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Official Organ of the National Tuberculosis Association

PUBLISHED MONTHLY BY JOURNAL OF THE OUTDOOR LIFE PUBLISHING COMPANY

381 FOURTH AVENUE, New York City JAMES ALEXANDER MILLER, M.D.

H. R. M. LANDIS, M.D.

CHARLES J. HATFIELD, M.D.
President
Vice-President

Secretary
PHILIP P. JACOBS, Ph.D.
Treasurer and Managing Editor

The aim of this Journal is to be helpful to persons seeking health by an outdoor life, and particularly to disseminate reliable information looking to the prevention and cure of tuberculosis. It should be distinctly understood, however, that the JOURNAL OF THEOUTDOOR LIFE is not intended to supplant personal medical advice. Anyone suffering from pulmonary trouble who is not under the care and guidance of a physician is taking grave chances.

PROGRAMS AND POLICIES In the building and execution of a has unearthed five or six cases to every program for a state or local Anti-Tuber- death, but that is hardly one-fourth of culosis Association there are two possible what may be expected, and along with lines of policy. A program may be built this problem goes the equally difficult upon the assumption that certain definite task of providing machinery to keep on tasks are to be accomplished and that unearthing new cases as fast as they may it is not desirable to go beyond these develop. tasks, either because of lack of funds There is not a community in America or for a lack of workers. Or, a program where adequate hospital and sanatoria may be conceived upon the assumption care for all cases is available. In a very that an Anti-Tuberculosis Association is few instances, one bed for every annual to work out a scheme for the ultimate death has been provided, but experience control of tuberculosis, and that no con- proves that at least two are needed. sideration of money or workers must Even where bed provision approaches a stand in the way.

standard of adequacy, the problem of The first line of policy requires a making the most of the hospital for the knowledge of the problem and a limited benefit of the patients and the benefit of amount of capital. The second requires the taxpayer is still relatively untouched. the same knowledge and capital, but, in We have learned that the hospital and addition, it requires faith, not alone in sanatorium, if it is to realize 100 per the ideal to be striven for, but also in the cent. on its work, must send its patients community where the work is to be done. home happy, contented, and resolved to If tuberculosis is worth controling it is win; and that, furthermore, it must exaxiomatic in American community life tend itself into the home to see that they that the means for control will be forth- do win. How few institutions have the coming

equipment to do these things ! Is it a No community, either rural or urban, task for Anti-Tuberculosis Associations need fear in the building of a program to undertake and perform? that there will be a paucity of things to This thought suggests another fruitful do, if the program is conceived in line line of progress, namely, the care of with the needs. Take, for example, a those patients who must for a variety of problem of the discovery of tuberculosis reasons receive some supervision and cases : there is not a community in the treatment at home. The training, securUnited States, with the exception of ing, and supervision of nurses and social Framingham, that has begun to find its workers for such a task are all well withliving tuberculosis, if the experience of in the field of endeavor of private Antithis little Massachusetts town counts for Tuberculosis Association. A conservaanything. Here and there a city or town tive estimate of the active tuberculosis

patients in the United States who must lieves, for example, that tuberculosis is and who should be cared for at home infectious. The problem of arousing a because of the lack of institutional beds community to take its health seriously would place the number at close to is only now being undertaken with scien1,000,000. Is there not a huge task here tific effort, and it will require all that the waiting the best brains and resources Anti-Tuberculosis Associations can give of the tuberculosis field ?

in the next ten years to solve it. What community in the country can These are but a few of the many lines claim to have educated its people to a of endeavor, but they will serve to inknowledge of the fundamental facts dicate to the serious-minded worker that about tuberculosis! There is plenty of his task is one that will require an abunroom for discouragement, even in those dance of faith, vision, knowledge and places where the campaign against tuber- perseverance. If the program is built culosis is the oldest, when one asks the upon a vision of the need, its success is proverbial "man on the street" if he be- assured and its support will be ample.

