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handbook
handbook Self-Assessment
Self-Assessment in Respiratory Medicine is an invaluable
tool for any practitioner wishing to test and improve their
knowledge of adult respiratory medicine. The completely
new, third edition includes 114 multiple-choice questions
Self-Assessment in
covering the full breadth of the specialty, using clinical
vignettes that test not only the readers’ knowledge but their
ability to apply that knowledge in daily practice.
The questions and structured comments have been compiled
and tested by the ERS adult HERMES examination committee
specially for this book, making it the perfect revision aid
for candidates for the European Diploma, as well as any
Respiratory Medicine
specialists in respiratory medicine who wish to exercise and
improve their skills.
3rd Edition
Konrad E. Bloch is Professor of Respiratory Medicine at the
University of Zurich, and is former Chair of the ERS HERMES
examination committee.
Thomas Brack is Head of Internal Medicine and Pulmonary
Medicine at the Cantonal Hospital Glarus, and is a former
member of the ERS HERMES Examination Committee.
Silvia Ulrich is Director of the Pulmonology Department at
the University Hospital Zurich, and is former Chair of the ERS
114
HERMES examination committee.
Self-Assessment
in Respiratory
Medicine
Editors
Konrad E. Bloch
with Thomas Brack and
Silvia Ulrich
PUBLISHED BY
THE EUROPEAN RESPIRATORY SOCIETY
EDITORS
Konrad E. Bloch
with Thomas Brack and Silvia Ulrich
ERS STAFF
Alice Bartlett, Rachel Gozzard, Jonathan Hansen, Aimée Hill, Catherine Pumphrey
ISBN 978-1-84984-160-3
Table of contents
Contributors ii
Introduction iv
ii
Lisette Kunz Anthony E. Redington
Haaglanden Medical Center East and North Hertfordshire NHS Trust,
The Hague, The Netherlands Lister Hospital
l.kunz@haaglandenmc.nl Stevenage, UK
Questions 24, 29, 41, 96 and 114 redingtonae@gmail.com
Questions 1, 55, 66 and 78
Yvonne Nussbaumer
Department of Internal Medicine and Christine Rüegg
Pulmonary Medicine, Spitäler Schaffhausen Department of Internal Medicine and
Schaffhausen, Switzerland Pulmonary Medicine, Spitäler Schaffhausen
yvonne.nussbaumer@spitaeler-sh.ch Schaffhausen, Switzerland
Questions 26, 34, 71, 75, 80 and 89 Christine.Rueegg@usz.ch
Questions 7, 9, 33, 39, 60, 76, 92, 99, 105 and 108
Alexis Papadopoulos
MedCare Clinic Szymon Skoczyński
Nicosia, Cyprus Department of Pneumonology, Faculty of
drpapadopoulosa@gmail.com Medical Sciences in Katowice,
Questions 31, 84, 110 and 112 Medical University of Silesia
Katowice, Poland
Andriana I. Papaioannou simon.mds@poczta.fm
1st Respiratory Medicine Department, Question 3
National and Kapodistrian University of
Athens, Sotiria Chest Hospital Guillermo Suárez-Cuartín
Athens, Greece Respiratory Department, Bellvitge
papaioannouandriana@gmail.com University Hospital and Bellvitge Biomedical
Questions 15, 21, 49, 93 and 103 Research Institute
Barcelona, Spain
Winfried Randerath gsuarezc@bellvitgehospital.cat
Bethanien Hospital, Clinic of Pneumology Questions 4, 6, 8, 17, 50, 70, 79, 81, 86 and 95
and Allergology, Center for Sleep Medicine
and Respiratory Care, and Institute of Silvia Ulrich
Pneumologie at the University of Cologne Department of Pulmonology, University and
Cologne, Germany University Hospital of Zurich
randerath@klinik-bethanien.de Zurich, Switzerland
Questions 2, 12, 22, 48, 54, 64, 69, 72, 107 silvia.ulrich@usz.ch
Questions 14, 19, 23, 42, 63, 73, 83, 91, 98 and 110
iii
Introduction
In recognition of the increasing demand for education and revalidation in respiratory
medicine, the European Respiratory Society has initiated the ‘Harmonised Education in
Respiratory Medicine for European Specialists’ (HERMES) project. It promotes highest
standards of practice in the specialty and contributes to harmonisation of training across
European countries and worldwide. The HERMES project has been implemented by the
European Respiratory Society through a task force coordinating inputs from representatives
of more than 52 countries. The knowledge and skills a European Respiratory Specialist
should have (see the index to this book)1 have been delineated2,3 and updated4. Moreover,
assessments and accreditation of training centres have been implemented5,6.
The European Examination in Adult Respiratory Medicine is a knowledge-based test based
on multiple choice questions (MCQs) evaluating topics outlined in the European syllabus4.
The MCQs are created by a panel of authors from various countries and settings, i.e. from
academic centres, community hospitals and specialist practice. The authors undergo
special training in order to produce valid questions. The HERMES examination committee
evaluates each MCQ during workshops and selects those meeting high standards in terms
of clinical relevance, unambiguous scientific accuracy and formal aspects. Only questions
passing this evaluation are subsequently incorporated into examinations.
