FIRST ANNUAL REPORT OF THE HENRY PHIPPS INSTITUTE FOR THE STUDY, TREATMENT, AND PREVENTION
OF TUBERCULOSIS A BRIEF ACCOUNT OF THE WORK OF THE FIRST YEAR AND A REPRINT OF THE LECTURES
DELIVERED UNDER THE AUSPICES OF THE INSTITUTE DURING THE YEAR PUBLISHED BY THE HENRY PHIPPS
INSTITUTE 238 PINES STREET, PHILADELPHIA TEMPORARY QUARTERS, 238 PINE STREET.
THE WORK OF THE FIRST YEAR
The Henry Phipps Institute was founded on February 1, 1903. It was incorporated September 1,
1903. The purposes of the Institute as set forth in its charter are: “The
study of the cause, treatment, and prevention of tuberculosis, and the dissemination of
knowledge on these subjects; the treatment and the cure of consumptives. The benefits shall be
administered without regard to race, creed, or color.” The founder of the Institute is
Henry Phipps, Esq., who also maintains it. Incorporators are Henry Phipps, Esq., Lawrence F.
Flick, M.D., Mr. Geo. E. Gordon, Miss Amy F. Phipps, and Mr. Samuel Harbison.
Clinical work was begun in the Phipps Institute in temporary quarters at 238 Pine street,
Philadelphia, on the second day of February, 1903, the day after foundation. Dispensary patients were seen on that day and from that day on. From
the first day on which work was begun the number of patients exceeded the capacity of the
Institute for clinical work. Bare floors and walls of the first-story front room, a few chairs,
a clerk, and three physicians constituted the equipment at the start. Dispensary work and
fitting up went hand in hand for months. During this time order was brought out of chaos and the
lines of work were developed, until finally a complete organization was brought into existence.
In the beginning arrangements were made with a drug-store to supply
medicine and with milkmen to supply milk to patients to whom these articles had to be given
free. These were temporary makeshifts until the Institute could create its own machinery
for supplying these commodities.
Number 238 Pine street is a well-built, large structure, which
had been put up for lodge purposes but had been unoccupied for some years. It is a four-story
building with a small threestory back building. The back building evidently was an old house
which had been moved back. The front building is twentysix feet front and sixty-six feet deep
and the back building is eighteen by thirty-two feet in dimensions. There is a side yard and å
back yard, the side yard being a narrow strip seven and onehalf by thirty-two feet and the back
yard an area of twenty-five by thirty-three feet. The front building has high ceilings on each
floor with fine large windows on two sides on the first floor, and three sides on the second,
third, and fourth floors. On the first floor there is a hallway with a stairway in the rear and
two large rooms which, no doubt, were used as reception rooms or parlors. On the second, third,
and fourth floors of the front building there is, on each, one large room, two small rooms, and
a stairway landing. In the back building on the first floor there is a very small kitchen, a
very small dining room, and a back stairway leading to the second floor. On the second floor
there is one small bedroom and a bathroom with a stairway leading to the third floor. On the
third floor there is one small bedroom. In the back building all the ceilings are low.
We divided the front room of the first floor into consultation rooms and an office, and the
back room into a consultation room, a waiting-room, a drug-store, and a laboratory.
We fitted up the little dining-room in the back building as a
consultation room, and the little kitchen as an autopsy room. We made wards of the large rooms
front on the second, third, and fourth floors, and a bathroom and linen room of one of the
little rooms back on each floor. The other little room on each of the second and third floors we
fitted up as a diet kitchen and that on the fourth floor
as the kitchen proper. There were platforms on both sides in the
front and the rear of the three large rooms front. We removed the platforms in the front and the
rear and retained those on the sides. These were about six inches above the level of the
floor.
We placed eighteen beds in each room on the second and third floors and sixteen in the room on
the fourth floor. We put a dining table in each of the wards for the patients who are up and
about and a food carriage to keep the food warm while being served. These three large rooms made
excellent wards, having high windows on two sides, and a ventilator above a door on the third
side. We placed three electric fans in each ward to supplement the natural ventilation and also
to keep the wards cool in summer. We placed a gas range in the little kitchen on the fourth
floor. This we did as a matter of cleanliness and economy.
The second floor of the back building we fitted up as a dining-room for the nurses. We lodged
the nurses temporarily in rented rooms outside. A little corner of the room we fitted up as an
office for the head nurse. The room on the third floor of the back building we fitted up as a
sterilizing room and laundry. Opening out from this, we constructed a flat over the bathroom
below for the purpose of drying clothing, and from this flat we ran lines to a pole at the end
of the yard as a means of extending the facilities for drying clothes.
