[From The Johns Hopkins Hospital Bulletin, Vol. XIX, No. 207, 
June, 1908.] 
THE METHODS OF THE HENRY PHIPPS INSTI- 
TUTE FOR THE STUDY, TREATMENT, AND 
PREVENTION OF TUBERCULOSIS IN PHILA- 
DELPHIA* 
Joseph Walsh, M.D., Philadelphia. 
The invitation to read a paper before the Laennec Society 
was accompanied by the request that the paper be on the de- 
tailed workings of the Henry Phipps Institute. This is 
therefore my excuse for the paper. 
The Phipps Institute was opened on February I, 1903, for 
the study, treatment, and prevention of tuberculosis and the 
word " study" was designedly put first. 
The institute comprises a dispensary and a hospital. The 
wards of the hospital accommodate only fifty-two cases, 
eighteen women and thirty-four men. The work was in- 
augurated with three physicians, the number of whom was 
gradually increased to thirty-two. These physicians are 
divided as follows: 
A medical director, four laryngologists, a dermatologist, 
a pathologist, a bacteriologist, a neurologist, an ophthal- 
mologist, a genito-urinary surgeon, and twenty-one clinical 
physicians. 
In both the dispensary and hospital only tuberculous cases 
are treated, and it is insisted upon that they be destitute. If 
they are capable of paying a physician even fifty cents a visit 
they are referred to their home physician. 
There are in the present temporary quarters no facilities 
for treating surgical cases, and hence no attempt is made to 
[1731 
* An address delivered before The Laennec, A Society for the 
Study of Tuberculosis, at the Johns Hopkins Hospital, March 19, 
1908. 
1 [173] 
treat them. The only operations ever done in the hospital or 
dispensary have been the opening of an ischio-rectal abscess, 
the tapping of a pleural effusion, the introduction of a tube 
for empyema or an urgent tracheotomy. 
It happened that the man chosen by Mr. Phipps to be 
director of the institute was already director of a large sana- 
torium for the treatment of early cases. In addition to this 
sanatorium there were three hospitals for early cases in 
and about the city of Philadelphia, and it appeared both 
to Mr. Phipps and Dr. Flick that the most good could be 
accomplished by a hospital for advanced cases. The hos- 
pital was designed, therefore, for these cases only. 
The good accomplished by a hospital for advanced cases is 
more in the way of prevention and study than of treatment. 
The typical suitable patient for the Phipps Institute hospital 
is a member of a very poor family in an advanced stage of con- 
sumption who is not only a burden to the rest of the family on 
account of the care required, but is also probably infecting 
other members of the family. A concrete example would be 
the father of a family in which there were small children. 
On account of the illness of the head of the house, the wife 
is obliged to work for the support of the family, and when she 
is at home is obliged to care for the children and the patient. 
It is almost impossible for an ignorant housewife to thus take 
proper care of a patient, especially without infecting herself, 
or without allowing the children to become infected. It is 
also practically impossible in our day for a woman to get 
sufficiently remunerative work to support such a household. 
The removal, therefore, of this case to a hospital removes one 
person from the support of the worker, removes a patient re- 
quiring considerable care from the hands of an ignorant indi- 
vidual already over-worked, and prevents the possibility of 
further contagion in the household. The patient is kept in 
the Phipps Institute until he either recovers sufficiently to do 
a certain amount of work or until he dies. 
In order to further the study, before the patient is admitted 
to the institute his nearest legal relative is obliged to sign a 
certificate permitting an autopsy in case the patient dies in 
the hospital. 
[174] 
2 In the hospital there are no resident physicians. The fifty- 
two cases are divided up among ten visiting physicians who 
visit the hospital at least every second day. The hospital has 
a history record sheet made up by the staff from the compari- 
son of a number of such blanks gathered in from all parts 
of the world. Each year this has been partially changed, 
corresponding to the experience of the members of the staff. 
This history sheet, therefore, is as complete as the staff deems 
necessary to show the physical condition and sociological 
status of the patient, although it is still changed somewhat 
every year. It is filled out entirely by the visiting physician 
in other words, the history is taken in its entirety by men of 
experience and not by recent graduates. In addition to this 
sheet, there is a diagram for the outline of physical signs, 
which is also filled in by the visiting physician. The staff of 
physicians meets every Monday evening; and once a month, 
all the histories in the house and in the dispensary are brought 
before a history censor committee, and any thing lacking on 
the sheet or diagram is called to the attention of the staff. By 
this means every history and diagram is kept absolutely com- 
plete in all details. In the histories and'diagrams it is neces- 
sary to indicate not only the abnormal, but also the normal. 
