Tuberculosis, 
a Family Problem Tuberculosis, a Family Problem 
The Story of 
The Home Hospital of the A. I. C. P. 
By JOHN C. GEBHART 
Director, Department of Social Welfare, New York Association for 
Improving the Condition of the Poor 
Issued by the 
New York Association for Improving 
the Condition of the Poor Copyright 1924 by the 
New York Association for Improving 
the Condition of the Poor 
105 East 22nd Street 
New York 
25 cents per Copy Tuberculosis, a Family Problem 
The Story of 
THE HOME HOSPITAL OF THE A. I. C. P. 
WHEN Dr. Edward Livingston Trudeau was a young prac- 
tising physician, he began, for some unknown reason, to fail 
rapidly in health. Acting on the advice of a' friend he con- 
sulted Dr. Janeway, who was in those days noted for his skill in physical 
diagnosis. In his autobiography Dr. Trudeau described the interview 
as follows: 
"He received me cordially and began the examination at once. 
When this was concluded he said nothing. So I ventured, 'Well, Dr. 
Janeway, you can find nothing the matter?' He looked grave and 
said, 'Yes, the upper two-thirds of the left lung is involved in an active 
tuberculous process.' 
"I think I know something of the feelings of the man at the bar 
who is told he is to be hanged on a given date, for in those days pul- 
monary consumption was considered as absolutely fatal. I pulled my- 
self together, put as good a face on the matter as I could, and escaped 
from the office after thanking the doctor for his examination. When 
I got outside, as I stood on Dr. Janeway's stoop, I felt stunned. It 
seemed to me that the world had grown suddenly dark. The sun was 
shining, it is true, and the street was filled with the rush and noise of 
traffic, but to me the world had lost every vestige of brightness. I 
had consumption, that most fatal of diseases Had I not seen it in all 
its horrors in my brother's case? It meant death and I had never faced 
death before! Was I ready to die? How could I tell my wife, whom 
I had just left in unconscious happiness with the little baby in our new 
home? And my rose-colored dreams of achievement and professional 
success in New York! They were all shattered now, and in their 
place only exile and the inevitable end remained." 
Dr. Trudeau was a man of some private means and with a host of 
influential and helpful friends, who rushed to his aid, not only with 
advice and consolation for himself but also to look after his wife until 
a plan for his own care and treatment had been worked out. In what 
a different plight is the young wage earner who learns for the first time 
that he is stricken with "consumption." To the shattering of youthful 
hopes and ambitions and the prospect of an early grave or a period of 
chronic invalidism is added the anxiety for the fate of the wife and 
3 children who now face destitution and the prospect of blighted lives. 
Thanks to the efforts of pioneers like Dr. Trudeau, who was spared to 
devote more than forty years of a useful life to the treatment of tuber- 
culosis, the scourge has lost much of its terror. There remains still for 
those whose prognosis is hopeful the prospect of a long period of 
enforced idleness or of a restriction to light, easy work at reduced pay; 
the prospect of a home broken up with the father or mother in a hos- 
pital or sanatorium, the children in preventoria. In spite of the great 
advance in medical knowledge and in facilities for treatment, tuber- 
culosis still hovers like a grim spectre over the homes of the poor. 
In its work with families in which either the father or mother is 
afflicted with tuberculosis, the A. I. C. P. has always sought to stand 
in the breach and to hold the family together while the patient him- 
self is fighting his battle with the disease. When tuberculosis invades 
the home the usual recourse is to place the patient, either the father 
or the mother in a sanatorium and to place the children in a prevento- 
rium, in a foster home or with friends or relatives. Separated from his 
loved ones, the patient becomes worried and discouraged, a factor 
which alone retards his progress; or he is likely to leave the sanatorium 
before a complete recovery has been effected. If there ever was a 
disease in which the family and not merely the patient is the unit of 
treatment, that disease is tuberculosis. 
The Home Hospital Established 
It was to meet this situation adequately that Mr. John A. 
Kingsbury, at that time General Director of the A. I. C. P., con- 
ceived the idea of the Home Hospital. It was accordingly established 
by the A. I. C. P. in March, 1912, for the care of tuberculosis families. 
The Home Hospital is a demonstration of the results which can be 
secured by housing the tuberculous patient and his family in a whole- 
some environment, by supplying the family with sufficient relief to 
provide for an adequate standard of living and by providing the neces- 
sary medical and nursing care not only to insure the recovery of the 
patient but to prevent tuberculosis from occurring among those members 
of the family who had not previously been afflicted. 
One section of the East River Homes, a model apartment house 
on the corner of East 78th Street and John Jay Park, was taken over 
in March, 1912, to house such families and to provide headquarters 
for the medical and nursing service. This space was twice increased 
until in 1916 four sections were available, providing space for nearly 
eighty families comprising four hundred individuals. These buildings 
4 are so constructed as to provide through ventilation from the street to 
the large courts around which they are built. The windows extending 
from ceiling to floor are provided with triple sash so that two-thirds 
of the space is unobstructed when the windows are open. Many of 
the windows are provided with iron balconies so that the patient's bed 
may be actually placed out of doors. The apartments are steam heated 
and are all supplied with running water and sanitary conveniences. 
