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"A body of facts on fatigue elimination was collected,
evaluated and made available.

"Methods of investigation laboratory and plant were
stated, evaluated and made available.

"An outline was worked out, not only of -what works in
practice, but of why it works.

"A realization was gained of likenesses between fatigue
problems in all countries and in all types of industries that
warrant cooperation, but differences mean the need of adapt-
ing methods to national, group and individual needs."

At the council meeting of the Association that followed
the summer school its sessions were commended, and it was
decided to hold similar schools on related subjects yearly
between the triennial congresses.




BEFORE interested friends and members of the Massa-
chusetts Department of Public Welfare, graduation
ceremonies were held recently at the Industrial School for
Girls at Lancaster for twenty-seven girls who were given
Honorable Discharge Certificates.

The presentation of such a certificate by the state is a
mark of special merit to a girl who has succeeded on parole
from the school. In Massachusetts girls are not committed
to the school for a period of years; they are committed to
the care of the trustees of Massachusetts Training Schools
until they become 21 unless they earlier earn the distinction
of honorable discharge. These twenty-seven girls had so
conducted themselves in the school and afterwards upon
parole that they were honorably discharged before attaining
the age of 21. Three or four times a year such a group is
graduated with proper ceremonies.

The law which permits the granting of honorable dis-
charges for special merit was passed in 1915, since which
time 339 girls have been so rewarded. The present group
averaged 15 years of age upon admittance to the Industrial
School, and they remained there an average of I year and II
months before being sent out on parole to their own homes
or to foster family homes. They now average a little more
than 20 vears of age. Eight of these girls are married,



August 15 September 15, 1927



THE SURVEY



54i



and eighteen of them have savings deposited with the
Division of Juvenile Training aggregating more than
$1,600.

The ceremonies were opened with a dinner at the school,
exercises and the presentation of the certificates, followed by
dancing. Among the special guests were the twelve women
visitors from the Division of Juvenile Training, through
whose efforts the girls' successes were largely made possible,
and other friends and relatives of the girls.




AT the request of the governments of the three Baltic
States of Finland, Poland, and Sweden a year ago the
Assembly of the League of Nations decided to discuss at its
meeting this month a resolution, to include the study of the
alcohol question as a function of the League Secretariat.
A plan of activity for the League was drawn up by a con-
ference of experts which met in Geneva last January.
Since that time three other European nations, Denmark,
Belgium, and Czecho-Slovakia have formally joined the
original three in urging the matter upon the Assembly, and
within the past month official request has been made by
the ambassadors of several of the interested governments
to Secretary Kellogg in Washington. If officially invited
to participate in a study of the alcohol question by the
League of Nations the United States can hardly decline.

Under the Covenant of the League it is in Article 22
dealing with mandatory powers and duties over half-
civilized regions that the liquor traffic with natives comes
under international ban. Article 23 provides for the preven-
tion and control of disease and is concerned with the traffic
in opium and other dangerous drugs, under both of which
headings it would appear logical to include a study of the
production and use of alcoholic beverages. One could
scarcely conceive of an efficacious protection of the woman
and the child which would disregard the importance of
alcohol, and as a matter of fact the Consultative Com-
mission of the League, for protection of children and young
people, has already taken up alcoholism as a determining
factor. The supporters of the resolution see a further
reason for active study of the alcohol question by the
League in Article 23, Clause (e), for does not smuggling
of liquor threaten the "just and honorable relations between
nations" and interfere with "freedom of communication
and of transit, and equitable treatment for the commerce
of all members of the League"? Baltic States at their
Helsingfors Convention, and the United States in its
treaties with most of the maritime nations of Europe have
practically declared liquor smuggling a modern form of
piracy, a scourge uncontrollable by a state single handed.
International peace which depends upon good understand-
ing between nations is found to be seriously threatened by
policies and laws of individual nations in the matter of
alcohol traffic.

