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Dispensary Department Bulletin No. 1
NURSES' PAPERS
ON
TUBERCULOSIS
PUBLISHED BY THE
CITY OF CHICAGO
MUNICIPAL TUBERCULOSIS SANITARIUM
SEPTEMBER 1914
CITY OF CHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM
STAFF OF NURSES
--OF THE--
DISPENSARY DEPARTMENT
ROSALIND MACKAY, R. N., Superintendent of Nurses
ANNA G. BARRETT
BARBARA H. BARTLETT
OLIVE E. BEASON
ELLA M. BLAND
KATHRYN M. CANFIELD
MABEL F. CLEVELAND
ELRENE M. COOMBS
MARGARET M. COUGHLIN
STELLA W. COULDREY
EMMA W. CRAWFORD
FANNIE J. DAVENPORT
ROXIE A. DENTZ
C. ETHEL DICKINSON
ANNA M. DRAKE
MARY E. EGBERT
MAUDE F. ESS{?}
SARA D. FAROLL
MARY FRASER
AUGUSTA A. GOUGH
FRANCES M. HEINRICH
LAURA K. HILL
ISABELLA J. JENSEN
EMMA E. JONES
LETTA D. JONES
JEANETTE KIPP
ELSA LUND
MARY MACCONACHIE
JOSEPHINE V. MARK
ISABEL C. MCKAY
ANNA V. MCVADY
ANNIE MORRISON
KATHERINE M. PATTERSON
LAURA A. REDMOND
GRACE M. SAVILLE
BERYL SCOTT
FLORENCE T. SINGLETON
MABELLE SMITH
FLORENCE A. SPENCER
HARRIETT STAHLEY
GENEVIEVE E. STRATTON
ANNABEL B. STUBBS
ALICE J. TAPPING
OLIVE TUCKER
ELIZABETH M. WATTS
MARY C. WRIGHT
MARY C. YOUNG
KARLA STRIBRNA, Interpreter.
BOARD OF DIRECTORS
THEODORE B. SACHS, M. D., President
GEORGE B. YOUNG, M. D., Secretary
W. A. WIEBOLDT.
GENERAL OFFICE
105 West Monroe Street
FRANK E. WING, Executive Officer.
[Illustration: FIELD NURSES, DISPENSARY DEPARTMENT CHICAGO MUNICIPAL
TUBERCULOSIS SANITARIUM]
Dispensary Department Bulletin No. 1
NURSES' PAPERS
ON
TUBERCULOSIS
READ BEFORE THE
NURSES' STUDY CIRCLE
OF THE
DISPENSARY DEPARTMENT
CHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM
PUBLISHED BY THE
CITY OF CHICAGO
MUNICIPAL TUBERCULOSIS SANITARIUM
105 WEST MONROE STREET
SEPTEMBER 1914
CONTENTS
PAGE
Introduction--Nurses' Tuberculosis Study Circle 5
Historical Notes on Tuberculosis 7
ROSALIND MACKAY, R. N.
Visiting Tuberculosis Nursing in Various Cities of the United
States 11
ANNA M. DRAKE, R. N.
Provisions for Outdoor Sleeping 30
MAY MACCONACHIE, R. N.
Some Points in the Nursing Care of the Advanced Consumptive 37
ELSA LUND, R. N.
Open Air Schools in This Country and Abroad 44
FRANCES M. HEINRICH, R. N.
Notes on Tuberculin for Nurses 56
NURSES' TUBERCULOSIS STUDY CIRCLE
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., President=
Chicago Municipal Tuberculosis Sanitarium.
HISTORICAL NOTES ON TUBERCULOSIS
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 the hectic 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 tuberculosis between 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 developed
tuberculosis 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.
VISITING TUBERCULOSIS NURSING IN VARIOUS CITIES OF THE UNITED STATES
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 is
divided 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 established in 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 and of 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 examination or 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 affected with 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:
"There are at present five nurses employed at Dispensary No. 21,
two of whom give their whole time to following up the return
cases from the State Sanatoria. As soon as the case is
discharged from the sanatorium, that information, with other
data regarding the condition on discharge, etc., is sent to us
at once. At the end of a stated period, if that case has not
been returned, the nurse looks it up, and gets it to come in.