An Adequate Standard of Living 
What a contrast these living conditions offer to the dark noise- 
some tenements from which the families came and where the disease 
finds its favorite lodging place! In the typical "old-law" tenements 
where most of these families are forced to live, the children usually 
sleep in a dark windowless room, the parents in an alcove room which 
borrows its light and air from the kitchen or living room. Inadequately 
heated, there is little incentive to depart from age-long traditions and 
keep the windows open in winter. For the first time in their lives 
many of the families had an opportunity to maintain proper standards 
of healthy living. 
But besides providing a wholesome physical environment, the plan 
also calls for underwriting the deficit between what the family earns 
or receives from friends and relatives and the cost of maintaining a 
proper standard of living. Warmer bedding is needed if windows are 
to be kept open. Good nourishing food for adults and children is 
essential both for preventing the disease among those who have so far 
escaped and for helping the patient to build up a reserve so sadly 
needed in his fight with the disease. In our statement of costs we 
shall see how important a contribution the A. I. C. P. is making to 
this element in the treatment of tuberculosis. 
Given a proper environment and the provision for physical needs, 
there is still needed daily painstaking educational work on the part 
of nurses to establish the right habits of living. Firmly established 
habits and traditions on the part of most of the families are diametri- 
cally opposed to the simple rules of living which are essential to the 
recovery of the patient and to prevent the infection of well members 
of the family. Each family on admission is given careful and oft- 
repeated instruction in precautions necessary to prevent the spread of 
tuberculosis within the family. The minutia of prophylaxis and sani- 
tation are gone into carefully in almost daily visits to the family and 
particular emphasis of course, is placed on the value of fresh air and 
personal hygiene, both as preventive and curative measures. Where 
5 the family's household furniture and toilet articles are inadequate or 
unsuitable for use in such a home, the necessary articles and furniture 
are provided. 
A Sanatorium and Preventorium Combined 
Apart from this general educational work for both patients and 
"contacts," a course of medical treatment and supervision modelled 
after that of the best sanatoria is carried out. All positive and sus- 
pected cases are examined every six weeks; healthy children every 
three weeks and healthy adults every three months. A daily morning 
and afternoon temperature and pulse record is kept of all positive and 
suspected cases. Sputum examinations are made and weight recorded 
every week for such cases. 
After each examination the patient is advised of his condition and 
is given instructions accordingly. If the patient has active symptoms, 
with cough, sputum, elevation of pulse or temperature, he is ordered 
to remain in bed. He sleeps in a room with all windows open, is care- 
fully fed, and isolated as far as possible from the well members of 
the family. The children are not allowed in the patient's bed chamber 
or in close contact with him. 
With improvement, the patient spends the day on the roof, reclin- 
ing in a steamer chair. Extra nourishment is given him in the mid- 
morning, the mid-afternoon and before retiring. Arrested cases are 
first allowed to do only very light work for a few hours each day, care 
being taken that the temperature, pulse, weight and physical signs re- 
main satisfactory. 
The patient himself keeps a note book in which he records his 
daily diet, amount of sleep, the occurrence of chills or night-sweats, 
whether he has slept with the windows open, and similar important 
data regarding both symptoms and daily hygiene. Similarly the weekly 
earnings, if any, are recorded and family expenditures as well. This 
is the family "log book," a device which has proved invaluable in 
guiding the educational work and treatment and studying the economic 
aspect of the family problem. 
The Home Hospital is a preventorium for the care of children as 
well as for the treatment of tuberculous adults. Physical defects noted 
by the doctor are given immediate attention. Dental treatment and 
tonsillectomy are most frequently indicated. When the plant was at 
the maximum capacity both were provided within the Home Hospital 
itself, by a surgeon and a dentist engaged by the A. I. C. P., tonsil- 
6 lectomies are now performed in other hospitals but dental work is done 
by our own dentists at the Association's dental clinic. 
Good nutrition is an important ally in fighting tuberculosis. The 
dietary of the family is supervised by trained dietitians so as to insure 
that the extra nourishment needed by such families is provided. As 
previously indicated, supplementary feedings are given to patients in 
the mid-morning and mid-afternoon and before retiring. If the mother 
is a patient who is not physically able to prepare the family meals, the 
family is fed in the common dining room. 
Special educational "nutrition" work is carried out for the children 
in the Home Hospital. Weights are recorded weekly and charted. 
The children are given instruction in the principles of food and hygiene 
and various devices are used to enlist the interest of both the children 
and parents. 