a

HITTING THE WHITE-HOT IRON The National Tuberculosis Association ing, hope and the promise of effective is face to face to-day with the greatest help to the stricken, as the machinery opportunity of its history. This means for relief can be made to move. not merely the opportunity that ordi- (2) Gather together at least $6,narily comes to us, as a result of which 500,000 to finance the pressing needs we press forward with our educational of the great cause during 1920 — the and preventive programs, but one that money to be used according to the estihas been created by the war and its mates made far in advance as wise and aftermath. At moment when the necessary for our next twelve-month of world is reeling from the effects determined fight against the white plague. of a terrible ordeal, weakened down to In the process we shall rivet the atan unprecedented extent through priva- tention of the public upon the peril as tion, hardship, sickness, disease and a it exists to-day, and on the proven general lack of proper foodstuffs where methods for combating that menace the same

were most needed, the call and rescuing countless thousands of comes for this association to gather up our people from untimely death. We are all its experiences and knowledge of the intent upon setting in motion, as never past, gird its loins for a great forward before, the mighty press of this country, movement, and with a mighty effort hurl both daily and weekly, together with the itself between the masses of the people standard magazines, technical journals and the on-marching menace of TUBER- and house organs, to the end that AmerCULOSIS — the invisible enemy which ica may stand seriously alert, but uninsidiously lays low more hosts than ever afraid, facing the menace itself and conthe sword put to death.

fident of overcoming it in due course. And the opportunity will be seized. The campaign in which all this is to With a spirit of high resolve to "hit the be striven for, will take place in Decemiron while it is hot,” the organization ber. Even now the work of preparation which in a decade has done so much to is far advanced, and the state and local forewarn the public and establish means organizations, in gear with the national of prevention and control against the headquarters which seeks to be an aid ravages of tuberculosis, will present a and useful engine for them all, are solid front and do two things;

functioning in unison with every prospect (1) Send six hundred million little ahead for achieving a great success, messengers, in the form of Red Cross It is not primarily the dollar or the Christmas Seals, into the highways and dime or even the penny that we are after by-ways, to carry the message of warn- in this great drive for a better health condition. It is for the friends that we In the coming campaign, an outline will make for this cause for the en- of which has already reached your hand, lightenment that we will carry to the and details of which will now rapidly people, and for the faith and hope that follow, we are relying on every member we will instill in the press and the public of this association, every employee and as we near the goal. If it were simply every associated friend, to do simply money that we sought, the national target their part. They have done it before, and could be multiplied by ten and it would splendidly; but never before was the not deter those who have the guidance of opportunity so vast and so wide open. this effort in their hands. But it is not Never before was the iron at such a the money-we are asking for exactly white heat. Never before was there such what we can wisely and effectively use strength in our arm to hit—to strike the to press forward, in 1920, the message blow for liberation from the menace of of the National Tuberculosis Associa- the White Plague! tion. It is the better understanding with The little Red Cross seals will carry the public that we are intensely interested

the message. The press will do its full in, with our message clarified and rooted share. By an intensive system never deep into the hearts of our people, and before resorted to, and applied wherever then secondarily we are interested in possible, the United States of America getting a fund large enough to permit of will be told the story of Warning and our work going forward without hin- of Hope, while at the same moment the drance in the months to come.

fund with which to carry on this work The press is ready and in a receptive for the coming year, will be gleaned. mood-we have evidence of that. The The spirit of this whole program is that material with which we shall seek, con- a service must be rendered for the people, servatively and wisely, to inform the to the people, and and the people thempeople, is compiled and available. The selves must be brought to realize that men to do the work, trained in their we are able and willing to give them just various branches of endeavor, and of that service! proven efficiency, are either at their posts

And so it is with a consciousness that or on call. The great tide of soldiers and

the emergency of war has brought to nurses from overseas is sweeping back

us the great emergency of peace, and

that we have really been preparing all upon us. The dispatches carry almost

these years to meet just this crisis, that daily reports of the desperate condition

we step forward equipped with a rational, of the underfed, half-frenzied people of workable plan and program, and bid Europe, now trying to readjust them- those who sit and wait in the shadow selves to the emergencies of peace. It of death that we are advancing to their all finds us-ready!

rescue!

TUBERCULOSIS IN CALIFORNIA STATE PRISONS

(Continued from page 231) small room with only six beds, which com- Even in 1891 the Folsom physician comprise our present hospital accommodations for ments again about tuberculosis. “Accidents, six hundred and sixty-five men? Let the doc- injuries, and deaths have been numerous, but tors, the lawyers, the committing magistrates, the causes therefore are too patent to require the Boards of Health, the police departments, much explanation. Apart from the casualties the citizens and tax payers of the state, gen- due to carelessness and contributary neglierally, unite in securing us appropriations with gence, the action of the courts, the recomwhich to provide right and proper accommo- mendations of health boards, and other predations, and we will then undertake to care sumptuous influences have implanted upon us for and administer to all that may be sent during the past year all the diseased and afto us."

flicted humanity during the past year they

possibly could, and ripened fruits thereof are to be found in this report. And it is needless to say that the upas tree is still in bloom, giving promise of another rich harvest for the Grim Reaper during the coming year.”