Self-Assessment in Respiratory Medicine is a collection of MCQs with answers and comments
intended to be a companion to the ERS Handbook of Respiratory Medicine7, which contains
a systematic and detailed discussion of topics relevant for the specialist in adult respiratory
medicine. We are fully aware that many respiratory professionals at all levels from senior
specialists to junior trainees wish to test their knowledge personally without necessarily
embarking on the HERMES examination. The MCQ handbook meets that need in a
constructive, didactic way. The broad range of topics is selected from the syllabus and the
relative representation reflects the weights attributed by the examination committee to the
different topics, according to clinical relevance and importance in specialist education as
listed in the ‘blueprint’ (see appendix).
The current, third edition of the Self-Assessment in Respiratory Medicine contains a
completely new selection of questions that have been prepared by experienced authors
and have undergone a rigorous evaluation according to the principles outlined above. The
majority of questions are introduced by a case vignette describing a clinical problem to be
solved. The purpose is not merely to test the knowledge of facts (which could be looked-
up in a text book or in the internet), but rather to evaluate the ability of a candidate to
apply knowledge and critically weigh different options in a clinical context. Accordingly,
the choice of answers often contains more than one reasonable alternative, from which
the candidate has to select the most appropriate one. As a welcome change, other, short
questions without vignette are interspersed to test specific knowledge in selected areas.
The structured comments to each question discuss evidence in favour and against the
various answers. Current literature references are provided for further reading.
iv
We hope that all readers of this handbook will enjoy solving the problems presented in the
case vignettes and questions, and benefit from assessing and refreshing their knowledge
in respiratory medicine.
References
1. Loddenkemper R, et al. HERMES: a European core syllabus in respiratory medicine.
Breathe 2006; 3: 59–69.
2. Loddenkemper R, et al. European curriculum recommendations for training in adult
respiratory medicine: crossing boundaries with HERMES. Eur Respir J 2008; 32: 538–540.
3. Loddenkemper R, et al. European curriculum recommendations for training in adult
respiratory medicine. Breathe 2008; 5: 80–120.
4. Tabin N, et al. Update of the ERS international Adult Respiratory Medicine syllabus for
postgraduate training. Breathe 2018; 14: 19–28.
5. Loddenkemper R, et al. Adult HERMES: criteria for accreditation of ERS European
training centres in adult respiratory medicine. Breathe 2010; 7: 171–188.
6. Loddenkemper R, et al. Multiple choice and the only answer: the HERMES examination.
Breathe 2008; 4: 244–246.
7. Palange P, et al. eds. ERS Handbook of Respiratory Medicine. 3rd Edn. Sheffield,
European Respiratory Society, 2019.
v
How to use this book
This handbook may be used in several ways: for self-assessment; to identify areas of
strengths and weaknesses as a guide for further studies; and to refresh and update your
knowledge in respiratory medicine. Those who wish to experience how it feels to undergo
the HERMES examination may set themselves the challenge of solving 90 of the multiple-
choice questions (MCQs) collected in this book within 3 hours. The answers should be
recorded on a separate sheet of paper without looking up the comments on the back of each
question page. Another way of using the book is to solve the MCQs step by step, reading
the comments at your convenience. The literature references listed with the comments on
the reverse of each MCQ allow further reading to obtain more in-depth information. Still
another approach is to use the index to locate and solve MCQs according to a particular
syllabus topic of interest in order to test and consolidate knowledge in a specific area.
The MCQs in this handbook are presented according to two different formats: In the single-
choice MCQ, the reader is asked to select the only correct answer, or the most appropriate
answer, from 5 options (alternatively, in negatively formulated questions, the only exception
or incorrect statement or the least appropriate of 5 answers has to be selected). In the
HERMES examination, a correct answer to this type of MCQ is awarded with 1 point. If more
than one answer is marked on the answer sheet, 0 points are given. In the second format of
MCQ, 4 answers or statements are listed and the reader must decide whether each one is
correct (true) or incorrect (false). In the HERMES examination, 4 correct true/false decisions
are awarded with 1 point, 3 correct true/false decisions are awarded with 0.5 points and
fewer than 3 with 0 points.
vi
List of abbreviations
CT computed tomography
ECG electrocardiography
Hb haemoglobin
KCO transfer coefficient of the lung for carbon monoxide (normalised for alveolar volume)
vii
Question 1
A 78-year-old man with known COPD (Global Initiative for Chronic Obstructive Lung Disease grade
III, group D) is admitted with worsening dyspnoea and increased sputum volume and purulence
for the past 3 days. He is fully conscious and not confused or agitated. His temperature is 37.8°C,
SpO2 is 96%, he is tachycardic (110 beats per min) but normotensive, tachypnoeic with a respiratory
rate of 30 breaths per min, and there is widespread wheeze on auscultation. A chest radiograph
shows hyperinflated lung fields but no new consolidation. Laboratory examination results include
C-reactive protein 45 mg·L−1 and neutrophils 12×109 cells per L. Arterial blood gases on arrival
are as follows: pH 7.28, PaCO2 10.1 kPa (76 mmHg), PaO2 16.3 kPa (122 mmHg) and bicarbonate
concentration 33 mmol·L−1.
References
Bourke SC, et al. Beyond the guidelines for non-invasive ventilation in acute respiratory failure:
implications for practice. Lancet Respir Med 2018; 6: 935–947.
Davidson AC, et al. BTS/ICS guidelines for the ventilatory management of acute hypercapnic
respiratory failure in adults. Thorax 2016; 71: Suppl. 2, ii1–ii35.
