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+The Project Gutenberg EBook of Nurses' Papers on Tuberculosis :, by Various
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Nurses' Papers on Tuberculosis :
+       read before the Nurses' Study Circle of the Dispensary
+       Department, Chicago Municipal Tuberculosis Sanitarium
+
+Author: Various
+
+Release Date: November 23, 2011 [EBook #38090]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK NURSES' PAPERS ON TUBERCULOSIS : ***
+
+
+
+
+Produced by Bryan Ness, Henry Gardiner and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+file was produced from images generously made available
+by The Internet Archive/American Libraries.)
+
+
+
+
+
+
+       *       *       *       *       *
+
+Transcriber's Note: The original publication has been replicated
+faithfully except as shown in the Transcriber's Amendments at the end of
+the text. Words in italics are indicated like _this_. Obscured letters in
+the original publication are indicated with {?}. Text emphasized with bold
+characters or other treatment is shown like =this=. Footnotes are located
+near the end of the text.
+
+       *       *       *       *       *
+
+
+
+
+                  Dispensary Department Bulletin No. 1
+
+                             NURSES' PAPERS
+
+                                   ON
+
+                              TUBERCULOSIS
+
+                            PUBLISHED BY THE
+                            CITY OF CHICAGO
+                  MUNICIPAL TUBERCULOSIS SANITARIUM
+
+                             SEPTEMBER 1914
+
+
+
+
+             CITY OF CHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM
+
+                             STAFF OF NURSES
+                               --OF THE--
+                          DISPENSARY DEPARTMENT
+
+             ROSALIND MACKAY, R. N., Superintendent of Nurses
+
+                            ANNA G. BARRETT
+                          BARBARA H. BARTLETT
+                            OLIVE E. BEASON
+                             ELLA M. BLAND
+                          KATHRYN M. CANFIELD
+                           MABEL F. CLEVELAND
+                            ELRENE M. COOMBS
+                          MARGARET M. COUGHLIN
+                           STELLA W. COULDREY
+                            EMMA W. CRAWFORD
+                           FANNIE J. DAVENPORT
+                             ROXIE A. DENTZ
+                           C. ETHEL DICKINSON
+                             ANNA M. DRAKE
+                             MARY E. EGBERT
+                             MAUDE F. ESS{?}
+                             SARA D. FAROLL
+                               MARY FRASER
+                            AUGUSTA A. GOUGH
+                           FRANCES M. HEINRICH
+                              LAURA K. HILL
+                           ISABELLA J. JENSEN
+                              EMMA E. JONES
+                             LETTA D. JONES
+                              JEANETTE KIPP
+                                ELSA LUND
+                            MARY MACCONACHIE
+                            JOSEPHINE V. MARK
+                             ISABEL C. MCKAY
+                             ANNA V. MCVADY
+                             ANNIE MORRISON
+                        KATHERINE M. PATTERSON
+                            LAURA A. REDMOND
+                            GRACE M. SAVILLE
+                              BERYL SCOTT
+                          FLORENCE T. SINGLETON
+                              MABELLE SMITH
+                           FLORENCE A. SPENCER
+                             HARRIETT STAHLEY
+                          GENEVIEVE E. STRATTON
+                            ANNABEL B. STUBBS
+                             ALICE J. TAPPING
+                               OLIVE TUCKER
+                            ELIZABETH M. WATTS
+                              MARY C. WRIGHT
+                              MARY C. YOUNG
+
+                       KARLA STRIBRNA, Interpreter.
+
+
+                           BOARD OF DIRECTORS
+
+                  THEODORE B. SACHS, M. D.,   President
+                  GEORGE B. YOUNG, M. D.,     Secretary
+                             W. A. WIEBOLDT.
+
+
+                             GENERAL OFFICE
+
+                         105 West Monroe Street
+
+                   FRANK E. WING, Executive Officer.
+
+
+[Illustration: FIELD NURSES, DISPENSARY DEPARTMENT CHICAGO MUNICIPAL
+TUBERCULOSIS SANITARIUM]
+
+
+
+
+                  Dispensary Department Bulletin No. 1
+
+                             NURSES' PAPERS
+
+                                   ON
+
+                              TUBERCULOSIS
+
+
+                             READ BEFORE THE
+
+                          NURSES' STUDY CIRCLE
+
+                                 OF THE
+
+                          DISPENSARY DEPARTMENT
+
+               CHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM
+
+
+                            PUBLISHED BY THE
+                            CITY OF CHICAGO
+                   MUNICIPAL TUBERCULOSIS SANITARIUM
+                         105 WEST MONROE STREET
+                             SEPTEMBER 1914
+
+
+
+
+                                CONTENTS
+
+
+                                                                   PAGE
+
+  Introduction--Nurses' Tuberculosis Study Circle                     5
+
+  Historical Notes on Tuberculosis                                    7
+  ROSALIND MACKAY, R. N.
+
+  Visiting Tuberculosis Nursing in Various Cities of the United
+  States                                                             11
+  ANNA M. DRAKE, R. N.
+
+  Provisions for Outdoor Sleeping                                    30
+  MAY MACCONACHIE, R. N.
+
+  Some Points in the Nursing Care of the Advanced Consumptive        37
+  ELSA LUND, R. N.
+
+  Open Air Schools in This Country and Abroad                        44
+  FRANCES M. HEINRICH, R. N.
+
+  Notes on Tuberculin for Nurses                                     56
+
+
+
+
+                   NURSES' TUBERCULOSIS STUDY CIRCLE
+
+
+It is well known that the gathering of facts and study of literature
+essential to the preparation of a paper on a certain subject is a very
+productive method of acquiring information. If the paper is to be
+presented to your own group of co-workers, and the subject covered by it
+represents an important phase of their work, or an analysis of some of its
+underlying principles, then there is a further incentive to do your best,
+as well as an opportunity for a general discussion which acts as a sieve
+for the elimination of false ideas and gradual formulation of true
+conceptions.
+
+Lectures on various phases of the work being done by a particular group of
+people are very important. Papers by the workers themselves are, however,
+greatest incentives to study and self-advancement.
+
+With this view in mind, I suggested the organization of a Tuberculosis
+Study Circle by the Dispensary Nurses of the Municipal Tuberculosis
+Sanitarium. The nurses chosen to present papers on particular phases of
+tuberculosis are given access to the library of the General Office of the
+Sanitarium; they are also given the assistance of the General Office in
+procuring all the necessary information through correspondence with
+various organizations and institutions in Chicago and other cities.
+
+As the program stands at present, the Nurses' Study Circle meets twice a
+month. At one of these meetings a lecture on some important phase of
+tuberculosis is given by an outside speaker, and at the next meeting a
+paper is read by one of the nurses. At all of these meetings the
+presentation of the subject is followed by general discussion. The program
+since January, 1914, was as follows:
+
+January 9th, 1914--"Historical Notes on Tuberculosis," by Miss Rosalind
+Mackay, Head Nurse, Stock Yards Dispensary of the Municipal Tuberculosis
+Sanitarium.
+
+January 23rd, 1914--"Channels of Infection and the Pathology of
+Tuberculosis," by Professor Ludwig Hektoen of the University of Chicago.
+
+February 13th, 1914--"Visiting Tuberculosis Nursing in Various Cities of
+the United States," by Miss Anna M. Drake, Head Nurse, Policlinic
+Dispensary of the Municipal Tuberculosis Sanitarium.
+
+March 13th, 1914--"Provisions for Outdoor Sleeping," by Miss May
+MacConachie, Head Nurse, St. Elizabeth Dispensary of the Municipal
+Tuberculosis Sanitarium.
+
+March 27th, 1914--"What Should Constitute a Sufficient and Well Balanced
+Diet for Tuberculous People," by Mrs. Alice P. Norton, Dietitian of Cook
+County Institutions.
+
+April 10th, 1914--"Some Points in the Nursing Care of the Advanced
+Consumptive," by Miss Elsa Lund, Head Nurse of the Iroquois Memorial
+Dispensary of the Municipal Tuberculosis Sanitarium.
+
+May 15th, 1914--"Open Air Schools in This Country and Abroad," by Miss
+Frances M. Heinrich, Head Nurse of the Post-Graduate Dispensary of the
+Municipal Tuberculosis Sanitarium.
+
+May 29th, 1914--"Efficient Disinfection of Premises After Tuberculosis,"
+by Professor P. G. Heinemann, Department of Bacteriology, University of
+Chicago.
+
+The organization of the Tuberculosis Study Circle among the nurses of the
+Dispensary Department of the Municipal Tuberculosis Sanitarium, calling
+forth the best efforts of the nurses in getting information on various
+phases of tuberculosis for presentation to their co-workers in an
+interesting manner has, no doubt, stimulated the progress of our entire
+nursing force. The first five papers presented by the nurses are given in
+this series. The pamphlet is published with the idea of attracting the
+attention of other organizations to this method of stimulating more
+intensive study among their nurses.
+
+                            =THEODORE B. SACHS, M. D., President=
+                                Chicago Municipal Tuberculosis Sanitarium.
+
+
+
+
+                    HISTORICAL NOTES ON TUBERCULOSIS
+
+                       By ROSALIND MACKAY, R. N.
+
+        Head Nurse, Stock Yards Dispensary of the Chicago Municipal
+                       Tuberculosis Sanitarium.
+
+
+So far as our information goes, pulmonary tuberculosis has always existed.
+It is, as Professor Hirsch remarks, "A disease of all times, all
+countries, and all races. No climate, no latitude, no occupation, forms a
+safeguard against the onset of tuberculosis, however such conditions may
+mitigate its ravages or retard its progress. Consumption dogs the steps of
+man wherever he may be found, and claims its victims among every age,
+class and race."
+
+Hippocrates, the most celebrated physician of antiquity (460-377 B. C.),
+and the true father of scientific medicine, gives a description of
+pulmonary tuberculosis, ascribing it to a suppuration of the lungs, which
+may arise in various ways, and declares it a disease most difficult to
+treat, proving fatal to the greatest number.
+
+Isocrates, also a Greek physician and contemporary of Hippocrates, was the
+first to write of tuberculosis as a disease transmissible through
+contagion.
+
+Aretaeus Cappadox (50 A. D.) describes tuberculosis as a special
+pathological process. His clinical picture is considered one of the best
+in literature.
+
+Galen (131-201 A. D.) did not get much beyond Hippocrates in the study of
+tuberculosis, but was very specific in his recommendation of a milk diet
+and dry climate. He held it dangerous to pass an entire day in the company
+of a tuberculous patient.
+
+During the next fifteen centuries, a period known as the Dark Ages and
+characterized by most intense intellectual stagnation, little was added to
+the knowledge of pulmonary tuberculosis. In the seventeenth century
+Franciscus Sylvius brought out the relationship between phthisis and
+nodules in the lymphatic glands. This was the first step toward accurate
+knowledge of the pathology of tuberculosis.
+
+Richard Morton, an English physician, wrote, in 1689, of the wide
+prevalence of pulmonary tuberculosis, and recognized the two types of
+fever: the acute inflammatory at the beginning, and the hectic at the
+end. He also recognized the contagious nature of the disease and
+recommended fresh air treatment. He believed the disease curable in the
+early stages, but warned us of its liability to recur. Morton taught that
+the tubercle was the pathological evidence of the disease.
+
+In 1690, Leeuwenhoek, a Dutch lens maker, started the making of short
+range glasses which resulted later in the modern microscope, making
+possible the establishment of the germ theory of disease, including the
+establishment of that theory for tuberculosis.
