. and Lundberg, E. O. Mental defect in a rural
county; a medico-psychological and social study of mentally defective children in
Sussex County. U. S. Public Health Service and U. S. Department of Labor,
Children's Bureau, Dependent, Defective and Delinquent Classes Series no.7
Bureau Publication no. 48. 96p.
»
'}ISTRICT OF COLUMBIA
Lundberg, E. O. Mental defectives in District of Columbia. U. S. Children's
Bureau Publication no.l3, 1915. 39p.
GEORGIA
Anderson, V. V. Mental defectives in a Southern state September 1918-Decem-
ber 1919; report of the Georgia Commission on feeble-mindedness and the survey
of the National Committee for Mental Hygiene; studies made mostly in institu-
tions and schools. 38p. Reprint from Mental Hygiene v.3 p52 7-565 October
1919.
Hutchings, R. H. Care and treatment of the insane in Georgia; report based on
survey of the state in September-November 1916 for National Committee for
Mental Hygiene, 161 typew. pages, (not published)
fLLINOIS
Chicago — Ransom, J. E. Study of mentally defective children in Chicago; an
investigation made by the Juvenile Protective Association, Chicago Association,
1915. 72p.
Cook County — Adler, H. M. And the mentally handicapped; a study of the pro-
visions for dealing with mental problems in Cook County. Report of survey
1916-1917. National Committee for Mental Hygiene Publication no.l3, 1918.
224p.
Springfield — Treadway, W. L. Care of mental defectives, the insane and alcoholics
in Springfield. Russell Sage Foimdation, Department of Surveys and Exhibits,
1915. 46p. (Springfield Survey)
INDIANA
Butler, A. W. Mental Defectives in Indiana; second report of the Indiana Com-
mittee on mental defectives to the Governor; a survey of 8 counties. Indianapolis,
1918. 56p.
1046 Hospital and Health Subvet
Wilgus, S. D. Survey of public care of the mentally diseased and defective in
Indiana, October 191&-December 1917. National Committee for Mental Hy-
giene. 186p. (not published)
Porter County — Clark, Taliaferro, Collins, G. L. and Tread way, W. L. Mental
studies of rural school children of Porter County. Reprint, U. S. Public Heahfa
Service, Public Health Bulletin no.77 1916. 127p.
KANSAS
The Kallikaks of Kansas; report of the Commission on provision for the feeble-
minded. Topeka, 1919. 31p.
KENTUCKY
Haines, T. H. Report on the condition of the feeble-minded in Kentucky to the
State Commission on Provision for the Feeble-minded. Frankfort, 1916. 23p.
LOUISiANA
Haines, T. H. 1920. (under way)
MAiNE
Report of the Maine commission for the feeble-minded and of the Survey by the
National Committee for Mental Hygiene. September 1917-Scptember 1918.
95p.
MAR YLAND
Anderson, V. V. 1920. (under way)
Baltimore — Campbell, CM. Subnormal child; a survey of the school children pop-
ulation in the Locust Point District of Baltimore. National Committee for Mental
Hygiene, Mental Hygiene v.l p96-147 January 1917.
MASSACHUSETTS
Community supervision of the feeble-minded; an analysis of 300 families in which
there is mental defect, by welfare agencies, members of the League for Preventive
Work. Boston, 1918. 14p.
Report of the commission to investigate the question of the increase of criminsla,
mental defectives and degenerates. Boston, 1911. 50p.
The mental defective and the public schools of Massachusetts; a study of special
classes for mental defectives in the public schools of Massachusetts. League for
Preventive Work, Publication no.2, 1917. 16p.
MICHIGAN
Report of the commission to investigate the extent of feeble-mindedness, epilepsy
and insanity, and other conditions of mental defectiveness in Michigan. Lans-
ing. 1915. 175p.
MISSISSIPPI
Haines, T. H. Mississippi mental deficiency survey, February-May 1920.
Jackson. 45p.
Bibliography 1047
MtSSOURi
HamUton, S. W. October 1919-April 1920. (to be published by State Board
of Charities)
NEW JERSEY
Wilgus, S. D. 1920. (under way)
NEW YORK
Defective delinquents; facts about defective delinquents, nature, prevalence,
institutional and legislative needs in the state of New York. Memorandum
submitted to the Hospital Development Commission by the New York Committee
on Feeble-mindedness and the Mental Hygiene Committee, State Charities Aid
Association, 1917. 15p.
Moore, Anne Feeble-minded in New York; a report prepcu^ for the Public
Education Association of New York. New York State Charities Aid Association,
1911. nip.
Naaaau County — Rosanofif, A. J. Survey of mental disorders in Nassau County.
National Committee for Mental H^ene Publication no.9 1916. 125p.
New York City — Irwin, E. A. Study of the feeble-minded in a west side school in
New York City. Public Education Association Bulletin no. 21 December 8,'_1913.
15p.
New York City — Kirby, G. H. Classification and treatment of mental defectives;
a preliminary report with recommendations to the Mayor. September-October
1916. 41 typew. pages.
New York City — Toas, E. M. A report of a survey of the children in the ungraded
classes of the Borough of the Bronx. Ungraded Teachers' Association of New
York City, "Ungraded" no3 p75-82 104-107. January-February 1918.
Oneida County — Carlisle, C. L. Causes of dependency; based on a survey of Oneida
County. State Board of Charities, Division on Mental Defect and Delinquency,
1918. Eugenics and Social Welfare Bulletin, no. 15. 465p.
NORTH CAROLINA
MacDonald, S. D. February-May 1920. (under way)
OHIO
Sessions, M. A. Feeble-minded in a rural county of Ohio. Bureau of Juvenile
Research, Biilletin no.6. Publication no. 12 February 1918. 69p.
PENNS YLVANIA
Finlayson, A. W. Dack family; a study in hereditary lack of emotional control.
Eugenics Record Office Bulletin no.lS May 1916. 46p.
Haviland, C. F. Treatment and care of the insane in Pennsylvania. Philadel-
phia Public Charities Association, 1915. 94p.
1048 Hospital and Health Subvet
Key, W. E. Feeble-minded citizens in Pennsylvania. Philadelphia Public
Charities Association, 1915. 63p.
Philadelphia — Three pamphlets: 1 — Fate of the friendless feeble-minded women,
8p; 2 — Number of the feeble-minded, 13p; 3 — Public provision for the feebfe-
minded, a symposium, 16p. Philadelphia Department of Health and Chaxities.
• J. S. Neff, Director.
Philadelphia — Salmon, T. W. June 1920. (under way)
Scranton — Salmon, T. W. Treatment of the insane in the Scranton poor district
1916.
SOUTH CAROLINA
Report on the State Hospital for the Insane at Columbia. January 1915. A. P.
Herring, investigator. 20p.
Columbia — Report sent to Hon. Richard I. Ifanning, Governor of South Carolina,
on the State Hospital for the Insane at Columbia, with recommendations by A. P.
Herring, 1915. 20p.
TENNESSEE
Haines, T. H. Department of State Charities and Tennessee Society for Mental
Hygiene, January-April 1919.
Wilgus, S. D. Report to National Committee for Mental Hygiene, October-
December 1915. (330 typcw. pages, not published)
TEXAS
Salmon, T. W. Most urgent needs of the insane in Texas; an address, February
1916.
Grayson County—Salmon^ T. W. Insane in a country poor farm. National Com-
mittee for Mental Hygiene. 9p. Reprint, Mental Hygiene v.l no.l p25-33. Jan-
uary 1917.
WISCONSIN
Anderson, V. V. 1920. (under way)
Hart, H. H. Wisconsin system of county asylums for the insane proposed for
adoption in Oklahoma; a special report. Racine. The author. 1908. 12p.
Haviland, C. F. County care. September-October 1913.
Gillen, J. L. Some aspects of feeble-mindedness in Wisconsin. Universit>' of
Wisconsin Bulletin Serial no.940, General Series no.727, June 1918. 30p.
CANADA
Ontario — MacMurchy, Helen The feeble-minded in Ontario. Toronto, 1913. 52p.
IBUOORAPHT 1049
INFANT MORTALITY AND CHILD WELFARE SURVEYS
ENERAL
Meigs, G. L. Infant welfare in wartime. American Medical Association. Re-
print from the American Journal of Diseases of Children v. 14 p80-97 August
1917.
WtTED STATES
Baby-saving campcugns; a preliminary report on what American cities are doing
to prevent infant mortality, 1913. U. S. Department of Labor, Children's Bureau,
Infant Mortality Series no.l. Bureau Publication no.3. 93p.
Infant mortality and its relation to the employment of mothers, prepared under
the direction of C. P. Neill v.l3 174p. Report on condition of women and child
workers in the United States, U. S. Senate 61st Congress Second Session, Docu-
ment 645. 19 vols.
Infant mortality and milk stations; special report dealing with the problem of re-
ducing infant mortality; work carried on in ten cities in the United States together
with details of administration of public and private agencies in New York State
during 1911 to determine the value of milk station work as a direct means of re-
ducing infant mortality. New York City, Milk Committee, 1912. 176p.
Hibbs, H. H. jr. Infant mortality; its relation to social and industrial conditions.
Russell Sage Foundation, 1916. 127p.
Phelps, E. B. Statistical survey of infant mortality's urgent call for action.
American Statistical Association, Quarterly Publication, v. 12 no.92 p341-359 De*
cember 1910.
Van Ingen, Philip Recent progress in infant welfare work. American Medical
Association, 1914. 23p. Reprint from the American Journal of Diseases of
ChUdren v.7 p471-493 June 1914.
lABAMA
Child welfare in Alabama; an inquiry by the National Child Labor Committee
under the auspices and with the cooperation of the University of Alabama, E. N.
Clopper, director. New York City. The committee. 1918. 249p.
9NNECTICUT
Water bury — Hunter, E. B. Infant mortality; results of field study in Waterbury,
based on births. U. S. Department of Labor, Children's Bureau, Infant Mor-
tality Series no.7. Bureau Publication no.29 157p.
.UNOIS
Chicago — Guild, A. A. Baby farms in Chicago; an investigation made for the Ju-
venile Protective Association. Chicago. The association. 1917. p27-34.
Chicago — Kingsley, S. C. Steps in the evaluation of baby welfare work in Chicago.
Elizabeth McCormick Memorial Fund, 1914 32p.
1050 Hospital and Health Subtet
Springfield — Gcister, Janet The child welfare special; description of child wd&re
special of Children's Bureau and its tour. Springfield, Institution Quarteriy,
December 31, 1919. pl20-125.
KANSAS
Moore, Elizabeth Maternity and infant care in a rural county in Kansas.
U. S. Children's Bureau, Rural Child Welfare Series, no.l, Bureau Publication do.
26, 1917. 50p.
KENTUCKY
Slingerland, W. H. Child welfare work in Louisville; a study of conditioos,
agents and institutions. Louisville Welfare League, 1919. 152p.
LOUISIANA
New Orleans and Louisiana — Slingerland, W. H. Constructive program of orgao-
ized child welfare work for New Orleans and Louisiana. An address delivered
before the Social Workers' Section Southern Sociological Congress at New Orleans.
April 1916. Russell Sage Foundation, 1916. Reprint from proceedings of the
Congress for the Department of Child Helping, Russell Sage Foundation, July
1915. 36p.
MASSACHUSETTS
Phelps, E. B. Infant mortality and its relation to women's employment; t
study of Massachusetts statistics. Women and Child Wage Earners in the United
States V.12 part 1 pl-121 1911.
Safford, M. V. Influence of occupation on health during adolescence. U. S.
Public Health Service, Public Health Bulletin no. 78, August 1916. 51 p.
Brockton — Dempsey, M. V. Infant mortality; results of a field study in Brockton,
based on births in one year. U. S. Department of Labor, Children's Bureau. In-
fant Mortality Series no. 6, Bureau Publication no. 37, 1919. 82p.
Fall River — Dublin, L. I. Infant mortality in Fall River; a survey of the molality
among 833 infants bom in June, July and August 1913. American Statistics!
Association, Quarterly Publication v. 14 p505-520 June 1015,
Fall River — Keisker, L. M. Infant mortality and its relation to the employment of
mothers in Fall River. Women and Child Wage Earners in the United States
v.12 part 2p75-174 1911.
MONTANA
Paradise, V. I. Maternity care and the welfare of young children in a home-
steading county in Montana. U. S. Department of Labor, Children's Bureau,
Rural Child Welfare Series no.3, Bureau Publication no.34, 1919. 98p.
NEW HAMPSHIRE
Young, A. A. Birth rate in New Hampshire. American Statistical Association.
Quarterly Publication v.9 p263-281 September 1905.
Bibliography 1051
NEW JERSEY
EtBex County — Infant mortality report of the Public Welfare Committee of Essex
County. Newark. The committee. 1912. 32p.
