The Project Gutenberg eBook ofNurses' Papers on TuberculosisThis ebook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this ebook or online atwww.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.Title: Nurses' Papers on TuberculosisAuthor: Chicago . Municipal Tuberculosis Sanitarium. Dispensary DepartmentRelease date: November 23, 2011 [eBook #38090]Language: EnglishCredits: Produced by Bryan Ness, Henry Gardiner and the OnlineDistributed Proofreading Team at http://www.pgdp.net (Thisfile was produced from images generously made availableby The Internet Archive/American Libraries.)*** START OF THE PROJECT GUTENBERG EBOOK NURSES' PAPERS ON TUBERCULOSIS ***
This ebook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this ebook or online atwww.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.
Title: Nurses' Papers on TuberculosisAuthor: Chicago . Municipal Tuberculosis Sanitarium. Dispensary DepartmentRelease date: November 23, 2011 [eBook #38090]Language: EnglishCredits: Produced by Bryan Ness, Henry Gardiner and the OnlineDistributed Proofreading Team at http://www.pgdp.net (Thisfile was produced from images generously made availableby The Internet Archive/American Libraries.)
Title: Nurses' Papers on Tuberculosis
Author: Chicago . Municipal Tuberculosis Sanitarium. Dispensary Department
Author: Chicago . Municipal Tuberculosis Sanitarium. Dispensary Department
Release date: November 23, 2011 [eBook #38090]
Language: English
Credits: Produced by Bryan Ness, Henry Gardiner and the OnlineDistributed Proofreading Team at http://www.pgdp.net (Thisfile was produced from images generously made availableby The Internet Archive/American Libraries.)
*** START OF THE PROJECT GUTENBERG EBOOK NURSES' PAPERS ON TUBERCULOSIS ***
Transcriber's Note: The original publication has been replicated faithfully except as listedhere. Obscured letters in the original publication are indicated with {?}.
PUBLISHED BY THECITY OF CHICAGOMUNICIPAL TUBERCULOSIS SANITARIUMSEPTEMBER 1914
CITY OF CHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM
STAFF OF NURSES—OF THE—DISPENSARY DEPARTMENT
Rosalind Mackay, R. N., Superintendent of NursesAnna G. BarrettBarbara H. BartlettOlive E. BeasonElla M. BlandKathryn M. CanfieldMabel F. ClevelandElrene M. CoombsMargaret M. CoughlinStella W. CouldreyEmma W. CrawfordFannie J. DavenportRoxie A. DentzC. Ethel DickinsonAnna M. DrakeMary E. EgbertMaude F. Ess{?}Sara D. FarollMary FraserAugusta A. GoughFrances M. HeinrichLaura K. HillIsabella J. JensenEmma E. JonesLetta D. JonesJeanette KippElsa LundMary MacconachieJosephine V. MarkIsabel C. McKayAnna V. McVadyAnnie MorrisonKatherine M. PattersonLaura A. RedmondGrace M. SavilleBeryl ScottFlorence T. SingletonMabelle SmithFlorence A. SpencerHarriett StahleyGenevieve E. StrattonAnnabel B. StubbsAlice J. TappingOlive TuckerElizabeth M. WattsMary C. WrightMary C. YoungKarla Stribrna, Interpreter.
BOARD OF DIRECTORS
Theodore B. Sachs, M. D.,PresidentGeorge B. Young, M. D.,SecretaryW. A. Wieboldt.
