Part 3

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

The head of the Division of Tuberculosis of the Milwaukee Health Department is a trained nurse. She has six field nurses under her, each handling about 100 patients. Nurses are in uniform, give bedside care when necessary, and receive $900 per year. The dispensaries are operated jointly by the Health Department and private charities. Each case of tuberculosis reported to the Department is turned over to a nurse, who visits the physician to see whether or not he wishes the help of the Department. If he does, the nurse instructs the patient and family, arranges for the patient's removal to a sanatorium upon the physician's advice, attends to disinfection of premises and examination of remaining members of family. If the family is in need of material relief she arranges for a pension. All returned sanatorium cases are kept under the supervision of this staff.

ST. LOUIS

The St. Louis Society for the Relief and Prevention of Tuberculosis has a staff of seven nurses, a social service department, a relief department, and an employment bureau. Conferences of nurses and workers are held three times a week, the social workers assuming the various problems met by the nurses in their daily work. St. Louis nurses carry on an average 100 patients each, about 25% being bed cases. Nurses are in uniform, and receive from $60 to $75 per month. Patients report to the City Dispensary or to the Washington University Dispensary, and the usual plan of home supervision is in force.

ATLANTA

Atlanta, Ga., has a staff of four nurses and a dispensary under the Atlanta Anti-Tuberculosis and Visiting Nurse Association. They seem to have a particularly well organized plan of work, very hearty co-operation from the entire city (although the city government has appropriated nothing for the work), and are doing much good along lines of prevention, with dental, and nose and throat clinics, and open air schools. They have had difficulty in obtaining nurses with social training, and have been at some pains to arrange a social service training school, the program of which seems very admirable.

* * * * *

According to the latest report of the National Association for the Study and Prevention of Tuberculosis, there are 4,000 visiting tuberculosis nurses in the United States. There are more than 400 special tuberculosis clinics as compared with 222 in 1909. This paper deals with only a few of the larger cities.

There are many other cities and small towns having tuberculosis nurses doing work well worthy of mention. Several states have adopted the plan of carrying on the work by visiting nurses in each county. These nurses have a wide field, and are accomplishing much along educational lines, the territory which they have to cover making any great amount of actual nursing impossible. It is interesting to note their varied experiences. We read of patients prepared and sent to sanatoria and hospitals, the family and neighborhood protesting against every step; of county agents, churches, lodges or communities called upon to assist in caring for families; of long drives into the country to inspect and practically reorganize some home where several members have died, or are dying with tuberculosis; of repeated admonitions to keep windows open in rural communities, "where the air is pure because all the bad air is kept closed up in the homes and school houses." When the city tuberculosis nurse reads of all this, she feels like taking off her hat to the rural tuberculosis visiting nurse and wishing her success and fair weather.

CHICAGO

The history of the present comprehensive tuberculosis work in Chicago is closely interwoven with the history of the Chicago Tuberculosis Institute, which was organized in January, 1906. The Institute succeeded the Committee on Tuberculosis of the Visiting Nurses' Association (the pioneer Tuberculosis Committee in Chicago).

The Chicago Tuberculosis Institute gives the following as its chief aim: "The collection and dissemination of exact knowledge in regard to the causes, prevention and cure of tuberculosis." The progress made in the tuberculosis situation of this city in the last seven years is directly due to the systematic campaign of the Institute. By exhibits, lectures, literature, stereopticon views and moving picture films, the Institute was energetically spreading during these years the knowledge concerning tuberculosis and its proper methods of prevention.

In the winter of 1906-07 a small and unpretentious sanatorium called "Camp Norwood" was built on the grounds of the Cook County Institutions at Dunning, with a total capacity of 20 beds. The Edward Sanatorium at Naperville, made possible by the munificence of Mrs. Keith Spalding, was under construction at the same time and was later made a department of the Chicago Tuberculosis Institute. The Edward Sanatorium was the chief factor in demonstrating and convincing this community that tuberculosis can be successfully treated in our climate.

In 1907, the Chicago Tuberculosis Institute established a system of dispensaries with a corps of attending physicians and nurses. The purpose was given as follows:

(a) Early diagnosis of tuberculosis.

(b) Control of tuberculosis by means of personal instruction and home visits.

(c) Education of the community in the necessity of further development of the dispensary and nursing systems.

(d) Spread of the gospel of fresh air and "right living."

Dispensaries were opened during the latter part of 1907 as follows:

(1) Jewish Aid Society Tuberculosis Clinic in existence since 1900; joined the Chicago Tuberculosis Institute, December 13th, 1907.

(2) Olivet Dispensary, May 15, 1907; transferred to Policlinic in December of same year.

(3) Central Free Dispensary at Rush Medical College, November 16th.

(4) Northwestern Tuberculosis Dispensary, November 21st.

(5) Hahnemann Tuberculosis Dispensary, December 9th.

(6) Policlinic Tuberculosis Dispensary, December 13th.

(7) West Side Dispensary at the College of Physicians and Surgeons, December 17th.

The South West Dispensary was opened in August, 1909.