Montclair — Infant mortality; a study of infant mortality in a suburban community.
U. S. Department of Labor, Children's Bureau, Infant Mortality Series no. 4,
Bureau Publication no.ll, 1915. 36p.
NEW YORK
New York City — Boarded-out babies, L. D. Wald, director. The Association of
Neighborhood Workers of the City of New York, n. d. 7p.
New York City — Infant mortality and the milk situation; special report of the Com-
mittee for the reduction of infant mortality of the New York Milk Committee, New
York City Milk Committee, 1912. 176p.
Ogd^aburg — Wakeman, B. R. Survey of the infant mortality and stillbirths of
the city of Ogdensburg, for the year 1915. 36th Annual Report of the New York
State Department of Health v.3 p44-73 1915.
NORTH CAROLINA
Bradley, F. S. and Williamson, Margaretta Rural children in selected coun-
ties of North Carolina. U. S. Department of Labor, Children's Bureau, Rural
Child Welfare Series no.2, Bureau Publication no.33, 1918. 118p.
Child welfare in North Carolina; an inquiry by the National Child Labor Com-
mittee for the North Carolina conference for social service. W. H Swift, director.
New York City. The committee. 1918. 314p.
OKLAHOMA
Child welfare in Oklahoma; an inquiry by the National Child Labor Committee
for the University of Oklahoma. E. N. Clopper, director. New York City. The
committee. 1917. 285p.
OREGON
Slingerland, W. H. Child welfare work in Oregon ; a study of public and private
agencies and institutions for the care of dependent delinquents and defective chil-
dren for the Oregon Child Welfare Commission. University of Oregon Extension
Division Bulletin, July 1918. 131p.
PENNS YLVANIA
Child welfare symposium; 25 special papers contributed by leading Pennsylvanians,
supplement to Child Welfare Work in Pennsylvania. Russell Sage Foundation,
4915. 138p.
Hart, H. H. Summary of child welfare work in Pennsylvania. Russell Sage
Foundation, 1915. 34p.
Slingerland, W. H. Child welfare work in Pennsylvania; a cooperative study of
child helping agencies and institutions. Russell Sage Foimdation, 1915. 352p.
1052 Hospital and Health Suevet
RHODE ISLAND
Aronovid, Carrol Some nativity and race factors in Rhode Island. Provi-
dence, 1910. Reprint from Annual Report of the Commission of Industrial Sta-
tistics of Rhode Island, 1909. p219-423.
WISCONSIN
Brown, F. B. and Moore, Elizabeth Maternity and infant care in two niral
counties in Wisconsin. U. S. Children's Bureau, Rural Child Welfare Series na
4, Bureau Publication no.46, 1919. 92p.
CANADA
Ottatoa — Traveling baby clinic; Ottawa trucks used as clinics. Conservation of
Life, July 1919. p60-62.
ENGLAND
Unwin, T. F. Second report on infant and child mortality in London. Alod
Annual Report of the Local Government Board, 1912-1913. 41 Ip. Supplement
in continuation of the report of the medical officer of the board for 1912-1913.
SOCIAL SURVEYS
UNITED STATES
Taylor, G. R. Satellite cities. New York, Appleton, 1915. 333p.
ALABAMA
Birmingham — Kellogg, P. U., Harrison, S. M. and others. Smelting iron ore and
civics. Survey v.27 pl451-1556 January 6, 1913.
CALIFORNIA
Los Angeles — Bartlett, D. W. Better city; a sociological study of a modem dty.
Los Angeles, 1907. 248p.
San Diego — King, E. S. and F. A. Pathfinder social survey of San Diego. San
Diego College Women's Club, 1914. 48p.
CONNECTICUT
Bridgeport — Report on welfare work in Bridgeport and elsewhere. Committee of
Manufacturers* Association, 1918.
New Haven — Documents of the civic federation. 15 pamphlets. The Federation,
1909-1915.
ILLINOIS
Chicago — Reports of the Bureau of Social Surveys. Chicago Department of Public
Welfare, semi-annual report, 1914-1915.
Springfield — Springfield survey. S. M. Harrison, director. 10 pamphlets. RusscO
Sage Foundation, Department of Surveys and Exhibits, 1915. Treadway, W. L.
Care of mental defectives, the insane and alcoholics. 46p. Schneider, Franii
jr., Public health. 159p.
Bibliography ' 1053
KANSAS
Belleville — Burgess, E. W. and Sippy, J. J. Belleville social survey. University of
Kansas, n. d. 70p.
Lawrence — Blackmar, F. W. and Burgess, E. W. Social survey of Lawrence, 1917.
122p.
Minneapolia — ^Elmer, M. C. Siirvey by, 1918. 39p.
Topeka — ^Topeka improvement survey. S. M. Harrison, director. 4 pamphlets.
Russell Sage Foundation, Department of Siuveys and Exhibits, 1914. Schneider,
Franz, jr., 3rd part — ^Public health.
MASSACHUSETTS
Lawrence — Todd, R. E. and Sanborn, F. B. Report of the Lawrence survey. Trus-
tees of the White Fund, 1912. 262p. Covers milk supply and housing.
Lowell — Kengott, George Record of a city. New York,* Macmillan, 1912 257p.
MISSOURI
Kanaaa Clf3^— Reports of public welfare board. 1913. 104p.
Springfield — Springfield social survey, W. T. Cross, director, R. H. Leavell, field
worker* Springfield Social Siuvey Council n. d. 33p.
iV:Ell^ JERSEY
Montclair — Bums, A. T. Need and scope of a social survey. Montclair. Survey
committee, 1912. 23p.
NEW YORK
Albany — ^Hun, M. V* Some facts about Albany. Albany. The author. 1912. 30p.
Buffalo — Daniels, John Americanizing 80,000 Poles. Survey v.24 p3 73-385 June
4, 1910.
#
Newhurgh — Newburgh siuvey. Z. L. Potter, director of field work. Russell Sage
Foundation, Department of Siuveys and Exhibits, 1913. 104p.
NORTH DAKOTA
Fargo — Social survey of Fargo, by Social Science Department, Fargo College, under
M. C. Elmer. Fargo Associated Charities, 1915. 46p.
PENNS YLVANIA
Cooperaburg — Morrison, T. M. Coopersburg survey. Easton, Moravian Country
Church Association, 1915. 34p.
Pittaburgh — Holdsworth, J. T. Economic survey of Pittsburgh. Pittsburgh. The
author. 1912. 229p.
Pittaburgh — Kellogg, P. U., editor Pittsburgh survey. New York Charities Pub-
lishing Committee, 1909-1914. 6 vols. Russell Sage Foundation publication 6
parts.
1054 Hospital and Health Survey
- — — - - f~ - I ■
Reading — Report on a survey of the municipal departments and the school dis-
trict. New York Bureau of Mimicipal Research, 8 pamphlets. Reading Chamber
of Commerce, 1913. 1 — Department of Health. 46p.
Scran ton — Harrison, S. M. and others. Scranton in quick review. Scrantoo Cen-
tury Club, 1913. 31p.
RHODE ISLAND
Newport — Aronovici, Carrol Newport siirvey of social problems, Newport Sur-
vey Committee, 1911. 59p.
Prowidence — Kirk, William Modem city. University of Chicago Press, 1909.
363p.
TEXAS
Austin — Hamilton, B. Social survey of Austin. 1913. Bulletin University of Tezat,
Humanistic Series no. 15.
Austin — Terry, C. E. and Schneider, Franz, jr. Social survey of the city of Austin.
40p. (Delineator 7th Baby Campaign, 1917.)
WISCONSIN
Milwaukee — Bureau of Economy and Efficiency. Bulletins 1-19. 1911-1912. (o. p.)
CANADA
London — Riddell, W. A. and Myers, A. J. W. Survey. Toronto Board of Sodil
Service and Evangelism, Presbyterian Church, 1913. 99p.
Regina — Woodsworth, J. S. Report of a preliminary and general social survey of
Regina. Toronto Board of Social Service and Evangelism, 1913. 48p.
Sydney — Stewart, B. M. Preliminary and general social survey of Sydney. To-
ronto Board of Social Service and Evangelism, Presbyterian Church, 1913. 29p.
INDUSTRIAL HYGIENE SURVEYS
UNITED STATES
Danger to workers from dusts and fumes, and methods of precaution. U. S.
Department of Labor, Bureau of Labor Statistics, Bulletin Industrial Accidents and
Hygiene Series no.3 whole no.l27 August 12, 1913. 22p.
Eye hazards in industrial occupations; a report of typical cases and conditions
with recommendations for safe practice. National Committee for Prevention of
Blindness no. 12, 1917. 145p.
Hygiene of the painters* trade. U. S. Department of Labor, Bureau of Labor
Statistics, Bulletin Industrial Conditions and Hygiene Series no. 2, whole no.l20
May 13, 1913. 68p.
Lead poisoning in the manufacture of storage batteries. U. S. Department of
Labor, Bureau of Labor Statistics, Bulletin Industrial Accidents and Hygiene
Series no.6 whole no. 165 December 15, 1914. 38p.
Bibliography 1055
Lead poisoning in potteries, tile works and porcelain enamelled sanitary ware
factories. U. S. Department Commerce and Labor, Bureau of Labor Statistics,
Bulletin Industrial Accidents and Hygiene Series no.l whole no. 104 August 7,
1912. 95p.
Lead poisoning in the smelting and refining of lead. U. S. Department of Labor,
Bureau of Labor Statistics, Bulletin Industrial Accidents and Hygiene Series no. 4
whole no.l41 February 17, 1914. 97p..
Schroeder, M. C. and Southerland, S. G. Laundries and the public health. U. S.
Public Health Service. Public Health Reports v.32 p225-246 February 9, 1917.
Boaton, New York City, Philadelphia, Baltimore, Washington, Chicago, St.
Louis — Hamilton, Alice and Verrill, C. H. Hygiene of the printing trades. U. S.
Department of Labor, Bureau of Labor Statistics Bulletin Industrial Accidents
and Hygiene Series no. 12 whole no.209. 118p.
Orange Valley, NeuMirk, Danhury, Philadelphia, Fall River — Sanitary standaids
for the felt hatting industry. Jrenton. The state. 1915
INDiANA
White, M. J. Sanitary survey of Indiana industries employing women labor.
U.S. Public Health Service, Supplement 17 to Public Health Reports, Jiily 17, 1914.
44p.
MASSACHUSETTS
Hygiene of the boot and shoe industry in Massachusetts. Boston. The state.
1912. 31p. 7 plates.
Report of the State Board of Health upon the sanitary condition of factories,
workshops and other establishments where persons are employed. Boston.
The state. 1907. 144p.
NEW YORK
New York City — Goldmark, Pauline. Notes on an industrial survey of a selected
area in New York City, with respect to sanitary conditions in the factories.
1917. Reprint of appendix 5 to preliminary report of the New York State
Factory Investigating Commission. Submitted to Legislature March 1, 1912.
p297-363.
New York City — Guilfoy, W. H. and Wynne, S. W. Illness census taken in Health
District no.l. New York City Department of Health Bulletin v.6 no.2 p71-80
March 1916.
New York City — Harris, L. I. Clinical and sanitary study of the fur and hatters
fur trade. New York City Department of Health Bulletin v.5 no.lO p267'-298.
October 1915.
New York City — Harris, L. I. Clinical study of the frequency of lead, turpentine
and benzine poisoning in 400 painters. New York City Department of Health
reprint, surveys no.65, August 1918.
1056 Hospital and Hel^lth Survey
New York City — Harris. L. I. Health of workers in garages; a preliminary study.
New York City Department of Health Bulletin v.8 no. 1 1 . November 1918.
New York City — Harris, L. I. and Swartz, Nelle Cost of clean clothes in tenns
of health; a study of laundries and laundry workers in New York City, 1916. 96p.
New York City — McMillan, M. B. Sanitary survey of a "Trial" city block. New
York City Department of Health Bi^etin v.6 no.8 p2 15-220. August 1916.
New York City — ^Pratt, E. E. Occupational diseases; a preliminary report on lead
poisoning in the City of New York with an appendix on arsenical poisoning. 1912.
Reprint of appendix 6 to preliminary report of the New York State Factory Investi-
gating Commission. Submitted to Legislature March 1, 1912. p365-596.
New York City — Price, G. M. General survey of the sanitary conditions of the
shops in the doak industry. Reprint from 1st Annual Report of the Joint Bosrd
of Sanitary Control in the cloak, suit and skirt industry of Greater New York.
1911. 40p.
New York City — Price, G. M. Special report on sanitary conditions in the shopi
of the dress and waist industry; a preliminary report made by the Joint Board
of Sanitary Control in the dress and waist industry, 1913. 23p.