+
+Starck, whose observations and writings were published in 1785 (fifteen
+years after his death), gave a more accurate description of tubercles than
+had ever been given before, and showed how cavities were formed from them.
+
+Leopold Auenbrugger introduced into medicine the method of recognizing
+diseases of the chest by percussion, tapping directly upon the chest with
+the tips of his fingers. The results of his investigations were published
+in a pamphlet in 1761. This new practice was ignored at first, but after
+the work of Auenbrugger was translated he attained a European reputation
+and a revolution in the knowledge of diseases of the chest followed.
+
+Boyle recognized in miliary tubercle, as it was afterwards called by him,
+the anatomical basis of tuberculosis as a general disease, and, in 1810,
+published the results of one of the most complete researches in pathology.
+He described the stages in the development of the disease, using miliary
+tubercle as its starting point. He opposed the theory that inflammation
+caused tuberculosis and declared hemorrhage a result and not a cause of
+consumption.
+
+Laennec discovered one of the most important, perhaps, of all methods of
+medical diagnosis--that of auscultation. By means of the stethoscope,
+which he invented in 1819, he recognized the physical signs and made the
+first careful study of the healing of tuberculosis; he gave also one of
+the best accounts of the sputum of the consumptive. He believed that every
+manifestation of the disease in man or animals was due to one and the same
+cause.
+
+Up to this time the views which were held concerning the infectious nature
+of tuberculosis were not based upon direct experiment, but in 1843 Klenke
+produced artificial tuberculosis by inoculation. He injected tuberculous
+matter into the jugular vein of a rabbit, and six months later found
+tuberculosis of the liver and lungs. He did not continue, however, his
+researches; so they were soon forgotten.
+
+To Villemin, a French physician, belongs the immortal fame of being the
+first to show the essential distinction in tuberculosis between the virus
+causing the disease and the lesion produced by it. By inoculating animals,
+he demonstrated that tuberculosis is a specific disease caused by a
+specific agent. His paper presented in 1865 before the Academy of Medicine
+in France contained a detailed account of his experimental investigations.
+This was a most remarkable contribution to scientific medicine.
+
+It remained for Robert Koch in 1882, after years of painstaking
+investigation, to announce to the world the discovery of a definite
+bacillus as the causative agent in all forms of tuberculous lesions. Koch
+isolated, cultivated outside the body, described and differentiated the
+infective organism of tuberculosis and proved that it could continue to
+produce the same lesions indefinitely. He showed the presence of the
+bacilli in all known tuberculous lesions and in tuberculous expectoration,
+and demonstrated the virulence in sputum which had been dried for eight
+weeks.
+
+Following directly upon the knowledge of the cause of tuberculosis came
+the recognition of its curability, and the proper means of its prevention.
+Although good food and fresh air have always been considered of importance
+in the treatment of the disease, it was not until the middle of the
+nineteenth century that anything like systematic treatment was undertaken.
+
+Dr. George Bodingon of Sutton Coldfield, England, wrote an essay in 1840
+advocating fresh air treatment. He denounced the common hospital in large
+towns as a most unfit place for consumptive patients, and established a
+home for their care, but met with so much opposition that it was soon
+closed.
+
+In 1856, Hermann Brehmer wrote a thesis on the subject which has been the
+foundation of our modern treatment. He opened a small sanatorium in 1864.
+Five years later he established the sanatorium at Goerbersdorf, in
+Silesia, which eventually became the largest in the world. He advocated
+life in the open air, abundant dietary and constant medical supervision.
+He believed that the heart of the large majority of consumptives is small
+and undeveloped, and that this predisposes them to the disease. In
+accordance with this theory he put a great deal of emphasis on exercise in
+the treatment of his patients. He built walks of various grades on the
+grounds of his sanatorium and installed a system of walking exercise.
+Patients began with the lowest grade, gradually accustoming themselves to
+ascend to the highest. Brehmer was himself a consumptive, and was cured by
+the method he so firmly believed in.
+
+Dr. Dettweiler, who opened the second sanatorium in Germany, at
+Falkenstein, near Frankfort, was also a consumptive, having developed
+tuberculosis during the arduous campaign in the Franco-Prussian War in
+1871. He entered the Goerbersdorf Sanatorium as a patient, becoming later
+an assistant of Brehmer. Dr. Dettweiler laid great emphasis upon rest in
+treatment.
+
+In 1888, Dr. Otto Walther opened his famous sanatorium at Nordrach in the
+Black Forest, in Germany.
+
+The first sanatorium for the care of the consumptive in the United States
+was opened at Saranac Lake by Dr. Edward L. Trudeau in 1884. He was the
+pioneer of the sanatorium treatment in this country, and an example of
+what a man, although tuberculous himself, can do for his fellow men. In
+1874, a seemingly helpless invalid, he made his home in the Adirondack
+Mountains. A little more than twenty-five years ago he became the founder
+of a village now crowded with tuberculous patients. The Saranac Lake
+institution, which began with one small cottage, has since developed into
+the best known sanatorium in this country.
+
+In 1891, Dr. Herman Biggs posted the first anti-spitting ordinance in the
+street railway cars of New York.
+
+Dr. Lawrence Flick brought about the formation of the first
+anti-tuberculosis society in 1892, and in 1894 the City of New York
+adopted a law to enforce notification and registration.
+
+Dr. Philip of Edinburgh was the first to systematically and completely
+organize the anti-tuberculosis campaign. In 1887 he inaugurated that new
+institution, the anti-tuberculosis dispensary, which has since rendered
+such inestimable service. The fundamental principle of the Edinburgh
+system is that the disease should be sought out in its haunts.
+
+The first dispensary in the United States was opened in New York in 1904,
+modeled after the Edinburgh system. About the same time came the Open Air
+Schools--Charlottenburg establishing one in 1904 and Providence, R. I.,
+following in 1908. The first Day Camp in the United States was opened in
+1905 in Boston. New Jersey established the first Preventorium for Children
+at Farmingdale in 1909. All this naturally led to better provision for
+advanced cases; sanatoria for hopeful cases at small cost; factory
+inspection; and, in some countries, industrial colonies for arrested
+cases.
+
+The tuberculosis patient of today presents a hopefulness previously
+undreamt of. The outlook is brighter with promise than ever before, and we
+have every reason to look forward to a steady reduction in the mortality
+rate from this dread disease; but the extinction of tuberculosis will be
+achieved only when the social and economic problems have been solved.
+
+
+
+
+   VISITING TUBERCULOSIS NURSING IN VARIOUS CITIES OF THE UNITED STATES
+
+                        By ANNA M. DRAKE, R. N.
+
+    Head Nurse, Policlinic Dispensary of the Municipal Tuberculosis
+                              Sanitarium.
+
+
+BALTIMORE
+
+In 1903, the first visiting tuberculosis nurse was assigned in Baltimore
+to follow up patients of the Johns Hopkins Hospital Out-patient
+Department. Her duties were varied as are the duties of the present day
+tuberculosis nurse. She was to instruct patients in the use of sunlight
+and fresh air and was allowed to furnish them with special diet in the
+shape of milk and eggs. She investigated home conditions and helped
+improve sleeping quarters. She placed patients in sanatoria, or brought
+them back to the dispensary for treatment. She gave bedside care to
+advanced cases, if she could not get them into hospitals, and applied to
+relief organizations for help in solving the problems of the family. From
+time to time other nurses of the Baltimore Visiting Nurse Association were
+assigned to the work, other dispensaries and agencies began referring
+cases to be followed up, and the work grew to such proportions as to be
+almost unmanageable for a private organization.
+
+In 1910, the Tuberculosis Division of the Baltimore Health Department was
+organized. It began its activities with a corps of fifteen nurses and a
+visiting list of 1,617 patients turned over to it by the Baltimore
+Visiting Nurse Association. The object of the Tuberculosis Division was to
+bring under the supervision of the Health Department all persons in the
+city suffering with pulmonary tuberculosis. Ambulatory cases were to be
+given advice and instruction; advanced cases, bedside care, if needed, or
+hospital care, if available. At present, it is upon the advanced cases, as
+well as those who are in contact with them, that the nurses of the
+Tuberculosis Division concentrate their efforts. The Staff at present
+consists of a Superintendent and sixteen Field Nurses. The city is
+divided into sixteen districts, a nurse being assigned to each district.
+Each nurse is responsible for the care of all cases of tuberculosis in her
+district.
+
+In 1912, the Tuberculosis Division opened two municipal tuberculosis
+dispensaries. These dispensaries receive patients on alternate days from 3
+to 5 p. m., nurses in districts nearest the dispensaries alternating for
+clinic duty. Other dispensaries are the Phipps Tuberculosis Dispensary at
+Johns Hopkins' Hospital, and the University of Maryland Hospital
+Tuberculosis Dispensary.
+
+The problems which chiefly concern the Tuberculosis Division in its
+efforts to control the spread of tuberculosis in Baltimore are the failure
+of physicians to report cases to the Department of Health until the
+patient is in a dying condition, and the inadequate provision for hospital
+care of advanced cases. These conditions are particularly marked in the
+case of colored patients, who are found going in and out of homes,
+restaurants, and laundries, as cooks, waitresses and servants of various
+kinds, as long as they are able to drag themselves about.
+
+The nurses of the Tuberculosis Division are graduate nurses and are
+registered. They are paid $75 a month, with car fare and telephone
+expenses, and are allowed two weeks' vacation with pay. They are not
+required to take a Civil Service examination, but are carefully selected
+with a view to obtaining women of a high grade of efficiency. They wear
+uniforms of blue denim with simple hats and coats, but not of uniform
+design. Each nurse wears under the lapel of her coat a badge reading
+"Nurse--Baltimore Health Department," which she uses on occasions. The
+nurses report to the Superintendent each morning at 8:30 to hand in
+reports of the previous day's work, to stock their bags, and to receive
+new work for the day. At noon each nurse reports at her branch office, of
+which there are seven, each situated on border lines of adjoining
+districts. An hour is spent at the branch office for lunch and rest, for
+receiving telephone calls and for restocking the bags for afternoon
+rounds. The nurse leaves her district at four o'clock to attend to about
+an hour's clerical work, which is usually done at home.
+
+The average number of patients per nurse is 212, about four per cent of
+whom are bed cases. These bed patients are visited two or three times a
+week, while ambulatory cases are visited on an average of twice a month.
+During the year 1912 the sixteen nurses made 72,058 visits for instruction
+and nursing care.
+
+
+NEW YORK
+
+The oldest tuberculosis clinic in New York City is connected with the New
+York Nose, Throat and Lung Hospital; it was established in 1894. In 1895,
+the Presbyterian Hospital established a special tuberculosis clinic. In
+1902, the Vanderbilt Clinic organized a special class for the treatment of
+tuberculosis. In 1903, Gouverneur and Bellevue Hospitals and, in 1904,
+Harlem Hospital added Tuberculosis Clinics. These were followed during the
+next few years by the establishment of many others. In 1906, when the
+Tuberculosis Relief Committee of the New York Charity Organization Society
+began its work among the tuberculous poor of the city, it met at every
+turn instances of overlapping and duplication in the work done by the
+various clinics. This lack of co-operation, with the resulting
+difficulties encountered by the Committee in its endeavor to efficiently
+administer its special tuberculosis fund, demonstrated the advisability of
+forming an organization having as its object the co-ordination of the work
+of the various tuberculosis clinics. In 1908, nine of these clinics and
+several allied philanthropic agencies were organized into the Association
+of Tuberculosis Clinics. Today there are 29 clinics, 14 philanthropic
+institutions and organizations, five departments of municipal and state
+government, six tuberculosis institutions, and numerous other institutions
+and organizations having special interest in tuberculosis work. Of the 29
+clinics, eleven are under the supervision of the Department of Health,
+three are connected with city hospitals, and the remainder are operated by
+private institutions. This voluntary association of private and municipal
+dispensaries, sharing equal responsibilities and acknowledging equal
+obligations, is a striking feature of tuberculosis work in New York and
+presents a unique example of co-operation.