In addition to these histories we have what are called 
monthly summaries. These monthly summaries repeat a 
certain number of the questions of the history in regard 
to things that may have changed since the admission of 
the patient, for instance, the cough, expectoration, haemor- 
rhage, curved nails, curved fingers, enlarged glands, etc., 
and repeat also the diagram. In other words, while the 
patient is in the hospital a complete examination in regard 
to symptoms and physical signs is made once a month. This 
is taken care of in the same fashion by the censor committee, 
as the original history. 
There is also a complete nose, throat, and ear record sheet 
for any patient who manifests symptoms pointing to disease 
of these organs, likewise, a complete nervous sheet which is 
filled out for every house case and many dispensary cases. 
Though the cases in the hospital are divided up among the 
different physicians and each physician has his own set of 
[1741 
3 [1741 
cases, there is a special understanding which not only allows 
but encourages every physician on both the house and dis- 
pensary staff to examine any or all the other cases. This ex- 
amination is voluntary and the physician may or may not 
make a diagram of it. It is particularly requested, however, 
that a physician making an examination in this fashion, make 
a diagram and attach his name to it, so that there may be as 
many examinations as possible, if the case should come to 
autopsy. It is very common, therefore, at autopsy to find 
several complete examinations by the physician who treated 
the case, and several others by other physicians on the staff. 
This not only makes the autopsy interesting, but causes it to 
be done in an exhaustive fashion. Like our history sheets, 
we have a very complete autopsy sheet, every question on 
which must be answered. 
At the end of the year all the statistics relative to cases are 
compiled and printed in an annual report. 
In the dispensary, as in the hospital, only absolutely desti- 
tute cases are taken. In regard to the financial condition, 
the word of the patient is taken for the primary examination 
and treatment. Subsequent to this, however, an inspectress 
visits the patient's house and if his financial condition is 
found better than stated, he is refused further treatment. 
The history and examination sheets used in the dispensary 
are the same as in the hospital, and they are filled out with 
the same exactness. The summary examinations, however, 
are required in the dispensary not once a month, but once in 
three months. We have fifteen men in the dispensary, each 
one spending four hours a week, seeing altogether an average 
of seven hundred new cases a year, and four hundred old 
cases. These dispensary physicians come two days a week, 
spend two hours each time, and see the different cases once in 
two weeks. It takes about an hour to see a new case the first 
time, hence they see only one or at most two new cases on any 
single day. Cases are seen only once in two weeks in order to 
give sufficient time for changes of condition to be noticed and 
in order to avoid too much medical interference, which can do 
harm. I have always thought that the greatest trick I learned 
in the treatment of tuberculosis was the infrequent seeing of 
4 [174] 
cases. It is not possible to treat every little symptom mani- 
fested by a tuberculous patient, and if the patient is seen fre- 
quently it is almost impossible to avoid overmedication, 
which only does harm. 
As soon as the patient comes into the dispensary, whether 
he is a new or old case, he is handed a spit cup by a nurse 
who is always present in charge of the dispensary, and he 
uses the spit cup while awaiting his turn, and takes it with 
him into the examining room. These spit cups are the regu- 
lation paste board spit cups in a brass container. As each 
patient is leaving, after his first visit, he is given free of 
charge a set of preventive rules to hang up in the house, one 
brass container, fourteen spit cups, and a number of paper 
handkerchiefs, and paper bags. He is shown exactly how to 
use these different things by the nurse in charge, and in- 
structed in the necessity for their use by the physician. 
If the patient is destitute he is frequently ordered milk by 
the physician. We have two milk stations in Philadelphia: 
one at the institute itself, and one in Kensington, in the north- 
ern section of the city, about three miles away from the insti- 
tute. In addition milk is delivered in the western and 
southern sections of the city through local milk dealers. 
