from 86 of the 88 counties of the state, and represent all classes of people.

Of the many uses to which this mass of material — gathered in a central office is being put, only a few of the most important will be dwelt upon. When the bureau receives one of these notifications of admission of a patient who comes frem a community which has a public health nursing service- and we have 68 of these centers in Ohio-a copy of the notification is sent to the nurse, with a request for a report on the patient's family and home condition. You will readily see that the nurse goes to the home armed with considerable knowledge about the case. Those nurses who have many times been requested to call upon a tuberculosis case, with the name and a doubtful address only, will appreciate this.

The blank form for the nurses' report is also supplied by the bureau and is designated, a "Report of Investigations." When this is returned, properly filled out, by the local nurse, it is filed with the sanatorium reports of the case. It contains the usual questions, such as those about home conditions; names, ages and physical condition of family; where and how children are being cared for; how suggestions are receivedi personal habits of patient; facilities for continuing open-air treatment at home; whether or not the case has been reported to the local health officer, and lastly, - when was this case first known to you? The answers to this last question lead us to believe that approximately 50 per cent. of the cases were unknown to the local nurses previous to our notification. The purpose of the form supplies to the nurses is two-fold; First, it brings to our bureau much useful information; second, it endeavors to suggest to the nurses, new in tuberculosis work and especially those alone in their fieldsome important points to be considered in investigating and handling

a case.

The assistance rendered to the bureau by the nurses is entirely voluntary, and in most instances has been prompt and satisfactory. The extent of the state nursing service is such that of the 5,000 notifications of sanatorium cases received 3.900 have been sent to local public-health nurses. We have obtained many valuable ideas from information volunteered by some of the more proficient of these workers, ideas which have shown that these workers possess the required insight into the nature of tuberculosis, and that they realize their share of responsibility in the great work.

A number of the home histories are returned containing little or no information. The reason for this, in the majority of cases, is that the patient is an unattached, homeless individual who cannot or will not give any information about his relatives. We have found approximately 400 of this type of patient, the greater number of them coming from our larger railroad centers. Another reason for these incomplete records is that the nurse herself is one who has not yet realized the significance of certain facts about environment and contact. This has been shown us by such incidents as the following: A nurse returned a home history blank with this protest under Remarks: "The patient has already gone to the sanatorium. This is

evidently a mistake." Another asked why we wanted the family visited while the patient was still in the sanatorium. Another made a rule that the record was to be closed and the family dropped when the patient died in the institution.

A

Our files hold evidence of the difference between the work of the nurse who looks upon a case of tuberculosis as a far-reaching family affair, and the one who regards it as a one-man problem. Family histories, coming, as they do, from all parts of the state to our office, have revealed a number of interesting relationships, which shows that the nurses' interest should not end with the patient, nor with the members of the family in her district. In one instance, that of a young wife, an advanced case, living in one of our larger cities, the nurse's report was on the young wife's new home and her husband's condition. No other relatives were mentioned. This was in January, 1916. In April, 1917, this record was proved by subsequent investigation to be about one-tenth of the patient's family history. younger brother was admitted to the state sanatorium from a small farm 60 miles from the city, where the sister, now dead, had lived. When visiting this home and talking with the mother of this boy, the relationship was discovered. Another young brother, living at home, was an advanced case, and there was also a dumb and feeble-minded half-sister. Members of the mother's family had died of tuberculosis, and she gave the names of two other married daughters who were said to be "complaining." The names and addresses of the latter were secured and referred to public-health nurses. The point in all this is that we should have known of the existence of this family in January, 1916, when these relatives could have been referred to the nurse in the nearby town, and both brothers then might have been incipient cases and so eligible for admission to our state sanatorium.

We do not wonder at this evidence of ignorance of the nature of tuberculosis, when we consider that these cases are seldom seen in the average general hospital, and that opportunities for public health education are few and far between. And we must remember. also that in many of our small cities the nurses are working alone, doing all kinds of public-health nursing, daily meeting difficulties which they have never before experienced. A lifetime would be too short a period in which to get sufficient education and experience to become an expert in every line of public-health nursing work.

I cannot do justice to the possibilities of the usefulness of the bureau without describing to you a work that is going on in our state, a work so far-reaching in its effects that I can only touch upon its most important aspects.

The State of Ohio has provided a supervising nurse for the extension and standardization of public-health nursing, and all the nurses engaged in this work are encouraged to feel free to write to her for advice or information. Each nurse that is placed through our Division is supplied with material for reference and study, and a circulating library which includes 15 volumes on tuberculosis is at her service. Many individual visits are made by the state supervising nurse to the various nurses in the field, frequently in response to calls

for help; and little informal conferences of nearby nurses are arranged by her from time to time. At these meetings the nurses discuss their problems with her, and with each other, and tuberculosis of course is a subject often brought up in such discussions. Thus many difficulties are cleared away, and all are benefited by hearing of the method by which some one of the number achieved success. In these ways a strong bond of mutual helpfulness is formed between the State Board of Health and the workers who are actually educating the people.

Before the actual work of the bureau began we visited the nurses and the superintendents of associations in the cities included in the various tuberculosis hospital districts, to explain the system and to ask for their assistance. In a number of places we found that there was little or no co-operation between the local nurses and the nearby sanatorium. But when the associations began to receive regularly these notices of the goings and comings of the patients, a connection between the field and institutional work was established which has steadily grown stronger.

