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Here food is of consuming importance, but it is of no importance unless it is consumed. There are various types of the disease: (1) mild pellagra, one or two mild attacks, with recovery, growth to manhood, and a healthy life; (2) chronic pellagra, recurring attacks, periodic attacks, and gradual progression of the disease. Death may come after a few years. One Italian pellagrin lived to the nineties, and had donned the pellagrous bloom since childhood; (3) acute pellagra, severe, with or without fever, death in a few weeks to two years; (4) pellagra without a typical attack-the pellagra sine pellagra, a gradual decay of the vitality, resistance and strength.

The treatment is very simple: (1) It is chiefly the proper diet. Directions, and not appetite, are to be followed. No pellagrin will ever recover if he follows his appetite. He hasn't any. If the pellagrin swallows, the food will go down, and nature will do the rest. We have tried a psychological experiment to get these pellagrins to eat. Celsus was an ancient physician; it is not known yet whether he was a quack or scientist, but his saying was this: "The part of the true physician is to go in and sit down beside the patient and chat for a few moments." We ought to cover our science with our art and our art with our human relations. Now if one sits down by a pellagrin, the conversation may be something like this: "We are going to give you real food. We think you need it."

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is responsible for it. They are going to bring you the finest food for you that can be had. Second, if you swallow, it will go down. The hospital has nothing to do with that. I have nothing to do with that, but if you swallow, it will go down. Third, we will all rejoice at the result." The first thing you know, they are beginning to swallow. "Well, he told me if I swallowed it would go down." Very simple psychology, but the food goes down.

Accent is to be laid on sweet milk, eggs, oatmeal, cream of wheat, roasts, steak, lamb chops, toast, milk toast, breads, macaroni, rice, peas, potatoes, beans and green vegetables. During the acute attack the accent is chiefly on milk, raw eggs, cereals, chicken, milk toast, and as the mouth heals, on a general diet. The adult pellagrin should have a calorie intake of between three and four thousand calories.

(2) Rest, until the gain in weight is ten pounds above the normal weight.

(3) Tincture of nux vomica and hydrochloric acid in suitable cases. In a great many cases with diarrhoea, it has been found that the hydrochloric content is low. Those cases should have hydrochloric acid dilute. Nux vomica is one of the greatest medicines, I sometimes think. For pellagra-a balanced diet and yet more food, rest, nux, and a great deal of hope, are the scientific essentials.

In the discussion that followed, Dr. Roberts stated that he does consider the psychology of the patient a potent factor in bringing on the disease; that corn, itself, has nothing to do with causing the disease, except that a person living largely on corn is not having a balanced diet; that it is not contagious; that it is not a mental disease.

Suggestions for Improving the Training School

JANE M. PINDELL, R. N.

An attempt will be made in this article to answer some of the questions raised in the very interesting paper by Mrs. Christine R. Kefauver, as published in the August number. Some of these questions are being asked by mothers and daughters in our publicity campaign for students.

The main problems may be classified under the following heads:

1. Housing. 4. Organization.

Housing: In order to provide adequate

recreation and social life for students suit

dents' health. This has resulted in architects planning for infirmaries in student buildings and usually a graduate nurse is placed in charge. Furthermore, we find the same planning in organized buildings. (hotel type) for women and girls.

In 1909, the graduate nurses of New York City had finally organized so well through Alumnae Associations that it was

It was

2. Health. 3. Finance. possible to obtain a really representative vote
in regard to important matters.
then decided that the question of uncertain
work and living expenses might be regu-
lated through organizing a Central Regis-
try and Club House. Excellent! But the
demand exceeds the supply, and we anx-
iously await a solution to the present hous-
ing situation. I believe that the Club
House type of building is the best economic
solution. Within three years delegates from
Alumnae Associations have conferred and

able space must be furnished. In buildings
having assembly and reception rooms, we
have been able to plan for a normal social
life. When students want to have doctors
in addition to friends from the home circle
the privilege has been granted, and the good
effect has been marked in the hospital life.
It has been understood that the privilege
would be withdrawn if abused. In my own
experience it has not been possible to plan
for all schools alike, students differ so wide-
ly in their ideas of what constitutes pleasure.

Dr. Hubbard's suggestion for non-resident students would be a wonderful relief to hospitals, but alas! few want the responsibility of housing students. Last year I was engaged in housing problems, when trying to find suitable apartments near Columbia for a foreign student foyer, it was a revelation to hear the objections by real estate firms and superintendents of buildings. Apartment houses were finally purchased by Columbia to meet their needs. Again, in a University center, situated in a small city, I found that the boarding house plan was rapidly being replaced by the dormitory, under University control. A vital factor to consider is that of illness among the students. The most frequent criticism we have to meet is that of neglect of stu

voted to increase the rates due to H. C. L.