New York City — Report on the sanitation of bakeries in New York City. New
York Commissioner of Sanitation of Bakeries, 1911. 16p.
New York City — Schcrcschewsky, J. W. Health of garment workers. U. S. Pub-
lic Health Service, Public Health Reports v.31 no.21 pl298-1305 May 26,
1916.
New York City — Schroeder, M. C. and Southerland, S. C. Laundries and the public
health. U. S. Public Health Service, Public Health Reports v.32 no.6 p225-246
February 9, 1917.
New York City — Studies in vocational disease: Schereschcwsky, J. W., Health of
garment workers; and, Schereschcwsky, J. W. and Tuck, D. H., Hygienic con-
ditions of illumination in workshops of the women's garment industry. U. S.
Public Health Service Bulletin no.71, 1915.
New York City — Wynne, S. W. Second illness census in the experimental health
district. New York City Department of Health Bulletin v.6 no. 11 p289-314
November 1916.
OHIO
Hayhurst, E. R. Industrial health hazards and occupational diseases in Ohio.
Columbus State Board of Health, 1915. 438p.
GREAT BRITAIN
Hours, fatigue and health in British munition factories. U. S. Department of
Labor, Bureau of Labor Statistics Bulletin Industrial Accident and Hygiene Series
no.l5 whole no.221 April 1917. 147p.
Bibliography 1057
TUBERCULOSIS SURVEYS
GENERAL
Homan, J. Instruction of the public in anti-tuberculosis measures by a traveling
exhibit. Journal American Medical Association v.55 pl072-1073. September 24,
1910.
Ransome, Arthur International researches in tuberculosis. The Weber-Parkes
Prize Essay, 1897. London, England, 1898. 84p.
ALASKA
Michel, H. C. Tuberculosis survey of an Alaskan Eskimo village, using children
under the age of 15 years as an index. Reprint 90, Medical Record, October 14,
1916, P663-666. Wm. Wood & Co.
GEORGIA
Anti -tuberculosis activities in Georgia. Atlanta Raoul Foundation, 1916. Folder
no.3. (unpublished)
ILLINOIS
Chicago — O'Neill, E. J. School siuvey as observed at Stock Yards dispensary.
Municipal Tuberculosis Sanitarium Monthly, Bulletin no.l pl3-15 March 1918.
Chicago — Robertson, J. D. Tuberculosis problem in the city of Chicago. Reprint,
American Journal of Public Health, April 1918. lip.
INDIANA
Richmond — Perry, J. C. Report of a survey to determine an incident of tubercu-
losis. U. S. Public Health Service, Supplement 26 to Public Health Reports,
October 8, 1915. 62p.
MASSACHUSETTS
Barnstable County — Billings, B. W. Tuberculosis survey. Boston State Depart-
ment, Health in Commonwealth v.5 p207-210 August 1918.
Boston — Locke, E. A. and Floyd, Cleaveland Economic study of 500 consump-
tives treated in the Boston Consimiptive Hospital, 1911. Reprint, Transactions
of the New York Association for the Study and Prevention of Tuberoilosis. 9p.
Framingham — Armstrong, D. B. Community health and tuberculosis demon-
stration; a series of pamphlets Monograph 1 — The program, Medical series 1 — The
sickness census, 2 — Medical examination campaign, 3 — Tuberculosis findings.
1917-1918.
MICHIGAN
Report of the tuberculosis survey of the State Board of Health for the 12 months
from October 1915 to October 1916. Lansing. The state. 1917. 89p.
MINNESOTA
Minneapolis — Lampson, H. L. Study of the spread of tuberculosis in families.
University of Minnesota studies in Public Health Bulletin no.l, December 1913.
50p.
1058 Hospital and Health Survey
MISSOURI
Joplin — Lanza, A. J. and Higgins, Edwin Pulmonary disease among miners m
the Joplin district and its relation to rock dust in the mines; a preliminary it-
port. Department of Interior, Bureau of Mines, Educational paper 105, 1915.
47p.
NEW JERSEY
Tuberculosis survey of New Jersey and report. Newark, New Jersey, Anti-
Tuberculosis League, 1917. 48p.
NEW YORK
Amaterdam — Brown, U. D. Houses of Amsterdam with some notes on the prev-
alence of tuberculosis. State Charities Aid Association, 1917. 61p.
Clinton County — Smith, J. A. A tuberculosis survey of Clinton County. New
York State Department of Health, Health News, March 1919, p56-62.
New York City — Dispensary control of tuberculosis in New York City. 11th Annual
Report of the Association of Tuberculosis Clinics of the City of New York, 1918.
35p.
Saranac Lake — ^Ames, F. B. A tuberculosis survey of the residents of Saranac
Lake. National Tuberculosis Journal, American Review of Tuberculosis v.2 na4
p207-236 June 1918.
OHIO
Survey of the tuberculosis situation in the state of Ohio; prepared by the Ohio
State Society for the Prevention of Tuberculosis. State Board of Health, 1912.
49p.
Cincinnati— Nelson, N. A. Study of tuberculosis mortality, 1910-1917. with
special reference to the Negro. Anti-Tuberculosis League allied drive for PuUic
Health, pl8-29.
Cincinnati — Robinson, D. E. and Wilson, J. G. Tuberculosis among industrial
workers. U. S. Public Health Service, Public Health Bulletin no.73, 1916. 143p.
PENNS YLVANIA
Pittsburgh — Steward, A. E. and Simmonds, V. S. Tuberculosis League; first sur-
vey report of Dispensary Aid Society on tuberculosis and infant welfare; a study
of 8 city squares, 1916. 65p.
RHODE ISLAND
Gilbert, R. W. A study of a typical mill village from the standpoint of health.
Rhode Island Anti -Tuberculosis Association report, 1910. 15p.
VERMONT
New features in the anti-tuberculosis campaign. Vermont State Board of
Health Bulletin v.l3 no.3 p71-75 March 1, 1913.
Bibliography 1059
GERMANY
Care of tuberculosis wage earners in Germany. U. S. Department of Commerce
and Labor, Bureau of Labor Bulletin Workman's Insurance and Compensation
Series no.l, whole no.lOl July 1912. 183p.
SICKNESS SURVEYS
MASSACHUSETTS
BoBton — Frankel, L. K. and Dublin, L. I. Sickness survey of Boston. New York
City, Metropolitan Life Insurance Co., 1916. 23p.
MISSOURI
Kansas City — Frankel, L. K. and Dublin, L. I. Health census of Kansas City.
New York City, Metropolitan Life Insurance Co., 1917. lip.
NEW YORK
Dutchess County — ^A sickness survey in Dutchess County. New York, State Chari-
ties Aid Association^ Publication no.l36, 1915. 102p.
Dutchess County — Weber, J. J. A county at work on its health problems; a
statement of accomplishment by the Dutchess County Health Association during
the 16 months from August 1916 to December 1917, inclusive. New York,
State Charities Aid Association. 27p.
New York City — Health census of Chelsea neighborhood by Metropolitan Life
Insurance Company and Chelsea Neighborhood Association. New York City,
Metropolitan Life Insurance Co., 1917. 16p.
Rochester — ^Frankel, L. K. and Dublin, L. I. Community sickness survey. New
York City, Metropolitan Life Insurance Co., 1917. 22p.
NORTH CAROLINA
Frankel, L. K., and Dublin, L. I. Sickness survey of North Carolina. U. S. Public
Health Service, Public Health Reports v.31 no.41 p2820-2844 October 1916.
OHIO
O'Grady, John Public care of sick and diseased; a survey of hospital care in
Ohio infirmaries. Board of State Charities, Ohio Bulletin of Charities and Cor-
rection V.24 no.4 December 1918. 19p.
PENNSYLVANIA AND WEST VIRGINIA
Frankel, L. K. and Dublin, L. I. Sicknes3 survey of the principal ' cities in Penn-
sylvania and West \^rginia. New York City, Metropolitan Life Insurance Co.,
1917. 78p.
FENNS YLVANIA
Pittsburgh — Frankel, L. K. and Dublin, L. I. Sickness survey of Pittsburgh.
New York City, Metropolitan Life Insurance Co., 1917. 22p.
1060 Hospital and Health Survey
SOUTH CAROUNA
Sydenstricker, Edgar, Wheeler, G. A* c^nd Goldberger, Joseph Disabling sick-
ness among the population of seven cotton mill villages of South Carolina, in re-
lation to family income. U. S. Public Health Service, Public Health Rqxxts,
V.33 no.47. November 22, 1918. 14p.
WEST VIRGINIA
Frankel, L. K. and Dublin, Ll I. Sickness survey of West Virginia cities. New
York City, Metropolitan Life Insurance Co., 1917. lip.
WEST VIRGINIA AND PENNSYLVANIA
Frankel, L. K. and Dublin, L. I. Sickness survey of the principal cities in Peon-
sylvania and West Virginia. New York City, Metropolitan Life Insurance Co,
1917. 78p.
UNCLASSIFIED
Armstrong, D. B. Methods of investigation in social and health problems; necessity of
health standards, 1917. 24p.
I
Aronovici, Carrol Suggestions for social surveys of small towns and cities. 1913. 77p.
Aronovid, Carrol The social survey. 1916. 255p. Health 228-230, bibliography.
Bannington, B. G. English public health administration. 1915. 330p.
Dublin, L. I. The application of the statistical method to public health research.
Fisher, Irving National vitality. 1910. 130p.
Harrison, S. M. Community action through surveys. Russell Sage Foundation, Sep-
tember 1916. 29p.
Peabody, S. W. Historical study of legislation regarding public health in the states
of New York and Massachusetts. Journal of Infectious Diseases,
1909.
Schneider, Franz, jr. Some shortcomings of socio-sanitary investigations.
Ind
ex
By Elizabeth R. Cummer
Absenteeism due to sickness, 541-42
Accident and health hazard, construction
trades, 535; department stores, 593;
domestic service, 603; metal trades,
560; printing, 592; telephone work,
571, 594; textile and knitting mills,
561
Accident incidence, see Industrial acci-
dent and sickness statistics
Academy of Medicine, 136-37, 141, 214,
401, 403, 413; history and activities,
664-65; suggested cooperation with
Dispensary Committee, 899-900, 913
Administrative areas, 42, 46
Agricultural and domestic service, for
children, 602-3
Ambulance service, in industry, 533;
necessity for adequate, 458; no pro-
vision for City Infirmary, 964; plan
for city- wide, 964; present facilities,
961; promptness, 961-62; provisions
in other cities, 961 ; recommendations,
964-65; requisites for efficient, 962-63
American habit of mind or work, from
practical to theoretical, 25
American Medical Association, pamphlets
on nostrums and quackery, 677
American Society for Control of Cancer,
program for prevention and cure,
221-25
Animal Protective League, factor in con-
trol of rabies, 137; provisions for
transportation of dogs, 963
An ti -spitting ordinance, enforcement, 332,
354
Anti-Tuberculosis League, 193; activities,
362 ; development of educational work
in industry, 363; extension of pro-
gram, 369; follow-up of cases, 367
Arsphenamine, provision by state, 885
Artificial feeding, see Infant care
Associated Charities, activities, 196-97;
cooperation with health centers, 363;
families with mental disorders under
care of, 498; mental test registry, 500;
psychological approach to problems of
individuals, 497-98 '
Association for the Crippled and Disabled,
193; organization and functions, 204-6;
responsibility for adequate follow-up
work, 208; social service, 204-5, 953.
See also Care of cripples
Association for Prevention and Relief of
Heart Disease, cooperation in prepar-
ing program, 213
Autopsies, importance, 864; number in
hospitals, 191.9, 667,864; percentage,
668,865
Autopsy, use not appreciate, 667;
means for increasing use, 669
Babies* Dispensary, building, 893; clinic
training for University District stu-
dents, 751; cooperation with Humane
Society, 917-18; extension of scope,
897; fees and finances, 894; location,
892; medical supervision of boarded-
out children, 177; medical work, 895;
organization, 892-93; orthopedic fa-
cilities, 203; patients, 893; social
service, 895-96, 953; visits, 1019, 890.