An analysis of the mortality report discloses these important facts: "that 337/3%, or five of the deaths, were due to phthisis, chronic cases of long standing, all of them." And in 1894 he makes similar comment: “An examination of the hospital records for 1893-4, the year just ended, shows that but six deaths occurred during the year, being at the very unexceptionally low rate of 8.73 plus per thousand. One was from accident; four from chronic diseases of long standing; leaving but one, as in the year previous, due to a symotic disease.

"And this is in the face of the fact that the courts have continued their beneficent efforts in sending the consumptive criminal to Folsom to die; for the large number of cases with which our report is due to the action of the State Board of Health, which body some two years ago recommended that our courts should send all their pulmonary afflicted offenders here. In nearly every case must this advice have been heeded, for we have been taxed to the utmost with the care and treatment of more diseased and debilitated humanity than any other like institution in the country.

Dr. I. L. R. Mansfield, the Resident Physician, in his report to Warden Hale of San Quentin, for 1895, writes: “When it is borne in mind that a large percentage of the men committed to a penal institution are suffering from chronic ailments of some form or other -usually the result of previous vicious habits and unwholsome conditions of life—the mortality among the inmates must be regarded as unusually low. Phthisis pulmonis (consumpbegan in February, 1913, at which time I was tion) has been, as heretofore, the principal cause of death. In nearly every instance, however, those who have died from this cause contracted the disease prior to their admission to the prison, and several were in the last stages when they entered the institution.”

The Board of Prison Directors in 1902 were greatly exercised about the crowded condition at San Quentin, not from the standpoint of health, but from a disciplinary and correctional point of view. In their communication to Governor George C. Pardee, the Board writes: "In California, prisons are conducted under what is known as the congregate system, and nearly all the evils under which our prisoners suffer are traceable to the system of prison management. . . . At San Quentin, we have nearly 1500 convicts and only 600 cells, necessitating the placing of five and six convicts in one cell, and, in one instance, fortyfive in one of the larger rooms." Apparently they did not realize the deleterious effects on health of this condition, or if they did, they put that secondary to discipline.

Again in 1904, the newly appointed Warden, J. W. Tompkins, brought out again the crowded condition, commenting that “prisoners crowded together in this manner have ample opportunity to plot and scheme, and even commit felonies without detection. When inmates are in the upper yard, where they are forced to congregate on Sundays and holidays, the limited space makes it almost impossible for them to move about, much less obtain the exercise the physical condition of many of them demand.”

Dr. P. F. Casey, in the same year writes: "We have fortunately been free from any epidemic diseases. The death rate from all causes has been small, considering the population handled, being only thirty, including executions, in a population of over two thousand. I would call your attention to the large percentage of diseases of the respiratory organs, about 50% of the deaths occurring having been from tuberculosis. ... The bad ventilation of the jute mill causes the air to be full of fine particles of dust which injure the air passages, leaving a fertile field for the tubercle bacillus. I would suggest that some form of suction of ventilator be installed over the large dust producing machines to draw up the dust and discharge it into the air over the roof of the mill."

From 1904 to 1913 little was done for the betterment of the health of the inmates, although from 1909 on, an effort was made to perform necessary surgical operations. This was accomplished for the most part by visiting physicians, who rendered their services gratuitously. The surgical equipment was very crude, and comparatively little was done.

My personal experience with San Quentin appointed Assistant Resident Physician. If the surgical equipment was designated as being crude, the care of the tuberculous was primitive, even worse than crude.

At this time there were about twenty patients with active tuberculosis, treated, or rather, housed, in two small rooms on the top floor of the so-called “Old Hospital” which was built in 1859. The ventilation was abominable, the beds were crowded together, air space was extremely limited, a few old-fashioned windows, low and narrow, let in a very little light. The walls were of a dark hue, making the rooms cheerless and foreboding. Whites, Negroes and Indians commingled here indiscriminately. The surroundings were extremely sordid. Here, crowded in abject misery, lacking the essentials for cure-light and air-were these diseased prisoners, coughing, and too enfeebled for the most part, to leave their beds. To add to their discomfort, a dilapidated toilet and unsanitary bath were screened off in one corner by a shell of a partition, while in the center of the room a coal stove gave those men who were able the opportunity to cook the rations of eggs, or other food, they were allotted. These priosners were visited about once a week by the resident physician, although an inmate doctor

stayed in this ward most of the time and ministered to the men as best he could.