In the formal language of Geneva the approval of the
resolution by the Assembly will mean that tasks both
documentary and political would fall upon the Secretariat
or a commission developed for this purpose. There will be



required a central authority for collection of the facts of
production and consumption of alcohol ; of agricultural areas
used for alcohol crops (grapes, barley, hops, cider apples) ;
of persons engaged in manufacture and trade, wholesale and
retail, the exportation and importation, and tax revenue
from alcoholic beverages; the relationship of per capita
consumption of alcohol to morbidity, mortality, dependency,
and delinquency; the experience and practice of the various
nations in teaching the effects of alcohol to school children ;
practical and profitable substitute uses . for products now
used to make beverage alcohol; agricultural uses for land
other than for viticulture. Of a political nature would be
the proposed Consultative Alcohol Commission in its service
to the Permanent Mandates Commission, in its adjustment
of the many problems which have developed since that sign-
ing of the International Convention for repression of
smuggling, in assisting with accurate data when arbitration
is sought to adjust conflicts between nations with radically
opposed policies of importation and exportation of liquor.
When the matter is settled, and it is to be expected
affirmatively, there will be a period during which other
funds than those of the League will have to bear most of
the cost of the new work at Geneva. Shall we see the na-
tions which find alcohol of social benefit vie with others
where profit is seen in its exclusion in generous support of
an international clearing house of information and service?
The International Bureau Against Alcoholism at Lausanne,
Switzerland, supported by thirteen governments and at
present a private organization, would probably be put under
the authority of the League of Nations.




' I 'HE orchards of the middle west in the period of settle-
[ ment are credited to Johnny Appleseed. In the same
soil in the period following the Civil War many social
causes took root. The seeding down of ideas was done by
many hands, often unheard of outside their own localities,
their presence made known by the springy community life
and by the general progressive temper of the region when
big issues were afoot. In the sixties Mr. and Mrs. William
(Sarah M.) Scofield located in Washington, Iowa, and
their home became a general center, young and old gather-
ing there for inspiration, direction, encouragement. Mrs.
Scofield's father had been a Lutheran minister in Ohio, her
husband was a lawyer, she was a gardener for democracy
in the life of that small western town. For nearly a quarter
of a century before her death she had been a resident of
Palo Alto, California, and in her later years her active
interests did not flag. As a member of Survey Associates,
she kept in touch with causes she had long held to heart.
Only last year, her daughter wrote: "She has lived a long
life sponsoring progressive movements through their period
of unpopularity, has started and worked for many schemes
for the betterment of the communities in which she has
lived, and at the age of eighty-five has seen many of them
bear good fruits. . . . The Survey stirs the 'war-horse' spirit
in her that is so anxious for Peace that it is willing to
fight for it."



HEALTH



Finding the "Lost"



By ALICE M. HILL



IT is better economic policy for the farmer to make a
slight expenditure for solder than to continue to milk
the cow into a pail with a hole in it. Tuberculosis
clinics are faced with a similar economic problem but
many of them fail to realize it. Too many patients
are diagnosed tuberculous only to be permitted to stray from
under supervision. It costs money to diagnose a patient.
This cost includes the services of the physician who makes
the physical examination, of the nurse who searches out
the suspect and who attends during the examination, and
of the directing executives, as well as overhead expense such
as rent, heat, light, water, janitor services. All these are
direct charges against the cost of the patient's diagnosis.
Indirect, but proper, charges include also some share of the
cost of weeding out the numerous non-tuberculous in the
search for the tuberculous. Obviously the average cost of
rinding a tuberculous patient is appreciable.

That many patients are lost from sight, some as soon
as diagnosed, is a matter for serious consideration, both be-
cause of the waste of funds expended and because of the
loss of dividends in the form of increased health protection.
Figures for the actual number "lost" vary according to the
community and are not easy to obtain. During the year
1924, according to the report of the Department of Health
for that year, 2,921 cases were removed from the register
of the tuberculosis clinics of the New York City Health
Department for non-attendance.

