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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. 



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 correc ta ble 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 
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 





4 


1 


365 


3 
93 



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 

200 to 500 7 2, 118. 70 4 1 6 

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 21 

200 to 500 10 3 4 

1 to 200 2 2 

Totals ~ 18 10 26 2 56 



TABLE V. 
Medical Service in Mercantile Establishments and in Public Utilities 





No. 
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 





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 

Correct e d 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 
















5 




1 
1 


1 

2 




C«idy 




If Iscellaneoiis, 


1 








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 







500 to 1,000 200 to 500 




4 
5 





3 


1 




1 to 200 



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. 

S a l eiq |)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 



Co n struction,. ... 

« 

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 





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 





32 


76 


76 


61 





19 


71 


277 


14 


S3 


200 


334 


12 


S3 


24 


96 


• 23 


187 


36 


15 


121 


29 


202 


242 


26 


81 





160 


'' 


10 


76 


4 





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 





20 


4 


29 


1 


54 







2 


2 


17 





21 


75 


1 


13 


3 


23 


1 


41 







4 





2 





6 


47 


7 


8 


5 


35 


2 


57 




1 


1 


5 


24 





31 


88 


5 


31 


11 


19 


5 


71 







14 


7 


8 





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 





485 






57 


14 


23 


8 


103 


588 


3 


154 





4 


2 


163 






18 


5 


7 


10 


41 


204 




42 








1 


44 







6 


2 


1 


5 


14 


58 




3 


1 


3 





8 


. 







2 
307 





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 


4 


5 


17 


13 


17 


3 


5 


25 


14 


3 


• ••. 


.... 


3 


15 


1 




1 


2 


Total 


51 


15 


34 


100 







Work Till Night 






5 


6 


7 


8 


9 


10 


Tc/tM 




2 


1 




1 




^ 


> ■ ■ 


1 


2 


1 


«•*« 


•••• 


♦ 


5 


1 


•••« 


1 


.... 


1 


^ 


>•• 


1 


1 


2 


••«« 


•••« 


^ 


3 


4 


1 


1 


1 




1^ 


3 


9 


5 


2 


1 




2J- 


2 


9 


2 


3 


.... 




ir 


3 


12 


2 


4 


3 




2^ 


1 


1 


•h«> 


— 


— 






2 


•••« 


»«v« 


•... 


**«« 





^ 



19 



40 



14 



14 



7 10^ 



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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 p r of essors, 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 





. 
























Itimated 
Popula- 
tion of 
City 


Classification 
by Council o 
Medical Edu 
cation • 


No. of Stu- 
dents 
Registered 


M 

V 

9 

2 



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 





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 
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 

GlenviUe 1 or 2 

Grace unknown 

Huron Road 5 

Lakeside.^ 1 10 

Lutheran^ 

Maternity ^ 8 

Mount Sinai 50 

Provident- ..^-.. 

St. Alexis _ unknown 

St. Ann's 20 orphanage children • 

St. Clair 1 

St. John's 20 

St. Luke's 5 

St. Vincent's 27 

Woman's 

Lakewood a few 

455 



668 



Hospital and Health Survey 



Even at the ^hospitals where post-mortem study is urged and has its best 
chance in Cleveland the percentage of deaths which come to autopsy is piti- 
fully small as can be seen from the following list. 



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 de partm ents 
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 
treatm ents 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 

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 Perce n t 

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 i n ^>cc t ioo 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 p roportion 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 p ro portion 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? 

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 

Glenville._ 1 

Grace number unknown 

Huron Road 5 

Lakeside 110 

Lakewood number unknown 

Lutheran 

Maternity 8 



Mt. Sinai 


50 


Provident 





St. Alexis 


..number unknown 


St. AnnV„ 


_ 20 


St. Clair 


1 


St. John's 


-... 20. 


St. Luke's 


- ^ 5 


St. Vincent's 


. 27 


Woman's.^ 






Total 456 

Such a low percentage can only mean one of two things — either failure 
on the part of the medical staff to appreciate the importance of autopsies* 
as a real checking up of results, and setting a real standard of self-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 represen tatives 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 repo rt s, 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 oper ate d 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 C ommiiai o o et a 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 
ix pe ct s 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 r ep r e s ent 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 
ap pro vin g 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 
















*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 shou