GENERAL OFFICE
105 West Monroe StreetFrank E. Wing, Executive Officer.
Group photo of nursing staff.FIELD NURSES, DISPENSARY DEPARTMENT CHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM
Dispensary Department Bulletin No. 1NURSES' PAPERSONTUBERCULOSIS
READ BEFORE THENURSES' STUDY CIRCLEOF THEDISPENSARY DEPARTMENTCHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM
PUBLISHED BY THECITY OF CHICAGOMUNICIPAL TUBERCULOSIS SANITARIUM105 WEST MONROE STREETSEPTEMBER 1914
PAGEIntroduction—Nurses' Tuberculosis Study Circle5Historical Notes on Tuberculosis7Rosalind Mackay, R. N.Visiting Tuberculosis Nursing in Various Cities of the United States11Anna M. Drake, R. N.Provisions for Outdoor Sleeping30May MacConachie, R. N.Some Points in the Nursing Care of the Advanced Consumptive37Elsa Lund, R. N.Open Air Schools in This Country and Abroad44Frances M. Heinrich, R. N.Notes on Tuberculin for Nurses56
It is well known that the gathering of facts and study of literature essential to the preparation of a paper on a certain subject is a very productive method of acquiring information. If the paper is to be presented to your own group of co-workers, and the subject covered by it represents an important phase of their work, or an analysis of some of its underlying principles, then there is a further incentive to do your best, as well as an opportunity for a general discussion which acts as a sieve for the elimination of false ideas and gradual formulation of true conceptions.
Lectures on various phases of the work being done by a particular group of people are very important. Papers by the workers themselves are, however, greatest incentives to study and self-advancement.
With this view in mind, I suggested the organization of a Tuberculosis Study Circle by the Dispensary Nurses of the Municipal Tuberculosis Sanitarium. The nurses chosen to present papers on particular phases of tuberculosis are given access to the library of the General Office of the Sanitarium; they are also given the assistance of the General Office in procuring all the necessary information through correspondence with various organizations and institutions in Chicago and other cities.
As the program stands at present, the Nurses' Study Circle meets twice a month. At one of these meetings a lecture on some important phase of tuberculosis is given by an outside speaker, and at the next meeting a paper is read by one of the nurses. At all of these meetings the presentation of the subject is followed by general discussion. The program since January, 1914, was as follows:
January 9th, 1914—"Historical Notes on Tuberculosis," by Miss Rosalind Mackay, Head Nurse, Stock Yards Dispensary of the Municipal Tuberculosis Sanitarium.
January 23rd, 1914—"Channels of Infection and the Pathology of Tuberculosis," by Professor Ludwig Hektoen of the University of Chicago.
February 13th, 1914—"Visiting Tuberculosis Nursing in Various Cities of the United States," by Miss Anna M. Drake, Head Nurse, Policlinic Dispensary of the Municipal Tuberculosis Sanitarium.
March 13th, 1914—"Provisions for Outdoor Sleeping," by Miss May MacConachie, Head Nurse, St. Elizabeth Dispensary of the Municipal Tuberculosis Sanitarium.
March 27th, 1914—"What Should Constitute a Sufficient and Well Balanced Diet for Tuberculous People," by Mrs. Alice P. Norton, Dietitian of Cook County Institutions.
April 10th, 1914—"Some Points in the Nursing Care of the Advanced Consumptive," by Miss Elsa Lund, Head Nurse of the Iroquois Memorial Dispensary of the Municipal Tuberculosis Sanitarium.
May 15th, 1914—"Open Air Schools in This Country and Abroad," by Miss Frances M. Heinrich, Head Nurse of the Post-Graduate Dispensary of the Municipal Tuberculosis Sanitarium.
May 29th, 1914—"Efficient Disinfection of Premises After Tuberculosis," by Professor P. G. Heinemann, Department of Bacteriology, University of Chicago.
The organization of the Tuberculosis Study Circle among the nurses of the Dispensary Department of the Municipal Tuberculosis Sanitarium, calling forth the best efforts of the nurses in getting information on various phases of tuberculosis for presentation to their co-workers in an interesting manner has, no doubt, stimulated the progress of our entire nursing force. The first five papers presented by the nurses are given in this series. The pamphlet is published with the idea of attracting the attention of other organizations to this method of stimulating more intensive study among their nurses.
THEODORE B. SACHS, M. D., PresidentChicago Municipal Tuberculosis Sanitarium.
By ROSALIND MACKAY, R. N.
Head Nurse, Stock Yards Dispensary of the Chicago Municipal Tuberculosis Sanitarium.