It is not stated how many of these patients placed them-
selves under the care of private physicians and how many
"removed to some other address and could not be located."
The number of cases so removed from the register exceeded
the number of new diagnosed cases added to the register
during the same year by 199. In Chicago during 1924,
J >959 patients were discharged fey the dispensaries as "not
found," while 5,276 new cases were diagnosed by the dis-
pensaries during the year; at the clos>e of the year 3O.758
were under supervision. (Biennial Report for 1923 and
1924, City of Chicago Municipal Tuberculous Sanitarium,
pp. 61, 65, 71.)

A situation analogous to that in the clinics exists wit.* 1
respect to those cases reported to the health departments
of cities. During 1925 the Boston Health Department
"undertook one of its periodic surveys to determine the
present condition of the 12,540 cases of pulmonary tuber-
culosis which according to ... office records were pre-
sumably alive and living in Boston. Of these 12,540 cases,
9,106 were found to be still alive and living in the city . . .
Of the remaining 3,434 cases, about 3,000 were so complete-



Bulletin, Health Department, City of Boston, March 1926,
p. I.) Boston assumed that nearly all of them had left
the city. In New York City at the close of 1924 of the
28,471 diagnosed cases in the register, 6,114 were listed
as "homeless and not found." (City of New York, Depart-
ment of Health Report, 1924, p. 54.)

We are told that the clinic can not afford to spend very
much time hunting for these patients. But can it afford to
spend as little as it does? An investment has been made in the
diagnosis of the patient. If he continues under the care
of the clinic or places himself under the supervision of some
private physician the investment probably will be profitable.
But of what value is the diagnosis alone, or the diagnosis
plus a bare start on supervision ? The patient who is "lost"
may not think himself ill. Possibly he is in the early stage
of the disease. By the time he is "found" again by the
clinic or by a private physician the tuberculous disease may
be so advanced that arrest is practically impossible. Mean-
time he may have been spreading the disease to others.

A patient once discovered seldom needs be "lost" if some
one connected with the clinic has a slight detective sense.
Unquestionably it is easier for a local agency to keep track
of a patient than for a sanatorium to do so. Yet in North
Carolina, with almost no local workers to fall back upon
for aid, the State Sanatorium knows what has happened to
nearly every patient who has left the institution in the past
thirteen years.

How can so many patients drop completely out of sight
between one visit and the next? How many genuine at-
tempts are made to find the "lost" patient? It would
appear that many attempts stop when the nearest human
being accessible reports that the family has moved to parts
unknown. Why should not the searcher go a bit further
and ask if there is not some friend of the patient who can
tell where the latter moved? Even in large cities almost
every person makes a contact with someone nearby who
can give some information regarding that person and will,
if properly approached. The storekeeper may know. Or,
if a household moved, some one moved it. It is a good idea
for the clinic to be on close terms with the firms which do
the moving of the city. Why not ask the police officer
oyi the beat? The postman frequently will be of help. In
srr ,aller places the postmaster as a rule is glad to render
servu <:e -



GOVERNMENT rules prevent giving out informa-
tj^n about forwarding addresses but usually, if he feels
he canno* & ve a definite address, the postmaster will be

ly lost as to make it impracticable to try to find them or willing tc 1 ' state tnat f ^e patient has or has not moved out
to learn what had become of them with the resources at of the disf r ' ct ' c ' tv or coun ty, which the clinic serves. Of
the command of the Boston Health Department. (Monthly course the P a ti en t w ho has moved ought to be referred to



542






August 15 September 15, 1927



THE SU R7EY



543



the appropriate organization in the new community to which
he has gone, and the sketchy information outlined from the
postmaster will not permit of this, but if the patient is
known still to be within the area there is greater incentive
to make the effort to find him.

