sleeping porch. To be convenient, it should have an entrance from a
bedroom, and, when possible, from a hall; for every outdoor sleeper should
have, during cold weather, a warm apartment in connection with his open
air sleeping room. The best exposure in Illinois is south, southeast or
east. Sleeping out should be a permanent thing during all seasons. The
sleeping porch must be kept neat and attractive. A cot placed between the
oil can and the washtub on a dingy back porch is very dismal and bound to
have a depressing effect on the sleeper.
It costs very little to arrange an ordinary sleeping porch provided you
have the porch to begin with. If a porch is fairly deep and sheltered on
two sides by an angle of the house, sufficient protection for moderately
cold weather can usually be obtained by canvas curtains tacked to wooden
rollers. These can be raised and lowered by means of ropes and pulleys,
the bed being placed so that the wind will not blow strongly on the
patient's head.
ORDINARY PORCHES.[6] A useful porch can be built for $15 to $25 with cheap
or second-hand lumber, and if only large enough to receive the bed and a
chair will still be effective for the outdoor treatment. The roof can be
made with canvas curtain, or a few boards and some tar paper. The end most
exposed to the wind and rain and the sides below the railing should be
tightly boarded to prevent drafts.
Second or third story porches are supported from the ground by long
4x4-inch posts, or when small they can be held by braces set at an angle
from the side of the house. When the long posts are used they are all
placed six feet apart and the space between them is divided into three
sections by 2x4-inch timbers. The interior is protected by canvas curtains
fastened to the roof plate and arranged so as to be raised or lowered by
ropes and pulleys. These curtains are made about six feet wide and fit in
between the supporting posts and rest against the smaller timbers. This
arrangement keeps the curtains firm during a storm, as both rollers and
canvas can be securely tied to the frames. This porch would cost between
$30 and $50.
PORCH DE LUXE. When a bed on a porch is not in use it is often unsightly
and in the way, while in winter, unless well protected, the bed clothes
and bedding become damp. In order to overcome this, the Porch de Luxe[7]
has recently been devised. This consists of a low-built bedstead arranged
to slide through an opening in the wall of the house between the porch and
bedroom.
SLEEPING CABIN. To lessen the disadvantages of the high roofed, windy
porch, the home-made sleeping cabin is to be recommended. This cabin is
built on the porch. The frame is braced against the side of the house and
rests on the floor of the porch, but the top of the cabin is much lower
than the roof of the porch. The frame consists of 2x4-inch timbers. The
sides and roof are of canvas curtains; these can be rolled up separately.
Some of these cabins have had the roof hinged so that it can be raised in
warm weather. The greatest advantage of the cabin is the control of the
weather situation. The cost is $15 to $20.[8]
KNOPF'S STAR-NOOK. Another arrangement is Knopf's "Star-nook."[9] This is
a wall house supported by the roof of an extension, or on a bracket
attached to the wall of the building. This fresh air room consists of a
roof, floor and three walls and, with the exception of the roof and the
floors, is built of steel frames holding movable shutters. It is nine feet
long by six feet deep, the height being eight feet at the inner side with
a fall of two feet. At both ends are windows which can be opened outward.
The roof can be raised entirely off the apartment by means of a crank.
Also the upper sections of the front windows can be opened or closed.
Sometimes new doors or windows will be needed to give access to a desired
position. The "Star-nook" can be secured with safety, and when strongly
supported there need be no fear in regard to its stability.
Roofs
The value of roof space for outdoor treatment in cities is gradually being
appreciated. They can be made splendid sites for various kinds of little
buildings. The roof of an apartment house offers a choice of situations,
but there are different conditions to be considered, such as the best
exposure and the most protected place, one that cannot be overlooked from
neighboring buildings; also security from severe storms. Tents have been
erected upon the roofs of city buildings, but they are not to be
recommended for such positions unless they can be placed in the shelter of
a strong windbreak. When erected upon the roof of high buildings they
should be protected on two sides by walls, or by other parts of the
structure upon which they are to be placed.
