1809-1930: History Of Hospitals In Michigan

The hospital has not been a feature of the American frontier; nor has the professional nurse been a pioneer figure. The doctor, with his saddle bags, was in evidence early. For the bed-side care of his patients, he was obliged to rely upon mother or wife or good neighbors to keep the sick-watch. When the children were born, the doctor’s wife, or the preacher’s wife, held herself in readiness to “go in and help.” And when a disease was known to be both dangerous and “catching,” the possible other persons in the community that had already “had it” attended the sick ones in some improvised place apart.

Michigan, however, is unique in that it both lies on an international frontier and has a bi-peninsular shoreline. The Straits were fortified by a stockade and a blockhouse, as soon as frontier trading began, and the earliest semblance of a Michigan hospital appeared in some crude quarters for the sick men of the garrison. The log-book of Capt. Alex Harrison, of The Gage, a boat that was unloading at Detroit wharf, contains these stories: “October 11, 1785. One hand sent to the hospital October 14. Durett came on board in place of Butler, gone to the hospital.” A report on barrack conditions at Detroit of 1790, June 24, describes the hospital as one room entered by two doors, equipped with twenty-one single berths and having one chimney. Something more spacious and better equipped must have been provided before 1812, when cholera visited Detroit as an incident of the war with England. Cantonment surgeons handled the scourge and the mortality was almost entirely among the soldiers.

County Houses

Sickness and poverty are akin; and the civic conscience, under primitive conditions, has provided for the two afflictions in one institution. A very early Act of Michigan Territory for the support of the poor, February 1, 1809, when William Hull was governor, provides that the overseers of the poor in the several districts within the Territory shall relieve and support all the poor, lame, blind, and sick, and shall provide for them houses, nurses, physicians, surgeons, in such cases as they shall judge necessary. Nothing more was contemplated by this than the letting out of cases to families that were willing to take them cheap. A poor law of twenty years later date, October 29, 1829, authorizes the proper officers to contract with a “competent physician” by the year, and to offer the contract at public auction to the lowest bidder. Seven years before Michigan arrived at statehood in 1837, a public Act authorized the establishment of county poorhouses with a superintendent. The seeds of the county infirmary, the home for the sick that civic charity provides for the poor, are found in this legislation; they, however, were seeds of slow germination.

Wayne County had been authorized to establish and operate a poorhouse two years before the General Law; although immediate action did not follow. And it was specified that the directors might admit lunatics and other diseased persons, if the disease were not contagious. A poor farm was purchased in 1832; and a shed-like building was erected the next year. A second visitation of the cholera, the same crisis that improvised places to house a pestilence in Detroit, speeded up the development of hospital features at the County House.

The borrow from the vivid language of Mr. George G. Catlin’s “Story of Detroit”:

“On June 7, 1834, Governor Porter, of Michigan Territory, died very suddenly. The circumstances of his death must have aroused suspicion of Asiatic cholera in the minds of the attending physicians, for his funeral was held on the day of his death. Between that time and August 1, several cases occurred with the unmistakable symptoms of cholera, and an alarm went through the city. There was a hurried cleaning of streets and alleys, but the plaque continued.

“Fr. Kundig, priest of Holy Trinity Church, was quick to realize the emergency, for so great was the general terror that sometimes when one person was attacked in a house, the rest of the family would flee, leaving the victim to the care of physicians and nurses. Many people hurriedly left town, but the people of surrounding towns were afraid of them. They built fences across the roads leading out of Detroit and tore up the bridges. Some Detroit people who went to a tavern in Rochester were turned into the street and had their baggage thrown out after them. Holy Trinity Church was situated on the north side of Cadillac Square, at the northwest corner of Bates Street. Fr. Kundig tore up the benches, built a partition across the middle to separate the men patients from the women, and organized it as a hospital. He induced about twenty-five of the young women of his congregation to enlist as nurses. He also enlisted an Irish ditch digger named John Canaan to act as official grave digger, and procured a horse and two-wheeled cart for him with which to gather up the sick and bring them to his church and to carry away the dead each morning from the improvised hospital and the homes about town. It is said that in the worst period of the plaque, the total deaths in one day numbered thirty-six.

“The Presbyterian Church, at the northeast corner of Woodward Avenue and Larned Street, was also utilized as a cholera hospital; and there Dr. Douglass Houghton and several other physicians ministered to the afflicted.”

Telling how the results of the scourge reacted on the County House, Mr. Catlin says:

“Following the cholera, the city was burdened with many invalids, widows and orphans, and the poorhouse utilized to its capacity. In the lack of other provisions for their care, Bishop Resé placed the Sisters of St. Clare in charge of the inmates. Most of the inmates were brought to the institution by Fr. Kundig, who took pains to search out the needy, and, having assumed so many of the duties, he was appointed supervisor of the poor in the fall of 1934. The county allowed him 16 cents a day for the care of the inmates; but the actual cost was about double that amount, for provisions were hard to get, and labor was scarce, owing to the departure of many people from the city. There were more than 100 inmates of the poorhouse, and sixty of those were invalids.

“There were no nurses to keep up treatments after the doctors had left to hurry to the next sufferer, so Fr. Kundig organized a Catholic Female Association for nursing the sick and caring for children suddenly orphaned by the plague.”

Of that association and the common necessity came the organization known as St. Vincent’s Female Orphan Asylum.

Detroit Hospitals

From these primitive hospital endeavors undertaken by the commonwealth in connection with its early emergencies and charities, there followed the broader conception of better institutions with a wider purpose. Its gradual development is best pictured in a history of Detroit’s several hospitals.