Rochwerg B, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute
respiratory failure. Eur Respir J 2017; 50: 1602426.
Reference
Leigh-Smith S, et al. Tension pneumothorax – time for a re-think? Emerg Med J 2005; 22: 8–16.
A 64-year-old formerly healthy woman is admitted to the general ward for evaluation of
gastrointestinal complaints. Colonoscopy is scheduled. However, 48 h after admission, before the
procedure is performed, she develops a productive cough with purulent sputum and chest pain. Her
temperature is 38.5oC, her heart rate is 86 beats per min and her blood pressure is 125/85 mmHg.
Figure 1 shows a representative chest CT image. With the exception of a C-reactive protein
concentration of 128 mg·L−1 (normal concentration is <5 mg·L−1), there are no abnormalities in
the blood tests. Local epidemiology indicates an 8% prevalence of multidrug-resistant bacteria
including methicillin-resistant Staphylococcus aureus (MRSA).
Low MDR pathogen risk and High MDR pathogen risk and/or
low mortality risk >15% mortality risk
Single Gram-negative
Antibiotic monotherapy:
agent (if active for >90% Dual Gram–pseudomonal
ertapenem, ceftriaxone,
Gram-negative bacteria in coverage
cefotaxime, moxifloxacin
the ICU) ±MRSA therapy
or levofloxacin
±MRSA therapy
Reference
Torres A, et al. Summary of the international clinical guidelines for the management of hospital-
acquired and ventilator-acquired pneumonia. ERJ Open Res 2018; 4: 00028-2018.
A 36-year-old woman is referred to your respiratory medicine clinic due to recurrent episodes of
bronchitis. She is a nonsmoker, and has a history of nasal polyposis and chronic sinusitis. She
reports daily sputum expectoration and cough since the age of 22 years. She has had two episodes
of acute bronchitis in the past year requiring antibiotic treatment and has noticed mild dyspnoea
on exertion ever since. Sputum cultures from both episodes revealed growth of Staphylococcus
aureus. Currently, her symptoms are stable and pulmonary auscultation shows bilateral crackles.
Spirometry shows FVC 91% predicted, FEV1 67% predicted and FEV1/FVC 65%. Sections of the
chest CT scan are shown below. A new sputum culture shows persistence of methicillin-sensitive
S. aureus.
Which of the following is/are appropriate diagnostic tests in the assessment of this patient?
a. Sweat chloride test
b. Nasal nitric oxide
c. Serum immunoglobulins
d. Serum vascular endothelial growth factor-D
Reference
Polverino E, et al. European Respiratory Society guidelines for the management of adult bronchi-
ectasis. Eur Respir J 2017; 50: 1700629.
A 59-year-old man presents with a 2-week history of fever, night sweats, cough productive of
blood-streaked sputum and left-sided chest pain. He is an active smoker with 20 pack year history.
His medical history is notable for diabetes mellitus, treated with oral anti-diabetic agents. He
reports no relevant occupational exposures or recent travel. On general examination he appears
flushed with an oral temperature of 38.7oC and a heart rate of 105 beats per min. An ECG shows
sinus tachycardia and no other abnormalities. His blood white cell count is 18.0×109·L−1 with 85%
neutrophils, and his C-reactive protein (CRP) is 186 mg·L−1. A chest radiograph and a CT scan are
performed (below). The patient is admitted to the hospital and commences intravenous ampicillin-
sulbactam and metronidazole. Sputum culture remains negative. Flexible bronchoscopy shows
hyperaemic mucosa of the left upper lobe segmental bronchi with mucopurulent secretion, but
no endobronchial lesions. Cultures of bronchial washing grow Klebsiella species and cytology is
negative for malignant cells. On day 10 of admission, the patient is afebrile with a mild dry cough,
normalisation of the white cell count and reduction of CRP to 15 mg·L−1. Repeat radiology shows
reduction of the left upper lobe lesion.
What is the best course of action at this stage regarding the left lung lesion?
a. Refer the patient for a left upper lobectomy.
b. Stop antibiotics and plan outpatient imaging in 4 weeks.
c. Continue with oral antibiotics for 3 weeks with follow-up imaging.
d. Obtain a CT-guided percutaneous biopsy from the lesion.
e. Continue intravenous antibiotics until lesion resolution on follow-up imaging.
Reference
Athanassiadi K, et al. Abscess of the lung: current therapeutic options. In: Rohde G, Subotic
D, eds. Complex Pleuropulmonary Infections (ERS Monograph). Sheffield, European Respiratory
Society, 2013; pp. 81–89.
A 22-year-old woman is referred to the respiratory clinic for assessment of dyspnoea on exertion.
She is a nonsmoker, and has a history of scoliosis and a spontaneous pneumothorax 3 years ago.
She complains of dyspnoea on exertion (modified Medical Research Council grade 1) in the past
2 years and occasional palpitations. She has no other concomitant symptoms. Her SpO2 is 98% on
room air. Enophthalmos, retrognathia and malar hypoplasia are observed. The chest examination
shows pectus excavatum, symmetrical breath sounds and a mitral murmur. Pulmonary function
tests show FVC 72% predicted, FEV1 75% predicted, FEV1/FVC 84%, TLC 74% predicted, residual
volume/TLC 76% predicted and TLCO 82% predicted. A transthoracic echocardiogram shows mitral
valve prolapse, aortic root enlargement and reversed curvature of the free wall of the right ventricle.