We put steam heat in the building, an electric pump for pumping water to the roof, and new
plumbing. The back yard and cellar we cemented. We put up canopies in the back yard for the
protection of patients while sitting out. We transformed the rear cellar into a pathological
museum and part of the front cellar into a storage room. They immediately made a museum as part of the institute
For sanitary reasons we had
all the walls of the building scrubbed and repainted, all the woodwork thoroughly scrubbed, and
the cellar walls whitewashed. We put electric lights in the cellar, on the
fire-escape, and in the autopsy room, as a matter of safety against fire and also as a matter
of convenience. For lighting the rest of the building we use gas.
All of these details about the preparation of the building and the opening of the hospital are
here given for the purpose of showing how inexpensively and easily an
old building can be
p. 6
transformed into a fairly good modern hospital in a short time, and
how easy it is in any community to make provision for the treatment of the consumptive poor
without waiting until a great deal of money is at hand and ideal conditions present
themselves. It, moreover, will be of importance to keep all of these matters in mind in
connection with the results.
The wards of the hospital were opened on April 20th. It had taken all of this time to put the
house in condition for the reception of patients. Meanwhile the dispensary service had grown
very large. When the wards were opened they filled very rapidly -more rapidly, indeed, than was
desirable, for it was difficult to secure a nursing staff. The fear of tuberculosis materially
interfered with the organization of a nursing staff. The
nursing problem was finally solved by opening a training school with girls who had been cured
at the White Haven Sanatorium. The Institute is thus doing a double good work, that of training
women for the care of consumptives and that of making an occupation for cured
consumptives. The nursing staff at the end of the first year consisted of five trained
nurses and five pupil nurses.
As the work increased in the dispensary the medical staff was augmented, and by the time the
wards were open quite a fairsized staff had been organized. As with the nursing staff, there was
some difficulty in organizing a medical staff, partly on account of fear of tuberculosis and
partly, perhaps in a greater degree, on account of the high grade of men needed. Inasmuch as the
Institute is for the study of tuberculosis as well as for its treatment and prevention, men not
only of ability, but with preliminary training for original research and advancement of medical
science had to be selected. At the end of the first year there were sixteen men on the medical
staff.
The work accomplished by the Institute during the first year is interesting for its magnitude
as well as for its scientific and philanthropic worth. Its magnitude in some measure detracts
from its scientific value, because during the period of organiza-
p. 7
tion pressure of work led to inaccuracies of observation and incompleteness of records.
Besides, men had to be trained for the work, as it was along new lines. To
do exact scientific work in a dispensary was a new departure. It had to be made clear,
moreover, that the Institute stood for science as well as for charity. An earnest effort
was made by all to do good work, and whatever shortcomings occurred grew out of inexperience and
overwork. The magnitude of this first year's work is in a measure indicated
by the records of cases, which in bound form consist of ten octavo volumes of about one
thousand pages each. These records are brimful of scientific data, and will form the basis of
future scientific papers. Some of the data are summarized in this report.
It has taken much labor of the most painstaking kind to put this first year's records into
exact order, because of the confusion which grew out of the excessive amount of work always on
hand during the year. From the beginning each patient as he applied for
treatment was given a number in consecutive order and his name was inscribed on a history sheet
for examination. At all times there were more patients in the dispensary than could be taken
care of by the medical and clerical staffs. Sometimes patients were given numbers, but could
not be reached by the physician, and sometimes the physician in the desire to help as many of
these poor people as possible allowed sympathy to get the better of science, and gave treatment
without a complete record. It takes an hour to make a complete scientific record of a patient,
and with a crush in the waiting-room men gave treatment without a history in the expectation of
getting leisure to take the history later on when the pressure was less, but such a time never
came and the history was not taken. This sympathetic interference with the scientific work of
the Institute finally was checked by creating a waiting list in the dispensary and assigning
new cases to men only as they could take care of them.
p. 8
Some confusion also grew out of mistakes of the clerical staff. In a few
instances the same number was given to two patients, and in a few others two numbers were given
to the same patient returning for treatment unrecognized as having been there before.
The records have been put in perfect order and all mistakes have been
carefully eliminated. Future mistakes are guarded against by our present system of records. All
patients now are entered numerically in a book and indexed alphabetically in a card index.
Besides, the history sheets are filed away in numerical order in sections of ten.