The earliest hospital in the city of Detroit to have a continuous existence is St. Mary’s, dating from June 9, 1845. It is the earliest in the state of any operating under private management. Four Sisters of Charity, an order founded by St. Vincent de Paul, began this work in an old log building at the southwest corner of Larned and Randolph Streets, which the Sisters of St. Clare had used for a schoolhouse in the previous decade. St. Vincent’s Hospital was the original name. Dr. Vlemcke superintended the medical and surgical work during the opening years. Sisters were the nurses, and operating expenses were met by popular subscription. The hospital made early provision for contagions cases, and cared for cholera victims in 1849. November 6, 1850, marked the first new era in its history when the hospital occupied a new building on Clinton Street near St. Antonie, which had been erected by popular subscription at a cost of ten thousand dollars. The lot, having a frontage of 87 feet and running through to Mullet Street, was the gift of Mrs. Antoine Beaubien, at whose request the institution changed its name to St. Mary’s Hospital. It had accommodations for 150 patients and was a large establishment for its time. A hospital register, now in the Burton Historical Collection, show that the institution was receiving county patient in very considerable numbers over the period 1855 to 1873. A more faded order and account book shows that St. Mary’s was serving from December, 1864, to April, 1865, as a United State General Hospital, W. H. Goimger, A. A. Surgeon, U. S. A. in charge. A second material advance is marked by the date November 21, 1879, when an additional building was occupied that had been erected at a cost on $50,000 on ground worth $15,000. This accommodated 130 inmates and the older building was reserved mainly for out-patient purposes. A free dispensary was by this time an important feature. While patients were received mainly on order from the director of the poor, others could secure board and attendance by the week at prices not greatly differing from present time hospital rates. In its present form St. Mary’s Hospital has 330 beds, besides operating an out-patient department.

Other Roman Catholic homes for the sick at Detroit are less deeply rooted in the growth of the city than this pioneer, which goes back to Bishop Lefebre, the immediate successor of Bishop R., first incumbent of the Diocese of Detroit.

The beginnings of Providence Hospital, West Grand Boulevard, are inseparable from the House of Providence for destitute children and unfortunate women, opened by the Sister of Charity in 1869. This home was originally on Fourteenth Street, between Dazelle and Marantette. The institution was incorporated in 1872. Out of it has grown the largest Roman Catholic Hospital in the state. It has 475 beds, and compares favorably in equipment and service with the best hospitals of Detroit.

A third Roman Catholic home for the sick, St. Joseph’s Mercy Hospital, on East Grand Boulevard, is as recent as 1922. This is under the control of the Sisters of Mercy, two branches of which order are operating hospitals in Michigan, one of them centered at Dubuque, Iowa, and the other at Grand Rapids. St. Joseph’s has 185 beds and maintains an outpatient department.

St. Luke’s Hospital and Church Home, operated by St. Paul’s Protestant Episcopal Church, is interesting as the earliest continuous institution with hospital features set up in Michigan under Protestant auspices. It was made possible by bequest of Mrs. A. C. Caniff, 1861, amounting to $1500. After location, 1864, in Lafayette Street and in West Forth Street, 1868, modern Detroit knows it as situated in Highland Avenue, where it carries on a work for the aged, sick, and poor, under support of the Episcopalian church parishes.

The State of Michigan had its share in the hospital drama of the Civil War; and the principal scene was enacted at Detroit. The most important was staged on a plat of ground on the west side of Woodward Avenue, where Martin Place was later cut through to John R. Street. The federal government coöperated with the newly incorporated trustee of Harper Hospital in making provision for the soldier sick who were returning from the front wounded and invalided. The hospital corporation purchased this land, which had joined their holdings by gift of N. Martin. At the government expense a large wooden building, supported on either side by a line of cottages, was erected on the Woodward Avenue front for a military hospital. When hostilities were over, the government conveyed these building to the Harper trustees, on condition that invalided soldiers should be cared for at local expense. Arrangements were also made between the hospital management and the local United States Sanitary Commission, whereby that society, noble forerunner of the numerous relief agencies of the World War, paid over to the hospital its final fund amounting to about $6,000, and gave over the care of all sick and needy ex-soldiers who might come into its hands. Although the hospital opened for general patients on New Year’s day, 1866, its first beneficiaries were twenty ex-service men received from the Soldiers Home in the Arsenal Building at the corner of Jefferson Avenue and Main Street. This initial work of Harper Hospital was protracted over the period of a generation. Among the soldiers’ records preserved in the Burton Historical Library there are two massive volumes of medical prescriptions issued during the years 1864 to 1868 which probably throw upon present practice in medication the highlight of contrast.

The beginnings of Harper Hospital have a surpassing tinge of eccentric romance. In 1831, when the Jackson administration was furnishing names for counties and towns in Territorial Michigan, Walter Harper, in his boyhood an Irish immigrant, came from Philadelphia to Detroit. There came with him as an upper domestic servant Mrs. Ann Martin, a young widow. She had suffered a broken life and a distracted mind for the death of her little girl in a Roman Catholic convent; and seems to have come west along with her employer at the urge of her mother, who feared some active violence against those whom she held responsible. Both Harper and Mrs. Martin acquired land at Detroit and in the environs. The woman derived the small sums she had to invest from a huckstering trade in vegetables, poultry and game that she carried on in a stall at the old city market at the upper end of Woodward Avenue; also delivering her wares at certain business places where her epicurean patrons were employed. Walter Harper died in 1867, and “Nancy” Martin in 1875. Her crowning active philanthropy reveals her a noble soul, although in an exterior that classes her with the very rough diamonds. In the year 1859, by Walter Harper’s deed bearing date of February 3, and Ann Martin’s deed of March 10, their realty was conveyed to trustees to be used for the erection and maintenance of a Protestant charity hospital. Rev. George Duffield, Dr. George Russel, Alexander C. McGraw, Jacob S. Farrand, Buckminister White, Frederick Buhl and David Cooper were the parties of the second part. Rev. George Duffield, for thirty years pastor of the First Presbyterian Church at Detroit, had inspired Harper with the idea, and Mrs. Martin chose to supplement with all her wordly goods the philanthropy of her long standing benefactor. The hospital was named for the man; the trustees so incorporated May 4, 1863. “Nancy” Martin had been honored in the naming of the street cut from Woodward Avenue to John R. Street. The Civil War contact of the Harper trustees with the United States government had resulted in the conveyance of an outfit of cheaply erected wooden buildings. These served as the principal hospital plant until 1884. At that time a main building of red brick, erected at a cost of $115,000, was completed, and the Civil War structures were disposed of. A current of benefactions had now set in. The contributors’ list includes many persons of local prominence over this middle period of the history of the city and some of national fame, as Zachariah Chandler and Russell A. Alger. Miss Jean L. Coyle’s free bed endowment, rated at the time at $220,000, and in property of increasing value, was given in 1924 in memory of her father, William Kieft Coyle. It has meant much to this important philanthropy. Harper Hospital, for a number of years, operated a unit for the care of contagious diseases, housed in a small red brick building in the rear of the hospital plant. This discontinued when the Herman Kiefer Hospital was established. The Charles C. Case Cancer Research Fund is indicative of the forward stand for hospital on the scientific side. In its jubilee year, 1913, Harper Hospital experienced a notable expansion, to be surpassed in the aftermath of the World War. On the last day of that year, the J. L. Hudson Memorial Building and Theodore D. Buhl Memorial Building were opened. The second of these additions, a family gift, was a center for the out-patient and social service departments. The first had been projected by the hospital trustees and was completed as a monument to a leading benefactor of the City of Detroit, a gentleman high up in its business circles, who was president of the hospital board at the time of his death in 1912. The golden anniversary reports of Harper Hospital discovered that it had cared for 72,250 patients, totalling 933,390 hospital days, and that not over half of the patients had paid anything for their care or treatment.