See also University Hospital Group
Baby prophylactic stations, 826, 986. See
also Health Centers
*The subjects listed in the Index are given for the report as a whole and are not classified by the
various Parts. The pages of the report are numbered consecutively throughout the eleven Parts: Part I,
1-96; Part II, 97-260: Part III. 261-324; Part IV, 325-388: Part V, 389-436; Part VI, 437-516; Part
VII. 517-644; Part VIII, 645-700; Part IX, 701 to 812; Part X, 813-996; Part XI, 997-1082.
1062
Hospital and Health Survey
Bar Association, Americanization Com-
mittee, 677
Bathing beach waters, pollution by sew-
age, 62
Bellevue Hospital, 956
Benjamin Rose Institute, provision of
funds for care of crippled children, 204
Birth registration, check of, 167; in-
adequacy of, 276-77; method of secur-
ing 100%, 278; relative number of
births reported by midwives and
physicians, 277. See €dso Bureau of
Vital Statistics
Births, 1919, 275-76
Blindness, see Prevention of blindness;
Board of Education, special classes;
Society for Blind
Board of Education, cooperation in pre-
vention of heart disease, 214, 218,305;
cooperation with Division of Health,
272; physical training, 296-97, 312-13;
provision for crippled children, 206;
provision for tuberculous children, 362;
psychological clinic, 462, 486, 488; sani-
tary supervision, 297-301, 315-18;
special classes: cardiac, 295; for
blind, 294; for cripples, 206, 294-95;
for deaf, 294; for mentally defective,
295, 488-90; nutrition, 295; open-air,
293-94; speech defects, 295, 494-95
See also Department of Medical In-
spection; Health education
Boarding homes, dental work for children,
178; medical sup)ervision of children,
177-78; supervision, 178, 287, 762-63;
suggested procedure for placing-out of
children, 178-80
Bodily mechanics, need for community
education in, 198
Boston, City Hospital, 956; hospital
service per 1,000 population, 830
Boys' School, 486
Brace shop, present, 203; proposed cen-
tral. 200-1
Bratcnahl Village, school nursing service,
778
Breast feeding, see Infant care
Bureau of Child Hygiene, 143; activities,
280-83. See also Prenatal care; Mt-
temity care; Infant care
Bureau of Communicable Disease, 122-38;
cards used, 124-25; Charter provi-
sions for, 122; control of rabies, 137;
ciilturing in diphtheria, 125; disinfiw-
tion after smallpox, 127; disinfectiai
of library books, 126; duties of chief,
122; extension of scope, 122; im
munization against diphtheria, 126
need for skilled intubator, 136; per
sonnel, 122; quarantine, 125, 137-38
regulations of Sanitary Code, 123-24
reporting by physicians, 124; results
of control measures, 127; supervisico
of district physicians, 140; vacdnatioo,
126-27
Bureau of Food and Dairy Inspectioo,
148-54, 357; classification of milk
dealers, 153; control of communicabie
diseases in animals, 122; contrd of
rabies, 149-50. dairy inspection, 151;
defects in milk control, 150-1; organ-
ization, 148; appointment of person-
nel, 154; present separation of food
inspection service, 154; recommenda-
tions for milk and dairy inspectioo.
154; summary of work for I'Jli^, 148-
50; supervision of slaughtering and
sale of meat, 1 50
Bureau of Industrial Hygiene, need, 554;
proposed activity for Division of
Health, 185
Bureau of Juvenile Research, see State
Bureau of Juvenile Research
Bureau of Laboratories, 155-61; chief
criticisms of bacteriological laboratory,
157; duties of chief, 155; functions,
155-56; inspection work, 160-61; main
distributing stations for outfits, 157-59;
microscopic and serological examina-
tions for venereal diseases, 400; milk
examinations, 155-56; organization.
155; patent medicines, 161; summary
of results of examination of city water,
lurj, 159; work of bacteriological lab-
Index
1063
oratoiy, 156-57; work of chemical lab-
oratory, 160-61
Bureau of Preventable Diseases, scope of
such a bureau, 122-23
Bureau of Sanitation, 144-47, 357; activi-
ties, 144-45; actual work, 146-47;
excuse for lodging house conditions,
53; indifference to enforcement of
tenement ordinances, 48-49; lack of
constructive and preventive work,
144, 145; method of receiving com-
plaints, 144; organization, 144; re-
sponsible for abatement of nuisances
relating to dumps, 74; control of fly-
breeding places, 83; study of field
work, 145; supervision of field force,
144; tenement house code, 145-46
Bureau of Tuberculosis, closer relations
with Medical School, 369; need for
full-time chief, 368; organization and
activities, 355-56
Bureau of Vital Statistics, 165-72; ap-
propriation, equipment and personnel,
166; cooperation with Bureau of Com-
municable Disease, 168; duties of
registrar, 168-69, 171; three elements of
a reorganized service, 167; formulation
of new system, 167-72; inadequacy of
present records, 165; lack of enforce-
ment of birth registration, 276-77;
nature of data for tuberculosis, 357;
need for improved statistical work,
369; need for intelligent supervision,
168; present methods of operation,
166; recommendations, l!72
I^andy factories, employment of women,
562 ; employment of children, 590
[dancer, prevention and cure, 221-25
Zardiac disease, see Heart disease
ZJare of convalescents, study of 200 dis-
charged hospital cases, 927-37; com-
munity program for, 938-43
!^are of cripples, 197-212; funds provided
by Benjamin Rose Institute, 204; lack
of orthopedic supervision in schools,
197; points considered in problem,
201: present needs, 207-8; program,
208-9: recommendations, 209-12; re-
habilitation of industrial cripples, 198,
547, 550; vocational therapy, 205;
facilities: brace-making, 203; con-
valescent, 203; coordination by Asso-
ciation for Crippled and Disabled,
204-6; dispensary, 202-3; educational,
206; hospital, 202, 832; hydrotherapy,
202; physiotherapy, 202-3; social
service, 203-4
Care of chronic illness, at City Infirmary,
948-50; lack of provision for, 946-48;
medical service, 944; need for institu-
tion for, 945; nursing service, 944;
problem distinguished from that of
canvalescence, 945; responsibility of
city, 946, 948; summary, 951
Care of sick, factors determining choice of
resoiu-ces, 820-21; resources, 27, 820
Census tracts, see Sanitary areas
Central Child Hygiene Council, Commit-
tee on Infant Care, 283; Committee
on Maternity Care, 278; Committee
on Prenatal Care, 274; functions,
270, 272; membership, 270
Central Committee on Public Health
Nursing, activities, 757; composition
and activities, 112-13; organization,
756; recommendations, 757-58; sug-
gested inclusion of industrial nursing
representative, 807; plan for factory
service, 777; valuable asset to public
health nursing, 756
Central downtown dispensary, estimated
cost, 924; financing, 923-24; industri-
al clinic in cormection with, 553; initia-
tive for starting, 924-25; needs to be
met by, 922; suggested connection
with orthopedic center, 200; sug-
gested site and services, 923
Chamber of Commerce, housing survey,
353; quotation from report on
Housing Conditions of War Workers,
43; smoke prevention, 85
Charity Hospital, see St. Vincent's Char-
ity
1064
Hospital and Health Subtey
Child-caring institutions, licensing, 287;
medical survey, 287; number and
cai>acity, 287; number planning new
buildings, 175; objects of study of,
174-75; problems of delinquency, 487;
recommendations, 176-77, 287; sani-
tary survey, 287; summary of medical
service, 175-76
Child health work, four great features of
present program, 268; lack of pre-
ventive health functions, 267-68;
measure of its effectiveness, 319-20;
need of central control, 267-270; pres-
ent organization, 267-68; proposed
organization, 270-73; recommenda-
tions, 274-75, 278-80, 283-84, 285-87,
287-88, 301-18; summary of problem,
269-70; summary of report on, 29-30;
two fundamental bases, 268. 5ee also
Central Child Hygiene Council; Pre-
natal care; Maternity care; Infant
care; Pre-school age care
Child Labor Laws, age and educational
requirements, 582-83 ; enforcement,
583, 585-86; health requirements, 583;
reasons for evasion, 586-87; reasons
for inadequate enforcement, 586; rem-
edy for lack of enforcement, 587; spe-
cial vacation certificate, 583; street
trades, 583
Childhood, importance of adolescent
period, 580
Children and industry, brief outline of
study, 581 ; education's responsibility,
613-18; need for junior vocational
department, 596-97, 615; reasons for
including study in survey, 579; recom-
mendations, 619-21; summary of re-
port, 31-32; three general considera-
tions involved in health study, 579-80
statistics: sources of information,
583-84; number of children at work,
584; ages and number of children ap-
plying for work, 585; occupations
employing children, 588
See also Occupations employing chil-
dren; Street trades; Agricultural
work and domestic service; Child
Labor Laws
Children's Fresh Air Camp, dental senr-
ice, 687; preventorium advantages,
361 ; provisions for convaleaccnts, 941
Children's Placement Bureau, proposed
new activity for the Division of Health,
178-80
Chronic cases, classification, 947-48
City Charter, provisions, 106-9; suggested
changes, 119, 654, 839-40
City Farm, description, 465
City Hospital, admission procedure for
tuberculosis cases, 356; ambulance
service, 961; approval of bond issue
for, 458, 966; charter changes sug-
gested, 654, 839-40; deficiency of
nursing service, S3S; number of beds,
828; out-patient department needed,
918; plans for expansion, 966; pro-
posed psychopathic department and
"outposts", 458. 462, 479, 481, 4«6;
social service, 953, 955; study of con-
valescent cases from, 930-32; sug- j
gested plan for a venereal disease
service, 410;
facilities: contagious cases, 832;
dental surgery, 684-85, 687; mental
cases, 446-47, 458; tuberculosis cases,
360; venereal diseases, 402, 410, 832
training school for nurses: organiia-
tion, 714; minimum entrance require-
ments, 715-16; capacity of hospital
and services offered, 717-18, 724; in-
struction in nursing procedures, 724-
27; instruction in sciences, 728-32;
instruction in other subjects, 732-35:
ratio of nurses to patients, 735; day
duty, 736; night duty. 737-38; vaca-
tion, 738; living conditions, 740-41
City Infirmary, insufficient service, 839,
949; location and capacity, 948; per-
sonnel, 948; provision for mental
cases, 465-66; utilization for chronic
cases, 949
City Plan Commission, 48, 353
Climate, 46-47
Clinics, cardiac. 215, 219. 897: dental.