Milk is given to the patient under various circumstances 
and in varying amounts. The most common intention in giv- 
ing milk.is for the nourishment of the patient in order to 
make him well, and in this case the milk is usually given in 
quantities of about three quarts per day; it is given, however, 
also for the purpose of being able to control an advanced case 
even when it is evident nothing can be done in the way of 
cure or improvement. All patients coming to the dispensary 
are given preventive supplies in the shape of spit cups, and 
paper napkins; only about one-quarter of them are given 
milk. 
When a patient coming to the dispensary is an early case 
he is usually advised to go to the White Haven Sanatorium 
for six months, though if his resistance is very good, or if he 
refuses to go to the sanatorium on account of not wishing to 
leave his family without support, he is treated in the dispen- 
sary and encouraged to come once in two weeks. The nurse 
[i75] 
5 [175] 
visits his apartments or house and reports on it; if he is liv- 
ing in too confined an apartment, the nurse and physician 
both advise a change. Sometimes this change is accom- 
plished, again it is found practically impossible on account 
of lack of funds to meet more rent. In this case as much 
as possible is done at the present home. The wife, or other 
members of the family are instructed in the communicability 
of the disease and the steps required in order to prevent in- 
fection. They are advised to keep the children outside as 
much as possible during the day. It is insisted that the 
rooms be wide open at night, be disinfected immediately by 
the Board of Health, and be kept clean, practically disin- 
fected thereafter. The wife is instructed to boil all the eat- 
ing utensils or to wash the patient's separately. She is 
instructed to use a wet or moist broom in sweeping, not a 
dry broom; also a wet cloth in dusting, not a dry cloth. It 
is seen that the patient has a bed to himself, even though a 
makeshift in the shape of a couch has to be put up. 
The nurse visits the patient once in two weeks and reports 
on the following: The amount of milk received by the 
patient from the institute; whether or not it is used by the 
patient; whether or not he is working; whether or not he 
takes exercise out of doors; sleeps with the windows open; 
sits in the kitchen; uses a spit cup; uses his paper napkins; 
burns spit cups and napkins; spits on sidewalk when on 
street; uses handkerchiefs or rags ; whether or not the prem- 
ises are clean; whether or not there is a back yard and what 
its condition; how many people there are in the house; how 
many windows in the house; whether or not there are other 
inmates in the house sick; whether or not the patient uses 
stimulants; if the rules of the institute have been hung up in 
the house; and whether or not she (the nurse) has instructed 
the patient in the observance of the rules. There is a special 
printed blank for these questions which the nurse writes out 
and attaches to the history of the patient so that the physi- 
cian may see at the next visit of the patient the inspectress's 
point of view in regard to how the patient is co-operating 
with him. All the answers to the questions which go to 
show the patient is doing his duty are written in black ink. 
6 The things which the patient does contrary to what he ought 
to do are written in red ink in order to call the physician's 
attention to them without being obliged to read the whole 
report. 
If the patient is not following the physician's directions, 
his attention is called to the fact, and if he is found disobey- 
ing the emphasized directions, his milk is stopped, if he gets 
milk, or his treatment, if he merely gets treatment. 
If the patient has advanced tuberculosis he is encouraged to 
come into the Phipps Institute or go to the Philadelphia Gen- 
eral Hospital. Sometimes he refuses to come into the Phipps 
Institute on account of the autopsy requirement and refuses 
to go to the Philadelphia Hospital on account of it being also 
the alms house. Such a case is investigated before there is 
any question of giving him milk and then only in case he 
cannot be controlled without the milk is he given a quart of 
milk daily, and then only in case he can be controlled by it. 
Even in the dispensary we look more to prevention than to 
absolute cure, though we try also to accomplish the latter; in 
other words, even in the dispensary we are not satisfied to 
hold patients as life long milk pensioners. A patient is 
treated for a definite length of time, as for instance, six 
months or a year, being carefully instructed throughout this 
period. We consider then that if we have not cured him, we 
have at least instructed him so that he should not be a 
menace to others. If then he has been getting material aid, 
this aid is stopped. Of course the patient may continue and 
usually does continue coming to the dispensary for advice. 
In some of the European dispensaries, especially the one 
at Lille, before the patient is examined, he is sent to a bath 
room and while he is being bathed his clothes are disinfected. 
This is an added help in the way of instruction and in addi- 
tion aids in prevention since the patient's clothes are so likely 
to be infected. 