This action has been taken twice, chiefly by private duty representatives, and hospital authorities have granted the requests.

Health: Medical attention for students is very necessary. It is interesting to study time records. The days off duty credited to illness balance so evenly with the eight hour system. Frequently students favor, however, a full day off in preference to the strictly eight hour schedule. From a mathematical point of view it is usually impossible to give a student all the services due if she is not required to make up sick time.

The hot food served to night nurses is not only essential to the health but contributes more to the happiness of the staff than any known factor. A choice of food is possible through cafeteria srevice which is rapidly being developed.

Finance: An increase in the allowance for general expenses seems essential.

A

business woman states, that women must now contribute to the family expenses owing to H. C. L. and are no longer able to indulge in the choice of a profession. A budget allowance for the training school is essential, and in that budget should be inIcluded a definite amount to be used for the employment of graduate nurses, thereby making it unnecessary to call students for special duty.

Organization: It is a great privilege to join the students' rank occasionally by taking advantage of the special courses open to nurses. We see from the student's point of view and bring a new vision to our work.

A school meeting held monthly is helpful when the speaker is chosen to explain the daily problems and the reasons for all the bulletins and directions. I recall very delightful evenings when the speaker was an engineer. His reasons for plumbing disasters contributed real humor and left an impression which helped to reduce hospital

bills. Certain information must, however, be in print and we can never eliminate those little books of rules. A change in color for the cover makes them more acceptable also a slight change in wording and different. type. I have found school organizations very helpful.

The real strength of a school is known through its graduates and the alumnae should be a source of support by representation on the Training School Committee. Recognizing this fact last year, the Hon. Bird S. Coler, Commissioner Department of Public Welfare selected the President of each Alumnae Association as its representa

tive. The graduates have appreciated the honor and accepted the responsibility. They have contributed to special funds, i. e., scholarship, legislation, furnishing their sick room, etc., and are now recruiting students. Does not the sense of responsibility create loyalty?

Freight Car Hospital Wards

Freight cars in South Russia no longer carry merchandise, for there is no merchandise to carry; their load consists of living consignments of sick and dying human beings.

Thousands of refugees from the interior of Russia are crowding every town and hamlet in the Crimea. The entire region is now in the grip of a terrible typhus epidemic. Every hospital is crowded to twice and three times capacity already and still the number of typhus cases increases.

At the suggestion of the American Red Cross Relief Commission to South Russia, which recently established its headquarters at Theodosia, a little port on the Crimean

seacoast, the Russian civil authorities requisitioned hundreds of freight cars standing idle in the railway yards of Sebastopol and other rail centers and turned them into hospital wards for the accommodation of the typhus victims.

Each car is fitted with forty rough bunks, in three tiers, Russian women, most of them nurses of the Russian Red Cross, are in

charge. As fast as the cars are fitted for the reception of the sick they are filled. The demand for accommodation is far greater than the supply of hospital cars thus far put in operation. The American Red Cross is planning to extend its work to the furnishing of the hospital freight cars with blankets, mattresses and medical equipment.

Physiology and Hygiene of. Puberty

By ANNE E. PERKINS, M.D.

While children are growing, the difference in sex need not make a difference in their habits of play, exercise or study. It is unnecessary to dress girls in such a way that they cannot exercise like boys. There is no reason why girls should not learn to swim, ride horseback, run, play basketball, et cetera. Any habits of play or study, as an interest in out-of-door subjects, that take a girl out and keep her in the open air are much better than those restricting her to indoors and too much thought about fine clothes. She should come to puberty with as strong a body as possible.

Too little attention is paid by mothers to the hygiene, mental and physical, of schoolgirls at or near puberty. Often they remain up too late to secure the proper amount of sleep. The foundation of a fixed habit of constipation is often laid during this time. How many mothers know whether their girls have regular daily movements of the bowels? If they get up late and rush to the bathroom for a hasty toilet, then to breakfast, in the fear of being late to school, the bowels are neglected and no regular habit of stool formed.