A cabin is most desirable for the roof. In its construction it is best to
use a wooden frame for the foundation. It can then be moved and its
position and exposure changed easily. This frame should be made of
2x6-inch planks laid flat on the roof. The upright frame and siding boards
for the back and sides should be of 2x4-inch timbers. The front of the
cabin should be left open, but arranged with a canvas curtain tacked on a
roller so that it can be closed in stormy weather. Tar paper is used for
the roof. When completed, the framework should be braced to give firmness.
If two buildings connect and one is taller than the other with no space
between, a lean-to cabin is most desirable.
* * * * *
With the devices just described the home treatment can be secured with
little cost. Patients who are afraid of outdoor sleeping should begin in
moderate weather. All shelters should be as inconspicuous as possible. In
choosing a suitable position for a fresh air bedroom, it should be
remembered that early morning sounds and sunlight should be eliminated, if
possible. This can sometimes be done by selecting a room far from the
street and by shading the bed with blinds. One's neighbor should be taken
into consideration, and a position decided upon which does not overlook
his windows, porches or yards, and when arranging for the rest cure in the
reclining chair during the day one should always bear in mind that it is
much more agreeable and conducive to the well-being of the patient to have
a pleasant view to look upon.
SOME POINTS IN THE NURSING CARE OF THE ADVANCED CONSUMPTIVE
By ELSA LUND, R. N.
Head Nurse, Iroquois Memorial Dispensary of the Chicago Municipal
Tuberculosis Sanitarium.
The problem of caring for the advanced consumptive is a very complicated
one; it involves not only the patient, but the whole family as well. A
complete rehabilitation of the entire family is necessary in most of the
dispensary cases.
The first thing the nurse must do is to gain the confidence of both the
patient and the family. The chief requisite in the nursing of the advanced
consumptive is a clean, careful, patient and sympathetic nurse. Frequently
she finds her patient extremely irritable, and often this mental condition
has affected his whole family, or whoever has been associating with him. A
painstaking, sympathetic nurse will readily understand that the causes for
this state of affairs are most natural. The consumptive may have spent
wakeful nights, due to coughs and pains and distressing expectoration; the
enforced cessation of work may have caused pecuniary worries; all his
customary pleasures are now denied him, and he has strength for neither
physical nor mental diversion. Realizing this, the nurse must kindly but
firmly impress upon the patient the necessity of co-operation and the
danger of infecting others and of reinfecting himself. She should at once
create a more cheerful atmosphere by repeated suggestions that if he will
only do his duty as a hopeful patient, he will not be considered a menace
by those who come in contact with him, and his family will gladly
associate with him.
Next comes the concrete problems which the nurse must solve. That of
proper housing of the patient is one of the most important, and especially
so in the case of the advanced consumptive, because of the greater danger
of spreading the infection if the conditions are unfavorable. Where it is
necessary that the family should move, the nurse should assist in the
selection of a new home. If possible, a detached house should be chosen,
affording plenty of light and sunshine, away from dusty streets and
roads. Offensive drains and other insanitary conditions should be avoided.
The water supply should be abundant and the plumbing in good repair.
The room of the patient should be well lighted and well ventilated, and
preferably have a southern exposure. Cross ventilation is very desirable.
When all unnecessary furniture and all hangings and bric-a-brac have been
removed, and the old paper stripped from the walls, the walls should be
whitewashed, or covered with washable paper, or painted. Painted walls are
inexpensive, and they have the further advantage that they can be washed
frequently. The floor should be bare and likewise frequently washed.
Simple furniture is commendable, and old pieces can be made very
attractive by having them enameled. Proper furnishings include a
comfortable bed (one made of iron and raised on wooden blocks makes
nursing care easier), a bedside table, chairs, a rocking chair, a
washstand, and even a couch on which the patient could be placed
occasionally to relieve the monotony. Two or three pictures which can be
readily dusted and cleaned will brighten the bare walls one finds in what
are generally recommended as sanitary rooms. Flowers always add to the
attractiveness of a room, and when the bed is placed near the window the
patient is given the opportunity of enjoying, to some extent, at least,
the pleasures of out-of-doors. The mattress should be provided with a
washable cover. Strips of muslin sewed across the tops of the blankets
will protect them from sputum, in case the sheets happen to slip. Soiled
bed linen must be handled as little as possible, soaked in water, washed
separately and boiled. If sputum-covered, it should be soaked in a five
per cent solution of carbolic acid or a solution of chloride of lime.