The highest numbered history sheet at the end of the year was
twenty hundred and forty-eight. A careful elimination of all errors shows that twenty hundred
and thirty-nine patients were treated. Eight patients had received two histories each, two
patients had received the same number, and two numbers had been skipped.
Of the patients treated, two hundred and fifty-four were treated in the
hospital. Of these, one hundred and eighteen were treated in the dispensary before admission
into the hospital or after discharge. The number of patients who received treatment in the
dispensary therefore was nineteen hundred and three.
Nine hundred and four dispensary patients made one visit only; some
because they entered the hospital; some because they were unsuitable; some because they did not
have tuberculosis; and others because they merely came for an opinion.
Of the persons registered for treatment, three hundred and sixty did not
have tuberculosis, two hundred and fourteen were unsuitable in that they could afford to pay
for their treatment, and seven had no diagnosis recorded. In all, therefore, fourteen hundred
and fifty-eight poor people with tuberculosis applied for treatment.
In the dispensary nine hundred and ninety-nine patients made more than
one visit. These made a total of six thousand eight hundred and seventy-six visits, or an
average of six and eighttenths visits each. The entire number of visits made in the dispensary
was seven thousand seven hundred and eighty-one.
p. 9
Of the patients admitted into the hospital, two hundred and forty-five
had tuberculosis; seven had no diagnosis recorded; one was recorded as having bronchitis, and
one was undiagnosed.
One patient who had been diagnosed as having tuberculosis was
found on autopsy also to have had bronchiectasis. This patient is
made the subject of a special report. The patient who was recorded as having bronchitis
remained in the hospital only twelve days. This diagnosis was not scientifically established.
The probabilities are that the patient had tuberculosis.
One of the seven patients of whom no diagnosis was recorded, was diagnosed as having tuberculosis at autopsy. She died one-half
hour after admission.
The other six left the hospital before a diagnosis could be made. The two
hundred and fifty-four patients spent twelve thousand and sixty-eight days in the hospital,
averaging forty-eight and seven hundredths days each. Forty patients were in the hospital less
than one week. Of these, ten died and the others left for various reasons. The longest stay of
any patient was two hundred and eighty-six days. This patient was in the hospital at the end of
the year. He was a most advanced case when he came in, but had steadily improved.
NATIVITY
p. 10
NATIVITY.—(Continued)
MIXE PARENTAGE
p. 11
MIXED PARENTAGE.—(Continued.)
Nearly one-half of all patients registered were foreign-born. The
foreign-born males exceeded the foreign-born females about 19 %. Many of the foreign-born have
been in the country so short a time that it may be assumed they had the disease when they landed
on our shores.
It is interesting to note the places from which the foreign-born patients came. Russia
supplied us the greatest number in the first generation, Ireland the next greatest number, and
Germany the next. Going one generation back, Ireland changes places with Russia. In a measure
the number of cases from the various countries is in ratio with the immigration from those
countries. Russia is sending us the largest number of immigrants in the immediate generation and
Ireland sent us the largest number in the past generation. The racial element in these
statistics unfortunately is incomplete. It would have been interesting to have singled out the
Jews with a view of throwing light upon the question of immunity. In future this will be done.
The majority of the patients from Russia, Roumania, Austro-Hungary, and Poland, however, were
Jews. Racial science is prominent in this
kind of discussion. Explicitly, they are talking about Jewish people
Age
p. 12
More than one-half of the patients registered for treatment were of the
age which is of the greatest importance to the public weal. During the age-period between
twenty and forty, men and women not only are of greatest value as producers of wealth, but are
important factors in the propagation of the species. Death during this life-period is a serious
blow to the public weal. It not only strikes at the source of wealth, but also puts a drag on
the public weal in the production of dependent orphans. Most people who die between twenty and
forty leave behind them dependent children, and inasmuch as tuberculosis is a longdrawn-out
disease, dependent children who have been made orphans by this disease are apt to become public
charges.
SEX. Male,1179 Female,851 No Record,9
The number of males greatly exceeds the number of females. This is
probably due in part to the foreign element. This
preponderance cannot be accepted as an index of respective liability of the sexes to
tuberculosis.
COLOR.
The vast preponderance of white people over colored people among the patients registered is no
indication of the relative amount of tuberculosis in the races, nor of their relative poverty.
The colored people are much more prone to tuberculosis than are the white people. There probably
is as much poverty among the colored people as among the whites. The colored people, however,
are more loath to become a public charge and are more disposed to help themselves. They will not
go into a public institution if they can manage to crawl around.