+
+The task of standardizing the clinics was a difficult one. One clinic had
+ten rooms with every convenience. Another had one room and no
+conveniences. Some clinics made no provision for sputum beyond a cuspidor;
+others provided gauze or paper napkins when patients entered the room. Two
+clinics provided no drinking water; two had a metal water cooler in the
+waiting room; one provided sanitary drinking cups; and another had two
+enamel drinking cups chained to the wall. Some clinics had sanitary
+fountains; in others the nurse kept a glass on hand for the patients.
+Neither was there any uniformity in matters of dress. Nurses and doctors
+at some clinics wore ordinary street clothes. At other clinics, gowns or
+aprons, with or without sleeves, were worn. Three clinics occupied
+separate buildings of their own. Four clinics provided separate
+waiting-rooms for tuberculous patients. At one dispensary the tuberculous
+patients had the use of the general waiting room, there being no other
+clinics held at that time; other clinics made no distinction, tuberculous
+patients using the general waiting room in company with patients attending
+other clinics. After studying the conditions existing in the various
+clinics, it was decided that to belong to the association each clinic must
+subscribe to and comply with the following regulations:
+
+  a. Tuberculous patients must be segregated in a separate class.
+
+  b. Home supervision of all cases by a graduate nurse especially assigned
+     for this purpose must be maintained.
+
+  c. Each dispensary must serve a certain district, and all cases living
+     outside of this district must be transferred to the clinic serving
+     the district within which they live.
+
+Early in the history of the Association objection was made to this last
+rule by teachers of medicine, who held that it tended to deprive them of
+teaching material; but they soon fell in line with the other dispensaries
+when they saw the advantage it afforded them of improving their methods
+without loss of teaching material, and the further opportunity of securing
+home supervision.
+
+From time to time it has been necessary for the Association to adopt
+certain methods of procedure in the administration of the various clinics.
+The general policy of the Association is as follows:
+
+  (1) Each clinic should arrange for a physician to visit and treat in
+      their homes patients who are too ill to attend clinic, for whom
+      hospital care cannot be provided.
+
+  (2) Special children's clinics should be established wherever the size
+      of the clinic warrants it.
+
+  (3) Sputum of every patient should be examined once a month; patients
+      should be re-examined once a month, and the results entered on the
+      records.
+
+  (4) The physician should use the nurse's report of home conditions as a
+      basis for advising patients.
+
+  (5) Patients refusing to attend the proper dispensary shall be dismissed
+      as delinquent and reported to the Health Department.
+
+  (6) All supervising nurses should be affiliated with some local relief
+      organization in order to better organize the relief work of the
+      clinic.
+
+  (7) The home of every patient should be visited at least once a month.
+
+  (8) The classification of the National Association for the Study and
+      Prevention of Tuberculosis should be followed for recording stages
+      of disease and condition on discharge.
+
+  (9) A uniform system of record keeping should be used by nurses in order
+      to facilitate the compiling of monthly reports.
+
+  (10) The staff of physicians should be sufficient to allow at least
+      fifteen minutes for the examination of every new case, and at least
+      six minutes for every old case.
+
+  (11) There should be at least one nurse for every 100 patients on the
+      clinic register.
+
+  (12) Sputum cups, or a proper substitute, should be furnished to
+      patients to take home.
+
+  (13) Paper or gauze handkerchiefs should be given to each patient on
+      entrance to the clinic.
+
+  (14) No cuspidors should be used.
+
+  (15) Sanitary fountains or sanitary drinking cups should be provided.
+
+  (16) Gowns with sleeves should be worn by physicians. Nurses should wear
+      gowns with sleeves or washable uniforms while on duty in the
+      dispensary.
+
+That the Association found it necessary to make so many recommendations
+for the administration of the various clinics is evidence of the diverse
+systems, and in some instances, the entire lack of system, in vogue in
+some dispensaries. The salary of nurses in privately operated tuberculosis
+dispensaries averages about $75 per month; no standard uniform is in use.
+
+The first tuberculosis visiting nurse of the New York Department of Health
+was appointed March 1st, 1903. By January, 1910, the staff had grown to
+158, the Health Department becoming practically responsible for the home
+supervision of every registered case of tuberculosis in New York not under
+the care of a private physician or in an institution.
+
+The organization of the work of the new Health Department tuberculosis
+nurses has been based upon the district system in force among the
+Associated Clinics. In each clinic district a staff of Health Department
+nurses is maintained, charged with the sanitary supervision of cases of
+pulmonary tuberculosis in that district. They visit at least once a month
+all "at home" cases; that is, cases not regularly attending clinics, not
+in an institution, or not under a private physician's care. These nurses
+report daily at the tuberculosis clinic, which is used as a district
+headquarters, and there receive assignments. One nurse is detailed as
+Captain, or supervising nurse of the district, and acts as official
+intermediary between the clinic and the Department of Health. Each morning
+the nurse telephones to the Department of Health the daily report of her
+staff and of the clinic, and obtains information received at the
+Department regarding cases in the district. In case of death or removal of
+tuberculous patients from a home the district nurses order disinfection of
+the premises and bedding; they make arrangements for admission of patients
+to hospitals or sanatoria, investigate complaints made by citizens, see
+that regulations of the Department of Health regarding expectoration are
+observed, and use their authority to induce delinquent cases to resume
+attendance at the proper clinic. They also visit families of patients in
+hospitals at intervals. Each nurse keeps a complete index of all cases of
+pulmonary tuberculosis in her district, which is at all times accessible
+to nurses and physicians at the clinic.
+
+In the Department of Health clinics, the plan is as follows: a supervising
+nurse who does no district work, and several field nurses, each assigned
+to special duties on clinic days, such as registration room, throat room,
+examining rooms, etc. Field nurses are also responsible for the care of
+patients in their sub-districts, each nurse carrying an average of about
+125 patients on her visiting list at one time.
+
+
+BOSTON
+
+A staff of twenty-five nurses, working from the Out-patient Department of
+the Boston Consumptives' Hospital, has the supervision of all tuberculosis
+cases in their homes, and the follow-up work on all discharged sanatorium
+and hospital cases in the city of Boston.
+
+All cases of tuberculosis reported to the Health Department, whether under
+the care of a private physician or not, are visited at least once by a
+nurse from this staff, to see that they are carrying out a proper plan of
+isolation.
+
+The Boston Consumptives' Hospital Dispensary, centrally located, is open
+every morning and one or two evenings a week. Three or four nurses are on
+duty in the clinic each morning, taking histories, attending nose and
+throat room and preparing patients for examination. At the dispensary only
+a medical history of new patients is taken, the social history being
+obtained by the nurse on her first visit to the home. Pulse, temperature
+and weight are also taken at the dispensary, after which the patient waits
+his turn for examination. Each new patient is given an examination in the
+nose and throat room; old patients also, if necessary. After examination
+or treatment, all patients return to the general waiting room. From here
+each patient is called before the Chief of Clinic, who notes the general
+progress of the patient, the results of the last examination or any
+remarks recorded by the physician, and the report of home conditions as
+reported by the nurse. The Chief of Clinic advises the patient in
+accordance with the needs indicated. He makes no examinations, but sees
+each patient every time he comes to the clinic and is thus able to follow
+very carefully the progress of each patient and to advise such changes in
+treatment as may seem necessary.
+
+The city is divided into twenty-two districts, each nurse being
+responsible for the care of all tuberculous patients in her district. The
+number of patients cared for by each nurse is from 100 to 180. A very
+small percentage of bedside care is given; far advanced patients as a rule
+are sent to hospitals.
+
+Boston tuberculosis nurses do not wear uniforms. They are paid $900 a
+year, with no increase for length of service or efficiency.
+
+
+BUFFALO
+
+The purpose of the Buffalo Association for the Relief and Control of
+Tuberculosis has been to stimulate progress in fighting tuberculosis. It
+very modestly shares with the city officials and with private charities
+the credit for the work accomplished. All it claims for itself is that it
+has been able, and will continue, to "point the way." How thoroughly it
+has succeeded in this may be seen by the progress made since 1909 when the
+Buffalo Association made its first appeal for funds. At that time Buffalo
+had:
+
+  (1) A dispensary maintained by the Buffalo Charity Organization
+      Society.
+
+  (2) The Erie County Hospital for advanced cases.
+
+  (3) A day camp, with a capacity of thirty patients, supported by a group
+      of women.
+
+  (4) One visiting nurse supplied by the District Nursing Association.
+
+The present facilities are:
+
+  (1) A dispensary, open every day and one evening a week, with a nose
+      and throat clinic, and a dental clinic with a paid dentist in
+      attendance.
+
+  (2) The J. N. Adam Memorial Hospital for early cases, capacity 125,
+      supported by the city.
+
+  (3) The Municipal Hospital for the care of advanced cases, supported by
+      the city.
+
+  (4) The Erie County Hospital, as before.
+
+  (5) Tuberculosis Division of the Department of Health with two
+      tuberculosis inspectors and six visiting tuberculosis nurses.
+
+  (6) An Open Air Camp, with a capacity of from seventy to one hundred
+      patients, with a special department for children. Patients are kept
+      day and night. The camp has three resident trained nurses and one
+      interne, and is visited daily by the Association's paid medical
+      director.
+
+  (7) Two open air schools, with another promised.
+
+  (8) A City Hospital Commission, with a plan for the erection of a
+      pavilion for 500 advanced cases as the first of a general hospital
+      scheme.
+
+  (9) Teachers soon to be appointed for the education of tuberculous
+      children.
+
+  (10) The trades unions organized to promote the campaign among their own
+      members in a unique organization.
+
+  (11) The whole community alert to the menace of tuberculosis, willing to
+      shoulder the community burden and to assume the community
+      responsibility.
+
+The Dispensary is now operated by the Association for the Relief and
+Control of Tuberculosis, and the nurses are supplied by the Health
+Department. The nursing staff consists of a supervising nurse and six
+field nurses, the latter receiving $720 per year. They wear no uniform.
+They give a limited amount of bedside care, some member of the family
+being taught to properly care for the patient, if he cannot be sent to a
+hospital. Recently an additional nurse was engaged by the Association to
+follow up cases on whom no diagnosis has been made and who have not
+returned to the dispensary for re-examination. Since the Dispensary was
+opened in 1909, there have been over one thousand such cases. Many of
+these had suspicious signs when examined, but there has hitherto been no
+means of keeping in touch with them, as the nurses have been obliged to
+confine their attention to positive cases. One of the chief difficulties
+of the Buffalo campaign, as elsewhere, has been the fact that more than
+half of the cases have probably already infected others. This latest
+movement of the Association should anticipate this condition to a certain
+extent, and is one more means by which it is "blazing the trail" toward
+its goal,--"No uncared for tuberculosis in Buffalo in 1915."
+
+
+PHILADELPHIA AND PENNSYLVANIA
+
+In the General Appropriations Act of 1907 the Legislature of Pennsylvania
+granted to the State Department of Health, in addition to its regular
+budget, the sum of $400,000, "to establish and maintain, in such places in
+the State as may be deemed necessary, dispensaries for the free treatment
+of indigent persons affected with tuberculosis, for the study of social
+and occupational conditions that predispose to its development, and for
+continuing research experiments for the establishment of possible immunity
+and cure of said disease."