Instead of dry sweeping and dusting, the floors should be washed with soap
and water and dusted with wet cloths. Great care should be taken in
instructing and demonstrating to the family how to properly care for the
room. Special attention must be given to the bed, its comforts and its
cleanliness. Every nurse is familiar with what is known as the "Klondike"
bed, and it is unnecessary to discuss it here in detail. Since both
patient and family derive such direct benefit from a constant supply of
fresh air, too much attention can not be given to proper ways of securing
it, and at the same time keeping the patient warm. Where bed coverings are
limited, warmth can be secured by sewing layers of newspapers between two
cotton blankets; again, sheets of newspapers or tar paper keep out the
cold to a great extent. Proper ventilation prevents night sweats. Means of
heating the room must be provided, because of the low vitality of the
patient and the need of frequent care.
The patient's clothing needs to be light but warm; where wool proves
irritating to the skin, a heavy linen mesh has been found a good
substitute, due to the fact that it dries quickly when the patient
perspires. The patient should have two good soap and water baths a week.
The nurse should let the family know when she is coming to give these
baths and explain to them that she expects them to have ready for her
towels, soap, clean bed linen, wash basin, wash cloths, newspapers and hot
water. Night sweats demand careful rubbing, first with a dry towel;
vinegar sponging is found to be very effective; alcohol rubs prevent bed
sores.
The hair, nails and teeth require special attention; beards and mustaches
should be shaved. Every patient must learn to use the tooth brush after
meals, that the mouth may be kept scrupulously clean. Gargling should also
be insisted upon. Tooth brushes can be kept in a 50 per cent Dobell's
solution, Liquor Antiseptic (U. S. P.), or a 2 per cent solution of
carbolic acid colored with vegetable green coloring matter as a warning
against swallowing. As an aid in hardening the gums, all foreign deposits
should be removed, the gums massaged by the patient and normal salt
solution used as a gargle. Where the patient is suffering from pyorrhea,
the gums may be painted, on the order of the physician, with tincture of
iodine (U. S. P.) or a 2 per cent solution of copper sulphate. While the
patient is learning to cleanse his mouth carefully after every meal, he
may also be instructed to avoid placing anything in his mouth, except
food, drink, gargling solution or tooth brush. The reason for using some
kind of mouth wash, instead of merely water, is because in that way the
need of cleanliness is more forcibly impressed upon the patient.
Such matters as the use of separate dishes, etc., are so well known to
every tuberculosis nurse that it is unnecessary to dwell on them at length
in this paper.
Difficulties always arise regarding proper method for the care and
disposal of sputum. The following are some of the plans adopted by
tuberculosis hospitals for advanced cases:
=1. Infirmary of Eudowood Sanatorium, Towson, Maryland.=
Pasteboard fillers in such quantities as will be required during
the current day are issued to the patients. When the filler
becomes not more than two-thirds full, it is carefully filled
with sawdust, wrapped in a newspaper, tied with a cotton cord
and deposited in a large galvanized iron bucket, in which it is
carried, with the others, to the incinerator.
=2. North Reading (Mass.) State Sanatorium.=
A room specially equipped for the disposal of sputum is
recommended. Paper sputum boxes are changed twice daily,
inspected as to character, quantity and presence of blood. Then
the box is filled with sawdust, wrapped in newspaper and carried
to the incinerator for burning.
=3. Montefiore Home Country Sanitarium, Bedford Hills, N. Y.=
In cases where bed patients have a very large amount of sputum,
large cups of white enamel are used, with a hinged lid that
lifts readily. The sputum is from there thrown into receptacles
containing sawdust, taken to the incinerator and burned twice
daily. Both sputum cups and the large container holding sawdust
are sterilized by live steam.
=4. House of the Good Samaritan, Boston, Mass.=
Paper handkerchiefs and bags are recommended when the quantity
of sputum is small. Burnitol sputum cups without holders are
used; the bottom of each cup holds a small amount of sawdust,
which serves the purpose of hindering the sputum from
penetrating through the cup. All the cups are carefully tied up
in newspaper by the nurse or the patient before they are sent to
the incinerator.