The proportion of colored admissions to white admissions, however,
was
p. 13
greater than is the proportion of the colored population to the white
population in Philadelphia. The number of colored admissions was about 6 1/2% of the white
admissions.
RESIDENCE
As will be seen from the table, vastly the majority of the patients were
from Philadelphia.
A reference to the map published as a part of
this report, which gives the location of patients in the city of Philadelphia, will show that
the majority of the patients came from the immediate vicinity of the Institute. The
Institute is located in the poorest district of Philadelphia, and quite naturally a great deal
of tuberculosis exists in this district. This map, however, cannot be accepted as an indication
of the prevalence of tuberculosis in Philadelphia. The probabilities are that the disease is
fully as prevalent in the mill districts of the city.
SOCIAL CONDITION
There are two elements in the statistics of the social condition of the patients worthy of
notice:
one the number of married people,
and the other the number of widowed. Forty per cent. of the patients who applied for
assistance were married and consequently destined, unless the disease could be arrested, to
leave orphaned children and widowed consorts. Inasmuch as the poverty of these poor
people is distressing, it is to be anticipated that unless restored to health they will almost
necessarily become a public charge. It is remarkable that nearly nine per
cent. of the applicants were already widowed. What a sad picture of distress and sorrow can be
conjured up out of these figures!
p. 14
OCCUPATION
p. 15
OCCUPATION.-(Continued.)
p. 16
OCCUPATION.-(Continued.)
In the occupations of those who applied for treatment some very interesting points present
themselves. For a correct interpretation of occupation statistics one needs
to keep in mind such factors as the remuneration which goes with the occupation, the severity
of the labor involved, the propensities to alcoholism, the presence of irritating substances in
the air of places of employment, and the relative number of people employed in the
occupation. The occupation from which the highest number came for treatment at the Phipps
Institute during the year is housework. In this connection it must be borne in mind that among
the poor all married women and most widows give their occupation as housework. The wife and
mother is most intensely
p. 17
exposed to contagion in a household in which there is tuberculosis. It is not a matter for
surprise, then, that of the women who apply for charity in the treatment of tuberculosis nearly
one-half are houseworkers. The number of women who applied for
treatment is eight hundred and fifty-one and the number of houseworkers is three hundred and
sixty. The other female occupations most numerously represented in the table are, in respective
order: factory hand, forty-seven; weaver, thirty-two; seamstress, thirty-three; laundry-worker,
fourteen; store employee, twelve; and nurse, seven. Some of these occupations are pursued by
men as well as women. The occupation of seamstress is the only one exclusively filled by women.
With this occupation the question of remuneration plays a part. Seamstresses are poorly paid
and are compelled to work in unhygienic environments.
The male occupation which stands at the head of the list is that of laborer, with one hundred
and one. The laborer is not only poorly paid, and consequently poorly fed, but lives in poor
environments. He has more chance of having the disease in his home than most people, by reason
of his poverty, and consequently he is more apt to be exposed to contagion than most people.
A group of occupations all belonging to the same category is
that of tailor with fifty-nine; that of clerk with forty-three; that of cigarmaker with thirty;
that of salesman with thirteen; that of printer with fourteen; and that of shoemaker with
twelve. In all of these occupations there is poor pay, which means deprivation at home,
and bad sanitary conditions in the place of occupation. Another group is that in which alcohol
plays a part; those occupations in which, by reason of association, exposure, or hard work,
there is a temptation to use alcohol in some form or other. To
this group belongs the occupation of driver with forty-two; that of waiter with twenty-one;
bartender with fourteen; plumber with ten; and cook with ten. In these occupations
neither want of food nor lack of fresh air plays a part. There is usually plenty to eat and
there is either outdoor life or fair indoor
p. 18
environment. The propensity to tuberculosis in these cases is due to alcoholism. In these
occupations the temptation and opportunity for the use of alcohol are great. Another group is
that in which occupation exposes to inhalation of irritating substances given off in
manufacturing processes. These irritating substances may act in two ways, one as a medium of
contagion, the other as a means of traumatism. They probably act in both ways. To this group belongs the occupation of mill-hand with sixty-four;
machinist with thirty-five; weaver with thirty-two; iron-worker with twenty-one; upholsterer
with nine; and leatherworker with nine. The high morbidity in some of the occupations is
only intelligible upon the assumption that the occupations were taken up after the disease had
been contracted, because the occupations are easy and out-of-doors. Such are, for example, the
occupations of canvasser, agent, collector, and peddler. The occupation of car conductor, I
know, is frequently taken up by persons who have had tuberculosis and who have made a partial
recovery.