+
+Immediately after securing the above appropriation, the State Department
+of Health began to establish dispensaries throughout the state, one or
+more in each county. The staff of each dispensary consists of a chief, who
+is also county medical inspector, and a corps of assistant physicians and
+visiting nurses. There is a supervising nurse with one assistant at
+Harrisburg, who oversee and inspect the work of the staff nurses.
+
+The number of nurses in the dispensaries throughout the state varies from
+a nurse shared by another organization or a practical nurse giving part
+time, to from four to seven nurses in one dispensary. There are now more
+than 115 State Department Tuberculosis Dispensaries in Pennsylvania,
+Philadelphia having three.
+
+An idea of the general plan of the work may be gained from a description
+given of the State Department Dispensary No. 21, located in Philadelphia,
+by Dr. Francine:
+
+    "There are at present five nurses employed at Dispensary No. 21,
+    two of whom give their whole time to following up the return
+    cases from the State Sanatoria. As soon as the case is
+    discharged from the sanatorium, that information, with other
+    data regarding the condition on discharge, etc., is sent to us
+    at once. At the end of a stated period, if that case has not
+    been returned, the nurse looks it up, and gets it to come in.
+    The nurses make out detailed reports on all cases discharged
+    from the sanatoria, at periods of six months, whether our own
+    patients or not. These will be and are valuable for statistical
+    data. Practically all the data for reports as to subsequent
+    results in cases discharged from the sanatoria, which have
+    appeared in this country at least, have been made up from
+    information gleaned by writing the discharged patient and having
+    him fill out his own report. It does not tax the imagination
+    unduly to conclude which is the more accurate, the answers to
+    questioning by a trained worker (we have selected for this work
+    the two nurses who have been with us longest) who in addition
+    takes the temperature, pulse, etc., herself, and usually
+    succeeds in getting the patient back to the dispensary for at
+    least one re-examination; or such answers as a patient may see
+    fit to make to a printed questionnaire.
+
+    For the purpose of regular dispensary and inspection work, the
+    dispensary limits itself to receiving patients from certain
+    districts of the city, though as a state institution it is
+    impossible for the dispensary to refuse any case, no matter
+    where they live, if they insist upon treatment. Usually by a
+    little persuasion, however, we can get the patients to go to the
+    dispensary in their district, co-operating in this way with the
+    Phipps Institute of the University of Pennsylvania, the Gray's
+    Ferry State Dispensary, the Kensington Tuberculosis Dispensary
+    and the Frankford State Dispensary. The section of the city from
+    which we draw our cases is divided, for purposes of inspection
+    and Social Service Work, into three districts with a nurse
+    assigned to each, and this gives each of our nurses, roughly
+    speaking, about seventy-five patients per month to take care of.
+    These patients must be visited regularly every two weeks, which
+    gives the nurse at least one hundred and fifty visits a month to
+    pay, not including the visits to new cases.
+
+    Every new case which is admitted to the dispensary must be
+    visited within one week of the day of admission. The nurses come
+    in from their visiting work and report daily at 12:30 o'clock,
+    for one hour in the dispensary office, and new cases, according
+    to the district in which they live, are assigned to the nurse
+    having charge of that district. The advantage of having a nurse
+    report daily to the dispensary at a time when all the doctors
+    are there, lies in the fact that the doctor has thus the
+    opportunity of talking over with the nurse the new cases which
+    she is to visit and of making any suggestions which he has
+    gleaned from the history and examination of the patient. It is
+    thus possible for the nurses to visit the new cases in the
+    afternoon of the same day. The advantage of this close
+    co-operation between doctor and nurse must be at once apparent.
+    Further, each nurse is required to report to every physician one
+    morning a month, with the histories in hand of all the patients
+    of that particular doctor which are on her list. This is
+    valuable, because in no other way can the doctor get so thorough
+    an understanding of the home conditions and social problems of a
+    given patient as by talking the situation over directly and
+    personally with the nurse in charge."
+
+A similar plan is in operation at the other two State Department Clinics
+in Philadelphia.
+
+The best known tuberculosis dispensary in Philadelphia, conducted by a
+private organization, is the dispensary connected with the Henry Phipps
+Institute. This dispensary during the eleven years of its existence has
+contributed greatly to the standardization of tuberculosis dispensary
+work, not only in Philadelphia, but throughout the entire country.
+Connected with a scientifically conducted hospital for advanced cases,
+with its laboratories and other improved medical facilities, the
+Dispensary of the Henry Phipps Institute occupies a high place among the
+similar institutions of this country. The nursing staff of the Henry
+Phipps Dispensary consists of three visiting tuberculosis nurses, aided by
+two additional nurses (both colored) assigned by other organizations to
+work on the Phipps Dispensary staff, one by the Whittier Centre, and the
+other by the Pennsylvania Society for the Prevention of Tuberculosis. Some
+of the important features of the work of this dispensary in its relation
+to nurses are as follows:
+
+  (1) An efficient training school for tuberculosis nurses, affording the
+      opportunity of hospital and dispensary training.
+
+  (2) A course of lectures on tuberculosis given to the nursing profession
+      at large.
+
+  (3) Intensive home work among tuberculous families.
+
+Visiting tuberculosis work in Philadelphia is also done in connection with
+the Presbyterian Hospital Tuberculosis Clinic, St. Stevens Church
+Tuberculosis Clinic, and by the Visiting Nurse Society of Philadelphia.
+
+
+PITTSBURGH
+
+The Tuberculosis League Hospital of Pittsburgh was opened in 1907 for
+incipient and advanced cases, with a capacity of eighty beds. The League
+conducts at present a night camp, an open air school, a farm colony, a
+post-graduate course for nurses and tuberculosis clinics for medical
+students at its dispensary. There is also a post-graduate course in
+tuberculosis for nurses. The course requires eight months and nurses
+receive during that time $25 a month. Only registered nurses are accepted.
+The training is along the following lines: nursing advanced cases in
+hospital, open air school work, sanatorium care of early cases, service in
+dental, nose and throat clinics, and in the dispensary for ambulant cases,
+district nursing, service in baby clinics, educational work, and
+laboratory work. Patients discharged from the hospital, families of
+patients in the hospital, and cases reporting at various tuberculosis
+dispensaries, are given complete follow-up care by the nurses taking the
+course, thus giving them excellent training in public health work,
+especially that phase of public health nursing dealing with tuberculosis.
+At present there are nine nurses taking the course. The Dispensary of the
+Tuberculosis League employs six nurses.
+
+Pittsburgh has also a State Department of Health Tuberculosis Clinic, with
+ten nurses, each caring for from 90 to 100 patients per month. These
+nurses give a small percentage of bedside care and are not in uniform,
+except when on duty in the dispensary. They are paid $70 per month. The
+plan of work is similar to that of the Philadelphia State Dispensary.
+
+The Department of Public Health of Pittsburgh employs four visiting
+nurses, who investigate home conditions and instruct patients reported to
+the department who are not under the close supervision of a private
+physician, the State Department Clinic, or the Tuberculosis League Clinic.
+The nurses are able to correlate, in a way, the work of the two
+dispensaries by assigning patients to the clinic in the district in which
+they live. They receive $75 per month and are not in uniform.
+
+Pittsburgh, then, has in all twenty visiting tuberculosis nurses, under
+three separate and distinct organizations.
+
+
+CLEVELAND
+
+In Cleveland, as in nearly every other city, the work of organizing the
+fight against tuberculosis was accomplished by private organizations, the
+Anti-Tuberculosis League and the Visiting Nurse Association. For a number
+of years the Health Department confined itself to keeping a card
+catalogue of reported cases. In 1910 sufficient funds were voted by the
+City Council to enable the establishment of a separate Bureau of
+Tuberculosis, whose duty should be the development of municipal
+tuberculosis work. This Bureau has taken over and gradually developed five
+dispensaries, with a staff of twenty-four visiting tuberculosis nurses,
+and paid physicians, besides the director and office force. The work in
+Cleveland is centralized in its Health Department.
+
+General dispensaries are required to refer all cases of tuberculosis to
+the tuberculosis dispensaries, and physicians are required to report all
+cases to the Health Department. On report cards and sputum blanks is the
+statement: "All cases of tuberculosis reported to the department will be
+visited by a nurse from this department unless otherwise requested by the
+physician." With very few exceptions the physicians are glad to have a
+nurse call, and every effort is made to co-operate with the physicians in
+handling the case.
+
+The city is divided into five districts, with a dispensary located in each
+district. Patients are treated only at the dispensary serving the district
+in which they live. "This plan prevents cases wandering from one clinic to
+another and enables the nursing force to do more intensive work in each
+district."
+
+Once a week the chief of the Bureau of Tuberculosis and the Superintendent
+of Nurses meet with each separate dispensary staff, and cases are
+carefully considered and work discussed. In addition, meetings of the
+active nursing staff are held, informal talks on tuberculosis being given,
+or the work of allied organizations studied, speakers coming from the
+Associated Charities, Department of Health, Settlement Houses, etc. Each
+nurse is held responsible for the handling of every individual case in her
+district. By thus making the nurse responsible, the interest in her work
+is increased and much better results are obtained. If the problem
+presented is one that will take more time and energy than the busy
+dispensary nurse can give, it is referred to a Special Case Committee.
+
+All dispensary cases are visited in the home within twenty-four hours
+after the first visit to the dispensary, where a complete history of the
+case is taken. The patient and family are instructed and each member urged
+to come to the clinic for examination. Homes where a death from
+tuberculosis has occurred are visited immediately, with the consent of the
+physician. The family is carefully instructed as to disinfection, and
+advised to go to the physician or dispensary for examination.
+
+Cleveland nurses wear uniforms. Each nurse carries about three hundred
+patients, a very small percentage being bed cases, usually not more than
+two patients at a time. Nurses receive $60 for each of the first three
+months; $65 for each of the next nine; $70 a month for the second year;
+the third year $80; and the fourth year $85.
+
+
+DETROIT
+
+The Detroit Board of Health maintains a staff of ten visiting tuberculosis
+nurses. They give a small percentage of bedside care, wear a uniform, and
+receive $1,000 per year. They work in connection with the Board of Health
+Dispensary and have the same general follow-up plan as other cities.
+
+
+MILWAUKEE
+
+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.
+
+[Illustration]
+
+  --------------------------------------------------------------------------
+  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.
+
+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.
+
+=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.
+
+During its first year the Charlottenburg School was open for only three
+months, but upon publication of the first report of the results
+accomplished it was decided to keep the school open a longer period. The
+desire to open other schools of similar type spread rapidly throughout
+Germany, as well as the rest of Europe and other parts of the world.
+
+Probably the best argument for maintaining such schools was not only the
+physical benefit derived, but the actual advance made by the children in
+their studies, although they spent less than half as much time on school
+work as did their companions in the regular schools, not only fully
+maintaining their standing, but ever surpassing their companions in the
+regular classes. Through results obtained from this first experiment in
+Charlottenburg came the resolve on the part of school authorities of other
+cities to inaugurate Open Air Schools in their respective localities, and
+in less than three years the movement had spread to England, where, in
+1907, London opened her first school, modeled after that of
+Charlottenburg.
+
+The same remarkable results obtained during the first season here, as in
+the three years previously reported from Charlottenburg, awakened such
+popular enthusiasm that towns and cities in different parts of England
+began to plan for similar schools in the communities most needing them.