During the World War, Harper Hospital furnished the staff of doctors and nurses for Base Hospital Unit No. 17 that served in France under command of one of Detroit’s foremost surgeons, Colonel Angus McLean.

With the reconstruction time, the hospital entered upon another expansion commensurate with newer scientific and social ideas. Gray Pavilion, to house the operating rooms and x-ray department, was given by the children of John S. Gray in 1918. In 1926, the Harper trustees made a great appeal to the friends of hospital philanthropy, setting forth the fact that while Detroit had become, in numbers, the fourth city of the United States, it was lagging with its 4,723 hospital beds at ninth place in provisions for the sick. The appeal was for an approximate $2,500,000.00 for the erection of a 450-bed unit, for which sufficient ground was already owned, on Brush Street. The care of 650 patients at one time was declared to be the hospital’s ideal, 275 beds to be devoted to surgical cases, 200 to medical, and 100 to obstetrical, and 75 to eye, ear, nose and throat patients.

With this splendid addition a reality, the history of Harper Hospital becomes a matter of current events. Among the doctors who have had their part in its story of service and growth are E. L. Shurly and David Inglis in internal medicine, Theodore McGraw, H. O. Walker, and J. Henry Carstens in surgery; Howard W. Longyear, Walter P. Manton, and Benjamin R. Schenck in gynecology, and Daniel LaFerte in orthopedics.

The first suggestion of a homeopathic hospital at Detroit seems to be the offer of a building site at the southeast corner of Willis Avenue and John R. Street, made by Amos Chaffee in 1869. The first homeopathic physician to locate at Detroit, Dr. S. S. Hall, entered upon his long practice there as early as 1843. In 1879 the Detroit Homeopathic Association was incorporated. But the hospital project lagged until 1886, when Mr. James MacMillan expressed to Dr. C. A. Walsh his purpose to sponsor a building that should cost $100,000. Mr. John S. Newberry soon afterwards proposed a gift of $50,000 as an endowment for operating costs. Mr. Chaffee then renewed the gift of the building site, which had reverted to him within the seventeen years since his first offer. Stipulations were made that the hospital be maintained forever free to all needing its services and unable to pay for them. Grace Hospital was opened in December, 1888. Constructed for 100 beds, it was equipped for thee care of only eighty-five patients. The MacMillan and Newberry families, reinforced by Mr. D. M. Ferry, and supplemented by others, continued to subscribe to the general endowment fund in sums from $1,000 to $50,000.

The twenty-first year of Grace Hospital, 1910, opened a period of much needed enlargement. Patients were being cared for to the number of 156 under sorely crowded conditions. An addition to front on Willis Avenue was projected, the Board of Trustees undertaking to raise $50,000 and appealing to friends to subscribe a like amount. An addition devoted to surgery was the result. Thereafter continuous expansion is discernable, although checked by the drain of the World War. The Merriam Memorial Branch, constructed in 1913 on West Grand Boulevard, added fifty beds to the 242 of the main hospital. An x-ray department was added in 1916; a radiotherapy department in 1922. Between 1917 and 1919, 163 of Grace Hospital personnel received leave of absence or resigned to answer the call of the government; seventy-seven physicians, seventy-four nurses and twelve employees, many of them serving overseas.

Following a survey of hospital capacity in Detroit after the World War, the trustees of Grace formulated a program of enlargement in terms of $1,000,000, contemplating three major units and two minor constructions. Two of the proposed additions have been realized, the larger one being a building for the out-patient department occupied in 1926, when the Board received its program as including a private patient’s unit, home for nurses and home for staff and employees, all to be erected at the main hospital site; also a new main building on the west side to replace the Merriam Memorial Branch. Thanks to generous endowments, the charity work of Grace Hospital has kept pace with its general expenses. In 1925, of all the patients received, 24.2 per cent paid the full cost of care; 63.9 per cent were part pay patients; and 11.9 per cent were city, county and charity patients treated without personal charge to such patients. Eleven hundred and fifty-two were treated free; and in so doing the hospital expended $65,000. An increase was noted in the number of colored applicants for both out-patient and hospitalization. The most shining contribution of personal service to Grace Hospital is the long and distinguished career of Dr. Oscar LeSeure, for many years chairman both of the attending staff and of the executive committee.

The Woman’s Hospital and Infants Home, suggesting by its name a social work that has always lain close to the heart of womankind, was established as early as 1869 by the Ladies Christian Union, a society that had organized in 1860 and had operated a Home for the Friendless, and had re-organized in 1868. First occupying rented quarters on Cass Avenue, the institution was established in its own building on Thirteenth Street in 1875; and in 1893 found a more permanent home in Ferris Avenue. At the turning into the new century 270 cases was the measure of the year’s work. In 1922, 3,464 patients were cared for, 2,132 of them being mothers and babies. The imperative expansion took form in plans for a building to contain about 200 beds. The institution already enjoyed a Class A rating by the American College of Surgeons. The new plans drafted in the form of an X were determined by special concern for sunlight, retirement from street, and ease of operation. A drive for $600,000 was put on by trustees and other friends in 1923, and ground was broken shortly afterward. Some of Detroit’s noblest women among the fortunately circumstanced have served as patronesses of this institution. Officers of the modern social service work have contributed much to its effective operation; especially the Women’s Division of the Detroit Police.

The Children’s Free Hospital of Detroit was established by charitable ladies in 1886. Nine years later, Mr. Hiram Walker, in memory of his daughter, Jennie Walker, erected a fine building at the corner of Farnsworth and St. Antoine Streets. Attending physicians donated their services, and everything was free. About sixty children of parents of less than ordinary income received care. Senator James Couzens, while mayor of the city, re-established this especially appealing charity on a munificent scale, with a donation of $5,000,000, made upon the condition that the Children’s Free Hospital of Detroit and the Michigan Hospital School of Farmington be consolidated. The Children’s Hospital of Michigan is the result. It has 250 beds and an out-patient department. Prominent Detroit men and women, including Senator and Mrs. Couzens, make up the executive committee and the board of trustees.