The children are urged to lead an outdoor life as much as pos- 
sible. Provisions are made for admitting the children to open air 
classes in neighboring public schools. Adjoining the building is a 
large playground, well drained and with playground apparatus so that 
the children, when not in school, can play out of doors most of the 
time. A strictly enforced rule of the institution requires all persons 
to sleep with windows open at night. 
The Selection of Families 
It is obvious that there must be a careful selection of families so 
as to insure the necessary cooperation if the enterprise is to succeed. 
Only families in which the prognosis of the patient is favorable are 
admitted. This, however, does not restrict us to the selection of in- 
cipient cases, though such do make up the bulk of the cases, but even 
moderately advanced and far advanced cases are admitted if there is 
a fair prospect of an improvement within a reasonable length of time 
which will restore the patient at least to partial earning capacity. Ad- 
mission is also restricted to those families who the Association is con- 
vinced have sufficient intelligence and moral stamina to cooperate in 
the rather rigid regime of diet, personal hygiene and regulation of 
family life which the Home Hospital policy enjoins. Obviously, families 
are selected where poverty is as much a problem as tuberculosis, for 
the genius of the Home Hospital is that it treats both poverty and 
tuberculosis as social-medical problems which are inextricably bound 
together. 
Undoubtedly the Home Hospital makes its greatest contribution in 
families in which the mother is the patient. The A. I. C. P. is re- 
7 peatedly confronted with a situation where the mother of young chil- 
dren has been diagnosed as tuberculous, sometimes incipient, some- 
times advanced, and where the physician advised that she go to a sana- 
torium for at least six months. The mother asks at once, "What is to 
become of my children while I am away?" Practically the only answer 
that can be made is, "We must commit your children to a foster home 
or preventorium until you are well enough to care for them again." In 
almost every case she refuses even to consider such a proposal and 
accepts the alternative of denying herself proper rest and medical care 
rather than part with her children. In situations like this the Home 
Hospital renders a most valuable service. The entire family can be 
admitted to the Home Hospital. If the mother is not physically able 
to care for her family, the house work is done by the "house mother" 
and both mother and children receive their meals in the common dining 
hall. Just what this service means to such a mother can be best illus- 
trated by accounting briefly what happened to one mother typical of 
many known to the A. I. C. P. for several years. 
Two months after Mrs. B. had lost her husband, she came to the 
A. I. C. P. for help. The $250.00 which her husband had left in insur- 
ance had been exhausted after paying the burial expenses and other 
bills incidental to her husband's illness. Mrs. B. had been trying to 
support herself and her four children, all under nine, by the six dollars 
a week she earned by sewing and by the two dollars a week she received 
from a lodger. She herself had not been well and had spent consider- 
able time in hospitals, suffering from "weak lungs." The A. I. C. P. 
placed her on an allowance at once so that the lodger could be dismissed 
and she could give up her sewing and devote herself to her family. 
A complete physical examination at the Home Hospital revealed in- 
cipient tuberculosis and she was recommended for admission. After 
she had been in the Home Hospital for one year, she was discharged 
as arrested. The older girl (ten years old at discharge) had gained 
twenty pounds and the other children had made twice the expected 
gain. All were discharged free from physical defects. Mrs. B. is now 
in fine physical condition, with a healthy and happy group of growing 
children. 
Facilities Curtailed in 1918 
In 1918 we were obliged to curtail considerably the size of the 
Home Hospital. Prior to January of that year, we had a working 
arrangement with the Department of Public Charities for providing 
Home Hospital care to indigent tuberculous patients committed by the 
8 Department of Public Charities, for whom the city paid the regular 
per diem allowance which the city usually makes for the care of such 
patients in private hospitals. While these appropriations no more than 
covered the cost of treating such patients, it did make possible an 
extension of the facilities of the institution until by 1916 it had a 
capacity for nearly eighty families. The arrangement was ended on 
January 1st, 1918, when the Department of Public Charities refused 
to approve further allowances to the Home Hospital. For a long 
time it appeared that, with the withdrawal of public support, this 
significant experiment in the treatment of the medical and social aspects 
of the tuberculosis problem would be brought to an untimely end. 
Fortunately Mrs. Elizabeth Milbank Anderson, always a firm 
believer in the Home Hospital, came generously to its support. Mrs. 
Anderson purchased and deeded to the A. I. C. P. the Victoria Apart- 
ments at 315 East 158th Street to be used as the Home Hospital. 
While the size of the Home Hospital has been greatly curtailed, all 
the important features of the old Home Hospital have been preserved. 
Living quarters for twenty families are provided with a common dining 
hall, day camp on the roof, a clinic, a playground and administration 
rooms. 
A Ten Year Summary 
Previous reports have discussed in considerable detail the medical 
results achieved by Home Hospital care.* Recently a study has been 
made of the results of treating 469 patients of whom 306 were adults 
and 163 were children, covering practically ten years' experience in this 
field. For the detailed picture we must refer the reader to earlier 
reports; we shall try here only to prsent the results in a summary form. 