+
+Meanwhile, the movement spread to the United States. In 1908, one year
+after England had established her first Open Air School, this country
+opened its first Open Air School in Providence, Rhode Island. Although
+Providence has the distinction of priority in this matter, the school
+inaugurated by Providence was not, strictly speaking, the first Open Air
+School established on American territory, as a school of this type was
+opened in 1904 in San Juan, Porto Rico, by L. P. Ayres, now Associate
+Director of the Department of Hygiene of the Russell Sage Foundation, at
+that time Superintendent of Schools for Porto Rico. The San Juan school
+was an experiment. It was built to accommodate 100 children. It was simple
+in its arrangements; it had a floor and roof but no sides. Venetian blinds
+were provided to keep out rain and the too direct sunlight. The school was
+designed for children of no particular class, but was established in the
+endeavor to demonstrate that the regime which has proven beneficial for
+weak and ailing children will also benefit those that are strong and
+seemingly healthy. The results demonstrated fully the correctness of this
+idea. The children greatly preferred the outdoor classes, and even the
+teachers were most anxious to be assigned to outdoor work. Since then at
+least one more school of similar type has been opened in Porto Rico.
+
+Before showing what the United States has done in this very important
+movement, it might be interesting to learn how Germany and England have
+further developed their program, as the work done in these countries,
+particularly in Germany, served as the basis of the Open Air School
+movement in this country in the initial stages of its development.
+
+For the past fifteen years Germany has carried on medical inspection of
+schools in a very thorough and efficient manner. This has drawn special
+attention to backward children. These children are treated there in
+special classes and sometimes in special schools. The quantity of
+instruction given them is reduced and every endeavor is made to increase
+its effectiveness. The classes are taught by capable teachers and the
+children have the benefit of suitable dietary, bathing and other hygienic
+provisions.
+
+In Charlottenburg, in 1904, there were a large number of backward children
+who were about to be removed from the ordinary elementary schools to
+special classes. When examined, it was found that many of them were in a
+debilitated condition owing to anaemia, or various other ailments in an
+incipient stage. This circumstance afforded an ideal opportunity for the
+co-operation of the teacher and the school physician in devising and
+operating, for such children, an Open Air School. The general school
+regime was modified to meet the educational and physical needs of these
+children, the treatment consisting, as above stated, of abundance of fresh
+air, pleasant and hygienic surroundings, careful supervision, wholesome
+food and judicious exercise. The ordinary school work was modified to meet
+the individual condition of children; the hours of teaching were cut in
+two and the classes so reduced that no teacher had more than twenty-five
+pupils under her care. The site chosen for the first school in
+Charlottenburg was a large pine forest on the outskirts of the town. The
+sum of $8,000 was granted by the municipality for carrying out the plan,
+and inexpensive but suitable wooden buildings were erected. At first
+ninety-five children were admitted to the school, but later the number was
+increased to 120, and still later to 250. These children were mainly
+anaemic or suffering from slight pulmonary, heart or scrofulous
+conditions. Those suffering from acute or communicable diseases were
+rigidly excluded. Of the five buildings erected, three were plain sheds
+about 81 feet long and 18 feet wide, one of them being completely open on
+the south side and closed on the other sides, of sufficient size to
+shelter during rainy weather about 200 children. The other two sheds
+contained five classrooms and a teachers' room. These were closed in on
+all sides, provided with heating arrangements, and used for classrooms
+during very cold or unpleasant weather, only one of the buildings was
+fitted with tables and benches intended for meals, or for work in
+inclement weather. This building was open on all sides. All over the
+school grounds, which were fenced in, there were small sheds open on all
+sides, fitted with tables and benches to accommodate from four to six
+children. These served as shelters. There were small buildings for shower
+baths, kitchen and a separate shed where the wraps of the boys and girls
+were kept. In these were individual lockers which contained numbered
+blankets for protection against cold, and waterproofs against rain.
+
+The children in this school report at a little before 8 a. m. and leave at
+a quarter of 7 p. m. For breakfast they are given a bowl of soup and a
+slice of bread and butter. Classes commence at 8 o'clock and continue with
+an interval of five-minutes' rest after each half hour. At 10 a. m. the
+children receive one or two glasses of milk and a slice of bread and
+butter. After this they play, perform gymnastic exercises, do manual work
+or read. Dinner is served at 12:30 p. m. and consists of about three
+ounces of meat, with vegetables and soup. After dinner the children rest
+or sleep for two hours on folding chairs. At 3 p. m. comes more class work
+and at 4 p. m. milk, rye bread and jam is given. The rest of the afternoon
+is given over to informal instruction and play. The last meal consists of
+soup, bread and butter, after which the children are dismissed. Some walk
+home; some use street cars. In case of the very poor children the city
+pays the fare, while the transportation is furnished for others through
+the generosity of the street car company. The expense of the feeding is
+borne by the municipality, in the case of those who can not pay, and, for
+the others, is defrayed in part or whole by the parents.
+
+The work of the school physician consists of careful examination,
+treatment and supervision of these children. Attention is principally
+directed to heart, lungs and general condition with respect to color,
+muscular and flesh development. Weight and measurements are taken every
+two weeks, and at the end of the school period the children are very
+carefully examined and condition compared with that noted upon their
+admission.
+
+The regime covers such important phases of hygiene as suitable clothing,
+attention to daily habits, bathing, giving of warm baths for those who are
+anaemic and nervous, and of mineral baths for those who are scrofulous.
+Bathing plays a very important part. All of the children receive two or
+three warm shower baths a week. A trained nurse is in attendance.
+
+The educational, physical and moral results obtained are remarkable. There
+is a great improvement in their behavior, especially with regard to order,
+cleanliness, self-help, punctuality and good temper. This is undoubtedly
+due to their removal, during practically all of their waking hours, from
+the influences of the street life to the more wholesome influences of the
+school. The children are taught to regard themselves as members of a large
+family, are trained to assist in the daily work and are taught to be
+helpful and considerate of each other.
+
+This, in detail, is the regime of the first Open Air School conducted in
+Germany.
+
+The number of Open Air Schools at present in Germany is at least ten, with
+an attendance of approximately 1,500.
+
+       *       *       *       *       *
+
+In England the Open Air Schools were made possible through the work of the
+local educational authorities and co-operation of dispensaries for
+treatment and care of tuberculous children.
+
+As in other countries, general legislation for the control of tuberculosis
+has had considerable bearing on the Open Air School situation in England.
+Among the legislative acts should be mentioned:
+
+    (a) The Act of 1911 providing building grants for the
+        establishment of sanatoria, dispensaries and other auxiliary
+        institutions.
+
+    (b) Compulsory notification of tuberculosis, etc.
+
+Notification of tuberculosis, for instance, besides bringing to notice of
+the school medical officer cases of tuberculosis which might otherwise not
+come before him until a late period, serves in many cases to keep him
+informed as to "contact cases"--cases of children in contact with
+communicable tuberculosis.
+
+At Burton-on-Trent a system was instituted for periodical examination of
+school children who are either members of a family in which there is or
+has been a case of pulmonary tuberculosis, or who are attending school
+while residing in houses in which there is an existing case of this
+disease. All notified cases of tuberculosis are visited by the Assistant
+Medical Officer of Health, who is also Assistant School Medical Officer,
+and the names of any children living in the house, or related to the
+case, are ascertained, together with the school they are attending. These
+names are entered in a special register and when the pupils of a school,
+at which any of these children are attending, are examined, a special
+examination is made of the latter. This examination is repeated two or
+three times a year.
+
+In another part of England a special letter is sent to the occupants of
+all houses from which the disease has been notified, calling attention to
+the special importance of early detection of tuberculosis in children, and
+asking that the children should be brought to the school clinic for
+examination.
+
+In Lancashire the Medical Inspector calls on the Medical Officer of Health
+and obtains a list of names of persons suffering from tuberculosis, so
+that the children, if of school age, may be examined.
+
+At Newcastle-on-Tyne all children exposed at any time to infection are
+kept under observation and re-examined. The re-examination continues even
+after fatal termination of the tuberculosis case with which the child was
+in contact.
+
+Under the Finance Act of 1911 a sum of about $500,000 was especially
+appropriated for providing what are known as "Sanatorium Schools" for
+children suffering from pulmonary or surgical tuberculosis. These schools
+are known as the Residential Open Air Schools of Recovery, and the need of
+such schools for children requiring more continuous care than is provided
+at a day Open Air School is becoming widely recognized. Many children of
+the type already mentioned can not be satisfactorily treated unless they
+can be taken completely away, for a time, from their home environment.
+Such treatment as is needed for many of these children is not and can not
+be offered in the ordinary hospital and certainly not at their homes.
+
+The designs and arrangements of the Residential Open Air School of
+Recovery are very attractive. They are well equipped to fulfill their
+function. The children, received between the ages of seven and twelve
+years, are those suffering from anaemia, debility, or slight heart
+lesions. Cases of active tuberculosis are barred. No child is received for
+a shorter period than three months, and this period may be prolonged on
+the recommendation of the Medical Officer.
+
+The children rise at 7 a. m. and retire at 6:30 p. m. Those who are able,
+make their own beds and do some of the domestic work. The diet is liberal,
+with abundance of milk and eggs. Careful attention is given to inculcating
+habits of personal and general hygiene. All children receive a daily bath.
+Careful attention is paid to the teeth, tonsils and adenoids. All these
+conditions must be attended to before admission. Beyond this, very little
+treatment is given. Children are weighed once in two weeks. Instruction is
+chiefly practical. Instruction in gardening is given twice a week and
+other occupations taught are raffia work, plasticine modeling, cardboard
+modeling, brush work and needle work.
+
+The number of Open Air Schools at present in England is at least
+thirty-five, with an attendance of at least 2,500. Forty-two other cities
+are listed as carrying on some form of open air education.
+
+       *       *       *       *       *
+
+In the United States the Open Air School movement, from its inception, has
+been closely connected with the general anti-tuberculosis movement.
+
+The credit of establishing the first Open Air School in America belongs,
+as previously stated, to Providence, Rhode Island, where the work was
+begun in January, 1908. The school was opened in a brick school house in
+the center of the city. A room on the second floor was chosen and
+remodeled by removing part of the south wall. For the wall thus removed
+windows were substituted. These extended from near the floor to the
+ceiling, with hinges at the top and with pulleys so arranged that the
+lower ends could be raised to the ceiling. The desks were placed in front
+of the open windows in such a manner that the children received the fresh
+air at their backs and the light over their shoulders. Suitable clothing
+was provided for cold weather and, in case of necessity, soapstone foot
+warmers were used.
+
+The school was started as an ungraded school and ten pupils were enrolled
+at the time of its opening, the number later increasing to twenty-five.
+Practically all children were selected by the visiting nurse of the local
+League for the Suppression of Tuberculosis from infected homes under her
+supervision. In a few instances children with moderately advanced lesions
+were admitted.
+
+The children reported at 9 a. m. and a recess was given at 10:30, when
+they were served soup. At noon they had a light lunch of pudding served
+with cream, hot chocolate or cocoa made entirely with milk. Some of the
+children brought additional food from home. All of the cooking was done by
+the teacher. Careful attention to general cleanliness and hygiene of the
+teeth was insisted upon. Individual drinking cups and tooth brushes were
+provided. The children took turns in washing dishes, setting the table and
+helping to serve. Children were dismissed at 2:30 p. m. They were
+provided with car tickets by the League for the Suppression of
+Tuberculosis, some for traveling both ways, some for one way only,
+depending upon the means of the family. During school session light
+gymnastic exercises were given and proper methods of breathing taught. In
+the spring they had a garden to work in.
+
+The Providence school is at present a part of the general school system.