ALCOHOLISM
In former times alcohol was looked upon as a preventive and cure of tuberculosis. At the
present day alcohol is looked upon as a predisposing cause of the disease and as an impediment
to recovery. Neither of these views apparently gets much support from the statistics here given.
The word “alcoholism" as here used means an excessive use of alcohol, but not necessarily a use
of alcohol to the degree of drunkenness. A person was not put down as an alcoholic unless he
used enough alcohol to do himself some physical harm. Of course, it is not easy to get a history
of alcoholism from a patient, and some allowance must be made on this score for the smallness of
the numbers. As the figures stand, however, the percentage of alcoholics among consumptives and
among the relatives of consumptives does not
p. 19
seem to differ very much from that of nonconsumptives and relatives of nonconsumptives.
PREDISPOSING DISEASES.
It has been held that certain diseases greatly predispose to tuberculosis. This view has
originated from the observation that these diseases frequently precede tuberculosis within a few
years, and sometimes within a few months. The diseases which have best earned this reputation
are typhoid fever, pneumonia, and pleurisy. The figures would seem to indicate that pleurisy
most frequently precedes tuberculosis, pneumonia next, and typhoid fever last. More than
one-half the cases were preceded by one or the other of these diseases. There is good reason to
believe that the pleurisies, pneumonias, and typhoid fevers which precede tuberculosis
frequently are tuberculosis which goes unrecognized and simulates the diseases named. Some
observers even claim that practically all pleurisies are tuberculous. That irregular forms of
pneumonia and typhoid fever often are tuberculosis cannot be doubted.
SOURCE OF CONTAGION.
p. 20
An earnest effort has been made in history-taking to discover the source of contagion of each
case. In the majority of cases this was made out to the extent, at least, of finding a known
source of contagion. In many cases, however, owing to the ignorance and prejudice of patients
and their inability to understand and speak the English language, it was impossible to get a
satisfactory history. The histories of exposure to contagion which could be gotten emphasize in
a striking manner the part which family relationship plays in the spread of tuberculosis. With
this picture before one, it is easy to understand why the ancients looked upon tuberculosis as
an inherited disease. More than two-thirds of the cases in which a history
of exposure to contagion could be obtained gave contagion from blood relatives as the source of
the disease. The number of cases in which the disease was derived from consorts or from members
of their families is surprisingly large, and the number of cases which gave fellowemployees and
infected houses as the source of contagion is surprisingly small. Of course, it must not
be lost sight of that family contagion is always the most evident and easily recognized and that
the large number of cases in which the source of contagion remained undiscovered were in all
probability cases of occupation and house contagion. These forms of contagion are sometimes
difficult to ferret out even with intelligent observing people, because one cannot always know
when he is working with a consumptive or when the home into which he moves has been occupied by
a consumptive. Some of the patients gave histories of double and even
triple exposure.
PLACE OF BEGINNING OF TUBERCULOSIS OF THE LUNGS.
p. 21
An effort has been made to determine in what part of the lungs the disease began. The
conclusions here recorded were reached by trying to determine on which side the disease had made
the greatest ravages. The side which had the most extensive lesion was recorded as the side on
which the disease began. This cannot always be accepted as a safe deduction. Neither can it be
said that the observations upon which these records are based are entirely reliable. The
records, however, strongly support the universally accepted view that the right lung is most
frequently the first affected.
TISSUE INVOLVED.
A fair picture of the stages of tuberculosis in which patients applied for treatment is
presented in this table. The picture is underdrawn rather than overdrawn. In the beginning of
the service incomplete records were made. Of the dispensary patients more
than one-half had both lungs involved and about onethird were far advanced in the disease. Of the hospital patients only a little over 7 % had the disease limited to one
lung.
All this shows how slow people with tuberculosis are to recognize that they
are ill and need medical attendance. Tuberculosis is such an insidious disease that it makes
great progress before its existence is even suspected by the victim.
FREEDOM FROM COUGH.
p. 22
It is usually taken for granted that cough is an essential symptom of pulmonary tuberculosis.
Cough is a usual symptom, but not an essential one. It may be absent in tuberculous patients and
it may be present in nontuberculous patients. Forty-one patients
who were diagnosed as having tuberculosis were free from cough. At rest, with proper
regulation of diet, tuberculous patients cough very little. In the hospital no cough medicines
are used, and although the patients all are advanced, many with both lungs extensively diseased,
there is very little coughing.