A uniform method of classifying patients both on admission and 
discharge is now quite generally understood and accepted by all hos- 
pitals and sanatoria treating tuberculous patients. These terms are 
clearly defined in a previous report.f According to this terminology a 
patient on admission is either incipient, moderately advanced or far 
advanced; at discharge he is either arrested, apparently arrested, quies- 
cent, improved, unimproved or dead. More recent sanatoria reports 
have thrown the first three groups into one, thus ignoring distinctions 
between arrested, apparently arrested and quiescent. That procedure 
has been followed in this study. The above terms apply, however, only 
to adults; because of the obscure nature of tuberculosis in children it 
* Poverty and Tuberculosis-The Home Hospital Experience-Publication 84-New York 
A. I. C. P. 
t The Home Hospital-The Medical Report of the Work, March, 1912, to October, 1916- 
Publication 117, New York A. I. C. P. 
9 has been found impracticable to make similar classifications of children 
apparently suffering from tuberculosis. 
As has been previously indicated, in the selection of cases prefer- 
ence is given to those whose prognosis is hopeful. This has resulted 
in a slightly greater proportion of cases which were incipient on admis- 
sion than that found in most other sanatoria. Of those institutions 
whose records were available, the sanatorium conducted by the Metro- 
politan Life Insurance Company at Mt. McGregor, New York, alone 
exceeded that of the Home Hospital.* In the latter institution the pro- 
portion of incipient cases has steadily increased from the beginning in 
1914, when 28.3% were incipient, to 1920, when 70.0% were incipient. 
Obviously this fact must be kept in mind in interpreting the results of 
various institutions. In Table I we find a comparison of the propor- 
tion of incipient, moderately advanced and far advanced patients in 
Home Hospital and other institutions. 
Table I-Condition of Patients on Admission at Home Hospital Compared 
With Other Institutions. 
Condition on Admission 
T rudeau 
Loomis 
King 
Edward VII 
Mt. 
McGregor 
Home Hosp. 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
Total 
1,892 
100 
1,192 
100 
1,707 
100 
1,319 
100 
306 
100 
Incipient 
534 
28.2 
153 
12.8 
460 
26.9 
738 
56.0 
157 
51.3 
Moderately Advanced ... 
1,254 
66.3 
471 
39.5 
848 
49.7 
493 
37.3 
97 
31.6 
Advanced 
104 
5.5 
568 
47.6 
399 
23.4 
88 
6.7 
47 
15.3 
Not stated 
0 
0 
0 
0 
5 
1.6 
Medical Results 
Statements of results secured must obviously be made with regard 
to the condition of the patient on admission. Those institutions admit- 
ting large numbers of advanced or moderately advanced cases are not 
likely to report as large a proportion of cases arrested or quiescent on 
discharge as those which admit a larger proportion of incipient cases. 
The results of the Home Hospital experience for the period covered 
as summarized in Table II bring this out quite forcibly. 
* The After-History of Nine Hundred and Fifty-three Tuberculous Patients Discharged 
from the Metropolitan Life Insurance Sanatorium from 1914 to 1920-Howk-Dublin-and 
Knudsen, Transactions of the Eighteenth Annual Meeting of National Tuberculosis Asso- 
ciation. 
10 Table II 
Condition at Discharge 
Apparently 
Unimproved 
Total 
arrested or 
or 
Not 
cases 
quiescent 
Improved 
progressive 
Dead 
known 
Condition 
on Admission 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
Total 
. 306 
100 
195 
63.7 
30 
9.8 
48 
15.6 
29 
9.4 
4 
1.3 
Incipient 
. 157 
100 
132 
84.1 
14 
8.9 
8 
5.1 
1 
.6 
2 
1.3 
Moderately 
advanced 
. 97 
100 
57 
58.7 
13 
13.4 
19 
19.6 
6 
6.2 
2 
2.0 
Far advanced 
. 47 
5 
2 
21 
19 
0 
Not stated 
5 
1 
1 
0 
3 
0 
One can see at a glance that the chances of recovery or improve- 
ment are in direct proportion to the relative mildness of the condition 
on admission. Thus, 84.1% of those incipient on admission were ap- 
parently arrested or quiescent on discharge, while only 58.7 % of those 
moderately advanced were discharged as quiescent and only about a 
tenth of those far advanced were discharged as quiescent or appar- 
ently arrested. On the other hand, only one of those incipient on 
admission (.6%) had died before discharge, while 6.2% of those mod- 
erately advanced and about 42% of those far advanced had died before 
discharged. The success of the Home Hospital experiment is there- 
fore largely due to the fact that we were able to find fully half of the 
cases while they were still in the incipient stage. 
Comparison With Other Sanatoria 
How do these results compare with those of other institutions? 