The nurses make out detailed reports on all cases discharged
from the sanatoria, at periods of six months, whether our own
patients or not. These will be and are valuable for statistical
data. Practically all the data for reports as to subsequent
results in cases discharged from the sanatoria, which have
appeared in this country at least, have been made up from
information gleaned by writing the discharged patient and having
him fill out his own report. It does not tax the imagination
unduly to conclude which is the more accurate, the answers to
questioning by a trained worker (we have selected for this work
the two nurses who have been with us longest) who in addition
takes the temperature, pulse, etc., herself, and usually
succeeds in getting the patient back to the dispensary for at
least one re-examination; or such answers as a patient may see
fit to make to a printed questionnaire.
For the purpose of regular dispensary and inspection work, the
dispensary limits itself to receiving patients from certain
districts of the city, though as a state institution it is
impossible for the dispensary to refuse any case, no matter
where they live, if they insist upon treatment. Usually by a
little persuasion, however, we can get the patients to go to the
dispensary in their district, co-operating in this way with the
Phipps Institute of the University of Pennsylvania, the Gray's
Ferry State Dispensary, the Kensington Tuberculosis Dispensary
and the Frankford State Dispensary. The section of the city from
which we draw our cases is divided, for purposes of inspection
and Social Service Work, into three districts with a nurse
assigned to each, and this gives each of our nurses, roughly
speaking, about seventy-five patients per month to take care of.
These patients must be visited regularly every two weeks, which
gives the nurse at least one hundred and fifty visits a month to
pay, not including the visits to new cases.
Every new case which is admitted to the dispensary must be
visited within one week of the day of admission. The nurses come
in from their visiting work and report daily at 12:30 o'clock,
for one hour in the dispensary office, and new cases, according
to the district in which they live, are assigned to the nurse
having charge of that district. The advantage of having a nurse
report daily to the dispensary at a time when all the doctors
are there, lies in the fact that the doctor has thus the
opportunity of talking over with the nurse the new cases which
she is to visit and of making any suggestions which he has
gleaned from the history and examination of the patient. It is
thus possible for the nurses to visit the new cases in the
afternoon of the same day. The advantage of this close
co-operation between doctor and nurse must be at once apparent.
Further, each nurse is required to report to every physician one
morning a month, with the histories in hand of all the patients
of that particular doctor which are on her list. This is
valuable, because in no other way can the doctor get so thorough
an understanding of the home conditions and social problems of a
given patient as by talking the situation over directly and
personally with the nurse in charge."
A similar plan is in operation at the other two State Department Clinics
in Philadelphia.
The best known tuberculosis dispensary in Philadelphia, conducted by a
private organization, is the dispensary connected with the Henry Phipps
Institute. This dispensary during the eleven years of its existence has
contributed greatly to the standardization of tuberculosis dispensary
work, not only in Philadelphia, but throughout the entire country.
Connected with a scientifically conducted hospital for advanced cases,
with its laboratories and other improved medical facilities, the
Dispensary of the Henry Phipps Institute occupies a high place among the
similar institutions of this country. The nursing staff of the Henry
Phipps Dispensary consists of three visiting tuberculosis nurses, aided by
two additional nurses (both colored) assigned by other organizations to
work on the Phipps Dispensary staff, one by the Whittier Centre, and the
other by the Pennsylvania Society for the Prevention of Tuberculosis. Some
of the important features of the work of this dispensary in its relation
to nurses are as follows:
(1) An efficient training school for tuberculosis nurses, affording the
opportunity of hospital and dispensary training.
(2) A course of lectures on tuberculosis given to the nursing profession
at large.
(3) Intensive home work among tuberculous families.
Visiting tuberculosis work in Philadelphia is also done in connection with
the Presbyterian Hospital Tuberculosis Clinic, St. Stevens Church
Tuberculosis Clinic, and by the Visiting Nurse Society of Philadelphia.
PITTSBURGH
The Tuberculosis League Hospital of Pittsburgh was opened in 1907 for
incipient and advanced cases, with a capacity of eighty beds. The League
conducts at present a night camp, an open air school, a farm colony, a
post-graduate course for nurses and tuberculosis clinics for medical
students at its dispensary. There is also a post-graduate course in
tuberculosis for nurses. The course requires eight months and nurses
receive during that time $25 a month. Only registered nurses are accepted.