The chest CT scan is shown below, showing a Haller index of 4.2.
What is the most appropriate next step in the management of this patient?
a. Refer to thoracic surgery
b. Start treatment with a long-acting muscarinic antagonist
c. Start treatment with β-blockers
d. Refer to pulmonary rehabilitation
e. Start treatment with CPAP
Figure 1 The Haller index is the ratio of the largest inner diameter of the chest wall to the smallest
anteroposterior distance between the sternum and the vertebral column. In the presented case, this
index has a value of 4.2, suggesting severe pectus excavatum. A Haller index >3.25 is one of the
criteria considered in the evaluation of the indication for surgical repair of pectus excavatum.
Incorrect answers
b. Start treatment with a long-acting muscarinic antagonist
There is no clear indication that pharmacological treatment or ventilatory support improves
exercise tolerance in patients with symptoms related to pectus excavatum.
c. Start treatment with β-blockers
There is no clear indication that pharmacological treatment or ventilatory support improves
exercise tolerance in patients with symptoms related to pectus excavatum.
d. Refer to pulmonary rehabilitation
Although pulmonary rehabilitation may improve exercise tolerance in patients with pectus
excavatum, this patient presents with signs of pulmonary restriction and cardiac compression,
which are indications for surgical correction.
References
olombani PM. Preoperative assessment of chest wall deformities. Semin Thorac Cardiovasc Surg
C
2009; 21: 58–63.
Frantz FW. Indications and guidelines for pectus excavatum repair. Curr Op Pediatr 2011; 23:
486–491.
Jaroszewski D, et al. Current management of pectus excavatum: a review and update of therapy
and treatment recommendations. J Am Board Fam Med 2010; 23: 230–239.
Silbiger JJ, et al. Pectus excavatum: echocardiographic, pathophysiologic, and surgical insights.
Echocardiography 2016; 33: 1239–1244.
HERMES Syllabus link: 15 Diseases of the chest wall and respiratory muscles
A 58-year-old woman is admitted due to exertional dyspnoea for 1 week. She underwent bilateral
lung transplant 7 years ago due to end-stage COPD. Due to acute on chronic renal failure, renal
replacement therapy must be started. She experienced myocardial infarction 3 years ago, which
was treated by percutaneous transluminal coronary angioplasty, but has been asymptomatic ever
since. She takes nonopioid analgesics because of chronic pain due to a thoracic disc herniation. You
suspect acute lung transplant rejection, and perform bronchoscopy with bronchoalveolar lavage
and transbronchial biopsies. After the procedure, the patient describes stabbing thoracic ventral
and dorsal pain on her left side. Chest radiography is performed and shown below.
c. Myocardial infarction
See above.
d. Pulmonary embolism
See above.
References
Bell DJ. Pneumothorax in supine projection. https://radiopaedia.org/articles/pneumothorax-
in-supine-projection. Date last updated: 7 December 2020.
Cummin AR, et al. Pneumothorax in the supine patient. Br Med J (Clin Res Ed) 1987; 295:
591–592.
O’Connor AR, et al. Radiological review of pneumothorax. BMJ 2005; 330: 1493–1497.
A 56-year-old man is referred to the respiratory clinic due to an incidental finding on a chest CT
scan. He is a former smoker of 30 pack-years and has a history of dyslipidaemia treated with
simvastatin. He is otherwise healthy. He was admitted to the emergency department a week ago
due to a chest trauma in a car accident and a chest CT scan was performed (shown below). He has
no respiratory symptoms except for mild chest pain on inspiration. He has no apparent weight loss
or malaise. On physical examination, his SpO2 is 98% on room air. Breath sounds are present and
symmetrical, with no other significant findings. Spirometry shows FVC 94% predicted, FEV1 86%
predicted and FEV1/FVC 71%.
Which is the most appropriate next step in the management of this patient?
a. Perform transbronchial biopsy
b. Perform transthoracic needle aspiration
c. Refer to thoracic surgery
d. Perform chest CT scan in 6 months
e. Refer to radiation oncology
The campaign for safety is taking firm root in Detroit. The Detroit
Manufacturers’ Association has in its employ two safety inspectors
who are at the call of members for work in their plants at any time.
They are constantly hunting for danger points and suggesting
methods of eliminating them.
More recently, following the enactment of the Workmen’s
Compensation Law, there has been organized the Detroit Accident
Prevention Conference. There have been three meetings so far, with
such men as John Calder of the Cadillac Motor Car Company and W.
H. Bradshaw, safety director of the New York Central lines as
speakers and papers by those members who were equipped by
reason of experience to give instructive information. The meetings
are held in the evening in a down town hotel where a moderate
priced dinner is served, the addresses and discussions following. The
average attendance has been about one hundred. As no membership
fee is charged and as great enthusiasm is displayed it is hoped that
shortly the attendance will be double this number.
The ministers of the city feel much the same way about the effects
of the parliament.
Rev. A. E. Monger, pastor of the largest Methodist church in the
city and one of the promoters of the movement, says:
“Since the campaign there has been crystalized in the churches a sentiment of
responsibility for the welfare of the laboring man. The laboring men have found
that the gospel does have a message against the great sins under which they are
struggling.”