Not an important feature of this work is that the hospital notifications are bringing the attention of the public-health nurses to a more intelligent and well-to-do group of the tuberculous, among which are numbers of students and professional men. The welcome which the nurse receives from this class of patients should have the effect of extending her welcome into other well-to-do homes, where other kinds of advice may be needed. The better equipped of our nurses make it one of their first efforts to disabuse the public mind of its old habit of associating visiting nursing and charity, and to impress upon it the new idea of public-health nursing, which may well include all classes of people.

Letters have been received by us from the nurses, stating that the official notice from the bureau made their work with the cases much easier. When the nurse presents to the physician the facts that his patient is in a tuberculosis sanatorium, and that the notice to that effect is from the Division of Tuberculosis of the State Board of Health, the physician is not so apt to say, "I am not quite sure of the diagnosis in that case."

When a patient is known to have moved to another state, and we have a definite address, we notify the health department of that state; and several states, particularly Pennsylvania, have been notifying us of patients moving into Ohio.

In localities which have no public-health nursing service the patients and their families are visited by nurses on the staff of the will show to others as clearly as it has to us, who have studied and Division of Public Health Education and Tuberculosis of the State Board of Health. Three hundred and thirty-two of these cases have been visited by the Division nurses, and much follow-up work has been done by correspondence from the office. Many of those in this group are found in remote rural districts and small villages, and as it is seldom that more than one visit can be made to each of these "centers of infection," no effort is spared to make the message of prevention as impressive as possible. If we conclude that the patient

or his family cannot be depended upon to follow instructions, we try to find some intelligent person with whom we can leave some directions and to interest him in the welfare of the family. The physician and the health officer are usually seen, and often the school teachers, the county officials and others are visited in behalf of the one family in particular, and in the interest of the campaign against tuberculosis in general. The need of local institutions for the care of advanced cases especially is constantly being brought to the attention of the county commissioners. In some of the larger towns where no publichealth nursing service has been established, we have been able to show the need of such service from data collected by our bureau. The tabulation of facts about cases visited, when presented to some intelligent and interested group, has resulted in a request for a publichealth nurse.

The state nurses also make visits to tuberculosis cases in response to requests which usually come from health officers in districts having no such nursing service.

The first call after the beginning of the work in 1915 came from a small village where four children, whose mother had died of tuberculosis two months before, had been left by their father to the tender mercies of a very ignorant community. Application for their admission to an orphanage in Virginia had been made, but that institution requiring a report on physical condition before admission, the children were examined by a physician in the village, and all four pronounced tuberculous. On this account they were refused admission and refused also by the local county children's home. So they were left for several weeks, without any special attention being given them, and about this time came to our notice. We found that the baby, eighteen months old, with broken-down, discharging cervical glands, was being cared for after a fashion by a very poor but kind-hearted couple, and the other children, a boy of fourteen and two girls of eight and ten, were living among the neighbors, missing many meals. and sometimes sleeping in barns. Township officials were indifferent to the situation, and when the county-seat was visited, and the county officials interviewed, they declared that they had neither funds nor authority which would enable them to act in such a matter. Sections of the law which authorized them to replenish their poor fund and to support the children in a proper institution were pointed out to them in the ensuing correspondence. In the meantime a better home was found for the baby, and the older children were placed in the county children's home pending their admission to the state sanatorium, where they were sent two months later. They were discharged after a year's residence in the state sanatorium, and we are endeavoring to do a part of the follow-up work that we know should be done in their behalf.

In this connection I want to speak of the interest and cooperation of the Children's Welfare Department of the Board of State Charities. Since the organization of the Bureau of Tuberculosis Hospital Admissions and Discharges, our attention has been drawn to over 70 children whose fathers or mothers had been admitted to tuberculosis hospitals. These children had been placed in county children's homes

without any attention being paid to the fact that they had been thoroughly exposed to the disease. In a majority of the cases information about the former home condition and the family of these children has been forwarded to the Board of State Charities, and the director of the Children's Welfare Department has seen that special attention has been given them. Our records show twelve children transferred from county children's homes to tuberculosis hospitals.

A statistical analysis of the notifications of admission and discharge that were received during the first year of the work is now being made, and the results will be attached to this paper when it is published in the Transactions of The National Association for the Study and Prevention of Tuberculosis. We hope that this analysis will show to others as clearly as it has to us, who have studied and worked over it, who have visited the patients in the hospitals and in the remotest homes, the need of the establishment of hospital social service bureaus in connection with each and every district and county tuberculosis hospital in the state. Thus the work which this bureau has been endeavoring to do can be done more thoroughly and systematically in the smaller field.

CHILDREN IN WAR TIME.

War work for babies which resulted in lowering the infant death. rate in Great Britain, France, Belgium, and Germany is described by Dr. Grace L. Meigs of the Children's Bureau of the U. S. Department of Labor in a paper on Infant Welfare Work in War Time which the bureau has just made available for general distribution.

The special features of the work have varied in different countries. In England there has been a striking increase in the number of health visitors employed to help and to instruct mothers in the care of their babies and young children. An act providing for Government aid to local agencies had, as it happened, been passed in July, 1914.

"The Local Government Board (the central supervising and administrative body) has taken the stand that in war time, in spite of the general need for economy, no economy should be exercised in this direction. There is evidence that in a good many communities, on account of lack of money and private support, the authorities or voluntary agencies have been slow to increase their work or to undertake new work. These difficulties the Local Government Board has largely overcome. It has gone on with the greatest determination towards its acknowledged goalto have systematic supervision through the work of health visitors for all babies born who need care."

The available information for Germany concerns only the first 18 months of the war. Dr. Meigs refers to the emphasis placed on enabling mothers to care for their own children. A special committee of the Red Cross, for example, was organized in Berlin for the care of mothers and infants. The committee had a fund for needy