So far as our information goes, pulmonary tuberculosis has always existed. It is, as Professor Hirsch remarks, "A disease of all times, all countries, and all races. No climate, no latitude, no occupation, forms a safeguard against the onset of tuberculosis, however such conditions may mitigate its ravages or retard its progress. Consumption dogs the steps of man wherever he may be found, and claims its victims among every age, class and race."
Hippocrates, the most celebrated physician of antiquity (460-377 B. C.), and the true father of scientific medicine, gives a description of pulmonary tuberculosis, ascribing it to a suppuration of the lungs, which may arise in various ways, and declares it a disease most difficult to treat, proving fatal to the greatest number.
Isocrates, also a Greek physician and contemporary of Hippocrates, was the first to write of tuberculosis as a disease transmissible through contagion.
Aretaeus Cappadox (50 A. D.) describes tuberculosis as a special pathological process. His clinical picture is considered one of the best in literature.
Galen (131-201 A. D.) did not get much beyond Hippocrates in the study of tuberculosis, but was very specific in his recommendation of a milk diet and dry climate. He held it dangerous to pass an entire day in the company of a tuberculous patient.
During the next fifteen centuries, a period known as the Dark Ages and characterized by most intense intellectual stagnation, little was added to the knowledge of pulmonary tuberculosis. In the seventeenth century Franciscus Sylvius brought out the relationship between phthisis and nodules in the lymphatic glands. This was the first step toward accurate knowledge of the pathology of tuberculosis.
Richard Morton, an English physician, wrote, in 1689, of the wide prevalence of pulmonary tuberculosis, and recognized the two types of fever: the acute inflammatory at the beginning, and thehectic at the end. He also recognized the contagious nature of the disease and recommended fresh air treatment. He believed the disease curable in the early stages, but warned us of its liability to recur. Morton taught that the tubercle was the pathological evidence of the disease.
In 1690, Leeuwenhoek, a Dutch lens maker, started the making of short range glasses which resulted later in the modern microscope, making possible the establishment of the germ theory of disease, including the establishment of that theory for tuberculosis.
Starck, whose observations and writings were published in 1785 (fifteen years after his death), gave a more accurate description of tubercles than had ever been given before, and showed how cavities were formed from them.
Leopold Auenbrugger introduced into medicine the method of recognizing diseases of the chest by percussion, tapping directly upon the chest with the tips of his fingers. The results of his investigations were published in a pamphlet in 1761. This new practice was ignored at first, but after the work of Auenbrugger was translated he attained a European reputation and a revolution in the knowledge of diseases of the chest followed.
Boyle recognized in miliary tubercle, as it was afterwards called by him, the anatomical basis of tuberculosis as a general disease, and, in 1810, published the results of one of the most complete researches in pathology. He described the stages in the development of the disease, using miliary tubercle as its starting point. He opposed the theory that inflammation caused tuberculosis and declared hemorrhage a result and not a cause of consumption.
Laennec discovered one of the most important, perhaps, of all methods of medical diagnosis—that of auscultation. By means of the stethoscope, which he invented in 1819, he recognized the physical signs and made the first careful study of the healing of tuberculosis; he gave also one of the best accounts of the sputum of the consumptive. He believed that every manifestation of the disease in man or animals was due to one and the same cause.
Up to this time the views which were held concerning the infectious nature of tuberculosis were not based upon direct experiment, but in 1843 Klenke produced artificial tuberculosis by inoculation. He injected tuberculous matter into the jugular vein of a rabbit, and six months later found tuberculosis of the liver and lungs. He did not continue, however, his researches; so they were soon forgotten.
To Villemin, a French physician, belongs the immortal fame of being the first to show the essential distinction in tuberculosisbetween the virus causing the disease and the lesion produced by it. By inoculating animals, he demonstrated that tuberculosis is a specific disease caused by a specific agent. His paper presented in 1865 before the Academy of Medicine in France contained a detailed account of his experimental investigations. This was a most remarkable contribution to scientific medicine.