+The school supplies and teacher's salary are furnished by the Board of
+Education. Food and carfare are supplied by the League for the Suppression
+of Tuberculosis. A physician is delegated by the League and one of the
+regular Medical Inspectors of the city schools works in co-operation with
+him.
+
+Providence has at present two schools, with an attendance of forty. One
+more Open Air School and two roof classes may be provided by the Board of
+Education in 1914. In addition, the Providence League for the Suppression
+of Tuberculosis conducts a Preventorium for thirty children at the
+Lakeside Preventorium, Rhode Island.
+
+       *       *       *       *       *
+
+Boston started its first Open Air School in July, 1908. The work was
+carried on by the Boston Association for the Relief and Control of
+Tuberculosis. The school was located at Parker Hill, Roxbury. The same
+regime was followed as in previously reported schools. No formal
+instruction, however, was attempted at first. The school was simply a day
+camp. The benefit derived by the children in the first open air camp for
+children led the Association to ask the Boston School Board to co-operate
+with them in converting the camp into an outdoor school. This was agreed
+to, the School Board supplying teacher, desks, books, etc., the
+Association furnishing the necessary clothing, food, a nurse, attendants,
+home instruction and medical services. The same schedule was followed here
+as in the other Open Air Schools. General and personal hygiene was
+insisted upon. The school was kept open Saturdays and during the holidays.
+The children who were able paid ten cents a day to help defray the cost of
+food. In case they could not afford this, the money was supplied by some
+charity organization. While the combined public and private support had
+proved satisfactory, it seemed best, for many reasons, to reorganize the
+school so that it would be entirely under municipal authority, and this
+has since been done. At the present time the school is maintained by the
+Boston Consumptives' Hospital and the Boston School Board. The hospital
+furnishes transportation, food, etc., while the School Board gives school
+supplies, books, desks, etc., and pays the salaries of the teachers. The
+children are selected by the school physicians, the type considered being
+the anaemic, poorly nourished, those with enlarged glands, or
+convalescents. Cases of active tuberculosis are not admitted.
+
+Boston has at present fifteen Open Air Schools, with a total enrollment of
+about 500 children.
+
+       *       *       *       *       *
+
+The first school established in New York City was started under the
+auspices of the Department of Education and was located on the ferryboat
+Southfield, which was maintained as an outdoor camp for tuberculous
+patients by Bellevue Hospital. It was through the special desire of the
+children who were patients at the camp that the school was started, for
+they banded together one day and informed the doctor that they wanted to
+have a teacher and attend school. When their action was reported to the
+Board of Education it was felt that such an unusual plea should be given a
+favorable response, and in December, 1908, the school on the ferryboat was
+made an annex of Public School No. 14.
+
+This school, except for its location, does not differ from other schools
+of similar type. The Board of Education pays the teacher and furnishes the
+school supplies. Food and clothing are supplied by the hospital. The
+school is an ungraded one and the number of children taught by one teacher
+averages thirty.
+
+Four more Open Air Schools have since been established, three on
+ferryboats and one on the roof of the Vanderbilt Clinic at West Sixtieth
+street. Officially, all these schools are considered to be annexes of the
+regular public schools.
+
+In October, 1909, $6,500 was granted to the Board of Education by the
+Board of Estimate and Apportionment for the purpose of remodeling rooms in
+some of the public schools for use as Open Air Rooms. A special conference
+was held in December of that year by medical and school authorities to
+decide how best to remodel, furnish and equip these new rooms for this
+purpose; also how the children should be chosen for these classes.
+
+It was decided that the maximum number of children admitted to any one
+open air classroom should not exceed twenty-five, the children to be
+chosen by the director of the tuberculosis clinic nearest the school and
+the school principal. No child was to be assigned to the room until the
+parents' permission had been secured in writing. Children moving from one
+district to another were to be followed up and cared for in the new
+district. No special rule was adopted defining the physical condition
+entitling the child to admission. Each case was to be considered
+individually, and the only definite rule was that no open case of
+tuberculosis should be admitted. The minimum temperature of the room was
+50 degrees F. The rooms, wherever possible, were to be located on the
+third floor. The first of these open air classes was established in April,
+1910. Such popular interest was awakened by the inauguration of these
+classes that, as a direct result, a special privilege was granted by the
+Commissioners of Central Park permitting children of the kindergarten
+classes of the public schools to pursue their studies in the open air in
+Central Park.
+
+At present New York has thirty-three Open Air Schools and Open Window
+Rooms, with a total enrollment of at least 1,000.
+
+       *       *       *       *       *
+
+Chicago's first Outdoor School for Tuberculous Children was inaugurated as
+a result of the joint co-operation of the Chicago Tuberculosis Institute
+and the Board of Education. This school was opened during the first week
+of August, 1909, on the grounds of the Harvard School at Seventy-fifth
+street and Vincennes Road. The Board of Education assigned a teacher to
+the school and furnished the equipment, while the Tuberculosis Institute
+supplied the medical and nursing service, selected the children and
+provided the food.
+
+Except during inclement weather, the children occupied a large shelter
+tent in which thirty reclining chairs were placed. Meals were served in
+the basement of the school building, where a gas range, cooking utensils
+and tables were installed for this special purpose.
+
+The nurse, who was assigned by the Tuberculosis Institute on half-time
+attendance, visited the school each afternoon, took daily afternoon
+temperatures, pulse and respiration, looked after the general physical
+condition of the children, made weekly records of their gain or loss in
+weight and did instructive work in the home of each pupil.
+
+Of the thirty children selected, seventeen had pulmonary tuberculosis, two
+had tubercular glands, and eleven were designated as "pre-tuberculous."
+None of the children had passed to the "open" or infectious stage. On
+admission two-thirds of the children showed a temperature of from 99 to
+100.2 degrees.
+
+The daily program was similar to that already described for the Providence
+and Boston Schools. The school was kept open for a period of only one
+month, with excellent results. During this time the thirty children made a
+net gain of 115 pounds in weight, and at the close of the period
+practically all of them showed a normal temperature, with their general
+condition greatly improved.
+
+It is needless to say that the experiment created a great deal of local
+interest in the problem of better school ventilation. Those who had the
+success of the movement most intimately at heart realized, however, that
+the undertaking lacked the element of permanency and that the results
+accomplished by it lacked that degree of conclusiveness which would attend
+the same results if secured through the operation of an all-the-year-round
+school.
+
+The opportunity to demonstrate the effectiveness of such an
+all-the-year-round school was realized in the Fall of 1909 by a grant from
+the Elizabeth McCormick Memorial Fund to the United Charities for the
+purpose of conducting such a school on the roof of the Mary Crane Nursery
+at Hull House. This school was opened by the United Charities in October
+with twenty-five carefully selected children, and was conducted throughout
+the following winter and spring with the co-operation of the Board of
+Education and the Chicago Tuberculosis Institute. During the same winter
+the Public School Extension Committee of the Chicago Women's Club,
+co-operating with the Board of Education, established two classes for
+anaemic children in open window rooms--one in the Moseley and one in the
+Hamline School. Here the regular regime was broken by a rest period, and
+lunches of bread and milk were served twice each day. "Fresh Air Rooms,"
+in which the windows were thrown wide open and the heat cut off, were also
+established for normal children in several rooms in the Graham School. No
+attempt was made here to furnish lunches and no rest period was provided.
+
+There were, then, during the school year of 1909 and 1910, three distinct
+classes of children cared for by three distinct agencies--the classes for
+normal children in the low temperature rooms at the Graham School; anaemic
+children, with rest period and two lunches, in the Moseley and Hamline
+Open Window Rooms, and the Roof School for Tuberculous Children, with
+specially provided clothing, sleeping outfits, three meals a day and
+medical and nursing attendance, at the Mary Crane Nursery.
+
+The same condition existed throughout the following year--1910-11--with
+the addition of one Open Air School on the roof of the municipal bath
+building on Gault Court, given rent free by the City Health Department,
+and two Open Window Rooms for anaemic children in the Franklin School, all
+maintained by the Elizabeth McCormick Memorial Fund.
+
+In 1911 the Elizabeth McCormick Memorial Fund assumed the responsibility
+for all the open air school work carried on in the Chicago Public
+Schools, and began the standardization of methods which should be employed
+in the conduct of such schools.
+
+Through the initiative of the Elizabeth McCormick Memorial Fund the
+Chicago Open Air School work has been rapidly developed during 1912 and
+1913, the program being along the line of additional roof schools for
+tuberculous children and an increasing number of open window rooms for
+anaemic children and children exposed to tuberculosis. In all this work
+the Elizabeth McCormick Memorial Fund has had the co-operation of the
+Board of Education, the Chicago Tuberculosis Institute and the Municipal
+Tuberculosis Sanitarium. The Board of Education has supplied teachers and
+furnished rooms wherever there has been a distinct demand for such a
+provision. During the past two years the Municipal Sanitarium has made
+appropriations aggregating $12,000 to pay the cost of food for these
+schools, in addition to furnishing the necessary nursing service.
+
+At the present time four Roof Schools and sixteen Open Window Rooms, with
+an enrollment of 500 pupils, are being maintained.
+
+For full information concerning the Chicago Open Air School movement, see
+"Open Air Crusaders," January, 1913, edition, published by the Elizabeth
+McCormick Memorial Fund, 315 Plymouth Court, Chicago; or write Mr. Sherman
+C. Kingsley, Director, Elizabeth McCormick Memorial Fund, for more recent
+developments.
+
+       *       *       *       *       *
+
+Space will not permit a statement of the development of the Open Air
+Schools in other cities in the United States since this movement was
+started in 1908. It is, however, encouraging to note what has been
+accomplished and the comprehensive plans which are being made to further
+this great movement for the good of the future citizens of America.
+
+[Illustration]
+
+
+
+
+                      NOTES ON TUBERCULIN FOR NURSES
+
+   VARIETIES OF TUBERCULIN--THEORIES OF TUBERCULIN REACTION--TUBERCULIN
+                                 TESTS.
+
+                      By THEODORE B. SACHS, M. D.
+
+
+           VARIETIES OF TUBERCULIN AND METHODS OF PREPARATION
+
+OLD TUBERCULIN--T. Announced by Koch in 1890.
+
+    Tubercle Bacilli of human origin.
+
+    Grown on beef broth containing 5% glycerine, 1% peptone, sodium
+      chloride; growths 6 to 8 weeks.
+
+    Sterilized by steam one-half hour.
+
+    Evaporated (at a temp. not higher than 70° C.) to 1/10 its volume.
+
+    Filtered.
+
+    1/2% carbolic acid added. Let stand.
+
+    Filtered (porcelain filter).
+
+  Old Tuberculin contains:
+
+    1. 40 to 50% glycerine (a small percentage of glycerine is
+       evaporated)
+
+    2. 10% of peptones or albumoses
+
+    3. Toxic secretions of the tubercle bacilli into the culture fluid, or
+       such of them as are soluble in 50% glycerine
+
+    4. Substances extracted from the bacterial bodies by the alkaline
+       broth during the process of boiling and evaporation.
+
+  Appearance and Characteristics:
+
+    1. A clear brown fluid
+
+    2. Of syrupy consistency
+
+    3. Mixes with water in all proportions without producing any turbidity
+
+    4. Keeps indefinitely, but not advisable to use brands older than one
+       year.
+
+BOULLION FILTRATE--B. F. Denys--1907.
+
+    Method of preparation same as Old Tuberculin, with the exception of
+      subjection to heat;
+
+    B. F. is a filtered, unconcentrated culture.
+
+    Contains less peptone and less glycerine than Old Tuberculin.
+
+    Contains no substances extracted from tubercle bacilli by heat.
