Part 2

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