It remained for Robert Koch in 1882, after years of painstaking investigation, to announce to the world the discovery of a definite bacillus as the causative agent in all forms of tuberculous lesions. Koch isolated, cultivated outside the body, described and differentiated the infective organism of tuberculosis and proved that it could continue to produce the same lesions indefinitely. He showed the presence of the bacilli in all known tuberculous lesions and in tuberculous expectoration, and demonstrated the virulence in sputum which had been dried for eight weeks.
Following directly upon the knowledge of the cause of tuberculosis came the recognition of its curability, and the proper means of its prevention. Although good food and fresh air have always been considered of importance in the treatment of the disease, it was not until the middle of the nineteenth century that anything like systematic treatment was undertaken.
Dr. George Bodingon of Sutton Coldfield, England, wrote an essay in 1840 advocating fresh air treatment. He denounced the common hospital in large towns as a most unfit place for consumptive patients, and established a home for their care, but met with so much opposition that it was soon closed.
In 1856, Hermann Brehmer wrote a thesis on the subject which has been the foundation of our modern treatment. He opened a small sanatorium in 1864. Five years later he established the sanatorium at Goerbersdorf, in Silesia, which eventually became the largest in the world. He advocated life in the open air, abundant dietary and constant medical supervision. He believed that the heart of the large majority of consumptives is small and undeveloped, and that this predisposes them to the disease. In accordance with this theory he put a great deal of emphasis on exercise in the treatment of his patients. He built walks of various grades on the grounds of his sanatorium and installed a system of walking exercise. Patients began with the lowest grade, gradually accustoming themselves to ascend to the highest. Brehmer was himself a consumptive, and was cured by the method he so firmly believed in.
Dr. Dettweiler, who opened the second sanatorium in Germany, at Falkenstein, near Frankfort, was also a consumptive, having developedtuberculosis during the arduous campaign in the Franco-Prussian War in 1871. He entered the Goerbersdorf Sanatorium as a patient, becoming later an assistant of Brehmer. Dr. Dettweiler laid great emphasis upon rest in treatment.
In 1888, Dr. Otto Walther opened his famous sanatorium at Nordrach in the Black Forest, in Germany.
The first sanatorium for the care of the consumptive in the United States was opened at Saranac Lake by Dr. Edward L. Trudeau in 1884. He was the pioneer of the sanatorium treatment in this country, and an example of what a man, although tuberculous himself, can do for his fellow men. In 1874, a seemingly helpless invalid, he made his home in the Adirondack Mountains. A little more than twenty-five years ago he became the founder of a village now crowded with tuberculous patients. The Saranac Lake institution, which began with one small cottage, has since developed into the best known sanatorium in this country.
In 1891, Dr. Herman Biggs posted the first anti-spitting ordinance in the street railway cars of New York.
Dr. Lawrence Flick brought about the formation of the first anti-tuberculosis society in 1892, and in 1894 the City of New York adopted a law to enforce notification and registration.
Dr. Philip of Edinburgh was the first to systematically and completely organize the anti-tuberculosis campaign. In 1887 he inaugurated that new institution, the anti-tuberculosis dispensary, which has since rendered such inestimable service. The fundamental principle of the Edinburgh system is that the disease should be sought out in its haunts.
The first dispensary in the United States was opened in New York in 1904, modeled after the Edinburgh system. About the same time came the Open Air Schools—Charlottenburg establishing one in 1904 and Providence, R. I., following in 1908. The first Day Camp in the United States was opened in 1905 in Boston. New Jersey established the first Preventorium for Children at Farmingdale in 1909. All this naturally led to better provision for advanced cases; sanatoria for hopeful cases at small cost; factory inspection; and, in some countries, industrial colonies for arrested cases.
The tuberculosis patient of today presents a hopefulness previously undreamt of. The outlook is brighter with promise than ever before, and we have every reason to look forward to a steady reduction in the mortality rate from this dread disease; but the extinction of tuberculosis will be achieved only when the social and economic problems have been solved.