Henry Ford Hospital

The Henry Ford Hospital was visioned by a group of citizens and physicians who sensed the rapid growth that their city was passing through in the opening decade of the twentieth century, and foresaw the need for a larger hospital than any existing and one that should have the most up-to-date equipment. in 1909, a plat of twenty acres was purchased at West Grand Boulevard and Hamilton Avenue. Building operations began according to plans for a great general hospital, and two or three units were completed. Then the enterprise lagged under its own weight. Mr. Henry Ford took it over with some changes of plan, and the main building was ready for use not far from the time when the United States entered the World War. Mr. Ford handed it over to the government, and it became United States General Hospital in 1918. Thus it furnished a scene in the drama of nursing sick and wounded soldiers back to life, and of teaching disabled men some new way to earn a living. Fifteen hundred soldiers were care for. After their discharge, Mr. Ford resumed building operations. The hospital is remarked for its very complete equipment and for original features. It is a “closed hospital” in that the staff is attached to the institution and cares for all the patients. It has 548 beds and a high emergency capacity.

The year 1909 marked the beginning of a movement to establish a new hospital in rapidly growing Detroit. The Detroit General Hospital Association was organized to plan and build the Detroit General Hospital. With Mr. Henry Ford as chairman, the Finance Committee obtained subscriptions and purchased twenty acres of land bounded by West Grand Boulevard, Hamilton, Byron and Bethune Avenues. Plans of a pavilion type of hospital, drawn up after committees had studied hospitals in Europe and America, were accepted and the work of building began.

In 1911 ground was broken for the first building unit. As was the experience of many public enterprises at that time, enthusiasm lagged and subscriptions did not prove sufficient to carry the project through. The foundation of the building remained unfinished for eighteen months. In 1914 it was suggested that the City of Detroit take over the entire project. In June of the same year Mr. Henry Ford wrote to the trustees of the association as follows:

Detroit General Hospital
Detroit, Michigan

Gentlemen:

Learning that it is proposed to turn the assets of the Detroit General Hospital over to the City of Detroit, and believing that this would be a serious mistake, both for the city and from every other point of view. I hereby make you the following proposition: If you will make a good and sufficient deed to me or my assigns of the land and buildings now owned by you at the corner of West Grand Boulevard and Hamilton Boulevard, Detroit, Michigan, I will pay a sufficient sum of money on delivery of the deed to repay to each subscriber the moneys paid in by him or her to the hospital association, and I will assume the outstanding debts and contracts for buildings of the Detroit General Hospital, but you are to relive me of all other obligations such as continuing obligations to employ particular individuals and everything of that nature.

In conclusion I will state that It is my intention, if this proposition is accepted, to go forward with plans for a complete and creditable hospital for the benefit of Detroit.

Yours sincerely,
Henry Ford.

His offer was accepted immediately and there was apparently great satisfaction of the solution of the difficult and embarrassing situation in which the Detroit General Hospital Association had remained for several years.

On June 26, 1914, the present site of the Henry Ford Hospital was deeded to Mr. and Mrs. Henry Ford. On September 15, 1915, the articles of incorporation for the Henry Ford Hospital were recorded with the Secretary of State at Lansing. Five days later Henry Ford and his wife deeded the property to the Henry Ford Hospital, Incorporated. The first meeting of the incorporators was held September 20, 1915, and a board of trustees was elected. Mr. Henry Ford was made president and Mr. Edsel Ford, his son, vice president.

On October 1, 1915, the first patients were admitted, a pavilion for seventy-five patients of the original plan having been completed, together with the operation rooms, laboratories and service buildings. Dr. Frank J. Sladen, formerly resident physician at the Johns Hopkins Hospital and associate in medicine in the University, had received the appointment as physician-in-chief.

In February, 1916, Dr. Roy D. McClure, resident surgeon of the Johns Hopkins Hospital and associate in surgery in the medical school, was appointed as surgeon-in-chief.

From the beginning, the plan had been for a full time staff, that is, a staff engaged to spend their full time at the hospital. Many physicians and surgeons who were desired as members of the staff of the Detroit General Hospital were unwilling to come on the full time service of the Henry Ford Hospital.

The hospital, comprising only a small pavilion of the original plan, with operating rooms and service plants, was run for two years while plans were being made for the large hospital and staff.

By August 1, 1918, the new buildings were well under way. At that time there was an acute demand for medical men and nurses for the army. The hospital was closed for the duration of the war and the entire staff volunteered and entered the army, a number of the staff being associated in France with Evacuation Hospital No. 33.

On October 27, 1918, the huge shell of the new hospital building was turned over to the United States Army at a rental of one dollar a year and used as U. S. Army General Hospital No. 36, with Lieutenant Colonel Alexander T. Cooper as commanding officer, and wounded overseas men were received as patients early in 1919. The hospital was returned to Mr. Ford by the government on January 1, 1920, and the original staff returned from their army service and again opened the hospital.

In January, 1920, the second influenza epidemic arrived, and 300 emergency beds were made available for the city. The main hospital was opened in December, 1921, with a completely equipped diagnostic clinic, staff and 450 bed capacity.

The Clara Ford School of Nursing and Hygiene was opened in 1925, being unique in having the first separate school building with class rooms, laboratories, gymnasium and swimming pool.

The staff of the hospital has been organized for accurate diagnosis and treatment of patients and for post graduate training of doctors in every division of medicine and surgery. The training consists of one year’s rotating interneship, a second year consisting of six months in the diagnostic clinic and six months in general medicine or general surgery, or as an assistant in a division. Those making good then have the opportunity of three straight years in the division of their choice, if approved by the division head.

Seminars are held by the different division heads and weekly clinics by the department heads in medicine, surgery and pathology. Dr. Frank W. Hartman is chief pathologist and Dr. Joseph A. Johnston is head of the department of pediatrics.