The underlying and controlling belief of the Chicago Tuberculosis Institute has always been that no great progress can be made in the campaign against tuberculosis, or in any other reform movement, until the soil is sufficiently prepared. The soundness of this policy may be seen in the fact that the activities of the Institute, its exhibits, more especially the success of the Edward Sanatorium, and also the work of the dispensaries, led finally to the adoption by the City of Chicago of the Glackin Municipal Sanitarium Law and made possible the Municipal Tuberculosis Sanitarium now nearing completion.

The maintenance of the seven dispensaries having become a source of considerable expense to the Institute, they were turned over to the city and became a part of the Municipal Tuberculosis Sanitarium in September, 1910.

The Institute continued its activities as "an educational institution for the collection and dissemination of exact knowledge in regard to the causes, prevention and cure of tuberculosis." It concerns itself also with keeping before the minds of the public the proper standard of care for the tuberculous in public and private institutions. Through its Committee on Factories, the Institute conducted during the last three years a vigorous campaign for the adoption of the principle of medical examination of employes. The Robert Koch Society, an organization of physicians, is the outgrowth of the Institute. In brief, the Institute for years has led the fight against tuberculosis in this city.

The dispensary system of the Municipal Sanitarium, organized as above stated, has gradually developed into ten dispensaries with a superintendent of nurses, ten head nurses and fifty field nurses. A staff of thirty-one paid physicians are a part of the organization. The ten dispensaries hold twenty-six clinics a week. In 1913, the attendance at the Municipal Tuberculosis Sanitarium clinics was 43,989 patients. Nurses made in all 39,737 visits to the homes of the tuberculous patients. The system of visiting tuberculosis nursing in Chicago is steadily moving toward greater efficiency in coping with the existing situation. The chief features of the Chicago arrangement are as follows:

(1) Nurses are classified into:

=Grade II. Field Nurse=

Group C: $900.00

Group B (At least one year's service in lower group): $960.00

Group A (At least one year's service in next lower group): $1080.00

=Grade III. Head Nurse=

Group B: $1200.00

Group A (At least one year's service in lower group): $1320.00

=Supervising Nurse=

Group B: $1440.00

Group A (At least one year's service in lower group): $1560.00

=Grade IV. Superintendent of Nurses=

Group D: $1920.00

Group C (At least one year's service in lower group): $2100.00

Group B (At least one year's service in next lower group): $2280.00

Group A (At least one year's service in next lower group): $2400.00

(2) Civil Service examinations for all of the above positions render possible the selection of the best candidates.

(3) Efficiency of the nursing force is stimulated by conferences of various groups of nurses:

(a) Weekly conferences of junior nurses.

(b) Weekly conferences of head nurses.

(c) Conferences of the entire nursing force twice a month.

(d) A well organized system of lectures on various phases of tuberculosis by authorities.

(e) Bi-monthly meetings of the Nurses' Tuberculosis Study Circle, the proceedings of which are published in this pamphlet.

(4) A centralized system of administration, with brief medical and social records of all dispensary cases for the purpose of clearing and information, in the office of the Superintendent of Nurses located in the down town General Offices of the Sanitarium.

(5) Nurses wear uniforms beginning with the middle of October of this year (1914).

(6) Before January, 1915, all tuberculosis cases in their homes will be cared for by the Municipal Tuberculosis Sanitarium. This includes both far advanced and surgical cases.

The Chicago Anti-tuberculosis movement has been more fortunate in its development than that in other cities where the dispensaries are under one organization and the nurses under another. Here the dispensaries and their nursing and medical staffs have steadily developed under the same direction, the advantages of such an arrangement being clearly evident.

We look into the future with confidence. The Chicago Municipal Tuberculosis Sanitarium, with its 900 beds and its comprehensive medical and laboratory facilities for the study and treatment of cases, is to open before the year 1914 expires. The County Tuberculosis Hospitals for advanced cases are undergoing a revolutionary change in the direction of administrative and medical efficiency. The Dispensary Department of the Municipal Tuberculosis Sanitarium is extending sanatorium care to the homes of tuberculous patients by building and remodelling porches and supplying, if necessary, all equipment required for outdoor sleeping. We have eighteen open air schools. We have an effective tuberculosis exhibit. The principle of early detection of illness is being adopted by many business concerns and the sanitary conditions are gradually improving. The future is full of promise.

CITY POPULATION PRIVATE NUMBER AVERAGE BEDSIDE UNIFORMS YEARLY 1910 CENSUS OR OF NUMBER OF CARE SALARY PUBLIC NURSES PATIENTS FUNDS PER NURSE -------------------------------------------------------------------------- New York 4,767,000 Public (city) 158 $900.00 About 125 Yes No average Private 102 -------------------------------------------------------------------------- Chicago 2,185,000 Public (city) 50 135 Yes Yes $900.00 to $1,320 -------------------------------------------------------------------------- Philadelphia 1,549,000 Public (state) 12 Varies Yes Yes $900.00