293, 684-86, 903-4; industxial 553,
[ N D EX
1065
923; need for psychiatric, 462, 479,
481, 486; prenatal, 274, 826, 902-3,
986; psychological, 462, 486, 488;
venereal disease, 401, 404, 885. See
also Dispensaries
College of Dentistry, see Dental School
Commissioner of Health, appointment,
111; part-time office. 111; powers
and duties, 109
Commissioner of Publicity and Research,
duties, 108; reasons why position
should be filled, 110
Commissioner of Smoke Prevention, 88-89
Committee for Prevention and Relief of
Heart Disease, 214
Committee for vice investigations, 426-27
Committee on Nursing Education, studies
of hospital training schools, 712
Community, attitude toward hospitals
and disp)ensaries, 820-21; complaints
regarding provisions for mental cases,
444-45; 'interest of, 576-77; planning
of hospitals and dispensaries, 966-72;
spirit, 377, 983-84; supervision of
mentally defective, 495-96
Construction trades, accident and health
hazards, 535-36; accident incidence,
542
Consultation service, establishment of, 366
Consumers' League, campaign for en-
forcement of street trades ordinance,
598; cooperation in study of Children
and Industry, 581; investigation of
milk situation, 347; program for in-
creasing use of milk, 352
Consumption, see Tuberculosis
Contagious diseases, estimated number of
hospital beds needed, 832
Control of drug addiction, new activity
proposed for Division of Health, 189-90
Control of tuberculosis, see Tuberculosis
Control of venereal diseases, see Venereal
diseases
Convalescence, two things apparent in
study, 926-27; problem of, 938; in-
stitution needed for some cases, 938-39;
methods of dealing with problem, 940-
41
Coroner system, recommendations, 191
Correctional agencies, 482-87
Cost accounting, in hospitals, 870-71, 877-
79
Coimty commissioners, 872
County jail, provision for mental cases,
464-65
Courts, 476-82; relation to problem of
mental diseases, 476
Cripple School, 206, 294-95
Day nurs^ieS; admission procedure, 181-
82; attendance, 181, 28S; discussion
of social worth, 574-75; licensing, 181;
medical service, 182-83; number, 180-
81, 285; ordinances regulating, 181;
recommendations, 184-85; summary
of conditions found, 184; supervision
of, 181
Dental hygienists, licensing, 810; train-
ing and legalization, 689
Dental Research Laboratory, 689
Dental School, graduate education, 689;
present needs, 688-89; public dental
clinic, 685; work for boarded-out
chUdren, 178
Dental service, dispensary facilities, 293,
684-86; inadequacy, 686; in hospitals,
686-88; in industry, 545, 688; in
schools, 293, 684, 685; need for pay
clinics, 685; need for supervision in
disp)ensaiy, 686; surgical, 684-85,
685-86
Dental Society, 689
Dentistry, Ohio Dental Practice Act, 683 ;
private practice of, 683-84; recom-
mendations, 690; summary of report,
32; two movements important in ad-
vancing, 683
1066
Hospital and Health Survey
Dentists, education, 688-89; number
registeted, 683
Department of Buildings, responsible for
school sanitation, 297-301; recom*
mendations, 315-18
Department of Health, see Division of
Health
Department of Medical Inspection, clin-
ical facilities, 293; conferences, 295;
correction of physical defects, 290-92;
examination for and issuance of work
permits, 605-7; examination of teach-
ers, 297; health records, 295-96;
medical personnel, 289-90; organiza-
tion, 289; school dispensaries, 295;
supervision of control of communi-
cable diseases, 296; recommendations,
302-15
nursing service: analysis of activi-
ties, 783-86; conferences, 788; duties,
290-92; field nurses. 292-93, 786-87;
junior health workers, 293, 787; scope
of work, 782-83; staff. 783; staff
nurses, 787; supervisor, 786
Department of Physical Training, activi-
ties, 296-97; recommendations, 312-13
Department of Public Welfare, Charter
provisions for, 108-9; divisions, 110
Detention Home, 481-82, 484
Detention Hospital, 476
Diphtheria, reasons for high death rate,
136-37
Director of Public Service, plans for
changes in organization, 81 ; respon-
sible for cleanliness of city, 67
Director of Public Welfare, general powers
and duties, 108; appointment, 111
Dispensaries, adaptation of clinics to
clientele, 914; administration, 915;
admission of patients, 912; buildings,
893; classes of disease treated, 892;
classification, 826, 890; clinic manage-
ment, 899; deficiencies, 897; fees and
finances, 894, 913-14; for mental
diseases, 462; in industry, 533, 536;
in schools, 295, 311-12; location, 890,
892 ; inter-relations, 915; means of ad-
mission to hospital wards, 852; means
of providing after-care for hospital
patients, 856; medical organuEatkn,
846; medical relations, 899-900, 913;
medical work and records, 895; need
for general plan, 919-21 ; need for en-
largement of service, 862-63; needed
improvements in service, 918; organ-
ization and executive control, 892-93;
patients, 893; public health, 901-2,
986; relation to hospitals, 897, 899;
reports and tests of service, 896-97;
shortage of service, 912; social senr-
ice, 895-96; supervision, 417-18. 5ae
also Central downtown dispensary;
Clinics; Health centers; Hospitab
and dispensaries
Dispensary, definition of term, 826
District physicians, duties, 139; method
of receiving calls, 139; offices, 139;
organization, 138-39; recommenda-
tions, 141-42; records, 140; summary
of complaints of service, 141; super-
vision, 140; volume of work, 140
Division of Health, administrative dis-
tricts, 114-16; appointment of per-
sonnel , 111, 112-13; appropriation for
1920, 113; board or advisory com-
mission lacking, 110; bureaus. 112:
conferences, 116; cooperation with
Board of Education in child health
matters, 272; educational campaign
for control of venereal disease. 410-11;
filing, 119; hours of service. 111; legal
action, 119; library, 116-19; mo.ale,
121; need for full-time executive, HI;
number of employes, 114; organiza-
tion, 355-57; p>er capita cost ii^'-J-
19:^0, 113-14; per capita cost com-
pared with Detroit's, 114; rules fw
regulation of laboratories, 416-17;
Sanitary Code, 119; services not
offered, 112; supervision of dispen-
saries, 417-18; supply system. 111
activities projxjsed: 173, 214: con-
trol of drug addiction, 189-90; exten-
sion district, 769; industrial hygiene,
185; institutional inspection. 173-85;
Index
1067
licensing of child-caring institutions,
287; medical examination for city
employes, 185-86; public health edu-
cation, 186-89; supervision of board-
ing-out homes, 287; Venereal Disease
Bureau, 413-14
nursing service: appointments of
field nurses, 112-13; chronic illness,
944; communicable diseases, 759-60;
child hygiene, 281-83, 761-62; instruc-
tion of new nurses, 768; midwife
supervision, 277, 762; organization,
764; proposed extension district, 769,
803; parochial schools, 763; prenatal,
763-64; prevention of blindness, 762;
recommendations, 769-73; scope of
work. 758-59; staff, 759, 764, 767-68;
summary, 768-69; supervision of
boarding homes, 762-63; tuberculosis,
356-57, 760-61; imiforms, 768
See also Bureau of Child Hygiene;
Bureau of Communicable Diseases;
Bureau of Food and Dairy Inspection;
Bureau of Laboratories; Bureau of
Sanitation; , Biu'eau of Tuberciilosis;
Bureau of Vital Statistics; Health
centers
Division of Police, ambulance service,
961; modem conception of functions,
426; proposed Women's Bureau, 424-
26; test of efficiency in controlling
vice conditions, 427-28
Downtown dispensary, see Central down-
town dispensary
Draft boards, figures for venereal disease,
398; findings of medical examiners,
541-42
Education and practice in medicine, sum-
mary of report, 32
Endemic Index, 127
Epileptics, laws relating to, 469; state
hospital for, 473
Extension district, 769, 803
Fairview Park Hospital, number of beds,
828; out-j>atient department, 919;
provisions for mental cases, 461;
training school for nurses: organiza-
tion, 714; minimum entrance require-
ments, 715-16; capacity of hospital
and services offered, 723; teaching of
nursing procedures, 724-27; teaching
of fundamental sciences, 728-32; in-
struction in other subjects, 732-35;
ratio of nurses to patients, 735-36;
day duty, 736; night duty, 737-38;
vacation, 738; living conditions, 740-
41
Farm School, 484
Federal Bureau of Labor Statistics, 540
Federal Census Bureau, census units or
sanitary areas, 42
Federal Children's Bureau, summary of
standards of physical fitness for work-
ing children, 611-13
Federal Fraud Order Law, scope and limita-
tions, 676; suggested means for more
aggressive use, 677
Feeble-minded, see Mentally defective
Feeding of infants, see Infant care
First aid, training necessary for ambu-
lance crews, 962
Flies, 83-84
Foreign-language press, advertisements of
quacks, 672-75; income from quack
and patent medicine advertisements,
678; opportunities for Americaniza-
tion of immigrant, 678; patent medi-
cine advertisements, 675
Garbage collection and disposal, 67-73,
75, 80-82
Garment trades, earnings of employes,
562; number of women employed,
561; regularization of employment,
561-62; type of women in, 562
General environment and sanitation,
summary of report, 28
Generalized public health nursing, 115;
definition, 281, 334. 366-67, 754; dis-
cussion, 357, 754; need for change in
organization, distribution and super-
vision of nurses* work, 283; need for
1068
Hospital and Health Survey
specialized supervision, 367; neglect
of infant hygiene work under, 282-83 ;
prenatal and postnatal work, 801-2;
standard ratio of nurses to population,
375, 755; success of system, 754;
prime requisite of, 755; some causes
of failure, 755-56; used in University
public health nursing course, 746
Girls' Home, 484-85
Glenville Hospital, number of beds, 828;
training school for nurses: organiza-
tion, 714; minimum entrance require-
ments, 715-16; ca{>acity of hospital
and services offered, 723, 724; teach-
ing of nursing procedures, 724-27;
teaching of fundamental sciences, 728-
32; instruction in other subjects, 732-
35; day duty, 736; night duty, 737-38;
vacation, 738; living conditions, 740-
41
Goiter, detection and abatement, 291-92;
endemic, 46
Gonorrhea, see Venereal diseases
Government Diagnostic Clinic, 400-1
Grace Hospital, number of beds, 828
Griswold Act, authorization of institu-
tional inspection, 173; reference to,
124
Health administration surveys, aims and
methods, 1 009- 1 7 ; factors determining
scope, 1007-8; history of, 1005-7;
preliminary steps, 1004-5; reasons for
making, 1003 /
Health centers, administrative work, 908;
case classification, 343-44; dental
work, 684; description, 115; districts,
114; extension, 283-84, 971; facilities
for tuberculosis work, 355; financial
administration, 909-10; infant welfare
work, 280-83, 761-62; location and
clinics, 904-5, 986; medical work, 280-
81, 907-8; method of referring babies
to, 282; nursing service, 765-66; pa-
tients, 905-6; personnel, 907; pre-
ventive rather than curative, 826;
provision of milk by, 906-7; really
branch offices, 115; reasons for de-
crease in number of new tuberculoas
cases, 344; records, 119, 767, 908-9;
recommendations, 190, 910-11; sodil
work, 908; supervision of children of
pre-school age, 285-86; supplementary
equipment needed, 366; tuberculosis
attendance, 344; tuberculosis nurang,
356-57, 760-61
Health Department, see Division of Health
Health districts, location of hospitals, 835;
proposed use of one as extension dis-
trict, 769; facilities for preventioD and
treatment of sick, 116; statistics for
report based on, 42
Health education, anti-tuberculosis, 346,
363, 368; function of a downtown dis-
pensary, 922; importance in training
for industrial life, 614-15; important
part of industrial nur«ng, 805-6; in
industry, 363; in the public schools,
297; means of combating quackery
and {>atent medicines, 677; for pre-
vention of heart disease, 218; recom-
mendations, 189, 313-14; resume of
present services, 186-89; under Divi-
sion of Health, 108, 110, 112. 188;
views of International Red Cross in
regard to, 188-89; weapon against
disease and disability, 26-27. See also
Sex education; Mental hygiene
Health hazards, see Accident and health
hazards
Health services, recommendations, 226-28;
summary of report, 28-29
Health supervision in industry, see Medi-
cal service in industry
Health supervision in schools, see School
health supervision
Health supervision of children at work,
medical examination for work permit,
603-7; suggested content of Ohio law
re health certificate, 607; subnormal
children, 608-10; summary of stand-
ards of normal development and physi-
cal fitness, 611-13.
See also Work permits
Index
Heart disease, prevention and relief, 213-
21
Holy Cross House, facilities for care of
non-pulmonary tuberculosis, 361; pro-
visions for convalescents, 941
Home conditions of working people, rela-
tion to health, 557
Home work, a method used by factories to
increase output, 573; advantages in
special cases, 574; various kinds, 573
Hospital beds, for children, 831-32; for
contagious diseases, 832; for eye, ear,
nose and throat cases, 831; for ob-
stetrical cases, 275, 831; for orthopedic
cases, 202, 832; for tuberculosis, 361-
62, 366; for venereal diseases, 402,
832; shortage, 832-33, 836; total
number available, 828-29; utilization,
833-35, 836
Hospital census, economic status of
patient according to nativity, 851;
length of stay of patients, 844, 946;
location of residence of patients, 829;
nativity of patients, 850; percentage
of bed occupancy, 833; sources of
admission of patients, 852-53, 858;
type of service, 831-32
Hospital Council, 193, 214; activities,
872, 981-82; membership in, 981, 983;
number of beds in hospitals of, 828;
opportunities for service, 982; pro-
posed Dispensary Section, 406, 920-21,
982; Purchasing Bureau, 874-75, 882-
84; recommended interest in increase
of post-mortem examinations, 671;
report forms, 974; suggested coopera-
tion with Academy of Medicine, 899-
900
Hospital hygiene, milk supply, 888-89;
ventilation, 889; water supply, 889
«
Hospital statistics, autopsies, 667-68,
864-65; compilation thro a central
office, 169-71; number of beds per
1,000 population, 829; service per
1,000 population in other cities, 830.