In addition to milk, the French dispensaries supply eggs, 
meat, coal and sometimes lodging. It also takes care of all 
the patient's laundry in order to make sure that it is fre- 
quently washed and also in order to avoid the possibility of 
infecting the laundress. 
[175] 
7 [ 175] 
In addition to the hospital and dispensary the Phipps Insti- 
tute has an extensive laboratory in which all those connected 
with the institute, work. The laboratory is fitted up for bac- 
teriological and pathological study. Since it is simply a 
modern laboratory I omit details. 
One of the frequent questions asked us is, how much oppo- 
sition is manifested towards the autopsy requirements for ad- 
mission to the hospital. It is surprising to know how little 
opposition is made to it. There are practically only three 
classes of people who raise any objection whatsoever; first, 
the Hebrews, since it is definitely against their belief; second, 
the Irish, who have a great sentimental regard for the dead 
bodies of their friends; third, the colored people, who fear 
that the permission to do the autopsy carries with it the sure 
death of the individual. The Germans and the English make 
no objection whatsoever, and the objections of the others are 
so easily overcome that the majority of our patients are Irish 
and a few are colored people and Jews. 
The good accomplished by the Phipps Institute may be put 
under three heads : the good to the physicians, the good to the 
patients, and the good to the public at large, accruing from 
the study, treatment, and prevention of tuberculosis. In the 
study of tuberculosis the physician derives his benefit, first 
from the examination of the case, and particularly from the 
fact that the examination must be complete, thereby rendering 
him more thorough in his work; second, from the confirma- 
tion or non-confirmation of his examination findings at au- 
topsy ; and third, from the weekly staff meetings which aver- 
age more than twenty men out of the staff of thirty-two, at 
which cases and theoretical questions are discussed and to 
which uncommon or difficult cases and pathological speci- 
mens are brought. 
The benefit to the patients lies in the amount of improve- 
ment produced, the care taken of them while they are very 
ill, and the prevention of contagion in other members of the 
family. 
Since the hospital is intended for advanced cases, and since 
according to our statistics only advanced cases are admitted, 
it is readily intelligible that our results would not appeal to 
[176] 
8 a layman on account of the number of patients who die. To 
physicians, however, this is perfectly natural and from our 
standpoint what is remarkable is not the number who die be- 
cause that was to be expected, but the number that not only 
improve but improve sufficiently to go back to light work for 
one or more years. 
The following are the statistics of the results of treatment 
of cases in the Phipps Institute that remained in the hospital 
or came to the dispensary over a period of three months for 
the year ending February, 1907: 
[176] 
HOUSE. 
DISPENSARY. 
Incipient arrested 
6 (16.22%) 
improved 
27 (72.97%) 
unimproved 
4 (10.81%) 
" died 
Moderately advanced arrested .... 
improved .. 
... 6 (50%) 
53 (67-09%) 
unimproved 
... 2 (16.66%) 
22 (27.84%) 
" " died 
4 ( 5.06%) 
Far advanced arrested 
improved 
... i,8 (41.86%) 
7 (35%) 
unimproved 
• ..14 (32.55%) 
9 (45%) 
" " died 
...ii (25-58%) 
4 (20%) 
55 
136 
The benefit to the public is in the general prevention of the 
disease; in the education of physicians to be capable of recog- 
nizing the disease in an early stage, and capable of treating it 
so as to insure cure if cure is possible; in the popular lectures 
which are given by the various members of the staff on re- 
quest, either to popular societies, like labor and beneficial 
unions, or to medical societies; in the education of trained 
nurses in the care of tuberculosis, and in the running of tu- 
berculosis dispensaries and sanatoria; and in the general dif- 
fusion of education by means of the annual report published 
in an edition of five thousand copies and distributed gratis. 
A study of what is being accomplished in the way of the 
prevention of tuberculosis, published in the Third Annual 
Report, was entitled " A Statistical Study of the Influence of 
the Henry Phipps Institute upon the death-rate in Philadel- 
phia." This statistical study was made of all the wards in the 
9 [176] 
city of Philadelphia, and it was found that all the wards in 
which tuberculosis dispensaries or hospitals were located 
showed a definite decrease in tuberculosis, which was above 
the legitimate decrease taking place almost everywhere. The 
largest decrease in the city of Philadelphia was found in the 
wards in which the Phipps Institute does the greatest amount 
of its work, despite the fact that these are the slum wards of 
the city. The only wards which showed a definite increase in 
tuberculosis during the past three years were the fashionable 
wards, in which the wealthy people live. 