The so-called "New Hospital" was a hospital in name only, for the wards were dark, there was no equipment worthy of the name, and one large room on the ground floor served the purpose of a dental office, surgery, dressing room, clerk's office, and general utility

room,

oners.

The sanitation of the prison was good, however, for the most part, although the cells were overcrowded and one large room on the top floor of the furniture factory served as a dormitory for about 100 men. No satisfactory ventilation was provided for the cells. The new prison of modern construction had not yet been completed.

Only a few men were kept locked up all the time, there being the so-called “incorrigibles" about ten in number, who were kept in small wooden cells well guarded, for periods varying from six months to years.

After my appointment as Resident Physician in August, 1913, free hand was given me in the hospital management and I was enabled to bring before Warden Hoyle a large number of recommendations for the improvement of the hospital facilities. The Warden approved these plans, but resigned his office before any of them could be acted upon.

J. A. Johnston became Warden, and with his appointment came aid unbounded to the Medical Department. He had held a similar position at Folsom prison for some time, and had become thoroughly convinced of the importance of health measures in prison management. With his arrival a "renaissance" or awakening, took place. He believed that it is useless to attempt to reform a man morally or mentally, until his physical condition is attended to.

Of course, the tuberculosis problem was the first to be attacked, as its importance was of the greatest. To have continued the old tuberculosis ward would have been a crime. Accordingly, a modern open air tuberculosis hospital was built on the flat roofs of the "Old Hospital” and Library building, which joins the “New Hospital.” It covers an area of 4800 square feet, and is arranged in the form of two adjacent quadrangles, with concrete floored courts in the center. Surrounding these courts are the sheltered wards, enclosed by many sliding windows on the outside, and French windows and doors into the courts. In these wards are high iron beds, with sufficient sheets and blankets as well as a canvas spread. Near cach bed is a stand.

The whole structure is electrically lighted, has modern plumbing with shower baths, toilets, and lavatories. On summer days the wards may be thrown entirely open, allowing plenty of sunshine and air constantly to fill the place. Valuable suggestions, encouragement, and help in building the hospital were given by Drs. G. R. Hubbell, R. A. Peers, L.

S. Mace and many others interested in this problem.

Even before this open air hospital had been completed, the medical department had begun to make a thorough physical examination of every man who came to prison, in addition to examining cases which appeared to be possibly tuberculous, among the older prisoners. In this way many cases of tuberculosis were discovered as soon as the man entered prison, and many were found among the older pris

With this system, instead of having twenty cases under treatment, the number grew until the hospital designed for sixty prisoners was nearly full. As soon as a prisoner is suspected of having tuberculosis, he is immediately placed in the medical ward, where examination is made, sputum tested, temperature chart kept, x-ray pictures taken, and other means employed to make the diagnosis.

Because of the good facilities for caring for tuberculous patients at San Quentin, the Board of Prison Directors in 1915, decided to send all afflicted prisoners from Folsom to this place for care and treatment. About 40 have been transferred during the past three years.

Early in his administration, Warden Johnston abolished the solitary confinement of incorrigibles, and at the present time no man is kept shut away in a cell for a long period of time. As a light on what close confinement may do, it is worthy to note that of the dozen or so incorrigibles confined after the riot in 1911, two of them developed tuberculosis, one dying, and the other making a good recovery after treatment in the open air hospital.

The general sanitation of the prison has been improved in the past few years. Eight hundred single cells, of modern construction, have been built. The cells in the old prison have been equipped with fan ventilation, which pumps into each of them 28 cubic feet of air per minute. Electric lights have replaced the old air consuming oil lamps. And various suction devices have been installed in the furniture factory to draw away offending dust.

The treatment accorded the patients suffering from tuberculosis has been, for the most part, that of rest, air, sunshine and food, although Dr. Hubbell, who formerly visited this prison weekly, administered tuberculin with satisfactory results. On selected cases, artificial pneumothorax has been a therapeutic agent, and some cases have reacted favorably.

A glance at the accompanying charts will show that although the prison population is increasing, the morbidity is on the decrease, and that the death rate from tuberculosis is less than in former years. The death rate from tuberculosis at Folsom is nil, because such cases are sent here, while the San Quentin death rate is much lower than former years.

On the whole, the progress in combating this disease in the past five years is encouraging, and shows what can be done if effort is expended.

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