Research work has been encouraged and ample facilities have been made for it. Two outstanding research problems have been accomplished by this hospital since the War. The use of tannic acid in the treatment of burns, now widely used, was beautifully worked out in a scientific way by Dr. Edward C. Davidson. This treatment has reduced very materially the death rate from burns as reported by a number of clinics, as well as reducing the suffering and deformities. The American Medical Association last year awarded its Gold Medal to Dr. Frank W. Hartman and Dr. Howard P. Doub for their work in the experimental production of chronic nephritis by deep X-ray therapy, not only demonstrating the far reaching harm which may result from an unwise use of deep therapy, but in opening up for laboratory study, in a way never before possible, the subject of chronic nephritis.

It is too early to tell of the influence of this hospital on medicine in Michigan. It has not only done the shop work of repairing wrecks, but it has also seriously tried to carry forward the torch of knowledge. Its ideal is not only the care of the sick, but the more important service of habituating its clientele to annual examinations to head off disease and to advise concerning diet and the type of daily living necessary to health.

One hundred and ninety-two papers have been published by the staff. A volume of collected papers was published in 1925.

On July 1, 1929, 132,700 patients had been registered and had received complete examinations. All patients reporting for even a trivial ailment are urged to have a complete examination.

The City of Detroit has large hospital institutions operating under the municipal authority. All of these are incidents of that rapid growth which the census of 1910 brought home to the consciousness of the people. The Detroit Board of Health dates back to an act of the state legislature of the session of 1895. The State Board of Health, for two decades, had been agitating for isolation hospitals, and had issued a notable statement at its meeting in 1893 as to the prevalence of communicable diseases in Detroit. Smallpox was epidemic at the time. This can scarcely have been the original urge to operating as a city pest house the small building in the woods out Hamilton Boulevard. The Detroit Board of Health is specifically charged under the city charter to suppress the spread of contagious diseases, and to provide for the care and treatment of all persons in the city having malignant or infectious diseases. The Board is now operating two notable isolation hospitals. In 1906, the city established on the site of the little old pest house a spacious hospital for contagious diseases, 865 beds; and named it after Dr. Herman Kiefer, long an outstanding physician of Detroit and member of the Board of University Regents. The other institution under the City Health Department is Springhill’s Tuberculosis Sanatorium, at Northville. The Department of Public Welfare, formerly the Poor Commission, has authority under the city charter to establish and operate hospitals, infirmaries and farm colonies for the care of the sick, except persons afflicted with contagious or dangerous communicable diseases. The department has operated since 1915 the Receiving Hospital, a large institution located at St. Antoine and Macomb Streets. The report of the city physician to the Board of Poor Commissioners for the year next preceding the opening of this hospital shows a most interesting distribution of the city’s poor-sick among private hospitals and remedial institutions. The total number of patients cared for at municipal expense during that year was 16,352. St. Mary’s Hospital had 3,431; Grace Hospital, 1,097; Harper Hospital, 922; Providence Hospital, 493; Boulevard Sanatorium, 54; Harper Hospital, West Branch (afterwards Delray Industrial Hospital), 99; Samaritan Hospital, 63; Florence Crittenden Home, 80; Detroit Tuberculosis Sanatorium, 45; Woman’s Hospital, 68. The cost of caring for the city’s sick-poor by this system had mounted up to about $110,000 a year; and the change to a municipally operated hospital proved a substantial economy. The initial unit of the Receiving Hospital cost $250,000. At the expiration of five years the second unit was added, involving a much larger outlay. The hospital has beds for 560 patients and a staff of thirty-five doctors and 150 nurses. It has regular departments in medicine, general surgery, emergency work, psychiatry and orthopedic surgery; it has an out-patient department. The emergency department leads all the others combined in the numbers of patients. There is a considerable transfer from the Receiving Hospital to Eloise Infirmary. In the city budget of 1924-1925, a second enlargement was projected to cost $900,000. The architects followed the tower style that New York City has given to the country; a far cry from the little low log building in which St. Mary’s Hospital started only eighty years earlier. High up are quarters for 200 nurses, below operating rooms with the most modern accessories, X-ray and bacteriological rooms, psychopathic wards, laundries and executive offices, in step with the magical growth of first class American cities.

The “History of the City of Detroit,” 1701-1922, prepared under the distinguished editorship of Mr. Clarence M. Burton, gives space to seven hospitals and finds nineteen others to notice by name. It adds to this list, under the name of “Charitable Institutions,” eight that receive the more extensive treatment and twenty-one called by name only. Some of the names are interesting indices to race and religion. There are the William Booth Memorial Home and Hospital and the Serbian-American Hospital Relief Association.

An appreciation of the extent of the hospital work done in Detroit may perhaps be obtained if one glances at this list. Lack of space forbids further mention.

1. Children’s Free Hospital, 5224 St. Antoine.
2. Cottage Hospital, 54 Oak, Grosse Point.
3. Detroit Eye, Ear, Nose and Throat Hospital, 62 West Adams.
4. Delray Industrial Hospital, 7125 W. Jefferson.
5. Detroit Osteopathic Hospital.
6. Dunbar Memorial Hospital, 576 Frederick.
7. Evangelical Deaconess Hospital, 3245 E. Jefferson.
8. Highland Park General Hospital, Glendale Avenue.
9. Lincoln Hospital, 1051 25th.
10. Michigan Mutual Hospital, 1366 W. Grand Blvd.
11. Providence Hospital, 2500 W. Grand Blvd.
12. St. Luke’s Hospital, 228 Highland.
13. Salvation Army Woman’s Hospital, W. Grand Blvd. and W. Fort.
14. Joseph Mercy Hospital.

At Grosse Pointe Farms in Cottage Hospital, operated under Detroit Community Fund auspices. This was opened in an eight room house as a small nursing unit during the influenza epidemic of 1917. Later, another house was acquired, and a modernly equipped operating room and delivery room were built to join the other two. This was followed by adding emergency room and operating room, bringing the capacity to twenty-one beds. Added to this, a new fifty-bed hospital was occupied in the autumn of 1928. Cottage Hospital is standardized. Since the Detroit Community Fund makes up the annual deficit, amounting to one-fourth of operating expenses, patients are charged a very low rate. There is an endowment adequate to provide free service for the needy of the community.