As a further evidence of the parliament’s lasting effect, Rev. John
G. Benson, another of its promoters, may be quoted:
“We are getting requests from every quarter for a repetition of the parliament.”
NEW RECOGNITION OF SOCIAL
CHRISTIANITY
In religious periodical literature two high notes of social
significance have recently been struck. The Constructive Quarterly
has appeared from the press of the George H. Doran Company in
America and Hodder & Stoughton in England. It is planned to be a
free forum where all the churches of Christendom may frankly and
fully state their “operative beliefs” and their distinctive work,
“including and not avoiding differences,” but making “no attack with
polemical animus on others.”
The purpose of this undertaking is to afford opportunity for the
churches, without compromise, “to re-introduce themselves to one
another through the things they themselves positively hold to be vital
to Christianity,” “so that all may know what the differences are and
what they stand for, and that all may respect them, in order to
cherish and preserve whatever is true and helpful and to discover
and grow out of whatever is harmful and false.”
As it has no editorial pronouncements and no scheme for the unity
of Christendom to promote, the Quarterly will depend upon the
catholicity and representative influence of its editorial board,
selected from all countries and communions, to promote a fellowship
of work and spirit. The middle term of the Quarterly’s subtitle—a
journal of the Faith, Work and Thought of Christendom—is likely to
prove the basis for the correlation of the other two. For long before
the faith and the thought of Christendom may be correlated, the
churches will surely co-operate in their common work.
The Hibbert Journal, which for ten years has been the ablest
technical quarterly review of theology and philosophy, announces a
department of social service. This policy was foreshadowed by the
editor as early as October, 1906, in a notably direct and able protest
against the church standing aloof from “the world.” He stoutly
maintained that
“the alienation from church life of so much that is good in modern culture, and so
much that is earnest in every class, is the natural sequel to the traditional attitude
of the church to the world.”
How false and unintelligible, as well as untenable, this attitude is
appears in these categorical imperatives:
“If by ‘the world’ we mean such things as parliamentary or municipal
government, the great industries of the nation, the professions of medicine, law,
and arms, the fine arts, the courts of justice, the hospitals, the enterprises of
education, the pursuit of physical science and its application to the arts of life, the
domestic economy of millions of homes, the daily work of all the toilers—if, in
short, we include that huge complex of secular activities which keeps the world up
from hour to hour, and society as a going concern—then the churches which stand
apart and describe all this as morally bankrupt are simply advertising themselves
as the occupiers of a position as mischievous as it is false.
“If, on the other hand, we exclude these things from our definition, what, in
reason, do we mean by ‘the world?’ Or shall we so frame the definition as to ensure
beforehand that all the bad elements belong to the world, and all the good to the
church? Or, again, shall we take refuge in the customary remark that whatever is
best in these secular activities is the product of Christian influence and teaching in
the past? This course, attractive though it seems, is the most fatal of all. For if the
world has already absorbed so much of the best the churches have to offer, how can
these persist in declaring that the former is morally bankrupt?
“Extremists have not yet perceived how disastrously this dualistic theory thus
recoils upon the cause they would defend. The church in her theory has stood aloof
from the world. And now the world takes deadly revenge by maintaining the
position assigned her and standing aloof from the church.”
No better prospectus for the social work of either of these great
quarterlies could be framed than the intention to demonstrate and
bear home to the intelligence, conscience and heart of the churches
these very affirmations. For, while enough of church leaders and
followers thus face forward to warrant Professor Rauschenbusch in
declaring that it has at last become orthodox to demand the social
application of Christianity, yet there is a sharp reaction within every
denomination, which threatens to retard this hopeful movement of
the churches to serve their communities and thereby save
themselves.
But the ultimate issue between those who are thus fearlessly facing
the present and those who persist in backing up into the future
cannot be doubtful. Social Christianity is not only demonstrably
orthodox, but has won its recognition and its own place in any
theological, philosophical, historical or experiential conception of
Christianity that claims to be comprehensive, not to say intelligent.
Without a much larger emphasis upon the social aims and efforts of
Christianity in the thought, belief and work of the church, the need
that is finding expression in every parish and community cannot be
met—that which the Constructive Quarterly well states to be “the
need of the impact of the whole of Christianity on the race.”
THE FIRST ORPHAN ASYLUM IN THE
[8]
UNITED STATES
THAT OF THE URSULINE NUNS AT NEW
ORLEANS
8. This account of the founding of our first orphanage in the quaint language
of the time was obtained for The Survey from a friend of the institution by Albert
H. Yoder.
At the outset of the colonization of Louisiana by the French, ten
Ursuline nuns of France, with noble generosity and self-sacrifice,
volunteered to go to New Orleans, there to instruct the children of
the colonists. They left Rouen in January, 1727.
After great difficulties and countless perils, they reached the
mouth of the Mississippi whose waters they ascended in pirogues.
They finally landed in the Crescent City on the morning of August 7,
1727, after a sea voyage of nearly six months. They had set sail from
the port of Havre on February 23, 1727 after a month spent in Paris.
Arriving in New Orleans, they were met by Bienville, governor of
the province of Louisiana. As there were no proper accommodations
yet provided, the governor vacated his own residence and placed it at
their disposal for a convent and school. Immediately was begun the
erection of a new building which was completed in 1734.