It is not easy to answer this question. The degree to which the patient 
suffers from tubercular infection on admission and the degree of im- 
provement noted at the time of discharge can only be determined with 
approximate accuracy and is largely influenced by the judgment of 
the particular doctor. For example, a patient whom one physician 
would call "incipient" another would call "moderately advanced" or a 
patient whom one doctor would call quiescent on discharge another 
would designate simply "improved." Indeed the only case in which 
there is no uncertainty is where the patient has died. But in the case 
of the incipient and the moderately advanced this will account for a 
very slight proportion of the cases. Again, many sanatoria discharge 
cases before they become moribund, so that the death rate is either 
exceedingly low or absolutely nil. 
In spite of these difficulties, we have attempted to compare our 
results with those of certain well known institutions covering a con- 
siderable period of time. In the report of the Metropolitan Life In- 
surance Company, previously referred to, comparison was made of the 
results of the treatment offered at Mt. McGregor sanatorium main- 
tained by the Metropolitan and those of Trudeau, Loomis and King 
11 Edward VII. In the following table the results at Home Hospital have 
been added to the previous report: 
Table III-Comparison of Results Achieved on Discharge According to 
Condition at Home Hospital and Four Sanatoria. 
Trudeau 
All Cases 
Loomis 
King 
Edward VII 
Mt. 
McGregor 
Home Hosp. 
Condition on Discharge 
No. % 
No. % 
No. % 
No. % 
No. % 
Total 
Total No. of cases 
1,892 100 
1,192 100 
1,707 100 
1,018 100 
306 100 
Quiescent 
1,285 67.9 
496 41.6 
1,080 63.3 
632 62.1 
195 63.7 
Improved 
287 15.2 
335 28.1 
330 19.3 
229 22.5 
30 9.8 
Unimproved 
307 16.2 
258 21.7 
297 17.4 
92 9.0 
48 15.6 
Dead 
13 .7 
103 8.6 
0 0 
65 6.4 
29 9.4 
Not stated 
0 0 
0 0 
0 0 
0 0 
4 1.3 
1. Incipient on Admission 
Total No. of cases 
534 100 
153 100 
460 100 
592 100 
157 100 
Quiescent 
408 76.4 
114 74.5 
427 92.8 
478 80.7 
132 84 
Improved 
73 13.7 
32 20.9 
16 3.5 
88 14.9 
14 8.9 
Unimproved 
52 9.7 
7 4.6 
17 3.7 
19 3.2 
8 5.0 
Dead 
1 0.2 
0 0 
0 0 
7 1.2 
1 .6 
Not stated 
0 0 
0 0 
0 0 
0 0 
2 1.2 
2. 
Moderately Advanced 
on Admission 
Total No. of cases 
1,254 100 
471 100 
848 100 
366 100 
97 100 
Quiescent 
847 67.5 
257 54.5 
555 65.4 
152 41.5 
57 58.7 
Improved 
185 14.8 
112 23.8 
160 18.9 
133 36.4 
13 13.4 
Unimproved 
212 16.9 
80 17.0 
133 15.7 
48 13.1 
19 19.5 
Dead 
10 0.8 
22 4.7 
0 0 
33 9.0 
6 6.1 
Not stated 
0 0 
0 0 
0 0 
0 0 
2 2 
3. Far Advanced on Admission 
Total No. of cases 
104 100 
568 100 
399 100 
60 100 
47 100 
Quiescent 
30 28.8 
125 22 
98 24.6 
2 3.3 
5 10.6 
Improved 
29 27.9 
191 33.6 
154 38.6 
8 13.3 
2 4.2 
Unimproved 
43 41.3 
171 30.1 
147 36.8 
25 41.7 
21 44.8 
Dead 
2 2.0 
81 14.3 
0 0 
25 41.7 
19 40.4 
In general the results secured at Home Hospital are quite com- 
parable to those secured at Mt. McGregor, the sanatorium conducted 
by the Metropolitan Life Insurance Company. The fact that Mt. Mc- 
Gregor reports a slightly larger proportion of cases "improved" than 
Home Hospital is rather due to a different use of the term on the part 
of the physician than to a significant variation in results secured. 
Particular attention has been given to children, for we have as- 
sumed that all have been in close contact with the patient and that all 
were likely to develop active tuberculosis unless preventive measures 
were taken. Those children who exhibited the following symptoms, (1) 
underweight for age, (2) constant or frequent coughs, (3) occasional or 
constant temperature of undiscoverable origin, (4) rales (near one or 
both nipples, connstant or inconstant), interscapular dullness and posi- 
tive Von Pirquet (under four years), were considered patients and 
Results With Children 
12 received more intensive follow up. During the period covered 163 such 
children were admitted; of these 151 or 92.5% were discharged either 
in "good condition," "improved," "quiescent," or "negative"; 3 or 1.8% 
were fair or poor; 1 was progressive; 2 or 1.2% had died and for 6 or 
3.6% no adequate diagnosis on discharge was recorded. 