The fact that every ward in which a tuberculosis institu- 
tion exists has had a reduction in the death-rate from tuber- 
culosis is very interesting in view of the opposition which 
exists to the establishment of institutions for the treatment 
of tuberculosis on the score of danger to the neighborhood. 
There was the strongest opposition to the location of the 
Rush Hospital in the twenty-fourth ward. The twenty- 
fourth ward shows a reduction in the death rate from tuber- 
culosis while its neighbor, the thirty-fourth ward, with 
exactly the same kind of a population, has had an increase. 
Another very interesting fact is that the reduction in the 
death-rate from tuberculosis during the three years is among 
the poor in the crowded parts of Philadelphia rather than 
among the well-to-do in the sparsely built up parts of the city. 
The greatest reduction has been in the slum district, the 
foreign district, the colored district, and the manufacturing 
districts. These are just the parts of Philadelphia in which 
tuberculosis was most rife formerly. The wards in which the 
wealthy and the well-to-do live either have had an increase in 
tuberculosis or very little decrease. A corollary springs from 
these facts that the superficial instruction given to the wealthy 
and well-to-do for the prevention of tuberculosis as advocated 
by many is insufficient for the prevention of tuberculosis. 
One of the things at the Phipps Institute that we are 
proudest of and would not be without is our training school 
of nurses. 
When the institute first opened we were forced to take any 
nurse that we could get, and the majority of these knew little 
or nothing about the care of the tuberculous. Moreover many 
10 [176] 
of them were afraid of tuberculosis and accepted positions 
simply because they were out of a position at the time. The 
inauguration of our own training school was a great venture 
since we put into it only cured tuberculous cases. Practically 
all of these tuberculous cases came from the White Haven 
Sanatorium. We consider our training school a great success 
and it is a success for probably the following reasons: first, 
even when the girls enter they are already pretty well trained 
in the care of the tuberculous on account of the knowledge 
received in the cure of their own case; second, having gotten 
over tuberculosis themselves, they are not at all afraid of it; 
third, they are not disgusted by the unpleasant features of 
tuberculosis, namely, the expectoration, etc.; fourth, on ac- 
count of their own cure, they are extremely enthusiastic about 
the cure of others, and having seen quite advanced cases 
recover they are never ready to give up hope; fifth, they are 
a constant source of encouragement to the patients who have 
thus constantly before them an example of cured tuberculosis. 
The training school has been opened three years. So far 
we have taken in thirty-five girls of whom eighteen have 
graduated and have lucrative positions outside. Of the 
thirty-five, five have broken down. 
It is commonly thought that our nurses must have been 
very early cases of tuberculosis. This is not at all true. The 
majority of our nurses were moderately advanced cases of 
tuberculosis. A small number were early cases and a few far 
advanced. One of the nurses at present in our training school 
has a cavity at the top of each lung, has moist rales all over 
both lungs, and was for two years absolutely confined to bed. 
Another of our nurses came into the Phipps Institute in a 
far advanced stage and successfully graduated in our train- 
ing school this fall. I have gone into this question of nurses 
rather extensively because the most important essential of a 
tuberculosis dispensary is a well trained nurse. 
There are two ways of running a tuberculosis dispensary, 
namely, like the Phipps Institute dispensary or the German 
dispensaries. The Phipps Institute dispensary is devoted 
more to the study and the German dispensary more to the 
treatment of the cases. The Phipps Institute dispensary 
[1771 
11 [177] 
treats a small number of patients, the German dispensary a 
large number. In the Phipps Institute dispensary a physician 
does everything in connection with a case except visit it; he 
takes the complete history, makes the complete examination, 
weighs the financial condition, gives instructions, etc., etc. 
In the German dispensary the nurse takes the history, judges 
the financial circumstances, and gives the instructions, the 
physician deciding only on the diagnosis. I think there are 
good arguments for both classes of dispensaries. Where the 
amount of funds is limited I think the arguments favor the 
Phipps Institute method since the patient is not only treated 
but the physician is further educated. In the German dis- 
pensary there is practically no lack of funds on account of 
the backing by either the insurance companies or the gov- 
ernment. 
12