=5. Chicago Fresh Air Hospital.=
Paper fillers and metal holders are used. The fillers are placed
in a large can, covered with sawdust, and then burned in the
incinerator. The holders are sterilized daily. The Hospital
recommends paper napkins where the quantity of sputum is small;
if there is no possible means of burning the sputum, it should
be treated with a strong solution of concentrated lye and then
poured into the water closet.
The chief source of infection is undoubtedly the expectoration of the
consumptive, spread by careless coughing and spitting. Be very emphatic in
instructing the patient to cover his mouth with a paper napkin when he
coughs and then to dispose of it carefully in such a way that no particle
of the sputum touches either his hands or his face. Insist on frequent
washing of the hands.
The following methods and solutions are employed in the treatment of
laryngeal tuberculosis in various institutions:
=North Reading (Mass.) State Sanatorium.=
The following are used as _gargles_:
Dobell's solution; Dobell's solution and formalin (one drop of formalin to
an ounce of solution); alkaline antiseptic N. F. (one to four water); salt
and sodium bicarbonate (one dram of salt and two drams sodium bicarbonate
to a pint of water).
_Sprays_ used at this institution are as follows:
Spray No. 1. Menthol spray in proportion of fifteen grains of menthol to
one ounce of alboline.
Spray No. 2. Menthol (4 drams plus 10 grains); thymol (7 drams plus 25
grains); camphor (7 drams plus 25 grains); liquid petrolatum (64 ounces).
Heroin spray. From one to three grains of heroin to one ounce of water.
Cocaine spray. From one-half to two per cent, usually before meals, for
dysphagia.
For _local applications_: Argentide, 1 to 200; argyrol, 10%; iodine,
potassium iodide and glycerine; heroin powder applied dry to ulcerations;
orthoform powder applied dry.
=Montefiore Home Country Sanitarium, Bedford Hills, N. Y.=
In the _routine treatment_ of laryngeal tuberculosis at the Montefiore
Home Country Sanitarium orthoform emulsion is used, made up as follows:
Menthol, 2-5 grams; oil of sweet almonds, 30 grams; yolk of one egg;
orthoform, 12.5 grams; water added to make 100 grams.
In addition, silver salts are used in various strengths; also lactic acid
in various strengths. These two agents are applied by means of
applicators, whereas the emulsion is injected by a laryngeal syringe. The
laryngeal medicator of Dr. Yankauer, made by Tiemann, is also employed. By
means of this little apparatus a patient may medicate his own larynx,
using the emulsion mentioned or any other agent (such as formalin) which
may be desired.
=Eudowood Sanatorium, Towson, Md.=
At the Eudowood Sanatorium, Towson, Maryland, the following procedure is
used in the treatment of tuberculous ulcers of the larynx:
_Topical applications_ of lactic acid, 15 to 50%, followed by a spray
composed of 20 grains of menthol to 1 ounce of liquid alboline.
A _spray_ of 2% cocaine is used as often as is necessary to relieve the
pain.
Insufflation of orthoform powder, or the patient is directed to slowly
dissolve an orthoform lozenge in his mouth.
These treatments are enhanced by the application of an ice bag to the
throat, enforced rest of the vocal cords and rectal feeding, if necessary.
In laryngeal complications, semi-solid diet is generally more easily
swallowed. This is facilitated by a reclining position. Cold compresses
give some relief.
=Chicago Fresh Air Hospital=
For the relief of pains and difficulty in swallowing, the nurse is
instructed to spray the larynx with a 3 per cent solution of cocaine
before each meal.
As a more efficient treatment, but slower in action, the administration of
anaesthesine to the ulcerated epiglottis with a powder blower is
recommended. This is usually done by the physician, as is, also, the
insufflation of iodoform.
Cold packs are also used to give temporary relief, but they are not
recommended as being very reliable.
* * * * *
Authorities differ regarding the proper _diet_ for the advanced
consumptive. It is generally conceded, however, that it should not vary to
any great extent from the ordinary liberal diet, unless intestinal or
other complications arise. The physical idiosyncrasy of each patient must
first of all be taken into consideration, and this is primarily a matter
to be decided upon by the physician in charge. The nurse should, however,
be resourceful in her suggestions as to preparing a variety of palatable
dishes. According to Walters ("The Open Air Treatment"), in intestinal
tuberculosis, such foods as oatmeal, green vegetables, fruit and various
casein preparations are better dispensed with, as they are likely to cause
irritation and diarrhoea. Meat and meat juices should also be given with
caution, as they, too, cause diarrhoea.