By ANNA M. DRAKE, R. N.
Head Nurse, Policlinic Dispensary of the Municipal Tuberculosis Sanitarium.
BALTIMORE
In 1903, the first visiting tuberculosis nurse was assigned in Baltimore to follow up patients of the Johns Hopkins Hospital Out-patient Department. Her duties were varied as are the duties of the present day tuberculosis nurse. She was to instruct patients in the use of sunlight and fresh air and was allowed to furnish them with special diet in the shape of milk and eggs. She investigated home conditions and helped improve sleeping quarters. She placed patients in sanatoria, or brought them back to the dispensary for treatment. She gave bedside care to advanced cases, if she could not get them into hospitals, and applied to relief organizations for help in solving the problems of the family. From time to time other nurses of the Baltimore Visiting Nurse Association were assigned to the work, other dispensaries and agencies began referring cases to be followed up, and the work grew to such proportions as to be almost unmanageable for a private organization.
In 1910, the Tuberculosis Division of the Baltimore Health Department was organized. It began its activities with a corps of fifteen nurses and a visiting list of 1,617 patients turned over to it by the Baltimore Visiting Nurse Association. The object of the Tuberculosis Division was to bring under the supervision of the Health Department all persons in the city suffering with pulmonary tuberculosis. Ambulatory cases were to be given advice and instruction; advanced cases, bedside care, if needed, or hospital care, if available. At present, it is upon the advanced cases, as well as those who are in contact with them, that the nurses of the Tuberculosis Division concentrate their efforts. The Staff at present consists of a Superintendent and sixteen Field Nurses. The city isdivided into sixteen districts, a nurse being assigned to each district. Each nurse is responsible for the care of all cases of tuberculosis in her district.
In 1912, the Tuberculosis Division opened two municipal tuberculosis dispensaries. These dispensaries receive patients on alternate days from 3 to 5 p. m., nurses in districts nearest the dispensaries alternating for clinic duty. Other dispensaries are the Phipps Tuberculosis Dispensary at Johns Hopkins' Hospital, and the University of Maryland Hospital Tuberculosis Dispensary.
The problems which chiefly concern the Tuberculosis Division in its efforts to control the spread of tuberculosis in Baltimore are the failure of physicians to report cases to the Department of Health until the patient is in a dying condition, and the inadequate provision for hospital care of advanced cases. These conditions are particularly marked in the case of colored patients, who are found going in and out of homes, restaurants, and laundries, as cooks, waitresses and servants of various kinds, as long as they are able to drag themselves about.
The nurses of the Tuberculosis Division are graduate nurses and are registered. They are paid $75 a month, with car fare and telephone expenses, and are allowed two weeks' vacation with pay. They are not required to take a Civil Service examination, but are carefully selected with a view to obtaining women of a high grade of efficiency. They wear uniforms of blue denim with simple hats and coats, but not of uniform design. Each nurse wears under the lapel of her coat a badge reading "Nurse—Baltimore Health Department," which she uses on occasions. The nurses report to the Superintendent each morning at 8:30 to hand in reports of the previous day's work, to stock their bags, and to receive new work for the day. At noon each nurse reports at her branch office, of which there are seven, each situated on border lines of adjoining districts. An hour is spent at the branch office for lunch and rest, for receiving telephone calls and for restocking the bags for afternoon rounds. The nurse leaves her district at four o'clock to attend to about an hour's clerical work, which is usually done at home.
The average number of patients per nurse is 212, about four per cent of whom are bed cases. These bed patients are visited two or three times a week, while ambulatory cases are visited on an average of twice a month. During the year 1912 the sixteen nurses made 72,058 visits for instruction and nursing care.