The training is along the following lines: nursing advanced cases in
hospital, open air school work, sanatorium care of early cases, service in
dental, nose and throat clinics, and in the dispensary for ambulant cases,
district nursing, service in baby clinics, educational work, and
laboratory work. Patients discharged from the hospital, families of
patients in the hospital, and cases reporting at various tuberculosis
dispensaries, are given complete follow-up care by the nurses taking the
course, thus giving them excellent training in public health work,
especially that phase of public health nursing dealing with tuberculosis.
At present there are nine nurses taking the course. The Dispensary of the
Tuberculosis League employs six nurses.
Pittsburgh has also a State Department of Health Tuberculosis Clinic, with
ten nurses, each caring for from 90 to 100 patients per month. These
nurses give a small percentage of bedside care and are not in uniform,
except when on duty in the dispensary. They are paid $70 per month. The
plan of work is similar to that of the Philadelphia State Dispensary.
The Department of Public Health of Pittsburgh employs four visiting
nurses, who investigate home conditions and instruct patients reported to
the department who are not under the close supervision of a private
physician, the State Department Clinic, or the Tuberculosis League Clinic.
The nurses are able to correlate, in a way, the work of the two
dispensaries by assigning patients to the clinic in the district in which
they live. They receive $75 per month and are not in uniform.
Pittsburgh, then, has in all twenty visiting tuberculosis nurses, under
three separate and distinct organizations.
CLEVELAND
In Cleveland, as in nearly every other city, the work of organizing the
fight against tuberculosis was accomplished by private organizations, the
Anti-Tuberculosis League and the Visiting Nurse Association. For a number
of years the Health Department confined itself to keeping a card
catalogue of reported cases. In 1910 sufficient funds were voted by the
City Council to enable the establishment of a separate Bureau of
Tuberculosis, whose duty should be the development of municipal
tuberculosis work. This Bureau has taken over and gradually developed five
dispensaries, with a staff of twenty-four visiting tuberculosis nurses,
and paid physicians, besides the director and office force. The work in
Cleveland is centralized in its Health Department.
General dispensaries are required to refer all cases of tuberculosis to
the tuberculosis dispensaries, and physicians are required to report all
cases to the Health Department. On report cards and sputum blanks is the
statement: "All cases of tuberculosis reported to the department will be
visited by a nurse from this department unless otherwise requested by the
physician." With very few exceptions the physicians are glad to have a
nurse call, and every effort is made to co-operate with the physicians in
handling the case.
The city is divided into five districts, with a dispensary located in each
district. Patients are treated only at the dispensary serving the district
in which they live. "This plan prevents cases wandering from one clinic to
another and enables the nursing force to do more intensive work in each
district."
Once a week the chief of the Bureau of Tuberculosis and the Superintendent
of Nurses meet with each separate dispensary staff, and cases are
carefully considered and work discussed. In addition, meetings of the
active nursing staff are held, informal talks on tuberculosis being given,
or the work of allied organizations studied, speakers coming from the
Associated Charities, Department of Health, Settlement Houses, etc. Each
nurse is held responsible for the handling of every individual case in her
district. By thus making the nurse responsible, the interest in her work
is increased and much better results are obtained. If the problem
presented is one that will take more time and energy than the busy
dispensary nurse can give, it is referred to a Special Case Committee.
All dispensary cases are visited in the home within twenty-four hours
after the first visit to the dispensary, where a complete history of the
case is taken. The patient and family are instructed and each member urged
to come to the clinic for examination. Homes where a death from
tuberculosis has occurred are visited immediately, with the consent of the
physician. The family is carefully instructed as to disinfection, and
advised to go to the physician or dispensary for examination.
Cleveland nurses wear uniforms. Each nurse carries about three hundred
patients, a very small percentage being bed cases, usually not more than
two patients at a time. Nurses receive $60 for each of the first three
months; $65 for each of the next nine; $70 a month for the second year;
the third year $80; and the fourth year $85.
DETROIT
The Detroit Board of Health maintains a staff of ten visiting tuberculosis
nurses. They give a small percentage of bedside care, wear a uniform, and
receive $1,000 per year. They work in connection with the Board of Health
Dispensary and have the same general follow-up plan as other cities.
MILWAUKEE