In hemorrhage, a cold diet should be given, such as milk, eggs, gelatin
and custard. The nurse must insist in absolute rest and the patient should
not be permitted to move until the danger of bleeding is over. Nervousness
always accompanies hemorrhage, and the nurse can do much to allay this by
assuring the patient that few people die from hemorrhage.
In closing, it might be well to mention some points relative to the
nurse's equipment, her mode of dressing, etc. Her dress should be simply
made and washable. Aprons made of soft cotton crepe are recommended
because of the small space they occupy in the bag.
The contents of the bag, which should be lined with washable, removable
lining, should include: Alcohol, tr. iodine, green soap, olive oil, boric
acid powder, boric acid crystals, vaseline, cold cream, mouth wash, tongue
depressors, adhesive plaster (3" wide), bandages, safety pins (small and
large), applicators, scrub brush, face shields, probe, scissors (2 pair),
forceps, thermometers (3), medicine dropper, bags of dressings, dressing
towels, hand towels (2), apron.
Because tuberculosis is so lasting and makes a family, ordinarily
self-supporting, frequently dependent, it will be absolutely necessary for
the nurses to have access to a loan closet. This closet should contain the
following articles: Sheets and pillow slips, bed pan, blankets, rubber
rings, gowns or pajamas, rubber sheets, tooth brushes, cold cream, rubber
gloves, glass syringes, pus basins, enema bags, connecting tubes, rectal
tubes, nurses' hand towels, surgical towels, instrument cases, aprons and
gown, loan book.
* * * * *
Up to the present time the field nurses of the Dispensary Department of
the Chicago Municipal Tuberculosis Sanitarium have taken care chiefly of
ambulant cases, the total number of cases under observation in 1913 being
12,397, with 39,737 visits by nurses to positive and suspected cases in
their homes. Lately (September 1914) the nursing force of the Dispensary
Department has been increased to fifty nurses to take care of all
tuberculosis cases in their homes, including advanced cases and those of
surgical tuberculosis.
[Illustration]
OPEN AIR SCHOOLS IN THIS COUNTRY AND ABROAD
By FRANCES M. HEINRICH, R. N.
Head Nurse, Post-Graduate Dispensary of the Chicago Municipal
Tuberculosis Sanitarium.
In every community where the tuberculosis problem has been seriously taken
in hand the importance of the presence of the infection in children had to
be considered and this has been carefully studied by those who realize
that tuberculosis, far from being a disease chiefly of adult life, is
intimately associated with childhood. Therefore, is it not most important
that all children, who have either been exposed to tuberculosis through
the presence of an active case in their home, or show a family
predisposition to the disease, should be given special consideration, and
every opportunity furnished to make it possible for them to withstand the
latent infection or to overcome the inherited lack of resistance? The best
means of meeting this important problem, as far as school children are
concerned, is through the medium of Open Air Schools, not only because of
the benefit to the individual case, but also because of the very important
educational influence on the community at large.
The first Open Air School was opened in Charlottenburg, Germany, a suburb
of Berlin, in the year 1904, a school of a new type, to which the Germans
gave the name Open Air Recovery School. The object was to create a school
where children could be taught and cured at the same time, and this same
purpose has obtained in all other schools of similar type which have since
been opened. This new educational venture was designed for backward and
physically debilitated pupils who could not keep up with the work in the
regular schools and who were not so mentally deficient that they were fit
subjects for the classes of mentally subnormal children. It was felt that
if these children were sent to sanatoria they would undoubtedly improve
physically, but would fall back in the class work; while, on the other
hand, if they remained in the regular school they would deteriorate
physically. It was to meet these needs, then, that this new type of
school was devised. As the name implies, the school was held almost
entirely in the open air, the regime consisting of outdoor life, plenty of
good food, strict hygiene, suitable clothing, and school work so modified
as to suit the conditions of the children.