+
+    Some toxic substances may be more active (not having been subjected to
+      heat).
+
+TUBERCULIN RUCKSTAND (Residue)--T. R. Announced by Koch in 1897.
+
+    Ground, dried tubercle bacilli.
+
+    Distilled water added.
+
+    Centrifugalization.
+
+    Supernatant fluid removed (not to be used).
+
+    Sediment dried and ground; distilled water added; centrifugalization.
+
+    Fluid removed and _set aside_.
+
+    Sediment dried and ground again; distilled water added;
+      centrifugalization.
+
+    Fluid removed and set aside.
+
+    Sediment dried and ground, etc., as above.
+
+    The process continued until water takes up the sediment, then all the
+      fluids set aside (except the first one) mixed together.
+
+    Glycerine 20% added.
+
+    The mixture is T. R.
+
+Koch was prompted by the following consideration in bringing out T. R.: He
+thought that the Old Tuberculin conferred only a toxic immunity, not
+bacterial. T. R. was supposed to confer bacterial immunity.
+
+Each 1 cc. of T. R. contains 10 milligrams of dried bacilli.
+
+BACILLEN EMULSION--B. E. Announced by Koch in 1901.
+
+    Finely powdered tubercle bacilli--1/2 gram.
+
+    50 cc. of water and 50 cc. of glycerine.
+
+    All mixed together--prolonged shaking.
+
+B. E. is supposed to contain not only the extract of the body of the
+tubercle bacilli, as in T. R., but also its soluble products (which in the
+case of T. R. were discarded in setting aside the supernatant fluid).
+
+
+                    THEORIES OF TUBERCULIN REACTION
+
+_a_ ROBERT KOCH ascribes the tuberculin reaction to the increased
+      necrotic process around the tubercle, the histological changes
+      consisting of hyperaemia, exudation and softening.
+
+_b_ EHRLICH considers the formation of antibodies an essential feature in
+      the mechanism of reaction. Formation of antibodies takes place in
+      the middle of the three layers encircling the tubercle, the layer
+      damaged by toxins, but not yet rendered incapable of reaction.
+
+_c_ WASSERMANN maintains that the antituberculin found in the tuberculous
+      process draws the injected tuberculin out of the circulation to the
+      tuberculous focus. The interaction that takes place between
+      antituberculin and tuberculin results in formation of ferments which
+      digest albumin, resulting in the softening of tissue. Absorption of
+      softened tissue causes fever.
+
+_d_ CARL SPENGLER--Toxins in the blood of the tuberculous are kept in
+      check by antibodies. Injected tuberculin unites with antibodies,
+      thus setting the toxins free. Result--autointoxication.
+
+_e_ WOLFF-EISNER--Bacteriolysin is present in the organism of the
+      tuberculous, as result of previous infection; bacteriolysin sets
+      free the potent substances of the injected tuberculin; this acts on
+      the body and the tuberculous focus, producing a reaction.[10]
+
+
+                            TUBERCULIN TESTS
+
+I. SUBCUTANEOUS (hypodermic); introduced by Robert Koch in 1890.
+
+II. CUTANEOUS; introduced by Von Pirquet in 1907.
+
+III. CONJUNCTIVAL (ophthalmic); introduced about the same time by
+    Wolff-Eisner and Calmette in 1907.
+
+IV. PERCUTANEOUS (inunction or salve); introduced by Moro in 1908.
+
+V. INTRACUTANEOUS (needle track reaction); introduced as a test by Mantoux
+    in 1909. Described previously by Escherich.
+
+
+                     I. SUBCUTANEOUS TUBERCULIN TEST
+
+1. APPARATUS AND SOLUTIONS NECESSARY:
+
+    Glass cylinder graduated to cc.
+
+    1 cc pipette graduated to 1/10 cc.[11]
+
+    10 cc pipette graduated to 1/10 cc.[12]
+
+    Hypodermic needle suited to the syringe.
+
+    Two or more 1/2 oz. bottles.
+
+    1/2% carbolic acid solution.
+
+    Normal salt solution.
+
+    1 cc. Old Tuberculin.
+
+2. PREPARATION OF APPARATUS:
+
+    Glass apparatus, syringe and needles boiled before use.
+
+    Some keep needles and syringe in 95% alcohol.
+
+3. MAKING SOLUTIONS:
+
+         Tuberculin No. I:        Tuberculin No. II:
+
+         Label one bottle             Another
+
+         _.1 cc. = 1 mg. T_      _.1 cc. = .1 mg. T_
+
+  No. I  { Put 0.1 cc. T in bottle No. I
+         { Add 9.9 cc. of 1/2% carbolic acid solution
+
+         { Put 1 cc. of Tuberculin solution from
+  No. II { No. I into bottle No. II
+         { Add 9 cc. of 1/2% carbolic solution
+
+    In making dilutions you may use your syringe instead of pipette.
+
+    Dilutions can be kept _one week_ in a dark, cool place.
+
+    Discard turbid solutions.
+
+4. PREPARATION OF THE PATIENT FOR THE TEST:
+
+    Patient to keep quiet in bed, or reclining chair, for two or three
+      days before injection.
+
+    Take temperature every two or three hours for two or three days
+      (daytime).
+
+    If the test is to be applied, highest temperature should not be above
+      99.1 F, by mouth, according to Koch; not above 100 F, according to
+      others.
+
+    Site of injection--back, below the level of the shoulder blades,
+      alternately on the two sides.
+
+    Rub skin with ether or alcohol.
+
+    An exact record of physical signs, _just before injection_, should be
+      made by the physician.
+
+5. TIME OF INJECTION:
+
+    Between 8 and 10 A. M. (Bandelier and Roepke).
+
+    Late in the evening, 9 or 10 P. M., or later (others).
+
+6. DOSE:
+
+    According to Koch: Begin with 1/2 mg., or 1 mg., according to
+      condition of patient; give larger dose if no reaction. Order of
+      increase: 1 mg.; 5 mg.; 10 mg. (last dose repeated if necessary).
+
+    Interval between injections: two or three days.
+
+    Present Usage: First dose in adults, 1/2 mg., or 1/5 mg., or smaller,
+      according to physical condition.
+
+    First dose in children: 1/10 mg., or 1/20 mg., or even smaller.
+
+    Thus, in adults: 1/2, or 1, 3, 5, 8, and rarely 10;
+
+    In children: 1/10, 1/2, 1, 3.
+
+    Loewenstein and Kaufmann's Scheme: Repetition of small dose, relying
+      on exciting hypersensibility--2/10 mg.; in 3 days, 2/10 mg.; in 3
+      days, 2/10 mg.; in 3 days, 2/10 mg.
+
+    Some use 1/10 mg., or 3/4, or 1-1/4, in same way.
+
+    This scheme is based on hypersensibility created by repetition of same
+      dose in tuberculous subjects. Scheme not used at present.
+
+    Some advise single dose: 3 or 5 mg., (on the ground that gradual
+      increase of doses creates tolerance).
+
+7. RULES TO FOLLOW IN INCREASING DOSE:
+
+_a_ If no reaction with one dose, give a larger one next time, according
+to _b_.
+
+_b_ If temperature rises less than 1 degree F, repeat same dose; otherwise
+increase.
+
+_c_ Avoid large doses in cases of weakness, nervous temperament, children,
+etc. In a majority of cases smaller doses suffice.
+
+8. AFTER INJECTION:
+
+    _a_ Rest in reclining chair two or more days, unless severe reaction
+        requires absolute rest in bed.
+
+    _b_ Take temperature every 2 or 3 hours for 2 or 3 days.
+
+9. GENERAL REACTION:
+
+    _a_ Rise of Temperature. Positive reaction, if temperature rises at
+        least .5° C. (.9° F.), higher than previous highest temperature.
+
+    Degree of reaction according to Bandelier and Roepke: Slight reaction
+        if temp. rises to 38° C. or 100.4° F. Moderate reaction if temp.
+        rises to 39° C. or 102.2° F. Severe reaction if temp. rises above
+        39° C. or 102.2° F.
+
+    Typical reaction temperature curve: Rapid rise, slower fall, normal
+        temperature after 24 hours.
+
+    Rise begins, in average case, 6 to 8 hours after injection (may begin
+        within 4 hours or be delayed for 30 hours).
+
+    Acme of rise in 9 to 12 hours.
+
+    Duration of reaction, 30 hours or longer.
+
+    Rise, acme and duration of reaction vary.
+
+    _b_ Symptoms:
+
+        May begin with rigor or chilliness, followed by feeling of
+          warmth.
+
+        Following symptoms may be present:
+
+          Malaise, giddiness, severe headache, pain in limbs, pain in
+            affected organ, palpitation, loss of appetite, nausea,
+            vomiting, thirst, sleeplessness, lassitude, etc.; in short, a
+            general feeling of "illness."
+
+        With fall of temperature--disappearance of symptoms.
+
+10. REACTION AT POINT OF INJECTION: Area of redness, swelling,
+      tenderness; important as indicative of sensitiveness, pointing to
+      probable general reaction with repetition or increase of dose.
+
+11. FOCAL REACTION: Reaction at site of process, due to congestion around
+      it.
+
+    Focal reaction is demonstrable by:
+
+    _a_ Change in physical signs; breath sounds, resonance, appearance of
+        rales, etc.
+
+    _b_ Localizing symptoms, pointing to location of the tuberculous
+        process.
+
+        Lungs--increase of cough, sputum, appearance of bacilli, pain in
+          chest, etc.
+
+        Kidney--pain in the region of kidney, changes in urine findings,
+          etc.
+
+        Joint--swelling, tenderness, etc.
+
+        Lupus--redness and exudation.
+
+    Focal reaction is an important feature of the subcutaneous tuberculin
+        test; it permits localization of the disease in a certain
+        percentage of cases.
+
+    Physical examination, sputum examination, urinalysis, etc., are very
+        important _during the course of the reaction_.
+
+12. CONTRAINDICATIONS:
+
+    Subcutaneous tuberculin test should not be employed in:
+
+    1. Cases with temperature above 100° F, by mouth (99.1° F, by mouth,
+       according to Koch).
+
+    2. Cases in which the clinical history and physical signs make the
+       diagnosis certain (presence of tubercle bacilli in the sputum
+       render, of course, any other test unnecessary).
+
+    3. Cases of recent haemoptysis.
+
+    4. Grave conditions, as severe heart disease, nephritis, marked
+       arteriosclerosis, etc.
+
+    5. Convalescence from acute infectious diseases, typhoid fever,
+       pneumonia, etc.
+
+13. INTERPRETATION OF THE POSITIVE SUBCUTANEOUS TUBERCULIN REACTION:
+
+    Occurrence of reaction, following the subcutaneous tuberculin test,
+      signifies the _existence of infection_; it does not signify that
+      the individual is _clinically tuberculous_. To quote E. R. Baldwin,
+      of Saranac Lake: "The tuberculin test is of very limited value in
+      determining tuberculous _disease_; it is of extreme value in
+      detecting tuberculous _infection_."
+
+    The test results in positive reaction in cases with latent as
+      well as active processes.
+
+    The decision as to the patient being clinically tuberculous (ill
+      with tuberculosis) must rest on the consideration of the
+      clinical history and the results of the physical examination.
+
+    It is maintained by some that the subcutaneous tuberculin
+      reaction is _more rapid in onset_ and _more marked in degree_
+      in cases of _recent_ infection. On the other hand, the test is
+      negative in a certain proportion of far advanced cases.