Grand Rapids Hospitals

The settlement of Grand Rapids, on the west side of the state, dates from 1837; the municipal incorporation from 1850. Here it was Protestant philanthropy that developed the earliest hospital foundations. The details are of liveliest interest to lovers of local chronicles, and to those that despise not the day of small things. For the purpose of devising ways to care for the poor and sick independently of the town poor masters, a meeting was held in the fall of 1847, at Prospect Hills schoolhouse, on the site of the Ledyard Block. Thus began a Benevolent Association under the presidency of Mrs. Francis F. Cumming, wife of the rector of St. Mark’s Church, which operated a house-to-house relief work through district visitors. On January 16, 1857, a charter was taken out under the name Grand Rapids Orphan Asylum, by a group bearing a close personal identity with the unincorporated workers of the ten years preceding. A double function was herein authorized, namely, to provide for orphans and destitute children, and to extend relief to sick and indigent persons. In less than five years a more stirring function than either had interrupted the ordinary activities of the society. The benevolent and patriotic citizens of Grand Rapids devoted their energies to the Civil War encampments in their midst.

The war hospital was located near the site of the Central High School. Fountain Street, 1863. The troops were for a short time located on low ground near the river on the West Side, but soon moved to the Prospect Hill, the land the Union Benevolent Association lately occupied being part of the ground. The actual encampment with its cavalry occupied a large territory. Between six and seven thousand troops rendezvoused here.

The hospital proper was in the house now occupied by C. Tanis, 216 Prospect Avenue, the third north from Lyon Street, having a center dormer window. There was much serious illness. The nurse in charge was Mrs. Lucia Johnson, the matron of the Grand Rapids Orphan Asylum, who took up with splendid bravery the care of the soldiers. She literally gave her life to the relief work; she died from pneumonia while on duty in the hospital. A fine, rare woman, is the verdict of a man who, as a youth, knew her at her hospital work. There were no stretchers for the sick. The men were placed in blankets and four soldiers carried a man to the hospital.

February 14, 1863, the following appeal was issued: Hospital 7th Michigan Cavalry.

To the Ladies:

Feeling grateful for the many acts of kindness conferred upon the men entrusted to our care, we, the medical officers of the 7th Michigan Cavalry, feel encouraged to solicit from the Ladies of Grand Rapids further contributions in the way of bandages and lint and other suitable materials for the dressing of wounds. Experience has shown that large supplies of the above named are needed, etc.

William UpJohn Adna Sherman, Surgeons.

The hospital site at Camp Anderson, formerly the old fair grounds, is not known. One or two other places were certainly used for war hospitals, but the exact sites have not been located.

In 1873, January 18, the Benevolent Association reincorporated, with Union Benevolent Association for its official name. The Orphan Asylum had been closed in 1871, largely because state institutions for children at Coldwater were expected to take over a good share of its work. Its purpose now was to provide a home for infirm, aged, homeless persons, to care for and relieve temporarily any necessitous persons, and to erect and manage a general hospital for those suffering from disease or injuries. This two-fold work went on for twelve years at the old Gage place, on the west side of Bostwick Street, just south of Lyon. The first of two notable transformations was realized in the removal on February 23, 1886, to a new building at the southwest corner of College and Lyon Streets. The site was the gift of the Sarel Wood estate. The sale of the former property was a substantial contribution to the cash of the new one, $31,707.31; a final debt of $3,000 was cancelled by Hon. Thomas D. Gilbert. Local merchants contributed to the furnishing. Union Benevolent Association Hospital now developed along strictly professional lines. In 1890, the first medical staff was appointed, Dr. Charles Shepard being chief. When the third incorporation occurred, the articles taken in 1873 being limited to thirty years, the provisions for general philanthropy disappeared from the charter. The care of the aged had already been discontinued because other societies were competent to take it over. There are two noted names, Mrs. Wealthy M. Morrison and Mrs. Marion L. Withy, that appear in the charters of 1857, 1873 and 1903 respectively.

The latest and furthest step of Union Benevolent Association Hospital into the great things of medical science has been taken in its transformation into Blodgett Memorial Hospital, wrought by John W. Blodgett in memory of his mother, Jane Wood Blodgett. In November, 1914, the public was informed that Mr. Blodgett would tender a large gift to the trustees of the Union Benevolent Association. An architect from the New York firm of York & Sawyer had already been consulted. A plot of twenty-five acres situated between Wealthy and Sherman Streets, east of Plymouth Road and overlooking Fisk Lake, was purchased for a site. Ground was broken May 18, 1914, Mr. Blodgett turning the sod. A splendid hospital structure in Florentine style was erected without delay. On March 31, 1916, formal dedicatory exercises were held. The hospital, representing nearly fifty years of development of physical properties and institutional organization, is well adapted to the purposes and needs of the community. It has 150 beds and all the accessories that such a hospital should gave, and is at present one of the three general hospitals in Grand Rapids. Three persons intimately associated with its growth should be mentioned. Mrs. Marion L. Withey for many years devoted much of her time and effort to the institution. The training school bears her name. Miss Ida M. Barrett, a superintendent, devoted a large part of her life to the hospital and was largely responsible for the upgrowth of the service upon which the present hospital is founded. Miss Mary A. Welch, at present superintendent of the training school, has been identified with the hospital for more than a quarter of a century, and as an administrator has few equals. To her should be credited chiefly the fine spirit and ideals of nursing which are an outstanding feature of the institution.

In the winter of 1872-1873, St. Mark’s Church in Grand Rapids had under its care two aged and infirm women. To provide a home for them and for others who might come to the same need, the rector appealed to the philanthropic women of the church. Prominent in the group which responded and effected the desired organization was Mrs. E. P. Fuller, who, with her husband, gave encouragement to the project by donating the use of a small house at what is now the corner of Bond Avenue and Crescent Street. Here on February 11, 1873, was held the first recorded meeting of St. Mark’s Church Home, a voluntary association, in the modest inception of which lies the origin of Butterworth Hospital.

In 1875, the home was transferred to more commodious quarters at 144 Island Street, upon property belonging to Mr. and Mrs. E. P. Fuller, who generously donated its use rent-free for a number of years.

In June, 1876, the institution was incorporated under the name St. Mark’s Home and Hospital.

About 1887, Mr. Richard Edward Emerson Butterworth, who for many years had been identified with the business interests of Grand Rapids, offered to the city the sum of $10,000 towards a hospital building, but the offer was not accepted by the city. The diversion of Mr. Butterworth’s interest towards St. Mark’s Home and Hospital is attributed to the effective intercession of Mrs. E. P. Fuller.

A site was secured on Bostwick Avenue and plans progressed for the erection of a fine large modern hospital. Mr. Butterworth gave a further gift of $30,000, but unfortunately he did not live to see the hospital completed.