See also Hospital censusV
\
1069
Hospital survey, in northern England,
1007
Hospital training schools, rapacity of hos-
pitals and services offered, 716-24
conditions of work, 735-38; cost ac
coimting, 714; extent of study, 709
general characteristics, 709; instruc
tion, 724-35; living conditions, 740-41
minimum entrance requirements, 715
16; money allowance to students, 714
organization, 713-14, 842; provision
of ward helpers, 738-40; recommenda-
tions, 742-45
Hospitals, assistance in home conva-
lescence, 936-37; attitude toward non-
staff physicians, 858-60; authority of
superintendent, 843; autopsies per-
formed in 1919t 864-65; days of care,
833; deficient in provision for special
classes of cases, 831; democratization
of facilities, 862-63; difficulty in secur-
ing admission for venereal disease
cases, 402; distribution, 835, 837;
facilities for mental cases, 446-47, 458-
62; basis of organization, 838-40;
principles of organization, 845-48; pre-
dominantly devoted to surgery, 831;
planning of policy, 973; rate for in-
dustrial cases, 872; reimbursement by
county or city for public charges,
872-74; reports, 973-77; services of pub-
licity expert needed, 977-78; shortage
of beds, 830-31; social service depart-
ment, 843, 855;
administration: economics and sal-
vaging, 886-87; financial, 869-71,
877-82; general recommendations,
887-888; purchasing, 874-75, 882-86;
board of trustees: breadth of vision
needed, 978; complete authority of,
841; composition, 840, 841-42; duties,
843-45. 871;
classification: by diseases treated,
822; by relation to community, 822,
824; by quality of service, 824-26;
by range of service, 835-36;
medical staffs: foreign-bom physi-
cians, 863; functions, 861; member-
ship, 664, 858, 860; necessity for, 861;
1070
Hospital and Health Survey
negro physicians, 863; organization,
846-47, 862, 865-67;
relation to community: admission
procedure, 892; giving information
about {>atients, 851-52; problem of
the foreign-bom patient, 850-51, 853-
54; problem of after-care, 854-56;
cooperation with charitable organiza-
tions, 852-53; cooperation with in-
dustrial establishments, 853; financial
support dependent upon, 857; human
problem of the {>atient, 849-50; serv-
ice for middle classes, 871-72
See also Detention Hospital; Indus-
trial hospitals; State Hospital for In-
sane
Hospitals and dispensaries, attitude of
community toward, 820-21; classifica-
tion of, 822; cost of maintenance,
868-69; educational function, 863-65;
method of approach to study of, 820;
primary purpose, 819; problem of in-
terpreting to community, 827; sum-
mary of report on, 33-34; unit for
measurement of service, 826-27;
planning by community: 971-72;
building fund campaign, 966-67; ex-
tension of health centers, 971; loca-
tions and re-locations, 969-70; pro-
jected enlargements, 967-68; special
services needed, 968-69;
social service departments: coopera-
tion with charitable agencies, 956-57;
development, 952; functions, 954,
958, 959-60; importance of person-
ality and training of head worker,
957-58; lack of definite policy. 953-54;
organization, 843, 848, 957; recom-
mendation, 955
Hotels, earnings of women employes, 570;
present method of employment, 570;
supervision of, 570
House of Correction, 482-84
House of Good Shepherd, 485-86
Housing, advantages of zoning, 48; char-
acteristics of residential districts, 42,
43; conditions in lodging houses, 53-
55; conditions in tenements, 48-49,
53; legislation, 346-47; proximity of
home to industry, 43; reconunendt*
tions, 55-56; records of Division of
Buildings, 353-54; results of over-
crowding, 48; survey by Chamber of
Commerce, 48, 353; violation of ordi-
nances,. 53
Housing Conditions of War IVor^jers, quo-
tation from report by Chamber of
Commerce and U. S. Home Registra-
tion Service, 43
Humane Society, child placement work,
178; intelligence tests, 499; medical
supervision of boarded-out children,
916-18
Huron Road Hospital, number of beds,
828; plans for ezpension, 967;
dispensary: building, 893; clasaes
of disease treated, 892; defkaendes,
897; fees and finances, 894; location,
890; medical work, 895; organiza-
tion, 892; records, 895; visits, 1919,
890
training school for nurses: organiza-
tion, 714; minimum entrance require-
ments, 715-16; capacity of hospital
and services offered, 723-24; teaching
of nursing procedures, 724-27; teach-
ing of fundamental sciences, 728-32
instruction in other subjects, 732-35
ratio of nurses to patients, 735-36
day duty, 736; night duty. 737-38
vacation, 738; provision of ward
helpers, 738-40; living conditions,
740-41
Hydrotherapy, 202
Industrial accident and sickness statistics,
analysis of reportable accidents, 540;
computation of frequency and severity
rates, 540; importance, 539; investi-
gation of absenteeism due to sickness
and non-industrial accidents, 541-42;
tabulation of, 540; time loss in small
industrial establishments, 550-51
Industrial clinic, advantages of associat-
ing with ^ department of industrial
Index
1071
hygiene, 553; proposed in connection
with central dispensary, 553, 923
Industrial cripples, 198, 547, 550
Industrial dental service, 545, 688
Industrial establishments, number and
size, 525-26;
employing women: 558-59; acci-
dent and health hazards, 560, 561;
benefits, 564-65 ; earnings of employes,
561, 562, 564; hours of work, 561,
563; nature of women's work, 560;
number of women employes, 559, 561,
562, 563; physical conditions of work,
567-68; physical examinations, 560;
regularization of employment, .561-62;
supervision, 562, 565-66; type of
worker, 561, 562, 563; uniforms, 560
See also Medical service in industry;
Small industrial establishments
Industrial health supervision, see Medical
service in industry
Industrial hospitals, 552
Industrial hygiene survey, purpose and
methods, 525
Industrial medical records, forms used,
538-39; lack of essential data, 537;
standards for, 537-38; value in pre-
paring accurate reports and tables,
539
Industrial nurses, administration of medi-
cation by, 530; contribution to in-
dustrial hygiene, 529-30; home visit-
ing by, 531; need for counsel and
technical assistance, 531; number, 803;
some causes of failure, 806-7; training,
529, 553; type of service, 804-6; used
for absence follow-up, 531-32
Industrial Nurses' Club, value of, 531
Industrial ocular service, importance,
545-46; need for eye hospital, 546
Industrial physicians, inadvisability of
combining official and personal prac-
tice among employes, 528; special
training, 553; types, 527
Industrial psychiatry, value, 544-45
Industrial unrest, 544-45
Industrial visiting nursing, 531, 777
Industry, its interest in health of emplojres,
557, 558
Infant care, carried on thro 14 health
centers, 280, 761-62; committee on,
283; field not covered by health cen-
ters, 281; "generalized" [nursing un-
fortimate type in, 281; great value of
home visiting by nurses, 282-83; im-
portance of breast feeding, 282; meas-
ure of its effectiveness, 319; need
for agency to supply wet nurses, 283;
number of children in need of, 281;
recommendations, 283-84; too great
emphasis placed on artificial feeding,
282. See also Bureau of Child Hy-
giene; Health Centers
Infant mortality, reduction in, 273, 282
Institute of School Hygiene, 752
Institutional deliveries, in 1919, 275-76
Institutional inspection, proposed activity
for Division of Health, 173, 287
Institutions, study of, 174-85
International Red Cross, views in regard
to health education, 188-89. See also.
Red Cross
Insanity, see Mental diseases and de-
ficiency
Jewish Orphan Asylum, dental service, 687
Juvenile Court, Detention Home, 481-82
management of delinquency, 480
method of disposal of cases, 480-81
need for psychiatric clinic, 481 ; sources
of information regarding cases, 480
Laboratories supervision, 400, 416-417.
See also Bureau of Laboratories
Lakeside Hospital, dental service, 688;
number of beds, 828; orthopedic facili-
ties, 202; provisions for mental cases,
460-61; social service department, 952;
study of convalescent cases, 932-34;
1072
Hospital and Health SumTT
dispensary: building, 893; classes
of disease treated, 892; deficiencies,
897; fees and finances, 894; Icication,
890; medical work, 895; future plans,
919; organization, 892; orthopedic
facilities, 202; patients, 893; proposed
psychiatric clinic, 461; records, 895;
venereal disease clinic, 401, 406-7;
visits, 1919, 890;
training school for nurses: organi-
zation, 714; minimum entrance re-
quirements, 715-16; capacity of hos-
pital and services offered, 718-24;
teaching of nursing procedures, 724-27,
728; teaching of fimdamental sciences,
728-32; instruction in other subjects,
732-35; ratio of nurses to patients,
735-36; day duty. 736; night duty,
737-38; vacation, 738; living condi-
tions, 740-41
See also University Hospital Group
Lakewood Hospital, number of beds, 828;
provisions for mental cases, 461;
training school for nurses: organi-
zation, 714; minimum entrance re-
quirements, 715-16; capacity of hos-
pital and services offered, 723; teaching
of nursing procedures, 724-27; teach-
ing of fundamental sciences, 728-32;
instruction in other subjects, 732-35;
day duty, 736; night duty, 737-38;
vacation, 738; living conditions, 740-
41
Lakewood Visiting Nurse Association,
affiliation, 778
Laundries, earnings of employes, 570; ob-
jectional features of work, 569; scarcity
of female labor in, 569; working hours,
570
Legislation, anti - tuberculosis, 346 - 47;
housing, 346-47; milk, 346; relating
to Bureau of Juvenile Research, 473-
74; relating to insane, 468-69; re-
lating to mentally defective and epi-
leptic, 469; sex delinquency, 419-24.
See also Child Labor Laws; Pharmacy
Laws
Lutheran Hospital, number of beds, 828;
plans for expansion, 968
Manufacture of hosiery and knit goods,
employment of children, 590-91 ;
Massachusetts General Hospital, ortho-
pedic social service, 199
Maternity care, committee on, 278; hos-
pital facilities, 275, 279, 831; measure
of its effectiveness, 319; out-patient
service, 276; recommendatioDs, 278-
80. See also Prenatal and maternity
nursing service
Maternity Center Association of New
York City, accomplishments, 274
Maternity Hospital, number of beds, 828;
nursing service, 799-801; prenatal
clinics, 902-3;
training school for nurses: instruc-
tion, 727-28; day duty, 736; night
duty, 737-38; vacation, 738
See also University Hospital Group
Maternal mortality, see Mortality sta-
tistics
''Medical boarding house**, services offered
by. 825
Medical education, see School of Medicine
Medical examination, see Physical exami-
nations
Medical Journal, 666
Medical Library Association, history and
activities, 665-66
Medical practice, institutional, 822. See
also Physicians
Medical School, see School of Medicine
Medical service in industry, administra-
tive relations, 534-35; ambulance scr\'-
ice, 533; beyond the plant, 536-37:
clerical personnel, 532; cost of service,
533-34; dispensary equipment, 533:
needed in small establishments, 550;
number of firms offering, 526; oppor-
tunities for health education, 547;
physical examinations, 542-44; present
inadequacy, 363; purpose and methods
Index
1073
of survey, 525; quality, 526; recom-
mendations, 554-56; special services,
544-47; summary of report on, 31.
See also Industrial medical records; In-
dustrial nurses; Industrial physicians;
Small industrial establishments
Medical service in non-industrial estab-
lishments, 535-36
Medical service in schools, see School
health supervision
Medical social service, 895-96; assistance
in cases of chronic illness, 947; for
cardiac patients, 218-19; at City
Hospitals elsewhere, 956; City Hos-
pital, 953, 955; cooperation with
charitable agencies, 956-57; develop-
ment, 952; fimctions, 954, 958, 959-60;
lack of definite policy, 953-54; Lake-
side Hospital, '952; for orthopedic
cases, 203-6, 207; Mt. Sinai Hospital,
952 ; needed for convalescent care, 930,
932; problems, 954-55; recommenda-
tion, 955; St. Vincent's. 952, 953;
value in orthopedic departments, 199
Medical staff appointments, see Hospitals
Medico-social service, contribution to
study of, 25
Mental diseases, need for local society for
prevention of, 225
Mental diseases and deficiency, com-
plaints in regard to provisions for, 444-
45 ; methods of dealing with problems
presented, 443; part played in prob-
lems of social agencies, 497; preven-
tion, 501-2; recommendations, 503-11;
scope of survey, 444; summary of re-
port on, 31;
city facilities for care: dispensaries,
462; hospitals, 446-47, 458-62; infirm-
ary, 465-66; jail, 464-65; private
sanitaria, 462-64
state facilities for care: Board of
Administration, 467-68; Bureau of
Juvenile Research, 473-75; Hospital
for Epileptics, 473; hospitals for in-
sane, 469-71; Institution for Feeble-
minded. 471-73; laws, 468-69
See also Courts; Correctional agencies;
Red Cross; Associated Charities;
Humane Society; Women's Protec-
tive Association
Mental hygiene, 501-2
Mental medicine, facilities for teaching
460-61; lack of attention given to
problem of, 460
Mentally atypical children, in schools,
488-96
Mentally defective, estimated number in
state and city, 471-72 ; laws relating to,
469; need for supervision, 472, 495-96;
need for increased institutional pro-
vision, 472; special classes, 488-90;
state institution for, 471; two out-
standing needs in care of, 473; work
permits, 490-93
Mercantile establishments, earnings of em-
ployes, 568, 569; educational depart-
ments, 568; employment of children,
592-93; health departments, 568;
hours of work, 568; number of women
employed, 568
Metal trades, accident hazard, 560; acci-
dent incidence, 542; employment of
boys, 591; number of children em-
ployed, 591;
women employes: earnings, 561;
hours of work, 561; nature of {work,
560; number, 559; physical examina-
tion, 560; type, 561; uniforms, 560
Midwifery, comparison of courses in, 277
Midwifery control, evils of present system,
277-78; suggested program, 279-80
Midwives, inadequate supervision, 277;
number, 277; social need filled by, 277;
stringency of regulations for licensing,
277; supervision, 762
Milk, dietary and nutritional value, 348,
351-52; results from study of its con-
sumption, 348-51; the problem in
Cleveland, 347. See also Legislation
1074
Hospital and Health Subvet
Milk supply, control, 148-49, 150-51; in
hospitals, 888-89; reasons for unsatis-
factory condition, 154; results of bac-
teriological examinations in March and
June, 1920, 151-53
Modem hospital, services offered, 825
Morbidity statistics, compilation, 169;
contagious diseases of children, 284-
85; ratio of active tuberculosis cases
to deaths, 345; reporting of tuber-
culosis, 343, 345; venereal diseases, 398
!