The Ursuline nuns upon its completion took possession and
occupied it till 1824 when they removed to their present home below
the city. This structure, which is now the Archbishopric, or official
place for the transaction of the business of the Archdiocese of New
Orleans, is the oldest building in Louisiana and also in the vast
extent of what was known as the Louisiana Purchase.
The Ursulines began their self-sacrificing work immediately upon
their arrival on August 8, 1727 and opened a free school to which
were added a select boarding school and then a little later a hospital.
Moreover, in order to inculcate principles of civilization and,
especially, of religion in the hearts of the wives and daughters of the
Negroes and Indians, the nuns devoted one hour each day to their
instruction.
Shortly after their arrival a new field of labor was open to their zeal
in the shape of a poor orphan whom Father de Beaubois, had
withdrawn from a family of dissolute morals. Although their lodgings
at the time were insufficient, the nuns being still in Bienville’s house
(their new convent, the present old Archbishopric, was not ready for
occupancy until July 17, 1734), they adopted the child. This was the
tiny mustard-seed from which sprang the flourishing orphanage
which exists to the present day. It proved a real providence for the
country, especially in colonial times, as may be gleaned from
history’s record of the Natchez massacre, which took place on
November 28, 1729.
After this frightful tragedy, so pathetically described by
Chateaubriand, the Indians, who had spared only the young wives
and daughters of their French victims, were forced to give up their
hostages or to be massacred in turn. The generous Ursulines then
opened their home to these unfortunate little ones and mothered
them.
This act of disinterestedness and charity was truly heroic,
considering the great difficulties usually attendant on the founding of
a colony and was highly commended by Rev. Father le Petit, Jesuit,
in a letter addressed, July 12, 1730, to Rev. Father d’ Avaugour,
procurator of the American missions. Having given an account of the
appalling massacre of the French at Fort Rosalie by the Natchez
Indians, Rev. Father le Petit adds:
“The little girls, whom none of the inhabitants wished to adopt, have greatly
enlarged the interesting company of orphans whom the religieuses [Ursulines] are
bringing up. The great number of these children serves but to increase the charity
and the delicate attentions of the good nuns. They have been formed into a
separate class of which two teachers have charge.
“There is not one of this holy community that would not be delighted at having
crossed the ocean, were she to do no other good save that of preserving these
children in their innocence, and of giving a polite and Christian education to young
French girls who were in danger of being little better raised than slaves. The hope
is held out to these holy religieuses that, ere the end of the year, they will occupy
the new house which is destined for them, and for which they have long been
sighing. When they shall be settled there, to the instruction of the boarders, the
orphans, the day scholars, and the Negresses, they will add also the care of the sick
in the hospital, and of a house of refuge for women of questionable character.
Perhaps later on they will even be able to aid in affording regularly, each year, the
retreat to a large number of ladies, according to the taste with which we have
inspired them.
“So many works of charity would, in France, suffice to occupy several
communities and different institutions. But what cannot a great zeal effect? These
various labors do not at all startle seven Ursulines; and they rely upon being able,
with the help of God’s grace, to sustain them without detriment to the religious
observance of their rules. As for me, I fear that, if some assistance does not arrive,
they will sink under the weight of so much fatigue. Those who, before knowing
them, used to say they were coming too soon and in too great a number, have
entirely changed their views and their language; witnesses of their edifying conduct
and great services which they render to the colony, they find that they have arrived
soon enough, and that there could not be too many of the same virtue and the same
merit.”
After giving details relative to the visit of the Illinois chiefs, who
had come to condole with the French and to offer help against the
Natchez, Father Le Petit adds:
“The first day that the Illinois saw the religieuses, Mamantouenza, perceiving
near them a group of little girls, remarked: ‘I see, indeed, that you are not
religieuses without an object.’ He meant to say that they were not solitaries,
laboring only for their own perfection. ‘You are,’ he added, ‘like the black robes,
our fathers; you labor for others. Ah! if we had above there two or three of your
number, our wives and daughters would have more sense.’ ‘Choose those whom
you wish.’ ‘It is not for me to choose,’ said Mamantouenza. ‘It is for you who know
them. The choice ought to fall on those who are most attached to God, and who
love him most....’”
The records make mention of Therese Lardas, daughter of a
Mobile surgeon. After her father’s death, her mother brought her to
the Ursuline orphanage, where she intended leaving her just long
enough to make her first communion; but, when she came to take
her home, so earnestly did the child plead to remain, that the mother
could not resist her entreaties. At the age of sixteen, she entered the
novitiate. She led the life of an exemplary lay sister, and died at the
age of twenty-nine on November 22, 1786.
In testimony of the good education given to all classes by the
Ursulines, the Rt. Rev. Luis Penalvery Cardemas said in a dispatch
forwarded to the Spanish court, November 1, 1795:
“Since my arrival in this town, on July 17, I have been studying with the keenest
attention the character of its inhabitants, in order to regulate my ecclesiastical
government in accordance with the information which I may obtain on this
important subject.... Excellent results are obtained from the Convent of the
Ursulines, in which a good many young girls are educated. This is the nursery of
those future matrons who will inculcate in their children the principles which they
here imbibe. The education which they receive in this institution is the cause of
their being less vicious than the other sex....”