Do clinics make the use they might of the central bureau,
to be found in the majority of communities of any size,
which registers the cases known to social agencies? Be-
cause tuberculosis is a health rather than a relief problem,
data for comparatively few cases known to clinics are sent
by the latter to such a bureau. It is only on the cases for
which a clinic sends data that the bureau makes a report
to the clinic as to other agencies interested in the patient
and new addresses learned. If the names of all the "lost"
patients were to be compared with the names of cases on
file with the registration bureau, a considerable number
would be "found" again. This procedure need not involve
the registering of cases with the bureau not considered with-
in its field, or more clerical work than that necessary in
transcribing the new data found.

In communities where many cases slip from sight might
not the social history of the diagnosed case be enlarged a
bit with a view to making the finding easier? Would it
be considered unethical to ask to what lodge the patient
or some member of his family belongs? Or to ask for the
address of a relative inclined to stay put?

If the family of the patient includes a child of school age
the teacher should be able to furnish the new address to
responsible inquirers.



If <:he patient or some member of his family has an occu-
pation another person with the same occupation is likely to
know about him. People of the same mental caliber are
likely to know about others with similar interests. Some
years ago in the course of a survey of mental defectives in
a rural county the persons making the study were interested
to find that when a mental defective seemed "lost," another
mental defective, even one who lived twenty miles or more
away, could be found to give the directions needed to
locate him.

The agents of industrial insurance companies often know
patients and their addresses, since they call in the home at
frequent intervals.

Frequently persons of one family name know where an-
other of the same name lives, even though the latter may
not be related or known by sight.

Rarely would it be necessary in tracing patients to employ
all of these aids. From certain sources of information, as
the postmaster and the registration bureau, inquiries could
be made by the wholesale at intervals. If the workers in
the district were to keep in mind those patients who have
dropped from sight and conscientiously desire to locate them,
they would find that a surprising number of leads would
crop up in the course of the performance of their regular
duties.

The chief essential to having a small number of "lost"
cases is the determination that no cases whatever shall
be lost.

Solder up the leaks!



Work for the Ex-Tuberculous

By ALICE CAMPBELL KLEIN and GRANT THORBURN, M. D.



THE chief problem of the ex-tuberculous patient is
the choice of work, which is suitable not over-
taxing. There has been little but generalities upon
which to base vocational advice in these cases.
Three years ago, in response to the need and de-
mand for such information the New York Tuberculosis and
Health Association began a three-year experiment in super-
vised placement for the tuberculous. This experiment has
yielded some definite facts which are of sufficient importance
to warrant their publication in advance of the comprehensive
study of the cases which is in preparation.

The suggestions which are the outcome of this study
are made primarily for patients with inactive disease and a
negative sputum, in whom the disease is in a quiescent, ap-
parently arrested or an arrested condition. Further special
limitations on jobs other than those noted, of course, would
be necessary in cases of bone or skin tuberculosis, or in the
presence of such complicating factors as heart lesions, par-
tial blindness or other additional disabilities.

First, perhaps, should be noted the types of work which
have been found to be unsuitable for these people. For the
sake of the public, they should not take positions which
require :

Handling of food or drink, or handling or washing dishes.
(Handling wrapped bundles is allowable.)

Any work with non-tuberculous children under working age.

Work on unsterilized articles, such as clothing, toilet articles,
or toys, which non-tuberculous children will use.



Work which brings the patient in close personal contact with
other persons, such as barbering, or dentistry.

Jobs involving muscular strain, particularly on the chest,
such as carrying, lifting or pushing. This eliminates all farm
work, and all such work as carrying heavy sample cases, bell-
hopping, running freight elevators, heavy porter work, delivery
work and chauffeuring where repairs have to be made.

Occupations which are unsuitable for the sake of the
patient include:

Jobs which cause general fatigue, such as would be incurred
by stair climbing, excessive walking, constant standing, or
working under nervous strain. This includes such jobs as
canvasser or collector, inside watchman where stairs must be
used, department store clerking when there is no opportunity to
sit down, and piece work where high tension must be
maintained.

Work where the immediate job or those near it involve
fumes or marked odors. This covers industrial processes
where acids are used, such as metal polishing, battery making,
soldering, manufacture of celluloid novelties, all paint work,
banana oil processes, operations on fancy leather goods, cigar
making, press room work in the printing business, and so on.