Mortality statistics, general death rates,
1910-19, city, 338; heart disease death
rate for state and city, 213; leading
causes of death in city and state, 339;
maternal, 274
tuberculosis: at Division of Health,
357; distribution of deaths by age, sex,
occupation and form, 342-43; death
rates, 1S65-19U, 339; residence factor
in figures, 343
Mosquitoes, 83-84
Mothers* pensions, inadequacy, 575
Mount Sinai Hospital, number of beds,
828; orthopedic facilities, 202; pro-
visions for mental cases, 461; social
service departments, 952; study of
convalescent cases, 934-35;
dispensary: building, 893; classes of
disease treated, 892; deficiencies, 897;
dental clinic, 686-87; fees and finances,
894; location, 890; medical work and
records, 895; organization, 892; ortho-
pedic facilities, 202; patients, 893;
social service, 895-96; venereal disease
clinic, 401, 408;
training school for nurses: organi-
zation, 714; minimum entrance re-
quirements, 715-16; capacity of hos-
pital and services offered, 718-24;
teaching of nursing procedure, 724-27,
728; teaching of fundamental sciences,
728-32; instruction in other subjects,
732-35: ratio of nurses to patients,
735-36; day duty, 736; night duty,
737-38; vacation, 738; provision of
ward helpers, 738-40; living condi-
tions, 740-41
Mouth hygiene, need, 686; value, 685
Mouth Hygiene Association, activities,
689; clinics at Health Centers, 684,
903-4; extension of dental service
needed, 685
Municipal Court, need for psychiatric
clinic, 478-79; Parole Board, 479-80;
work of Probation Officer, 479
New York City, hospital service per 1000
population, 830
New York State, provisions for licensing
and inspecting private institutions for
mental cases, 463
Night work, its problem, 571-73
Northern Ohio Druggists* Association, co-
operation with Division of Health, 694
Nursing, summary of report, 32-33. See
also Nursing education; Public health
nursing; Private duty nursing
Nursing education, recommendations, 741-
45 ; standards of comparison for study,
709-10; study by Committee on Nurs-
ing Education, 712. See also Univer-
sity School of Nursing; Hospital
training schools; University course in
public health nursing; Institute of
School Hygiene
Nutrition classes, 295, 362
Occupations employing children, 588-89;
comments of employers, 596; educa-
tional requirements, 595-96; functions
of medical service, 591; health haz-
ards, 592, 593-94, 596-97; hours of
work, 589; nature of work and oppor-
tunity for advancement, 590-95; wages,
589
Ophthalmia neonatorum, 5cc Prevention of
blindness
Open-air classes, 293-94, 362
Index
1075
Drthopedic center, association with down-
town clinic, 200, 923; central brace
shop, 200-1; main physiotherapeutic
plant, 200; organization, 208-9.
Orthopedic Council, responsibility for all
medical and social follow-up work, 208
!>rthopedic organization, functions and
essentials for fulfillment, 198-99
Orthopedic surgery, at Medical School,
197, 201-2, 207-8; convalescent beds
needed, 199-200; hospital beds, 832;
departments in general hospitals, 199;
field, 197-98; functional rehabilitation
of injured wage-earners, 198; need for
children's service, 199; number of
specialists, 197, 663; possibilities, 197;
value of social service in clinics, 199
Outdoor Relief Department, admission
routine for Infirmary, 949
Out-patient departments, see Dispensaries
Parochial schools, dental service, 685;
medical inspection, 288, 301; nursing
service, 763
Patent medicines, advertisement, 675;
capital invested in manufacture and
sale, 161-62; cooperation of druggists
and City Chemist regarding, 694;
distribution and sale, 162-63; manu-
factiire, 162; need for classification,
162; recommendations, 164, 682;
local situation, 163-64
Per capita per diem cost, in hospitals,
869-70, 878-79
Pharmacists, indispensable auxiliaries to
physicians, 691; number registered,
691
Pharmacy, recommendations, 697-98;
summary of report, 32
Pharmacy laws, 691-94
Physical defects, correction, 290-92, 784-
85; emphasis on prevention, 308; in-
cidence in school children by age
periods and sex, 304
Physical examinations, for hospital per-
sonnel, 888; in industry, 542-44; for
city employes, 185-86, 544; for oper-
ators of conveyances, 544; for food-
handlers, 543. See also School health
supervision
Physiotherapy, care provided by Associa-
tion for Crippled and Disabled, 206;
main and branch plants, 200; present
facilities, 202-3, 207
Physicians, diagnostic training for, 366;
foreign-bom, 863; hospital staff ap-
pointments, 664, 858, 860; negro,
863; number and classification by
specialty, 663; professional oppor-
tunities, 664, 666-67; professional or-
ganization, 664-66
Pilgrim Church, nursing service, 777-78
Playgrounds, streets used as, 67
Police Departmeht, see Division of Police
"Police Emergency", method of sending
in calls, 961 ; provisions for ambulance
service, 962-63; stigma attached to
use of, 963-64; used as ambulance, 961
Population, hiistory of city's growth, 39
Population statistics, age and race distri-
bution, 41; city and county subdivi-
sions, 1918, 44-45; city and suburbs,
1000-18, 41-42; density, 42-43
Post-mortem examination, see Autopsies
Prenatal and maternity nursing service,
902-3; present facilities, 797; types of
cases in need of, 797-98; types of care
needed, 798; agencies considered for
city-wide, 798-803; recommendations,
803
Prenatal care, clinics, 274, 826, 902-3,
986; committee on, 274; measure of
effectiveness, 319; need for increase
of facilities, 274; number of mothers
provided for in 1919, 273; object. 273;
plan for city- wide service, 274-75;
797-803, 902-3; present provisions.
1076
Hospital axd Health Suavn
273; recommendations, 274-75; re-
duction in death rate from puerperal
sepsis, 274; reduction in infant mor-
tality, 273; reduction in stillbirth
rate, 274. See also. University District;
Division of Health, nursing service;
Visiting Nurse Association
Pre-school age care, gap in child health
program, 285; lack of facilities, 285;
measure of its effectiveness, 319; need
for, 284-85; recommendations, 285-87
Prevention of blindness, 793; activity of
Division of Health, 762 ; program pre-
pared by the national committee,
195-96; results from follow-up of
ophthalmia neonatorum cases, 278
Prevention of disease, devices for, 26-27
Printing and publishing, employment of
children, 592
Private duty nursing, study of unneces-
sary employment of full-time graduate
nurses, 808-9; employment of trained
attendants, 809-10
Probate Court, cost of committing mental
cases, 477-78; function in regard to
mental cases, 476; method of com-
mitment of mental cases, 476-77
Provident Hospital, number of beds, 828
Psychiatric clinics, in general hospitals,
461-62; needed in connection with
courts, 479, 481, 486; proposed uni-
versity, 461, 462; of Red Cross, 497
Psychiatry, definition of, 545. See also,
Industrial psychiatry; Mental medi-
cine
Psychological clinic, 462, 486, 488
Psychology, definition of, 544-45
Psychopathic hospitals, sec City Hospital;
State Psychopathic Hospitals
Public Health Association, 980; reconi-
mendation for creation, 104; section
on Child Hygiene, 270
Public health education, see Health educa-
tion
Public health nurses, present number in-
adequate, 366
Public health nursing, elements of succes,
753, 754; scope of survey, 753.
See also Division of Health; Depart-
ment of Medical 'Inspection; Visitiiig
Nurse Association; University Dis-
trict; Industrial nurses; Generalized
public health nursing; Central Com-
mittee on Public Health Nursing;
Pre-natal and Maternity service; Uni-
versity coiirse in public health nursing
Public health organization, additional
non-official agencies needed, 212; im-
portance, 25; official and non-official,
103
Public service organizations, employing
women, 569-71
Public utilities, employing women, 571
Pure Food Law, provisions of, 675
Quacks, dental, 683-84;
medical: peril to immigrant. 672;
advertisements in foreign-language
newspapers, 672-73, 679-82; expert
psychologists, 678; methods of evad-
ing the law, 673; methods of appeal,
674-75; instrument for detection of,
676; recommendations, 682
Rabies, control, 137; 149-50
Rainbow Hospital, convalescent care,
203, 941; enlargement of scope of
work suggested, 942; facilities for
care of non-pulmonary tuberculosis,
361; limited in field of action, 207;
number of beds, 828
Rapid Transit Company, quotation from
report, 43
Recommendations, 55-56, 59, 66, 81-82,
83-84, 90, 104, 141-42, 164, 172, 176-
77, 184-85, 189, 190, 191. 209-12, 219-
Index
1077
20, 226-28, 274-75, 278-80, 283-84,
285-87, 287-88, 301-18, 334-35, 370-76,
401, 403-4, 404, 406. 407-8, 409, 412,
421-22, 503-11, 554-56, 575-76, 619-21,
669-71, 682, 690, 697-98, 741-45, 751-
52, 757-58, 769-73, 781-82, 788-89,
796-97, 803, 887-88, 910-11, 917, 964-
65; summary, 35-38
Recreation, employment of a director, 429 ;
importance in venereal disease cam-
paign, 395, 429; suggested improve-
ment of facilities, 396
Red Cross, health education, 314, 363;
neuro-psychiatric clinic, 497. See also
International Red Cross
Restaurants, earnings and hours of work
of waitresses, 571
Rubbish and ashes, 73-75, 80-81; recom-
mendations, 81-82
St. Alexis Hospital, number of beds, 828;
orthopedic facilities, 202, 203; out-,
patient department needed, 918-19;
training school for nurses: organiza-
tion, 714; minimum entrance require-
ments, 715-16; capacity of hospital
and services offered, 718-23; teaching
727; day duty, 736; night ;duty, 737-
38; vacation, 738; living conditions,
740-41
3t. Ann's Maternity Hpspital, number of
beds, 828;
training school for nurses: teaching
of nursing procedures, 727-28; day
duty, 736; night duty, 737-38; vaca-
tion, 738;
>t. Clair Hospital, niunber of beds, 828
»t. John's Hospital, number of beds, 828;
orthopedic facilities, 202; out-patient
depculment needed, 918; provisions
for mental cases, 461;
training school for nurses: organiza-
tion, 714; minimum entrance require-
ments, 715-16; capacity of hospital
and services offered, 718-23; teaching
of nursing procedure, 724-27; teaching
of fundamental sciences, 728-32; in
struction in other subjects, 732-35
ratio of nurses to patients, 735-36
day duty, 736; night duty, 737-38
vacation, 738; living conditions, 740-
41
St. Luke's Hospital, dental service, 687;
number of beds, 828; orthopedic facili-
ties, 202; plans for expansion, 967;
dispensary: building, 893; classes
of disease treated, 892; deficiencies,
897; fees and finances, 894; future
plans, 919; location, 892; medical
work and records, 895; organization,
892; patients, 893; social ^ service,
895-96; visits, 1919, 890;
training school for nurses: organiza-
tion, 714; minimum entrance require-
ments, 715-16; capacity of hospital
and services offered, 718-24; teaching
of nursing procedures, 724-28; teaching
of fundamental sciences, 728-32; in-
struction in other subjects, 732-35
ratio of nurses to patients, 735-36
day duty, 736; night duty, 737-38
vacation, 738; living conditions, 740-41
St. Vincent's Charity Hospital, dental
service, 688; number of beds, 828
social service department, 952, 953
study of convalescent cases, 928-30
dispensary: buildings 893; classes
of disease treated, 892; deficiencies,
897; fees and finances, 894; location,
890; medical work and records, 895;
organization, 892; orthopedic facili-
ties, 202 ; patients, 893 ; social service,
895-96; venereal disease clinic, 401,
408, 409; visits, 1919, 890;
training school for nurses: organiza-
tion, 714; minimum entrance require-
ments, 715-16; capacity of hospital
and services offered, 718-23; teaching
of nursing procedure, 724-27; teaching
of fundamental sciences, 728-32; in-
struction in other subjects, 732-35
ratio of nurses to patients, 735-36
day duty, 736; night duty, 737-38
vacation, 738; living conditions, 740-
41
1078
Hospital, and Hr\lth Survey
Sanitaria, for mental cases, 462-64
Sanitary areas, definition, 42; number, 46;
reasons for adoption, 114-15
Sanitary Code, 119; authority for control
of acute communicable disease, 122;
regiilations in regard to communicable
diseases, 123-24; suggested section
about laboratory and dispensary super-
vision, 416-18
Sanitary Index, 127
Sanitation, see Collection and disposal of
garbage; Collection of rubbish and
refuse; Flies; Housing; Mosquitoes;
Smoke; Water supply; Milk supply
Schick test, used in institutions, 126
School attendance department, 583, 586
School doctors, see Department of Medical
Inspection
School for deaf, 294
School health supervision, measure of its
effectiveness, 319; parochial schools,
288, 301, 763; private schools, 301;
recommendations, 301-18;
public schools: health education,
297; lack of coordination of different
types of health work, 301-2; medical
inspections, 288-96; physical training,
296-97, 312-13; sanitary supervision,
297-301; nursing service, 782-88
School hygiene, see Department of Build-
ings
School nursing, see Department of Medical
Inspection
School of Medicine, community relations,
655-56; curriculum and instruction,
656-59; Dean, 659; deficient recogni-
tion of many specialties, 651; depart-
mental distribution of teaching staff,
660; distribution of graduates, 660-61;
educational v-Jue of hospital and dis-
pensary, 863-65; facilities for clinical
teaching, 653; faculty organization,
657-58; graduates on hospital staffs.