Up to 1824, that is, for well nigh a century, the Ursulines
maintained their orphanage in what is now the old Archbishopric. At
this period, New Orleans having spread considerably and become too
densely populated to afford the advantages and charms of the
country so necessary to a large boarding school, the institution was
removed three miles lower down, to the magnificent place which the
Ursulines hold to the present day. Owing to the encroachments of
the great Father of Waters, they are to transfer again, within a year,
to another site.
After 1824, several asylums having been founded for orphans of
both sexes, the Ursulines received but thirty or forty poor children.
In keeping with their sphere of life and future career, these children
are taught English, French, geography, arithmetic, elementary
history, and some housekeeping, sewing and laundry work. The nuns
endeavor, above all, by religions instruction and careful training, to
inculcate in the hearts and minds of their youthful charges principles
of duty, so as to form for the future women of confidence, courage,
self-sacrifice and devotion.
SOCIAL SERVICE OF THE PRESBYTERIAN
CHURCH IN CANADA
J. G. SHEARER
“The church must be a great, perennial fountain of spiritual and moral energy to
the whole people in all the avenues of human interests. She must realize her
obligation to champion the cause of the oppressed, whatever the cause and
whoever the oppressor, whether in her fold or out of it. She must watch to prevent
the rich from grinding the faces of the poor. She must when necessary provide for
every legitimate desire of the people. If politics are corrupt, then she must enter
aggressively into the field of politics, only for purity and not for party. She must
fight all saloons and organize neighborhood opposition to their continuance, but
provide too for some form of social life to replace them.
“The rich churches most be big sisters to the poor, providing means and sending
talented workers wherever they are needed. If the church needs money for
neighborhood enterprise, let her lop off her choirs and stained glass windows and
bells, expensive altars, and put the money saved into human lives. She must
discourage all extravagances which give the poor just cause for bitterness and
arouse envy and set up unworthy standards. Let the church make a map of
neighborhood conditions. This will serve as an object lesson and as a basis for
action. In weekly classes she should then study such social problems as:
SANITATION AT DAYTON
[The widespread flood disaster in Ohio during the last week of
March led members of the Pittsburgh Flood Commission to study
the situation. Morris Knowles, a member of the Engineering
Committee of this commission, has had two assistants in the field
for this purpose. One of these, M. R. Scharff, who had previously
been employed by Mr. Knowles in making a sanitary survey of
the coal-mining camps in Alabama, paid particular attention to
the sanitary conditions resulting from the flood. The present
article embodies observations made on this trip.—Ed.]
Following in the wake of great disasters which descend from time
to time upon our cities, paralyzing the public services that make
crowded city conditions possible, is the outcropping of disease that
may, if unchecked, prove more disastrous even than the catastrophe
itself. This tendency was discernible in the first reports of the floods
that have recently devastated Ohio, Indiana and adjoining states, due
to the heavy rains of March 24–28. Nearly every flooded city
reported that its water works plant had been put out of commission,
or the water supply polluted, which with the increased chance of
infection, and the general lowering of vitality presented a situation of
unusual menace and one demanding complete and immediate
handling.
The most serious situation is Dayton, for here every sanitary
problem presented at any other point was involved. The complete,
immediate and effective organization to handle the situation which
was formed there was typical of the effective work now done at such
emergency periods.
At Dayton the water works plant was incapacitated by water that
reached ten feet above the boiler grates; there was unknown damage
to water distribution and sanitary sewerage and drainage systems;
storm sewers and catch basins were clogged with filth and debris;
dead animals were strewn on every side; the population was at high
nervous tension, their vitality lowered by shock, exposure, cold, and
lack of food and drink; hundreds of people were crowded for days in
single buildings or dwellings; thousands, probably, had been exposed
to intestinal infection by drinking the dirty flood water as it swirled
through the streets; hundreds had only wet cellars and rooms to
return to, if their homes were not altogether destroyed; and
everywhere on everything—walls, ceilings, floors, furniture, streets
and sidewalks—was a thick coating of the black, sticky, slimy mud
left by the retreating waters. This in a measure pictures the situation
at Dayton as the flood waters receded. And Dayton knew at once that
the toll of the flood would be as nothing compared to the pestilence,
unless attention and energy were directed to these problems.
This appreciation of the paramount importance of sanitation was a
striking revelation of the success of the campaign of sanitary
education that has characterized the last century. In every phase of
the work of recovery, in the warning signs and directions on almost
every post, in the placards on the automobiles of the sanitary
department stating that “This car must not be stopped or delayed day
or night,” in the daily exhortations in the free newspapers distributed
throughout the city, in a thousand ways, Dayton declared again and
again:
“Sanitation first and foremost. Then everything else.”
Such was the spirit of the members of the Dayton Bicycle Club,
when they met as the waters receded from their club-house to
consider what service they could best render to their stricken city,
and volunteered to remove the dead animals strewn it the streets.
Such also was the message reiterated by the Ohio State Board of
Health, the city health officials, the representatives of the national
government, the Red Cross, the Relief Committee, the Ohio National
Guard, and every one of the splendid organizations that are working
shoulder to shoulder to clean up Dayton and to prevent conditions
more costly in toll of life than the deluge itself.
One of the remarkable features of the handling of the relief work at
Dayton was the entire absence of red tape, the lack of conflict, and
the universal evidence of harmonious co-operation between the
various organizations at work, notwithstanding that there was no
complete centralization of direction and that some of the
organizations were proceeding practically independent of the others.
“Results, not credit,” was the watchword, and the results were such
as to reflect the most lasting credit upon all engaged in the work.