NEW YORK
The oldest tuberculosis clinic in New York City is connected with the New York Nose, Throat and Lung Hospital; it was establishedin 1894. In 1895, the Presbyterian Hospital established a special tuberculosis clinic. In 1902, the Vanderbilt Clinic organized a special class for the treatment of tuberculosis. In 1903, Gouverneur and Bellevue Hospitals and, in 1904, Harlem Hospital added Tuberculosis Clinics. These were followed during the next few years by the establishment of many others. In 1906, when the Tuberculosis Relief Committee of the New York Charity Organization Society began its work among the tuberculous poor of the city, it met at every turn instances of overlapping and duplication in the work done by the various clinics. This lack of co-operation, with the resulting difficulties encountered by the Committee in its endeavor to efficiently administer its special tuberculosis fund, demonstrated the advisability of forming an organization having as its object the co-ordination of the work of the various tuberculosis clinics. In 1908, nine of these clinics and several allied philanthropic agencies were organized into the Association of Tuberculosis Clinics. Today there are 29 clinics, 14 philanthropic institutions and organizations, five departments of municipal and state government, six tuberculosis institutions, and numerous other institutions and organizations having special interest in tuberculosis work. Of the 29 clinics, eleven are under the supervision of the Department of Health, three are connected with city hospitals, and the remainder are operated by private institutions. This voluntary association of private and municipal dispensaries, sharing equal responsibilities and acknowledging equal obligations, is a striking feature of tuberculosis work in New York and presents a unique example of co-operation.
The task of standardizing the clinics was a difficult one. One clinic had ten rooms with every convenience. Another had one room and no conveniences. Some clinics made no provision for sputum beyond a cuspidor; others provided gauze or paper napkins when patients entered the room. Two clinics provided no drinking water; two had a metal water cooler in the waiting room; one provided sanitary drinking cups; and another had two enamel drinking cups chained to the wall. Some clinics had sanitary fountains; in others the nurse kept a glass on hand for the patients. Neither was there any uniformity in matters of dress. Nurses and doctors at some clinics wore ordinary street clothes. At other clinics, gowns or aprons, with or without sleeves, were worn. Three clinics occupied separate buildings of their own. Four clinics provided separate waiting-rooms for tuberculous patients. At one dispensary the tuberculous patients had the use of the general waiting room, there being no other clinics held at that time; other clinics made no distinction,tuberculous patients using the general waiting room in company with patients attending other clinics. After studying the conditions existing in the various clinics, it was decided that to belong to the association each clinic must subscribe to and comply with the following regulations:
a. Tuberculous patients must be segregated in a separate class.
b. Home supervision of all cases by a graduate nurse especially assigned for this purpose must be maintained.
c. Each dispensary must serve a certain district, and all cases living outside of this district must be transferred to the clinic serving the district within which they live.
Early in the history of the Association objection was made to this last rule by teachers of medicine, who held that it tended to deprive them of teaching material; but they soon fell in line with the other dispensaries when they saw the advantage it afforded them of improving their methods without loss of teaching material, and the further opportunity of securing home supervision.
From time to time it has been necessary for the Association to adopt certain methods of procedure in the administration of the various clinics. The general policy of the Association is as follows:
(1) Each clinic should arrange for a physician to visit and treat in their homes patients who are too ill to attend clinic, for whom hospital care cannot be provided.
(2) Special children's clinics should be established wherever the size of the clinic warrants it.
(3) Sputum of every patient should be examined once a month; patients should be re-examined once a month, and the results entered on the records.
(4) The physician should use the nurse's report of home conditions as a basis for advising patients.
(5) Patients refusing to attend the proper dispensary shall be dismissed as delinquent and reported to the Health Department.
(6) All supervising nurses should be affiliated with some local relief organization in order to better organize the relief work of the clinic.
(7) The home of every patient should be visited at least once a month.
(8) The classification of the National Association for the Study and Prevention of Tuberculosis should be followed for recording stages of disease and condition on discharge.
(9) A uniform system of record keeping should be used by nurses in order to facilitate the compiling of monthly reports.
(10) The staff of physicians should be sufficient to allow at least fifteen minutes for the examination of every new case, and at least six minutes for every old case.
(11) There should be at least one nurse for every 100 patients on the clinic register.
(12) Sputum cups, or a proper substitute, should be furnished to patients to take home.