TUBERCLE BACILLI IN SPUTUM.
Many sputum examinations were not recorded. This was on account of the
constant pressure of work. Of the cases recorded, a little less than two-thirds showed the
presence of tubercle bacilli in a limited number of examinations. This gives a fair
picture of the frequency with which sputum of tuberculous patients is negative. One or two examinations, when negative, mean very little. Tubercle bacilli may
be absent from the sputum upon repeated examinations even in advanced cases. This was demonstrated in some of the cases which came to autopsy. A
negative report on sputum, even when repeated examinations have been made, should not be
allowed to stand against positive clinical evidence of tuberculosis in making a diagnosis. It
is only when the clinical symptoms agree with the negative report of the sputum that a negative
diagnosis should be
made.
HOARSENESS.
p. 23
Hoarseness in tuberculosis is not necessarily an indication of laryngeal tuberculosis even
when the hoarseness is persistent. Usually persistent hoarseness does mean laryngeal
tuberculosis. Tuberculosis of the pharynx and tonsils occurs pretty often in advanced stages of
the disease and sometimes accounts for persistent hoarseness. Mixed infection alone may be
responsible for this symptom, however. Chronic catarrhal rhinitis and pharyngitis occur
frequently in tuberculosis and sometimes keep up hoarseness for a long time.
DISEASES OF THE CIRCULATORY SYSTEM. These statistics upon lesions and
functional diseases of the circulatory system, it must be admitted, cannot be accepted as giving
an accurate picture of the frequency with which such conditions occur in tuberculosis. It
requires great skill and large clinical experience to make exact trustworthy records of organic
heart lesions. Such skill and experience cannot be claimed for the medical
staff in the beginning of the work, at least. In many cases, moreover, no record was made at
all of the condition of the circulatory system. Even in the matter of functional disturb-
p. 24
ances, such as accentuated second sound, the record is very incomplete. Some of the members of
the staff recorded accentuated second sound in a majority of the patients and others recorded it
in almost none. Neither was there always a distinction made between accentuation of the aortic
second sound and the accentuation of the pulmonic second sound. This kind
of work is more accurately done now than it was in the beginning, so that future statistics
will throw more light upon the subject.
URINARY ABNORMALITIES.
Although it is part of the program of the Institute to make a careful
urinary analysis of all patients who apply for treatment, little was accomplished in this line
during the first year. Many examinations which were made were not recorded, and there is no way
of determining the number of cases on which this table is based. Our shortcomings were due
principally to the heavy pressure under which we have worked from the beginning and to the lack
of facilities for such work.
GENITO-URINARY DISEASE.
The statistics here given, it must be frankly admitted, are unreliable.
In many cases the thorough investigation necessary for determining whether or not there was
genito-urinary involvement was not made. It is not an easy matter to determine clinically
whether or not such organs are tuberculous. The symptoms which may indicate genito-urinary
tuberculosis may also
p. 25
indicate other diseases, and it is sometimes impossible to differentiate. Besides, in the
cases in which genito-urinary disease is recorded there is no record as to whether or not the
genito-urinary diseases were tuberculous in character.
HEMOPTYSIS.
It is rather surprising that so large a percentage of cases gave a history of hemoptysis. This
same ratio probably would not hold with people better situated in life. Hemoptysis undoubtedly
is largely due to overexertion. The pulmonary circulation becomes embarrassed by reason of
obstruction and the heart is stimulated to greater effort. Bodily fatigue adds to this
overaction, and with contraction of the blood-vessels hemorrhage The patients who entered the
hospital and were placed at rest remained almost free from hemorrhages even in the advanced
stages.
NIGHT-SWEATS.
In practically all of the patients in the hospital the nightsweats
stopped after the patient had been at rest for awhile and had had his diet regulated. No
drugs are used in the hospital for night-sweats and none are necessary. The large number of cases with night-sweats both in the hospital and dispensary indicates how
advanced many of the patients were when they came under treatment. It also shows how few
patients with tuberculosis come under treatment early.
p. 26
DIARRHEA.
Of the patients with persistent diarrhea, fifty were in the
hospital. Persistent diarrhea in a tuberculous patient usually indicates that the patient
has tuberculous ulceration of the bowels. Sometimes, however, extensive ulceration of the bowels
exists without much disturbance of the bowels; and sometimes great disturbance of the bowels
exists without ulceration.