The Dayton Bicycle Club showed wisdom in volunteering to
remove the dead animals from the street. Nearly every horse in the
more than seven square miles of the city that was under water—and
this area contained all the important livery stables—was drowned,
and quick action was needed to remove the bodies to prevent serious
results. A sanitary department was organized, and as rapidly as
automobile trucks and wagons were volunteered, they were pressed
into service. Over 100 vehicles and about 600 men were engaged on
this work. A rendering company, which handles all the garbage
collected in the city, agreed to take care of the horses and did so as
fast as they came for a time. When the carcasses came so rapidly that
it was necessary to heap them up on the grounds of the plant, and
then on a vacant field nearby, the plant was a grewsome place
indeed. Up to the night of March 31, 1,002 had been received. A
number were picked up the next two days, so that the final total was
probably in the neighborhood of 1,100.
At about the time this work was started, a reconstruction
department was organized, under the Citizens Relief Committee,
with divisions, each under an engineer, assigned to street cleaning,
sewers and drains, streets, and levees. By March 31, the removal of
dead animals had been practically completed, and the organization
and equipment of the sanitary department were merged with those
of the street cleaning division of the reconstruction department.
Sanitary notices directed that all mud and rubbish be deposited at
the curb, the city was divided into districts and collection progressed
rapidly, considering the wagons and trucks available. More wagons
could have been put into service, but horses were lacking. All mud
and rubbish was hauled to one of the half-dozen city rubbish dumps
located in low outlying sections, or was dumped off bridges into the
river. The employes of the city water works department were able to
get into the pumping station on March 28 and the following day
pumping was resumed. Dayton’s water supply comes from a number
of deep drilled wells along the Mad River. It is pumped direct into
the mains without storage, by means of a Holly vertical, triple-
expansion, crank and fly-wheel engine. This pump has given rise to
the local name of “Hollywater” applied to the city supply. It was
feared at first that the distribution system had been badly damaged,
but investigation showed that only three small mains had been
broken. Water, at reduced pressure, was therefore possible, except in
one or two small sections.
AN IMPROVISED COMFORT
STATION
IMPORTANT
Sanitary Notice
FOR YOUR OWN HEALTH
(1.) Do not use Sanitary sewers and Closets until notified by the Board of
Health. Even if the hollywater system is on, the sewers are full of mud and
will clog. Burn or bury all excreta garbage and filth. Add lime and bury deep.
Use disinfectant in out-door trenches also.
(2.) Thoroughly scrub, clean and dry your cellar. Keep your cellar
windows open. Remove and burn or bury all rubbish. Sprinkle lime around
cellar, especially in damp places. Sprinkle floor with disinfectant sent
herewith (two tablespoons-full to one quart of water.)
(3.) Thoroughly clean your in and out door premises.
(4.) Place concentrated lye or a tablespoon of disinfectant in each sink or
trap in toilet, basement and kitchen. Allow to stand over night. Do this every
evening.
(5.) Boil all water, even holly water, and thoroughly cook all food. Boil all
cooking utensils. Do this for months to come.
(6.) Do not enter houses which have been flooded until thoroughly
cleaned and dried.
(7.) Keep your own self clean.
Do these things to avoid pestilence and sickness.
Do it for yourself.
Do it for Dayton.
Take care of yourself and you will take care of Dayton.
Maj. L. T. Rhoades,
U. S. Army.
ONE OF THE EARLY NOTICES
“Do not use water closets. Contents will reach cellars. Use vessels, disinfect, and
bury in back-yards. Disinfectants: carbolic acid, chloride of lime, bichloride of
mercury, and creolin.”
“Do not use sanitary sewers and closets until notified by the Board of Health.
Even if the “Hollywater” system is on, the sewers are full of mud and will clog.
Burn or bury all excreta, garbage and filth. Add lime and bury deep. Use
disinfectant in out-door trenches also.”
Inspection showed a much better condition than was anticipated.
In all but three districts, the sanitary sewers were running freely and
the warnings were replaced by new notices:
“Sewers are open and ready for use. If the water supply is not sufficient for
flushing, fill the tank of the closet with a bucketful of water, and flush as usual.”
Wooden public convenience stations were also established over
sewer manholes in the business sections and in residential sections
without sewer connections.
The three sewer districts that were out of commission were the St.
Francis, the North Dayton, and the Riverdale low line. The St.
Francis sewer is a gravity line, and a manhole at the lower end was
completely choked up. It was necessary finally to dynamite this
manhole in order to open the line. The two latter lines are both low,
and sewage has to be pumped into the river by pneumatic ejectors.
The air lines from the compressor plant in the water works pumping
station were laid in the levees which were washed out and at one
point about 200 feet of pipe was lost. This was difficult to repair, and
these districts had to be left without sewerage until April 2, when a
by-pass on each line into the storm drains was opened, and the
backed-up sewage lowered sufficiently to clear most of the cellars
and to permit the use of water closets.
While this work was proceeding the organizations devoting their
energies to control of infectious disease, inspection, and
administration had been far from idle. The State Board of Health had
three sanitary engineers and two physicians, trained in public health
work, in the city before the waters receded. The city Board of Health
was one of the first in the field, and the medical corps of the Ohio
National Guard promptly took up the work. Co-operating with one
another, under the direction of Major L. T. Rhoades of the United