(13) Paper or gauze handkerchiefs should be given to each patient on entrance to the clinic.
(14) No cuspidors should be used.
(15) Sanitary fountains or sanitary drinking cups should be provided.
(16) Gowns with sleeves should be worn by physicians. Nurses should wear gowns with sleeves or washable uniforms while on duty in the dispensary.
That the Association found it necessary to make so many recommendations for the administration of the various clinics is evidence of the diverse systems, and in some instances, the entire lack of system, in vogue in some dispensaries. The salary of nurses in privately operated tuberculosis dispensaries averages about $75 per month; no standard uniform is in use.
The first tuberculosis visiting nurse of the New York Department of Health was appointed March 1st, 1903. By January, 1910, the staff had grown to 158, the Health Department becoming practically responsible for the home supervision of every registered case of tuberculosis in New York not under the care of a private physician or in an institution.
The organization of the work of the new Health Department tuberculosis nurses has been based upon the district system in force among the Associated Clinics. In each clinic district a staff of Health Department nurses is maintained, charged with the sanitary supervision of cases of pulmonary tuberculosis in that district. They visit at least once a month all "at home" cases; that is, cases not regularly attending clinics, not in an institution, or not under a private physician's care. These nurses report daily at the tuberculosis clinic, which is used as a district headquarters, and there receive assignments. One nurse is detailed as Captain, or supervising nurse of the district, and acts as official intermediary between the clinic and the Department of Health. Each morning the nurse telephones to the Department of Health the daily report of her staff andof the clinic, and obtains information received at the Department regarding cases in the district. In case of death or removal of tuberculous patients from a home the district nurses order disinfection of the premises and bedding; they make arrangements for admission of patients to hospitals or sanatoria, investigate complaints made by citizens, see that regulations of the Department of Health regarding expectoration are observed, and use their authority to induce delinquent cases to resume attendance at the proper clinic. They also visit families of patients in hospitals at intervals. Each nurse keeps a complete index of all cases of pulmonary tuberculosis in her district, which is at all times accessible to nurses and physicians at the clinic.
In the Department of Health clinics, the plan is as follows: a supervising nurse who does no district work, and several field nurses, each assigned to special duties on clinic days, such as registration room, throat room, examining rooms, etc. Field nurses are also responsible for the care of patients in their sub-districts, each nurse carrying an average of about 125 patients on her visiting list at one time.
BOSTON
A staff of twenty-five nurses, working from the Out-patient Department of the Boston Consumptives' Hospital, has the supervision of all tuberculosis cases in their homes, and the follow-up work on all discharged sanatorium and hospital cases in the city of Boston.
All cases of tuberculosis reported to the Health Department, whether under the care of a private physician or not, are visited at least once by a nurse from this staff, to see that they are carrying out a proper plan of isolation.
The Boston Consumptives' Hospital Dispensary, centrally located, is open every morning and one or two evenings a week. Three or four nurses are on duty in the clinic each morning, taking histories, attending nose and throat room and preparing patients for examination. At the dispensary only a medical history of new patients is taken, the social history being obtained by the nurse on her first visit to the home. Pulse, temperature and weight are also taken at the dispensary, after which the patient waits his turn for examination. Each new patient is given an examination in the nose and throat room; old patients also, if necessary. After examination or treatment, all patients return to the general waiting room. From here each patient is called before the Chief of Clinic, who notes the general progress of the patient, the results of the last examinationor any remarks recorded by the physician, and the report of home conditions as reported by the nurse. The Chief of Clinic advises the patient in accordance with the needs indicated. He makes no examinations, but sees each patient every time he comes to the clinic and is thus able to follow very carefully the progress of each patient and to advise such changes in treatment as may seem necessary.
The city is divided into twenty-two districts, each nurse being responsible for the care of all tuberculous patients in her district. The number of patients cared for by each nurse is from 100 to 180. A very small percentage of bedside care is given; far advanced patients as a rule are sent to hospitals.