The new building, under the name of St. Mark’s Hospital, was opened in 1890, and was devoted exclusively to hospital purposes, which meant the discontinuance of what had been at first the primary object of the association, namely, the institutional care of homeless old people.

In 1894, the name was changed to Butterworth Hospital in memory of the man whose generous gifts had made possible the erection of the hospital.

A training school for nurses was established in 1890, and since that time 480 graduates have gone forth. Many of the graduate are filling important positions in institutions, public health, and every other nursing endeavor. The missionary spirit has taken our graduates to many of the foreign fields, as Arabia, Abyssinia, China, India, Korea, as well as the home missionary fields of Alaska, Kentucky, and New Mexico. Several Butterworth graduates served during the Spanish-American War, and many more had a part in the World War.

In 1925, the present beautiful well-equipped hospital of 270 beds was opened largely through the generous gifts and personal interest of Mr. and Mrs. Edward Lowe. Mr. Lowe was president of the Board of Trustees from 1898 to 1928, a period of thirty years. It is worthy of note that Mr. Lowe was a grandson of Mr. Butterworth.

To Mr. and Mrs. Lowe’s subscription of $500,000 were added approximately $1,000,000 by the citizens of Grand Rapids. Mr. Robert W. Irwin headed the building committee which raised the funds, and to his untiring and well directed efforts should be chiefly credited the success of the movement. It made possible the erection of a hospital which was in keeping with the long and sound development of a philanthropic institution of this kind and the needs of a growing, prosperous industrial city.

St. Mary’s Hospital, at Grand Rapids, is one of the enterprises of the Sisters of Mercy, an order founded in Dublin, Ireland, in 1831, by Mother Catherine McAuley. It is the largest of the system of hospitals conducted by this order in the State of Michigan. The bringer of the work of the Sisters of Mercy into the American Old Northwest was Mother Mary Joseph Lynch, a woman of rare personality and varied gifts. She came to Grand Rapids from Kinsale, Ireland, in 1873. Twenty years before she had done a nurse’s service in the Crimean War, where she was intimately associated with Florence Nightingale. The Sisters of Mercy, coming to Grand Rapids at the request of Rev. J. P. McManus, opened an Academy on South Division Street, and members of their order were the first non-secular teachers of St. Andrew’s School. But to Mother Joseph, influenced by her early contact with suffering in Ireland, the care of the sick and the relief of the poor made a more immediate appeal than education did. And she took her little community to Big Rapids, where they instituted a hospital for the care of men injured in the lumbering business, ministering to thousands of patients.

The Sisters of the Order of Mercy established their hospital at Grand Rapids in August, 1893, when Sister Mary Ignatius, accompanied by two or three others, arrived from Big Rapids. Their original property, donated by Mrs. Mary McNamara, was a dwelling house known as 145 South Lafayette Street. To this was attached a small house brought from the corner of Sheldon and Maple Streets. In 1898 and 1900, additions were made, at a cost of $10,000. The hospital association was incorporated March 23, 1901. The enlargement that greeted the new century was but a beginning. The old Coffinberry home adjoining the hospital on the south, was acquired by it in 1903; the Smiley residence at the southwest corner of Cherry and Lafayette Streets, in 1905. This became the site of a new building that was dedicated June 26, 1911, and received patients a month later. The Amberg property directly west was also acquired, and converted into a nurse’s home.

Increase of hospital service is but poorly measured by statistics; yet the most beneficent institutions have no other way. In its first year St. Mary’s Hospital treated sixty-nine patients; twenty-one years afterwards its annual report showed an increase of eighteen hundred over this. A number of Sisters Superior had filled the position of hospital superintendent.

Fifteen years after possessing its first new building, and almost simultaneously with the erection of the new Butterworth Hospital, 1926, St. Mary’s Hospital enlarged its quarter and perfected its equipment on the scale that the social growth of the twentieth century demands. The realty know as The Elmwood, lying south of the main hospital building, was acquired. An addition was made to the main building, and a new unit was erected for maternity and children’s cases. The extension was largely planned by Sister Superior Mary Bernard. A high Authority on nursing, who visited Grand Rapids shortly after it went into operation, declared that the unit for mothers and children was one of the most perfectly planned buildings for the purpose in the United States, and that some woman must have thought it out. St. Mary’s Hospital in its new form is arranged according to the Bacon plan. The latest additions represent an outlay of $550,000 in buildings and of $50,000 in equipment and furniture. The architect were Berlin and Swern, of Chicago, with Harry L. Mead, of Grand Rapids.

Flint Hospitals

Hurley Hospital

Hurley Hospital was originally built through the generosity of James J. Hurley, pioneer Flint business and civic leader, who willed to the city an entire block of land at Begole and Sixth Avenue, and $50,000 in cash for the construction of a city hospital. The Stockdale estate added $34,000 to Mr. Hurley’s bequest.

The old hospital was opened in 1908 and had a capacity of thirty-six beds. Arrangements was made for free patients, to be examined by the health department. Under the city charter at that time, there was provision for a one-mill levy for maintenance. This gave the hospital $20,000 a year with which to operate. Thus the city hospital came into existence.

Dr. J. C. Wilson, an early and accomplished physician of Flint, was chairman of the first hospital board.

In the month of April, 1928, a new million-dollar Hurley Hospital was opened for public inspection. Complete in every detail, with different color schemes carried out on every floor, the new building presents features of great interest. The Board of Health Clinics are quartered in the basement. The physicians are provided with a library, a large auditorium and amphitheatre operating rooms. The patients have advantage of the complete physiotherapy, X-ray and laboratory departments. The new Hurley Hospital takes high rank among the modern hospitals of this country.

A training school for nurses is maintained. A beautiful five-story nurses’ home has been constructed.

The hospital is governed by a hospital board appointed by the mayor and a medical advisory board representing the different medical specialties. Chiefs of the different services are appointed annually by the medical advisory board.

Three hundred and ten patients can be cared for in the new building. The construction of the hospital in the shape of a Maltese cross provides for ample room for expansion.

On Wednesday evening, October 24, 1928, the Merliss Brown Auditorium of Hurley Hospital was officially dedicated and turned over to the Genesee County Medical Society. The Auditorium is built as an integral part of the hospital. Architecturally it conforms to the regular theater style, with a suitable for speakers and a seating capacity of three hundred. The acoustics are exceptionally good. Very infrequently does one find such perfect ventilation, the air remaining clear and fresh. The decorations are subdued and in excellent taste. The sidewalls are paneled in antique oak for a height of about eight feet; above this the walls are stippled in a warm brown; overhead the ceiling is beamed and richly decorated with conventional design done in blue, red, and gold. The lighting fixture are very decorative and unique, in that ample light has been provided without glare. Comfortable upholstered seats have been purchased with funds raised by voluntary subscriptions from members of the county medical society.