When the Home Hospital idea was first conceived the objection 
was made by some that without complete segregation of the tuber- 
culous many new cases would develop with the institution itself. In 
our ten years' experience no new cases of tuberculosis, either of chil- 
dren or adults, has developed while a family was in the institution. 
This remarkable record we attribute to the educational work with 
families as to the importance of fresh air and sunlight and to simple 
precautions regarding sleeping arrangement and the use of common 
towels, glasses and dishes. 
Condition of Patients After Discharge 
But it is not enough to discharge a tuberculosis patient as "quies- 
cent" or "improved." The effect of the treatment must be such as to 
provide a reasonable assurance against a relapse, which is likely to 
result either in diminished earning capacity or in early death. This 
objective from the first has been recognized as of prime importance in 
the Home Hospital. It has been our conviction that by dealing with the 
family as a unit and not simply with the patient, we should be able to 
establish a standard of living and habits of personal hygiene which 
would follow the family after its discharge from the institution. In 
order to test the permanent effect of Home Hospital treatment, we 
have followed up the after-history of all but the most recently dis- 
charged cases within the period under consideration. 
The attempt to discover whether or not the patient had suf- 
fered a relapse subsequent to discharge was abandoned, because of 
the difficulty of getting reliable statements based on a doctor's diag- 
nosis. We had, therefore, to content ourselves with finding answers 
to two questions: (1) How many of the discharged patients died 
subsequent to discharge? (2) How many of those alive at the time 
of the follow-up were able to work? Despite the many difficulties 
of conducting an inquiry of the 277 discharged patients only 15 or 
5.5% either could not be located or refused information. 
In table IV we have summarized the results of this follow-up. 
The average period of time elapsing since discharge was 3.2 years, 
with a range of from 6 months to 9 years. This fact must be kept 
13 clearly in mind in evaluating these results, for it is in the first years 
after discharge that the mortality is highest. 
Table IV-After-History of Discharged Adult Tuberculous Patients 
of the Home Hospital. 
Condition on 
discharge 
Total cases 
Dead 
Able to work 
Not able to work 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
T otal 
262 
100 
71 
27.1 
157 
59.9 
34 
12.8 
Quiescent 
186 
100 
26 
14.0 
148 
79.6 
12 
6.4 
Improved 
26 
« 
13 
# 
5 
* 
8 
♦ 
Unimproved 
46 
* 
30 
* 
2 
* 
14 
* 
Not stated 
4 
* 
2 
* 
2 
♦ 
* Percentage not calculated because of small numbers. 
The fact that practically 60% of the patients in spite of their 
tremendous handicap are able to assume the full responsibility to- 
ward their families after discharge is abundant evidence of the last- 
ing effect of Home Hospital treatment. Of those discharged as 
quiescent practically 80% were found on the follow-up to be alive 
and productive. 
Obviously the results of the follow-up are dependent on the 
period of time elapsing since discharge. While our data are too 
meagre to permit a detailed study by years, we have, in Table V, 
compared the results for three year periods. A glance at this table 
will indicate that the chances of death are greatest in the early years 
after discharge and the chances of those surviving being able to 
carry on effectively are greatest in the later years. 
Table V-After-History of Discharged Adult Tuberculous Patients of the 
Home Hospital by Period of Follow-Up. 
Total 
Able to work 
Not able to work 
Dead 
Period of follow-up 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
Total 
262 
100 
157 
59.9 
34 
12.8 
71 
27.1 
Less than 3 years 
108 
100 
44 
40.7 
12 
11.1 
52 
48.1 
Three years less than 6 
124 
100 
89 
71.7 
21 
16.9 
14 
11.3 
Six years less than 9. . 
26 
100 
24 
1 
1 
Not stated 
4 
0 
4 
The results of Home Hospital treatment in prolonging the life 
span and in restoring the earning capacity of the patient may now 
be compared with the results secured by leading sanatoria in Amer- 
ica. In a recent study by the National Tuberculosis Association 
the results of the follow-up of 12,708 patients discharged from 
American Sanatoria are given.* The report of the Metropolitan 
Life Insurance Company previously cited gives the results of its 
follow-up.+ After excluding cases which could not be reached the 
following comparison is made: 
* Sanatorium Follow-Up Studies by Dorothy E. Wiesner-American Review of Tuber- 
culosis, Vol. VI, No. 4, June, 1921. 
t After-History of Nine Hundred and Fifty-three Tuberculosis Patients Discharged from 
the Metropolitan Life Insurance Company Sanatorium-Howk-Dublin-Knudsen Transactions 
of the Eighteenth Annual Meeting of the National Tuberculosis Association. 
14 Table VI-Comparison of the Condition of Discharged Patients from (a) 13 
Leading Sanatoria Surveyed by the National Tuberculosis Association, 
(b) Mt. McGregor, (c) Home Hospital. 