Boston tuberculosis nurses do not wear uniforms. They are paid $900 a year, with no increase for length of service or efficiency.
BUFFALO
The purpose of the Buffalo Association for the Relief and Control of Tuberculosis has been to stimulate progress in fighting tuberculosis. It very modestly shares with the city officials and with private charities the credit for the work accomplished. All it claims for itself is that it has been able, and will continue, to "point the way." How thoroughly it has succeeded in this may be seen by the progress made since 1909 when the Buffalo Association made its first appeal for funds. At that time Buffalo had:
(1) A dispensary maintained by the Buffalo Charity Organization Society.
(2) The Erie County Hospital for advanced cases.
(3) A day camp, with a capacity of thirty patients, supported by a group of women.
(4) One visiting nurse supplied by the District Nursing Association.
The present facilities are:
(1) A dispensary, open every day and one evening a week, with a nose and throat clinic, and a dental clinic with a paid dentist in attendance.
(2) The J. N. Adam Memorial Hospital for early cases, capacity 125, supported by the city.
(3) The Municipal Hospital for the care of advanced cases, supported by the city.
(4) The Erie County Hospital, as before.
(5) Tuberculosis Division of the Department of Health with two tuberculosis inspectors and six visiting tuberculosis nurses.
(6) An Open Air Camp, with a capacity of from seventy to one hundred patients, with a special department for children. Patients are kept day and night. The camp has three resident trained nurses and one interne, and is visited daily by the Association's paid medical director.
(7) Two open air schools, with another promised.
(8) A City Hospital Commission, with a plan for the erection of a pavilion for 500 advanced cases as the first of a general hospital scheme.
(9) Teachers soon to be appointed for the education of tuberculous children.
(10) The trades unions organized to promote the campaign among their own members in a unique organization.
(11) The whole community alert to the menace of tuberculosis, willing to shoulder the community burden and to assume the community responsibility.
The Dispensary is now operated by the Association for the Relief and Control of Tuberculosis, and the nurses are supplied by the Health Department. The nursing staff consists of a supervising nurse and six field nurses, the latter receiving $720 per year. They wear no uniform. They give a limited amount of bedside care, some member of the family being taught to properly care for the patient, if he cannot be sent to a hospital. Recently an additional nurse was engaged by the Association to follow up cases on whom no diagnosis has been made and who have not returned to the dispensary for re-examination. Since the Dispensary was opened in 1909, there have been over one thousand such cases. Many of these had suspicious signs when examined, but there has hitherto been no means of keeping in touch with them, as the nurses have been obliged to confine their attention to positive cases. One of the chief difficulties of the Buffalo campaign, as elsewhere, has been the fact that more than half of the cases have probably already infected others. This latest movement of the Association should anticipate this condition to a certain extent, and is one more means by which it is "blazing the trail" toward its goal,—"No uncared for tuberculosis in Buffalo in 1915."
PHILADELPHIA AND PENNSYLVANIA
In the General Appropriations Act of 1907 the Legislature of Pennsylvania granted to the State Department of Health, in addition to its regular budget, the sum of $400,000, "to establish and maintain, in such places in the State as may be deemed necessary, dispensaries for the free treatment of indigent persons affectedwith tuberculosis, for the study of social and occupational conditions that predispose to its development, and for continuing research experiments for the establishment of possible immunity and cure of said disease."
Immediately after securing the above appropriation, the State Department of Health began to establish dispensaries throughout the state, one or more in each county. The staff of each dispensary consists of a chief, who is also county medical inspector, and a corps of assistant physicians and visiting nurses. There is a supervising nurse with one assistant at Harrisburg, who oversee and inspect the work of the staff nurses.
The number of nurses in the dispensaries throughout the state varies from a nurse shared by another organization or a practical nurse giving part time, to from four to seven nurses in one dispensary. There are now more than 115 State Department Tuberculosis Dispensaries in Pennsylvania, Philadelphia having three.
An idea of the general plan of the work may be gained from a description given of the State Department Dispensary No. 21, located in Philadelphia, by Dr. Francine: