Part 4

Window tents have a few advantages. The patient's prolonged rest in bed will be more endurable when he is permitted to look out on the street and watch life than when obliged to gaze at the four walls of his room. Also patients, who can be persuaded only with difficulty to sleep with the window wide open, will not hesitate when they have this tent as an inducement. Draft which the patient usually dreads, particularly in cold weather and when he perspires, need not be feared when sleeping in a window tent. Further, this limits the possible infection to the interior of the window tent, which is obviously an advantage. While, as a matter of course, the patient will have been taught to always hold his napkin before his mouth when he coughs or sneezes, this is not always done, and cannot be done when coughing in sleep. The constant exposure to air and light of the bacilli, which may have been expelled with the saliva and remain adhered to the canvas, will soon destroy them. Also the canvas of the tent is attached to the frame by simple bands and its removal from the frame for thorough cleansing, washing and disinfection is thus made easy.

Tents

Tents are frequently used for open air living. However, they are not to be recommended for those who can afford to construct open buildings of more durable material. Ordinary tents hold odors. They are often very hard to ventilate; for a strong draft is produced when the flaps are open. There is no ventilation through the canvas, as it is impenetrable by currents of air. In order to make a tent comfortable for a sick person it should have a large fly forming a double roof with an air space between, a wide awning in front where the patient can sit during the day, a board floor laid at least a few inches above the ground, and the sides boarded up two or three feet from the floor. Many modifications of the ordinary tent have been made for the purpose of obtaining a well ventilated canvas shelter.

GARDNER TENT. The Gardner tent[4] is conical in shape with octagonal floor area, with an opening in the center of the roof and one at the bottom between the floor and the sides. These openings act like a fireplace and produce a constant upward current of air through the interior. "The floor is in six sections and can be bolted together. It is made of 1×4-inch tongued and grooved boards supported eight inches above the ground on 2×4-inch joists. Around the edge of the floor is a wainscoting of narrow floor boards four feet in height. There is no center pole, as the tent is supported by an eight-sided wooden frame. The roof and sides are of khaki colored duck. The lower edge of the canvas walls are fastened several inches below the floor and one inch out from the wainscoting on all sides. This leaves an opening through which a gradual inflow of air is obtained without causing a draft. The opening in the center of the roof is one foot in diameter and is covered with a zinc cap." The cap is raised or lowered by a pulley attachment.

TUCKER TENT. The Tucker tent is similar to the Gardner in that it is supplied with ventilation in the wainscoting near the floor and in the center of the roof. It is rectangular rather than octagonal in shape and is made in two sizes--one, eight feet wide by ten feet long, and the other, twelve feet wide by fourteen feet long. It has a wooden floor, wooden base and canvas side, with window openings on each side. "The canvas above the base in the front is attached to awning frames so that it can be raised or removed altogether for the free entrance of air and light." The roof and fly are made of 12-ounce army duck.

LA POINTE TENT. The La Pointe tent is similar to the Tucker tent. It is a canvas cottage with doors, windows and floor. The top is made of canvas, with a fly which projects two inches on all sides. The windows have a wire netting and canvas shutters, the canvas being so arranged that it can be pulled up as a curtain, or extended as an awning. Its cost is $85 to $100.

ARMY TENT. A simple ordinary tent is the United States Army tent. There are two different styles, one with closed corners and one with open corners. It is made of army duck with poles, stakes and guys, and costs according to size. A small tent eight feet four inches long and six feet eleven inches wide would cost $7.50, and lumber for floor about $2.00 extra. This tent is easily put up, care being taken to select a dry soil, places where the water stands in hollows after a rain should be avoided. A small trench about one foot deep around the tent will help in keeping the soil dry.

TENT COT. For experimenting in outdoor sleeping a tent cot is a very simple arrangement. It consists of a plain canvas cot with a frame supporting a small tent. Ventilation is secured by openings at both ends; also at the side where the patient enters. These openings are covered with flaps which can be opened or closed. It is light, weighing from twenty to fifty pounds, and its position and exposure can be conveniently changed. The cost is $9.

KNOPF'S HALF TENT. Another simple arrangement is Knopf's half tent.[5] It consists of a frame of steel tubing covered with sail duck and secured with snap buttons on the inside. It is used for patients sitting out of doors. The reclining chair is placed in the tent with its back to the interior. Its weight helps to hold down the floor bracing attached to the frame.

Sleeping Porches

One of the most important arrangements for outdoor sleeping is the 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 4×4-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 2×4-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 2×4-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 2×6-inch planks laid flat on the roof. The upright frame and siding boards for the back and sides should be of 2×4-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.