Private 4 150 No No -------------------------------------------------------------------------- St. Louis 687,000 Private 7 100 Yes Yes $720.00 to $900.00 -------------------------------------------------------------------------- Boston 671,000 Public 100 (city) 25 to 180 Yes No $900.00 -------------------------------------------------------------------------- Cleveland 561,000 Public (city) 24 300 Yes Yes $720.00 to $1,020.00 -------------------------------------------------------------------------- Baltimore 558,000 Public (city) 16 212 Yes Yes $900.00 -------------------------------------------------------------------------- Pittsburgh 534,000 Public (city) 4 No No $900.00

State 10 100 No No $840.00

Private 6 Yes Yes $300.00 -------------------------------------------------------------------------- Detroit 466,000 Public (city) 10 100 Yes Yes $1,000 -------------------------------------------------------------------------- Buffalo 424,000 Public (city) 6 125 Yes No $720.00 --------------------------------------------------------------------------

PROVISIONS FOR OUTDOOR SLEEPING

By MAY MacCONACHIE, R. N.

Head Nurse, St. Elizabeth Dispensary of the Chicago Municipal Tuberculosis Sanitarium.

In the treatment of tuberculosis, the best results have been obtained in sanatoria. In most cities, however, sanatorium treatment is not possible for many patients; consequently home treatment must be provided. This can be done most successfully when we imitate as far as possible the sanatorium method. This paper describes some of the arrangements for outdoor sleeping which may be provided for a patient taking the "cure" at home.

The Fresh Air Room.

Select the best lighted and best ventilated room, preferably one with southern exposure, for the patient to sleep in. All superfluous furniture and hangings should be removed. In doing this, however, the room need not be made cheerless; small rugs, washable curtains and one or two cheerful pictures may be allowed.

There should be some means of securing cross ventilation in all sleeping rooms, as for the ideal fresh air room this is most essential. When this cannot be arranged and when there are windows only on one side of the room and a transom is lacking, the window should be open at both upper and lower sash. This arrangement allows the bad air to escape through the opening at the top, while the fresh air enters below. The "French window" which opens from floor to ceiling by swinging inward is to be recommended for the ideal sleeping room. In ventilating a room which is used for a sitting room in the daytime, especially in stormy weather, it is sometimes necessary to protect the patient from a direct draft. For this purpose a shield may be made from an ordinary piece of hardwood board, eight inches wide (or larger) and long enough to fit in between the side casings. It can be covered with wire netting, cheese cloth or muslin. There are a variety of wind shields on the market called sash ventilators, or air deflectors.

Window Tents

In the treatment of tuberculosis the window tent was originally devised to give fresh air to patients in their own rooms. To a poor family the window tent has an economic advantage, especially if the room where the patient lies serves as a living room for the rest of the family. The fact that the well members should not shiver is of vital importance in many respects. A simple home window tent, and one which can be made easily in the homes of the poor, consists of a straight piece of denim or canvas hung from the top of the window casing and attached to the outer side of the bed. The space between this and the window casing on each side is closed with the same material properly cut and fitted. Ten to twelve yards of cloth is necessary. If made of denim, the price of the tent would be about $3.00; if of canvas, about $4.50. If this cannot be obtained, take two large, heavy cotton sheets, sew them together along the edge, tack one end to the top of the window casing and fasten the other end to the bed rail with tape. There will be enough cloth hanging on each side to form the sides of the tent, and this should be tacked to the window casings. The manufactured window tents are all constructed practically on the same principle. The difference between them is in their shape and the manner of their operation. There are two types: the awning variety, as illustrated by the Knopf and the Allen tents; and those of the box order, of which the Farlin, Walsh, Mott and Aerarium are examples.

KNOPF WINDOW TENT. The Knopf window tent[1] is constructed of four Bessemer rods furnished with hinged terminals, the hinges operating on a stout hinge pin at each end with circular washers so that it can be folded easily. The frame is covered with yacht sail twill. The ends of the cover are extended so they can be tucked in around the bedding. The tent fills half of the window opening and can be attached to the side casings three inches below the center of the sash, this space being for ventilation. The patient enters the bed and then the tent is lowered over him, or he can lower the tent himself by means of a small pulley attached to the upper portion of the window. The bed can be placed by the window to suit the patient's preference for sleeping on his right or left side. A piece of transparent celluloid is inserted in the middle of the inner side so that the patient can look into the room or can be watched.

ALLEN WINDOW TENT. The Allen window tent[2] is on the same order as Knopf's, the difference being chiefly in size. The Allen tent covers the entire window and has the appearance of an ordinary window awning turned into the room, ventilation being secured from openings above the upper and below the lower sash.

BOX WINDOW TENT. The box variety of window tent consists of a light steel frame covered with canvas or cloth. The frame fits between the window casing like a wire screen frame. The bottom, through which the head is passed, can be made of flannel and can be drawn closely around the neck.

AERARIUM. Dr. Bull's aerarium[3] is another device similar to a window tent. This arrangement consists of a double awning supported on a wooden or steel frame and attached to the outside of the window with a special ventilating arrangement. The head of a cot bed is put through the window and the patient's head rests out of doors. The lower window sash must be raised about two feet and a heavy cloth or curtain hung from its lower edge so that it will drop across the body and shut off the room from the outside air.