Total cases 
Dead 
Able to work 
Not 
able to work 
Study 
No. 
% 
No. 
% 
No. 
% 
No. 
% 
N. T. B. Association... 
.. 12,708 
100 
6,100 
48 
4,073 
39 
1,426 
13 
Mt. McGregor 
896 
100 
87 
9.7 
719 
80.2 
90 
10 
Home Hospital 
262 
100 
71 
27.1 
157 
59.9 
34 
12.8 
Thus the results secured by Home Hospital are not quite so 
good as Mt. McGregor but distinctly better than those of other 
sanatoria. A word of explanation is needed. The results of the 
study by the National Tuberculosis Association are largely deter- 
mined by the great number of patients who were far advanced on 
admission. A recent tabulation by that organization for 1920 indi- 
cated that 50% of the patients were advanced cases on admission. 
On the other hand, it is difficult to explain why nearly three times 
the proportion of patients died after discharge from Home Hospital 
as from Mt. McGregor. The social and economic status of the dif- 
ferent groups must, we fancy, go far toward explaining this differ- 
ence. Discharged cases from Mt. McGregor were immediately 
returned to their positions with the Metropolitan Life Insurance 
Company, whereas no such security of tenure could be assured our 
discharged patients. Moreover, provision is made for the imme- 
diate re-admission of relapsed cases discovered through careful peri- 
odical medical examinations with a corresponding effect on the death 
rate. 
The proportion of children found to have died or to be totally 
incapacitated on follow-up was much smaller than in the case of 
adults. While this is undoubtedly due in a large measure to the 
permanent effect of Home Hospital care it must also be attributed 
partly to the fact that among the general population death rates at 
these ages are at their lowest point, and total incapacity because of 
illness is very rare. These results are summarized in Table VII. 
Table VII-Condition of Discharged Patients (Children Under 16) 
on Follow-Up. 
Total 
Dead 
Able to work 
Not able to work 
No. 
% 
No. 
% 
No. ' 
% 
No. 
% 
148 
100 
3 
2 
139 
94 
6 
4 
It may be pointed out that again the greatest risk is soon after 
discharge, for all of the deaths occurred in the group followed up 
for three years only. 
So far as the treatment of persons known to be suffering from 
tuberculosis is concerned, we may therefore conclude that the re- 
sults secured both during the period of residence at Home Hospital 
15 and after discharge to their own homes are quite as good as those 
of the best sanatoria. Equally important, however, is the fact that 
during our ten years' experience with this institution no new cases 
have developed during residence. It is clear, then, that we have suc- 
ceeded, therefore, not only in curing tuberculosis but in preventing 
its spread within the family. 
Cost of the Plan 
Granted that the results secured have been good, the question 
of whether the Home Hospital plan is the most economical method of 
dealing with needy families where tuberculosis is a major problem 
still remains unanswered. Fortunately we have been able through 
our own experience to observe the cost of dealing with such situa- 
tions according to two different plans: first, that of placing the 
patient in a sanatorium, either keeping the family together and 
doing as much educational work as possible in the home, or placing 
the children in an institution; second, that of placing the family in 
the Home Hospital and treating the entire family as a unit. To 
determine which plan involves the greatest expenditure of the Asso- 
ciation's funds is relatively simple; to determine which plan is the 
most economical in the long run is a much more difficult problem. 
While the Association is not called upon to meet the cost of the care 
of patients admitted to other institutions, this cost must be met in 
some way either out of public or private funds. Our problem, there- 
fore, is two-fold: (1) which plan actually involves a greater ex- 
penditure of our own funds? (2) which plan is the more economical 
if the total cost both to the families themselves and to the com- 
munity either out of public or private funds is considered? 
In analyzing the cost of a plan which combines the treatment 
of tuberculous patients and suspects with family rehabilitation, 
obviously all necessary family expenditure for medical and nursing 
care must be considered. The families themselves with what they 
are able to earn despite their handicap make a very substantial con- 
tribution to the expense of maintaining an adequate standard of 
living and of providing the necessary medical and nursing care. 
The deficit occasioned by the failure of family earnings completely 
to cover the cost of both service and living expenses are met by the 
Association. The families in the Home Hospital in addition to the 
intensive medical and nursing supervision already described receive 
excellent living quarters, warm clothing, good food and some of the 
amenities of life usually denied families in their station. This pro- 
16 vides, however, for only 30 of the 700 tuberculosis families annually 
under the care of the A. I. C. P. For the great majority of such 
families the A. I. C. P. is not able, therefore, to render as intensive 
service as it is to those admitted to the Home Hospital; they receive 
such educational nursing care in the Home, social service and the 
relief necessary to meet an adequate standard of living as the 
A. I. C. P. is able to provide through its Tuberculosis Division. 
Sanatorium and hospital care for tuberculosis patients is provided 
by agencies other than the A. I. C. P. 