860; history, 659; hours of work re-
quired, 660; inadequacy of educt-
tional facilities in orthopedics, 207-S;
lack of recognition of orthopedics, 197;
post-graduate instruction, 662; fadfi-
ties for teaching mental medioDe,
460-61 ; problems of construction and
endowment, 653-55; proposed depart-
ment of industrial hygiene, 553, 656;
recommendations, 669-71; statistics,
661-62; suggested activities in ^^
search and teaching, 368
School of Pharmacy, faculty, 69S;
finances, 695; history, 694-95 ;i hos-
pital service offered by, 696-97, 875-
76, 885; needs, 695-96; standard, 697
Sewage disposal, 60-66; recommendatioos,
66
Sex delinquency, institutional care of
offenders, 430; laws and machinery
for enforcement, 419-27; preventive
work, 429; probation work, 425, 429;
protective work, 425, 429-30
Sex education, method for control of
venereal disease, 396; for children.
431-32; for young men and ^ women.
432; permanent measures for, 432-33;
social hygiene information for parents
an J leaders of public opinion, 432
Shortage of labor, reasons, 559
Sickness, cost, 26; relation to dep>endency,
26; three services necessary for care
and prevention, 26; studies of, 819
Sickness incidence, see Industrial accident
and sickness statistics
Small industrial establishments, 550-51
Smallpox, problem, 126-27
Smoke, effect of air pollution on health,
88; effect on climate, 47; necessity
for prevention, 85; present expendi-
tures for prevention, 89; present or-
ganization for prevention, 88-89; rec-
ommendations, 90; soot-fall studies,
85-87
Index
1079
Smoke investigation of Pittsburgh, quota-
tion from Bulletin 8, 85
Social hygiene, see Venereal diseases; Sex
education
Social service, see Medical social service
Social Service Clearing House, functions,
958-59; suggested extension of scope,
935; use, 959
Society for the Blind, 193-95
Soot-fall studies, analyses, 86-87; appa-
ratus used, 86; extent, 86; purpose of,
86
State Board of Administration, direction
of care of insane, 467-68
State Board of Pharmacy, lack of in-
spectors, 693
State Bureau of Juvenile Research, 473-
74
State Dental Practice ^ Act, need for
amendment, 683
State Department of Health, registration
of hospitals and dispensaries, 822;
suggested extension of supervisory
powers, 979-80
State Fire Marshal, control over sanitaria,
463; responsible for health among food
handlers, 544, 570
State Hospital for Epileptics, 473
State Hospital for Insane, dental service,
688; description, 470-71; facilities for
care of tuberculosis cases, 360
State Industrial Commission, analysis of
reportable accidents, 540, 550; Depart-
ment of Factory Inspection, 583, 586,
587; hospital rates for accident cases
872; powers to safeguard health and
safety of working-people, 553; statis-
tics for eye injuries, 546
State Institution for Feeble - minded,
capacity, 471
State Medical Board, detection of quacks,
676
State Psychopathic Hospitals, description
of one located in city, 470-71 ; need for
second in city, 470; nimiber, 469-70.
See cdso State Hospital for Insane
State Sanatorium, 360
Statistics, health districts iised as basis
in' report, 42; list of statistical tables,
19-20; list of graphs, 21-22; wastage
from sickness and premature d^th,
25-26. See also Children and industry;
Federal Bureau of Labor Statistics;
Hospital statistics; Industrial acci-
dent and sickness statistics; Popula-
tion statistics; Vital statistics
Statistical analysis, importance, 338
Street cleaning,^ 78-82
Street trades, extent and general charac-
ter of newsboy trade, 599-601; ordi-
nance, 597-98; reasons for non-
enforcement of ordinance, 598; recom-
mendations, 601-2; undesirable nature
of work for children, 598-99
Surveys, child health, 1006; industrial
hygiene, 1006; mental hygiene, 1006;
Pittsburgh, 1006; sickness, 1006;
social, 1006; Springfield (Illinois),
1006; tuberculosis, 1006. See also
Health administration surveys
Syphilis, see Venereal diseases
Telegraph work, employment of children,
595; number of women employed, 571
Telephone work, employment of girls
under 18, 593; earnings, 571; health
hazard, 571, 594; hours of work, 571;
security of operators, 571
Textile and knitting mills, health and
accident hazards, 561; number of
women employed, 561
1080
Hospital and Health Survey
Tobacco factories, difficulty of learning
trade, 563; number of women em-
ployed, 563
Topography, 46
Tuberculosis, detection, 365-66; equip-
ment for control, 331, 346; expert
consultation service needed in indus-
try, 547; follow-up of cases, 367; im-
mediate needs for prevention and
control, 332-34; importance of ma-
terial relief in treatment, 367; impor-
tance of niirsing in treatment, 366;
institutional care, 357, 360-62; means
of prevention, 364-65; past accom-
plishments in control, 331-32; preva-
lence in industry, 546; recommenda-
tions, 334-35, 370-76; research and
teaching, 368; summary of report, 30;
treatment, 366-67; work at health
centers, 344, 355. See also Health edu-
cation; Legislation; Morbidity sta-
tistics; Mortality statistics
Tuberculosis nursing, 356-57; 366-67;
760-61; 775; 791-92
Tuberculosis survey, methods, 336-37;
primary objects, 336
Undertakers, ambulance service, 961
United States Home Registration Service,
quotation from report on Housing
Conditions of War Workers^ 43
United States Marine Hospital, provisions
for mental cases, 461-62
United States Public Health Service, ac-
tivity in combating venereal diseases,
547
University course in public health nursing,
field work, 748-51; finances, 746; in-
struction, 748; measure of success
achieved by, 751; organization, 745-
46; origin, 745; staff, 746-47; stu-
dents, 747-48; recommendations. 751-
52
University District, a community service,
789-90; dcscripti<Mi, 115-16; factor in
success of public health nursing course,
746; plan of administration, 790; prac-
tice field for public health nursing
course, 745; recommendations, 796-97;
results of prenatal care in, 273. 274;
staff, 790; summary of work, 795-96;
supervision, 795; supervision of work
of students in University course, 747,
749-50;
activities: visiting nursing, 790-91;
child hygiene, 791; tuberculosis, 791-
92; communicable disease control,
793; prevention of blindness, 793;
supervision of boarding homes, 793;
prenatal nursing, 793-94; school nurs-
ing, 794; clinics, 794-95, 902-3
University Hospital Group, 967; order of
precedence in erection, 654-55
University psychiatric clinic, 461, 462
University School of Nursing, a shorter
basic training for nurses, 712; im-
portant contribution to solution of
problem of nursing education, 710;
recommendations, 741-42; some bene-
fits, 710-11; special function, 7!1-12
Vaccination, 126-27
Venereal diseases, diagnosis, 400-1; draft
board figures for, 398; follow-up of
treatment, 414-16; hospital beds for
care of, 401-2, 410, 832; method of
combating in industry, 547; preva-
lence. 398-99; prevention, 411-12;
recommendations, 401, 403-4, 406,
407-8, 409, 412, 421-22; summary of
report, 30; treatment by private
physicians, 402-3; treatment in dis-
pensaries, 401, 404, 406-9;
control: campaign for, 410-11;
methods, 396-97, 429-30; needs, 225,
395-96; past accomplishments, 395;
present facilities, 395
See also. Sex delinquency; Sex educft-
tion; Recreation
Index
1081
Venereal Disease Bureau, proposed or-
ganization, 413-14
Ventilation, in hospitals, 889; in schools,
298
Vice conditions, investigation, 427-28
Vice investigation, proposed committee
for, 426-27
Visiting Nurse Association, 193, 214; ad-
ministration, 778-81; agency for city-
wide prenatal service, 802-3; care of
chronic illness, 944; experience with
trained attendant service, 810; pres-
ent equipment, 774; recommendations,
781-2; scope of work, 773-74; sug-
gested annual classification of patients,
945;
activities: care of sick, 774-76;
prenatal nursing, 776; maternity serv-
ice, 776-77; industrial nursing, 777;
out-patient maternity affiliation, 777;
Pilgrim Church service, 777-78; serv-
ice outside city, 778
Vital statistics, definition, 165; state law
regarding, 167; suggestion for institu-
tion of a system, 167-72. See also
Birth registration. Morbidity statistics;
Mortality statistics
Vocational guidance, advantage of bu-
reaus connected with schools, 616;
development in England and the
United States, 615; need, 596-97;
outline for department, 617-19
Vocational therapy, facilities, 205
Vocational tiaining, 614
Warrensville Children's Camp, 361
Warrensville Tuberculosis Sanatorium,
case bookkeeping, 368; living condi-
tions, 367; location and equipment,
357, 360; method of admission, 366;
number of beds, 361, 828; per cent of
cases leaving, 367-68
Water supply, 57-59; in hospitals, 889;
recommendations, 59; summary of
results of examination of city water,
1919, 159
Welfare Federation, 197, 499; appropria*
tion of money to dispensaries, 920;
establishment of expert accountant
service, 870-71; functions, 980-81;
history, 104-6; present equipment for
public health service, 104; proposed
organization for health service, 104;
publicity service, 876, 978
Western Reserve University, education
subject to three main limitations, 651;
feeling of public for, 652; lack of in-
struction in bodily mechanics, 198;
material resources for teaching and
research, 652; only local institution
preparing physicians, dentists and
pharmacists, 651; trustees, 652. See
also University School of Nursing
Wet nurses, see Infant care
Wholesale and retail trade, see Mercantile
establishments
Woman's Court, 424-25; establishment,
427
Woman's Hospital, number of beds, 828
Woman's Police Biireau, 424-25; func-
tions, 429
Women's Protective Association, 425, 429;
need for facilities for nr.ental examina-
tions, 499; social investigations for
Probate Court, 476
Women's work, method of surveying, 558
Women and industry, day nurseries, 574-
75; home work, 573-74; mothers*
pensions, 575; night work, 571-73;
recommendations, 575-76; summary
of report, 31. See also. Industrial es-
tablishments; Mercantile establish*
ments; Public service organizations;
PubUc utiUties
1082
HOBPTTAL AND HeALTH SuBYET
1
Work permits, examination made 1^ De-
partment of Medical Inspection, 605-6;
for safeguardmg, 557
Federal Children's Bureau health
Worionen's Compensation Act, 543
duitry, 603-4; informatioo as to
Year Book, suggeited publication, 171
mental deficiencies, 608-9; iMuance
1^ Department of Medical Inspection,
Zone, definition of term as used in Quid
606-7; for the mentally defective,
Health report, 272 •
490-93
THE CLEVELAND HOSPITAL AND HEALTH SURVEY
REPORT
List of Parts and Titles
I. Introduction.
General Environment.
Sanitation.
II. Public Health Services.
Private Health Agencies.
III. A Program for Child Health.
IV. Tuberculosis.
V. Venereal Disease.
VI. Mental Diseases and Mental Deficiency.
VII. Industrial Medical Service.
Women and Industry.
Children and Industry.
VIII. Education and Practice in Medicine^ Dentistry* Pharmacy.
IX. Nursing.
X. Hospitals and Dispensaries.
XI. Method of Survey.
Bibliography of Surveys.
Index.
The complete set may be obtained at a cost of $5.50 plus the
postage and single parts at 50 cents each plus the postage, from
THE CLEVELAND HOSPITAL COUNCIL,
808 Anisfield Building,
Cleveland, Ohio
;.
r -
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