Processes where the immediate vicinity or the general at-
mosphere is dusty, such as carpentry or leather work where
no blower system is provided; cement work, stone-cutting,
mechanical dentistry, lens-grinding, and certain forms of polish-
ing, buffing, and the like. These jobs and those in the preceding
group are, of course, particularly to be avoided by those whose
throats are tuberculous or even inflamed.

Work involving extremes of temperature, draughts, bad air,
or exposure to inclement weather. In this group are included
work in cold storage plants, in rooms where many gas heaters



544



THE SURREY



August 15 September 15, 1927



or Bunsen burners are used, subway jobs, work on elevated
railroad lines except where proper shelter is provided, and
most work on docks or other draughty places. Pulmonary
tuberculosis is, of course, sometimes complicated by emphysema
and asthma, and such jobs as these are particularly to be
avoided in such cases.

Processes involving marked vibration, such as is felt in op-
erating certain machines the pebbling machine in leather work,
for instance, the bottom-leveler machine in shoe manufacture.

Jobs averaging more than nine hours a day for shop work-
ers or more than eight hours a day for office work with the
possible exception of watchmen's jobs or other positions where
the duties are not active. This cuts out much of the seasonal
trade work where overtime is required in the rush seasons;
and it also eliminates most bank and insurance work, since
overtime is frequently required.

All jobs where there is not a reasonable amount of sunlight,
ventilation, and sanitation, and where more than three flights
of stairs ordinarily have to be climbed to reach work.

Though it certainly is easier to tell the ex-tuberculous
patient what to avoid than what to do, the three-year study
of the New York Tuberculosis and Health Association has
disclosed five general occupational classifications within
which the average patient may find satisfactory work. These



Professional, executive, or artistic work where the responsi-
bilities are not over-taxing.

Clerical or office work which is not greatly rushed.

Light factory work which involves none of the hazards listed
among the unsuitable occupations, such as: assembly, packing,
inspecting, testing, labelling, cashiering, machine feeding, simple
machine operating; many of the skilled processes in the light
trades, such as cabinet work, jewelry-making, pen point work,
the needle trades when conditions are good, lamp-shade work,
bookbinding, radio operating, clerical work; monotype operat-
ing (linotype work is not suitable), work on eyeglass frames,
and so on.

Odd jobs as light porter, telephone operator on small switch-
boards where individual mouthpiece is used, or bell-boy, when
the duties are somewhat varied and, therefore, not fatiguing.

Almost any position from director down to orderly in a
tub rculosis sanitorium, provided no heavy manual labor is in-
vol. d. The special advantages of the sanitorium regime and
the constant medical surveillance often are somewhat offset,
however, by the danger the ex-patient runs of becoming in-
stitutionalized unawares. For this reason, one often hesitates
to recommend sanitorium positions for young people.

THERE are conditions external to the job itself which
may affect a given job adversely from the standpoint of
the ex-patient, and these must be borne in mind. For instance,
a long subway or train trip to and from work, or the un-
avoidable mingling and jostling with great crowds, add to
the strain of a working day. Therefore, if these cannot be
avoided, the day's work should be proportionately shorter.
We know, too, that the patient's peace of mind or lack
of it is an important factor in the amount of fatigue which
his work induces. Therefore his work and surroundings
should be, so far as possible, familiar; the income he de-



rives therefrom should be adequate; he should have a feel-
ing of permanency on the job and some prospect of advance-
ment in return for doing his work well.

Not the least essential to the needed feeling of security
is the knowledge that the employer is aware of his tuber-
culous condition and does not fear it. This, and the ex-
patient's confidence that his work is not going to prove
harmful, all help to minimize his exhaustion at the end
of the day.

IN classifying ex-patients according to work capacity, the
following points are basic:
The duration and history of the disease.
The character and extent of the lesion.
The symptoms of the disease, if any.



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