EDEMA.
Edema in tuberculosis usually is the result of damaged circulation following in the wake of
the tuberculous process in the lungs and other organs. Right-sided dilatation of heart with
consequent dilatation of the left heart occurs frequently in advanced tuberculosis. This no
doubt plays a part in edema. Tuberculosis of the kidneys, however, probably also plays a part.
The kidneys frequently become the seat of tuberculosis. The records as
given here probably understate the percentage of cases in which edema occurs in tuberculosis.
In many cases no careful investigation was made for edema and no records were kept.
DURATION OF DISEASE.
The records here given understate the actual duration of the
disease. It takes considerable experience to be able to bring
p. 27
out the full duration of tuberculosis when taking the history of a case. In our first year's work there has been a continuous increase in the duration of disease as
the experience of our men grew in taking histories.
Patients, as a rule, fix the beginning of the disease by the first severe
break in health. As a matter of fact, the beginning of tuberculosis gives no symptoms.
Very often even a number of serious interferences with health, recurring at intervals of three
to six months, may take place before suspicion points to what is the matter. Tuberculosis exists
from the time of implantation, and the duration of the disease really should be counted from the
time of exposure to contagion.
WEIGHT.
The weights given in this table are net weights. When a patient gained
and then lost, only that which he held was counted; and when a patient lost and then gained,
only the gain above
p. 28
what he weighed when he began treatment was counted. In the same way the
losses were based upon the weight when treatment began.
Weight is a criterion of the progress of tuberculosis up and down. Loss of weight undoubtedly
is one of the results of tuberculous toxemia. One of the first evidences of deterioration is
loss of weight. An early sign of improvement in a tuberculous patient, on the other hand, is
gain in weight. While this is the rule, there are exceptions. Tuberculosis may terminate fatally
without emaciation. A person with tuberculosis may be so fed up as to become quite rounded and
well filled out and still go on to death. In these cases death is usually due to complications
of one kind or another. Sometimes so many organs have been damaged by the tuberculous process
that life is snuffed out by a simple cold. This is especially true when the kidneys are
extensively diseased.
Both in the dispensary and in the hospital there were some very large gains. Along with these
gains went general improvement and progress toward recovery. The
highest gain in the hospital was thirty-three and one-half pounds. The greatest loss in the
hospital was twenty-five and three-quarter pounds. The highest gain in the dispensary was
thirty-nine pounds and the greatest loss in the dispensary was thirty and one-quarter
pounds.
RESULTS OF TREATMENT.
The word improved is here used to indicate any amelioration of symptoms with increase in
weight and gain in physical health--
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one or both. The improvement in some cases was very marked, and this applies even to advanced
cases. Some of the patients who came into the hospital as
advanced cases were restored to a condition of physical health which enabled them to return to
their occupations. Unimproved includes all cases in which there was no perceptible progress
toward recovery. Even patients who gained weight for awhile and lost it again, were recorded as
unimproved. The cases recorded as unimproved sometimes were lost sight of, either by removal
from the hospital or by giving up treatment at the dispensary. Many of them no doubt died. The
record of deaths in the dispensary, and in a less degree in the hospital, for this reason, has
little value.
SPECIAL WORK.
For the purpose of studying tuberculosis from every possible point of
view and giving relief in all forms of the disease, special departments have been established
in the Institute and others will be established as the work develops. Up to the present time
there have been organized a neurological staff, a laryngological staff, and a dermatological
staff. The laboratory, both in its bacteriological department and in its pathological
department, has been established and partly equipped, but not fully organized.
A consulting ophthalmologist has been appointed on the staff. Separate
reports on laryngological and neurological work are made by Drs. Geo. B. Wood and D. J.
McCarthy. Dr. Joseph Walsh reports upon the autopsies and Dr. M. P. Ravenel upon a case of
fibroid phthisis. Drs. H. R. M. Landis and J. W. Irwin report special work assigned by the
medical director.
PREVENTION OF TUBERCULOSIS.
One of the objects of the Institute is the prevention of tuberculosis.
What has been accomplished during the year in this direction cannot be recorded, because it
cannot be measured.
The patients who have been taken into the hospital have been taken out of
squalid, poverty-stricken homes, where they had
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been sources of danger to others. The probabilities are that every
removal of such a patient has been the means of preventing at least one implantation. Even when
the patient returned again to his home, something had been accomplished, because he went home
trained in preventive measures.