An auditorium such as this constituting a unit of a city hospital is rather unique, and it is the only one of its kind in the state. Visitors during the recent post-graduate conference at Flint were enthusiastic in their praises and Genesee County Medical Society may be very proud indeed of its new acquisition.

In accepting this gift from the Board of Hospital Managers and through them the citizens of Flint, the society assumes a moral obligation to make use of this splendid equipment in disseminating medical knowledge. The tax-payers will, we hope, quite fittingly benefit by receiving improved medical care.

J. B. Pengelly, as representative of the citizens of Flint, introduced Merliss Brown, member of the Board of Hospital Managers, after whom the auditorium was named. Mr. Brown, in an appropriate manner, turned the auditorium over to the medical society. Dr. W. H. Winchester, in his usual charming way, expressed the appreciation of the physicians to the Board and the citizens of Flint. A short talk was given by Dr. F. C. Warnshuis, of Grand Rapids, on “Organized Medicine.” Following this, Dr. J. D. Bruce, of Ann Arbor, told of the effort being made to place post-graduate education on a suitable footing in Michigan. Our honored guest, Dr. M. L. Harris, of Chicago, president-elect of the A. M. A., spoke on “Doctors, Patients and the Community.”

On October 24 and 25, 1928, at the new Merliss Brown Auditorium at Hurley Hospital, at Flint, was held a medical and surgical conference and clinic. Attendance each day was about one hundred. The subjects discussed were all very well received and appreciated by those in attendance. All felt that the bringing of these conferences is a big step forward in post-graduate work and as they are more appreciated by the medical profession, the attendance will increase. Men could spend much time and at greater expense visiting clinics hundreds of miles away and not received and valuable information given by these papers.

The Women’s Hospital

The Women’s Hospital, Flint, Michigan, was founded in 1917 by a woman physician, Dr. Lucy Elliott, whose life dream it was to provide special hospital services for women and children.

After two years the financial burden became too great for Dr. Elliott. Just as she was on the verge of giving up the work, Mrs. J. Guy Blackinton, with several friends, came to the aid of the hospital, securing support for five rooms for one year. Mrs. John M. Hammond, with several of her friends, sponsored the sixth. The nucleus for the present hospital auxiliary was formed on the suggestion of Mrs. Forrest Boswell, who had knowledge of a successful organization in another city for the support of its hospital. The first president of the auxiliary was Mrs. Van Meter. Mrs. N. Hammond was elected vice president, Mrs. I. E. McConnel, secretary, and Mrs. Charles Ballard, treasurer.

On April 28, 1919, the Flint Chamber of Commerce approved of the incorporation of the Women’s Hospital Association, which took over the hospital and made plans for a new site and a larger building. Committee from the Rotary and Kiwanis Clubs, as well as from the Genesee County Medical Society, were active with the Chamber of Commerce in furthering the re-organization.

In 1912, five acres of land on Lapeer Street were purchased from Mr. and Mrs. D. P. Smith. A campaign to raise money to pay for the property and to remodel the house into a small hospital procured $76,000 by December, 1912.

The building was ready and occupied in April, 1923. With many improvements, and an addition of twelve private rooms made possible in 1926 by gifts totaling $41,000, the hospital now has forty beds for women and twenty-four cribs for infants. An active maternity and surgical service is maintained.

The staff is organized under the plan of the American College of Surgeons. Staff conferences are held on alternate months with the meeting of the medical advisory board. The advisory board, 24 in number, is appointed by the Board of Trustees from the general staff.

Between eighty-five and one hundred patients are admitted to the hospital each months; average number of births is fifty-three and about forty surgical cases are cared for each month.

The first board of trustees was A. E. Raab, chairman, Charles A. Cumings, secretary, and J. Guy Blackinton, treasurer, George A. Barnes, D.D., John L. Pierce, the late Horace E. Potter, Charles S. Mott, Forrest W. Boswell and Grant J. Brown. The same board still serves with three exceptions. George Simmons was appointed to succeed John L. Pierce, William S. Ballenger to succeed Rev. Dr. Barnes, and Samuel Morgan in place of the Rev. Horace J. Potter.

The hospital (May, 1928) is under the superintendency of Margaret E. McLaren, R.N.

St. Joseph’s Hospital

St. Joseph’s Hospital was founded in May of 1912, by four Sisters of the nursing order under the patronage of St. Joseph. One of the fine old residences of Flint, the Stockton home at 722 Ann Arbor Street, was remodeled, and an addition built, making room for forty beds for adults and a nursery with eleven cribs for infants.

Few hospitals in the state have done more with so little equipment. Last year 2,024 patients were cared for, which included 773 surgical, 661 medical and 590 maternity patients.

The hospital operating deficit is each year included in the Community Fund, as about 25 per cent of those cared for are charity patients.

The nursing order in charge of the hospital has been incorporated under the name of Burgess Hospital with headquarters at Kalamazoo.

The Sisters are soon the to be rewarded for their wonderful work, as a fine new hospital is at present (May, 1928) contemplated.

Private Hospitals

The Axford

The earliest hospital, for years a landmark in Flint, was the Axford, a building constructed in two parts, the one to serve as a residence for the family of Dr. S. M. Axford, a pioneer physician, the other as a hospital mainly for his surgical cases. He was useful, very energetic and competent, and had a large practice.

The Murray

Dr. W. P. Murray was an excellent surgeon and for years enjoyed a lucrative and extensive practice in Flint and its environs. His physiognomy, general appearance, intonation and manner of speaking were of the Yankee type, but nothing of the Puritan was displayed in close contact. Indeed, his interest in speedy horses and the race track contributed not a little, in the opinion of associates, to his financial undoing. He bred contestants for turf honors and aspired to high accomplishment in this field of activity, but ventures went wrong, and he often experienced disappointment.

At one time his surgical practice was so exigent that he secured a large centrally located colonial house and remodeled and refurnished it for his hospital purposes. From this, the second undertaking in private hospital lines in Flint, he realized, regrettably, nothing aside from augmentation of anxiety and care.