Young girls should not be allowed to eat indiscriminately between meals, candy, pastry, pickles, "sundaes" on the way to or from school, thus destroying the appetite for plain, nourishing food at mealtime. The craving for sweets is a physiological one, but parents should see to it that enough healthful sweets are provided at and after meals. If a lunch is taken from home, it should be of simple articles of food, chosen sensibly, containing plenty of bread and butter, fruit, eggs, et cetera. It is always better, where it can be obtained, to have a hot luncheon at or near the school, if distance prohibits going home. Nutrition, habits of play and exercise all have an im

portant bearing on the development of puberty. Well directed gymnastics at school or in a gymnasium should be an important part of every girl's life.

Girls grow in height and weight more rapidly from 12 1-2 to 14 1-2 years, and such physiologic demands are made on them at this time at the advent of puberty, that the pressure of schoolwork should be less than it is. While they should have some light work to do at home, it is far better to exact too little than too much, and leave household instruction and serving until vacation, unless a girl is robust.

Tennis, rowing, skating, basketball, swimming, and horseback riding are all valuable, and above all the simple brisk walk. If a girl is healthily tired from being outof-doors, one need not fear bad habits or wakefulness.

But after puberty exercise must be less strenuous and gymnastics carefully supervised by a physician or physical director.

Probably women dress more sensibly now than for years past, with less weight to skirts, less constriction of corsets, and no high collars, but there is still far to go, and corsets should not be put on young girls. There are harmless substitutes or their dress can be adapted so that corsets are not needed. High heels and narrow shoes should not be tolerated.

Since it is inevitable that girls should learn the facts about reproduction and menstruation, it is certainly the mother's place to prepare them in a measure for the advent of the menstrual flow. There is too much secrecy on the part of parents, and girls get obscene, vicious or erroneous information from wrong sources. The girl should be told when puberty approaches, in a very simple general way of what is to be expected at any time, so that, if she has

heard nothing of it from others, she will not be alarmed by the appearance of blood. She can be told that it is a secret between herself and mother, that girls do not talk of it to other people. Too much attention must not be directed to sexual things, and if the girl is very young, it is unnecessary to tell her about reproduction except in the most general way.

She should not be put to bed during the menses, unless there is pain, (which should receive prompt attention) nor be given vaginal douches after menstruation.

Contrary to the popular belief, she should bathe daily, although a cold tub-bath or surf-bath is inadvisable. She should be instructed to avoid wetting her feet. Many girls take violent exercise during the menses, but excessive exercise as tennis or dancing should be avoided especially for the first two days. Jumping after puberty is established is unwise. While many women can exercise as strenuously as men and make no difference at the menstrual period, young girls should be guarded against overstrain at such times.

Epilepsy not infrequently begins at puberty. Headaches which are periodic often have their inception at approaching puberty. It is well known that acne (" pimples ") of the face is most common at or near puberty, and generally clears up later, even if not treated.

It is not at all unusual for the menstrual period not to appear again for six months after the first advent of the menses. Irregularity for the first year or two is not alarming and generally needs no treatment, unless the girl is anaemic and requires constitutional treatment.

Puberty means the earliest age at which children may be gotten, and is derived from a Latin word meaning adult, from "pubes," the hair appearing at puberty over the pubic region. The entire body undergoes changes. The breasts and hips develop, the childish figure begins to take on more womanly

at about the fourteenth year in our climate, not infrequently at eleven or twelve, or at fifteen. It is generally believed that girls menstruate earlier in hot climates, and in the city, as they mature earlier. This statement is always made, and it is doubtless. correct, yet is not always borne out by statistics or personal experience. There are cases recorded where menstruation is precocious, appearing at eight years or earlier.

Menstruation is the periodic discharges of blood from the lining of the uterus, occurring during the time of a woman's sexual activity, from puberty till the menopause.

Not infrequently before the menses are established, there is nosebleed which may be quite profuse and in some cases it is regarded as vicarious menstruation, i. e., taking the place of the regular flow. It may be due simply to the flushing and congestion which accompanies puberty in some girls, but generally ceases when the menses are regular.

On the mental side of hygiene of puberty, the mother should have her daughter's confidence and a close but kindly supervision over her not only through childhood but doubly so as puberty approaches.

There is too little recognition of the changes in girls at this age in their relation to puberty. Many are regarded as "lazy" because they show no interest in work, are listless, dreamy, often antagonistic to their family, and unlike themselves in general. Those of us who come into close contact with nervous and mental patients have learned that there is appalling need of more careful surveillance of children's play, associates, and reading. We cannot safely defer till puberty what should have begun earlier. I venture to say that the average mother would be absolutely incredulous if told of some of her daughter's habits of thought, play, reading, sex-ideas, and acts.

When we obtain an honest history of a patient's early life, we find that there is a much earlier sex-curiosity and vague awak

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