All the dispensary patients are taught and drilled in
preventive measures. As each patient comes into the waiting-room he is handed a spit-cup, and
during his stay is taught to use it. When he goes away he is given a tin spit-cup holder, a
bundle of paper cups, and a bundle of paper napkins and paper bags to take home with him. He is
also given a set of rules on a large cardboard to hang up in his house, and on a folder to
carry in his pocket. Every time he comes back to the dispensary he is given a new supply of
preventive measure material, and is further instructed in its use. At regular intervals he is
visited in his home by a pupil nurse and is given such instruction and assistance as he may
need for prevention of the spread of the disease.
FOOD.
In the hospital all patients are placed upon a carefully
selected diet. This consists of milk, eggs, and plain nutritious food. As a rule, patients take
three quarts of milk and six raw eggs a day and one meal of solid food. This meal consists of
beef or mutton, fresh vegetables, and fruit. To the dispensary patients milk is served at their
homes from the Institute wagon or through milkmen. In the beginning all milk was served through
milkmen. This system of serving through milkmen was not found satisfactory, first because the
Institute could not control the quality of the milk, and secondly because the system was open
to fraud. As an experiment the Institute has equipped a milk wagon of its own.
MEDICINE.
To the house patients all medicine is furnished free. To the
dispensary patients it is furnished either free or at a nominal
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cost. A nominal charge, consisting of twenty-five cents for one
prescription, forty cents for two prescriptions, and fifty cents for three or more
prescriptions to one and the same person at the same time, is made to such patients as can
afford it, for two reasons: first, to give them a semblance of independence; and, secondly, to
discourage as far as possible unnecessary drugtaking. The majority of
dispensary patients are, however, unable to maintain even this little pretense of
self-support.
SCIENTIFIC RESEARCH.
The study of tuberculosis is one of the purposes of the Institute. For
this reason a laboratory and pathological museum and an autopsy room have been equipped.
In the crowded, cramped quarters of the Institute in its temporary home, it has been
difficult to carry out this purpose. Something has been accomplished, however. Nearly all patients who have died have been carefully
autopsied; a valuable collection of pathological specimens has been collected; many sections
have been made for microscopic study, and a beginning has been made in laboratory research. The
staff meets weekly for scientific discussion and exchange of thought. All work done is
carefully scrutinized and criticized at these
meetings.
EDUCATIONAL WORK.
Early in the Institute's first year an international lecture course on tuberculosis was got up
for the education of the public. Prominent workers from different parts of the world were
brought to Philadelphia to speak to the world from a Philadelphia platform. The lectures
delivered on these occasions were published in the medical journals and in abstract in the daily
papers. They are republished as part of this first annual report, although all of them were not
delivered within the first year.
The lecturers were Drs. E. L. Trudeau, of Saranac; Wm. Osler, of Baltimore; G. Sims Woodhead,
of Cambridge, England;
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Herman M. Biggs, of New York; and Edoardo Maragliano, of Italy. Dr. Trudeau, the pioneer
worker in the field of tuberculosis in America, opened the course. He was followed by the other
gentlemen in the order named. Dr. Maragliano was prevented from coming to America at the last
moment by serious personal illness, but his paper was read at the time set for his appearance
and was subsequently published. The course of lectures was well attended and the publication of
the lectures has stimulated much activity in the warfare against the disease. On the occasion of
Dr. Maragliano's lecture the National Association for the Study and Prevention of Tuberculosis
was organized.
THE FIRST YEAR'S HARVEST.
To organize a new work is a difficult undertaking. The Henry Phipps Institute for the Study,
Treatment, and Prevention of Tuberculosis is in its conception and establishment an embodiment
of a new idea-namely, concentrated effort upon a single disease for its extermination. The
financial resources were at hand through the generosity of Mr. Henry Phipps, but there was no
precedent for the creation of machinery and the formation of the line of battle. Everything had
to be worked out and tested. Classical prejudices of all kinds and complexions stood in the way.
The line of action lay in opposition to preconceived notions and the teaching of medicine for
generations. Weighed in the balance of these difficulties, the harvest of the first year's labor
has been good. In addition to what has been
accomplished in treatment, prevention, and education, there has been some golden fruit in the
training of medical experts and special nurses. This perhaps is the best of the Institute's
work. The training of women for the care of tuberculous subjects and the creation of a new field
of labor for women who have had tuberculosis and have recovered, perhaps, would be worth the
labor and money which have been expended. These women become missionaries in the crusade against
tuberculosis.
LAWRENCE F. FLICK.