It will readily be inferred that so far as A. I. C. P. funds are 
concerned the Home Hospital plan is by far the most costly, as the 
following table clearly indicates: 
Cost per family 
per day 
Cost per individual 
per day 
Cost per "Ammain" 
per day 
Home 
Tuberculosis 
Home Tuberculosis Home Tuberculosis 
Hospital 
Division 
Hospital 
Division 
Hospital 
Division 
Medical and nursing service. . 
. . $1,903 
$ .178 
$ .366 
$ .031 
$ .676 
$ .055 
Total living costs 
.. 5.026 
3.226 
.967 
.558 
1.786 
1.005 
A. I. C. P. contribution 
.. 2.459 
.718 
.473 
.124 
.874 
.224 
Family earnings 
.. 2.403 
2.241 
.462 
.388 
.854 
.698 
Other sources 
168 
267 
031 
.046 
.058 
.083 
Total cost 
. . 6.929 
3.404 
1.333 
.589 
2.462 
1.060' 
Table VIII. 
The "Ammain" is a value which reduces the expenditures of 
all families to the common denomination of the adult male. The 
"cost per ammain per day" represents in each instance the cost of 
maintaining a man at his period of "maximum economic demand." 
The costs of each plan are therefore placed on a comparable basis, 
since variations in size of family and the age and sex of the indi- 
viduals are avoided. It is not surprising that the cost for medical 
and nursing service per ammain per day is fully twelve times as 
great in the Home Hospital, for the services are really in no way 
comparable. That the A. I. C. P.'s contribution to living expenses 
is four times as great for families in the Home Hospital as for 
similar families in their own homes may be attributed to the fact 
a large share of Home Hospital care consists in providing warmer 
clothing and bedding, additional furniture, specially prepared food 
and household assistance, which are seldom provided in the average 
tenement home. 
But our contribution to the cost of maintaining tuberculosis 
families in their own homes and of providing nursing care is only a 
portion of the total cost which the families themselves and the com- 
munity at large must bear. Sanatorium and preventorium care are 
provided in many cases but without expense to the Association. 
17 We have made an attempt to secure reliable up-to-date estimates 
of such costs but with little success. 
On the basis of such data as we were able to secure we may safely 
say that where the patient is a widow with three dependent children 
the cost of Home Hospital care would be about $4.76 a day, while to 
place her in a sanatorium and the children in institutions, usually the 
only alternative, would involve a daily cost of at least $4.21, a difference 
of only 13%. In the interest of more continuous and satisfactory 
treatment and for the social welfare of the family itself this cost is more 
than justified. 
Conclusions 
Ten years' experience has demonstrated the value of Home 
Hospital care as an effective, humane and economical plan for deal- 
ing with tuberculosis in needy families. Judged by medical results 
the Home Hospital is quite as effective in arresting and improving 
tuberculous patients-during residence as any sanatorium in the country. 
It is further one of the most effective measures yet devised for 
safeguarding the health of well members of the family both by building 
up their resistance and by preventing the spread of infection within the 
family. 
Despite the social, educational and economic handicaps which first 
brought the families to our attention, patients discharged from Home 
Hospital apparently live longer and are economically more productive 
than those discharged from other sanatoria. 
Home Hospital care is humane in that it keeps many families to- 
gether for whom ordinarily there would be no alternative but the 
breaking up of the home and the commitment of one or both parents 
in a sanatorium and the children in institutions. 
The plan is economical in that for the type most in need of its 
service the final cost to the community in dollars and cents is no more 
than other plans which are less effective and certainly less humane. 
18 The Home Hospital is conducted by the New York Association 
for Improving the Condition of the Poor. 
Cornelius N. Bliss, President; George Blagden, Treasurer; 
Acosta Nichols, Secretary. 
HOME HOSPITAL COMMITTEE 
Thomas Cochran, Chairman 
Theodore J. Abbott, M.D. 
George Blagden 
Mrs. Cornelius N. Bliss 
Haven Emerson, M.D. 
Homer Folks 
Mrs. Charles Dana Gibson 
Samuel S. Keyser 
John A. Kingsbury 
Frankin B. Kirkbride 
J. Alexander Miller, M.D. 
Mrs. William C. Potter 
Mrs. John H. Prentice 
Miss Ruth Twombly 
Philip Van Ingen, M.D. 
Herbert B. Wilcox, M.D. 
Joseph S. Wheelwright, M.D. 
Linsly R. Williams, M.D. 
DIRECTING STAFF 
Bailey B. Burritt, General Director 
William H. Matthews, Director, Department of Family Welfare 
Alta Elizabeth Dines, Superintendent of Nurses 
Joan T. Gardner, Supervisor, Tuberculosis Division 
Helen S. Millrea, Superintendent, Home Hospital 
E. C. Brenner, M.D., Medical Attendant, Home Hospital 
19