+
+    Occurrence, then, of a subcutaneous tuberculin reaction does not
+      indicate necessarily sanatorium or institutional treatment;
+      neither does it absolutely indicate the necessity of
+      tuberculin treatment. The decision rests on the consideration
+      of all the clinical features of the case.
+
+    _In the absence of any symptoms or physical signs of disease_, a
+      reaction should call for regulation of every day life, tending
+      to increase the state of general resistance (improvement of
+      nutrition, etc.) frequently without discontinuance of work.
+
+    The occurrence of reaction, _in the presence of slight symptoms
+      or physical signs_, calls, according to individual condition,
+      either for home treatment with or without discontinuance of
+      work, or sanatorium treatment.
+
+14. INDICATIONS FOR THE SUBCUTANEOUS TUBERCULIN TEST:
+
+      The following considerations should guide its employment:
+
+      1. A thorough study of the history, thorough physical examination,
+           examination of sputum (if any) give sufficient data for a
+           reliable diagnosis in the vast majority of cases.
+
+      2. Cases, with uncertain symptoms or inconclusive physical signs,
+           pointing to possible existence of tuberculous infection, may be
+           treated as "suspicious" cases (without resorting to
+           subcutaneous tuberculin test), the treatment consisting of
+           rearrangement of mode of life, diet, work, etc., that would
+           tend to increase of general resistance of the patient. This can
+           and should be done in the vast majority of suspicious cases.
+
+      3. The subcutaneous tuberculin test is indicated in cases in which,
+           in the absence of conclusive symptoms or signs, an absolutely
+           positive diagnosis is desired; then the test should be applied,
+           with the consent of the patient, _after all other methods of
+           diagnosis are exhausted_ (thorough study of the case, thorough
+           physical examination, repeated examinations of sputum, etc).
+
+      4. The focal reaction (the reaction pointing to the seat of the
+           disease) occurs in about 1/3, or less, of the general reactions
+           following the subcutaneous tuberculin test; this enhances the
+           value of the test in some cases where a focal reaction would
+           clear the diagnosis.
+
+    Above all, the subcutaneous tuberculin test should be used
+      rarely, and then only after all other methods of diagnosis
+      were thoroughly applied.
+
+
+                      II. CUTANEOUS TUBERCULIN TEST
+
+1. SYNONYMS: Von Pirquet Test or Skin Test
+
+2. APPARATUS AND DILUTIONS NECESSARY:
+
+    Inoculation needle of Von Pirquet
+
+    Koch's Old Tuberculin (undiluted or dilutions according to method).
+
+    A centimeter tape measure (divided to 1/10 cm.) to measure reactions
+
+    Ether
+
+    Alcohol lamp
+
+    Medicine dropper
+
+3. APPLICATION OF TEST:
+
+    Inner surface of the forearm; clean the site with ether; place
+      two drops of tuberculin 4 inches apart; stretch the skin and
+      scrape off the epidermis (at a point midway between the two
+      drops of tuberculin) by rotating the Von Pirquet needle
+      between thumb and index finger, with slight pressure on the
+      skin; repeat same through the two drops of tuberculin; let the
+      tuberculin soak in for a few minutes. No dressing is
+      necessary. The middle scarification is the control test. One
+      tuberculin and one control test may suffice. A separate needle
+      should be used for the control test.
+
+    After each inoculation, clean the needle of tuberculin and heat
+      the point red hot in the alcohol flame before applying it
+      again.
+
+4. REACTION:
+
+    Gradual elevation and reddening of skin around the point of
+      tuberculin inoculation, beginning in 3 hours or later; the
+      reaction (papule) well developed, generally, in 24 hours and
+      most distinct in 48 hours after inoculation.
+
+    Size of papule varies from a diameter of 10 millimeters in the
+      average case to 20 mm. occasionally, and 30, rarely (Bandelier
+      and Roepke).
+
+    At the end of 48 hours the swelling and redness subside
+      gradually, with the subsequent bluish discoloration of the
+      skin, remaining for various periods of time, and slight
+      peeling of the epidermis. Individual reactions vary in degree
+      of redness, elevation, size, contour of the border, etc. All
+      these points should be observed and recorded.
+
+    Time of inspection--24 and 48 hours after inoculation.
+
+    Single inspection--best time in 48 hours.
+
+5. CAUSE OF REACTION:
+
+    Interaction between inoculated tuberculin and the antibodies
+      (bacteriolysins, according to Wolff-Eisner) present in the
+      skin of a tuberculous individual; interaction results in
+      hyperaemia and exudation (papule).
+
+6. INTERPRETATION OF REACTION:
+
+    Occurrence of positive reaction signifies presence of a
+      tuberculous focus somewhere in the body. No indication as to
+      activity or location of the focus.
+
+    A negative reaction in adults (especially if repeated) signifies
+      non-existence of tuberculosis (unless great deterioration of
+      health, far advanced process, or tolerance to tuberculin
+      established by tuberculin treatment).
+
+    A positive reaction in children under two years of age
+      signifies, generally, active tuberculous process; with the
+      advance of age the determination of active tuberculous
+      processes by means of cutaneous tuberculin test becomes
+      impossible.
+
+
+                   III. CONJUNCTIVAL TUBERCULIN TEST
+
+1. SYNONYMS: Eye Test; Ophthalmic Test; Wolff-Eisner's Test; Calmette's
+      Test.
+
+2. APPARATUS AND DILUTIONS NECESSARY:
+
+    1 cc. pipette graduated to 1/10 cc.
+
+    10 cc. pipette graduated to 1/10 cc.
+
+    10 cc. glass cylinder
+
+    Medicine dropper
+
+    Koch's Old Tuberculin
+
+    1/2% and 1% dilution of Old Tuberculin in .85% sterile normal salt
+      solution.
+
+    To make 1% dilution, add .1 cc. Old Tuberculin to 9.9 cc. of diluent.
+
+3. APPLICATION OF TEST:
+
+    Patient sitting, with head thrown back
+
+    Lower eyelid drawn slightly down and toward the nose--to form a small
+      pouch of the lid;
+
+    One drop of 1% or 1/2% instilled in that pouch and the lower lid moved
+      up gently over the eye until the lids meet;
+
+    Eye kept closed for one minute or so.
+
+4. REACTION:
+
+    Onset in 12 to 24 hours (may begin earlier); acme in 24 to 36 hours;
+      duration of reaction--3 to 4 days or even longer (in severe cases).
+      Some reactions are of short duration. 3 grades of reaction,
+      according to Citron:
+
+    1. Reddening of caruncle and palpebral (lid) conjunctiva.
+
+    2. More intense reddening, with involvement of ocular (eyeball)
+       conjunctiva, and increased secretion.
+
+    3. Very intense reddening of the whole conjunctiva, with much
+       fibrinous and purulent secretion, etc.
+
+5. TIME OF INSPECTION:
+
+    12 and 24 hours after instillation; then once a day.
+
+6. CAUSE OF REACTION:
+
+    Hyperaemia and exudation resulting from interaction between
+      _instilled tuberculin_ and _antibodies in conjunctiva_
+      (bacteriolysin, according to Wolff-Eisner).
+
+7. INTERPRETATION OF REACTION:
+
+    Wolff-Eisner maintains that positive conjunctival tuberculin
+      reaction means _active_ tuberculosis, a conclusion accepted by
+      but a few.
+
+8. FIELD OF APPLICATION OF CONJUNCTIVAL TUBERCULIN TEST:
+
+    _Should not be used_; connected with _danger_ to the eye.
+
+    Conjunctival test used very rarely at present.
+
+
+                   IV. PERCUTANEOUS TUBERCULIN TEST
+
+1. SYNONYMS: Salve Test; Moro Test.
+
+2. SALVE: Equal parts of Old Tuberculin and anhydrous lanolin.
+
+3. APPLICATION OF TEST:
+
+    Site: abdominal wall below ensiform process, _or_ breast below
+      nipple, _or_ inner surface of forearm.
+
+    Application: rub in with the finger (using moderate pressure) a small
+      particle of salve about the size of a pea.
+
+    Rub it in into an area about 5 cm.; rub 1 minute.
+
+4. REACTION:
+
+    In 24 to 48 hours--_either_ numerous small reddened spots which
+      disappear in a few days, _or_ numerous small nodules, _or_
+      coalescing nodules on a red base, etc.
+
+5. INTERPRETATION OF REACTION:
+
+    Positive reaction is assumed to indicate existing tuberculous
+      infection somewhere in the body; does not indicate that the process
+      is active.
+
+6. FIELD OF APPLICATION OF PERCUTANEOUS TUBERCULIN TEST:
+
+    The percutaneous tuberculin test fails in a large proportion of
+      tuberculosis cases.
+
+    The test is used rarely at present.
+
+
+                             LIGNIERES TEST
+
+    A modification of the Moro Test
+
+    Instead of salve, a few drops of Old Tuberculin rubbed in.
+
+    Used rarely at present.
+
+
+                    V. INTRACUTANEOUS TUBERCULIN TEST
+
+1. SYNONYMS--Mantoux Test
+
+2. APPLICATION OF TEST:
+
+    Injection into skin (needle parallel to skin) of 1/100 mg. of Old
+      Tuberculin (according to Mantoux).
+
+3. REACTION:
+
+    Onset in a few hours, well developed in 24 hours, acme in 48 hours.
+      Reaction consists of a central nodule surrounded by a halo of
+      redness.
+
+    This is the intracutaneous test as originally suggested by Mantoux.
+
+
+                              CONCLUSIONS
+
+Comparing the various tuberculin tests we find that:
+
+1 _The Subcutaneous Tuberculin Test_ has the advantage of focal reaction,
+disclosing in a certain percentage of cases the seat of the disease.
+
+The subcutaneous test should, however, never be employed unless _as a last
+resort_, and then only after all other methods of diagnosis are exhausted
+and an absolute diagnosis is very essential.
+
+In the vast majority of suspected cases of tuberculosis, thorough study of
+the history of the case, combined with thorough physical examination,
+furnishes all the necessary data for diagnosis and an efficient plan of
+treatment.
+
+2 _The Cutaneous Tuberculin Test_ is a very efficient diagnostic measure
+in children under two years of age in whom a positive cutaneous tuberculin
+reaction indicates active disease.
+
+Positive cutaneous tuberculin reaction in adults indicates existence of a
+tuberculous process, somewhere in the body; it does not indicate that the
+process is active.
+
+Negative cutaneous tuberculin reaction is one of the corroborative
+evidences of absence of tuberculosis, unless reaction is prevented by very
+advanced disease or tolerance to tuberculin established by tuberculin
+treatment.
+
+3 Thorough study of the history and thorough physical examination of each
+individual case are more important and should precede the application of
+any test.
+
+
+FOOTNOTES:
+
+[1] For illustration, see Knopf, "Tuberculosis," Chap. IV, page 67.
+
+[2] See Carrington, "Fresh Air and How to Use It," Chap. II, page 29.
+
+[3] For illustration, see Carrington, "Fresh Air and How to Use It," Chap.
+II, page 37.
+
+[4] For illustration, see Carrington, "Fresh Air and How to Use It," Chap.
+VIII, page 128.
+
+[5] For illustration, see Knopf, "Tuberculosis," Chap. IV, page 58.
+
+[6] For illustration, see Carrington, "Fresh Air and How to Use It," Chap.
+VII, page 108.
+
+[7] See previous footnote.
+
+[8] For illustration, see Journal of Outdoor Life, January 1914.
+
+[9] For illustration, see Carrington, "Fresh Air and How to Use It," Chap.
+IV, page 55.
+
+[10] For a diagrammatic presentation of Wolff-Eisner's theory, see
+"Tuberculin Treatment" by Riviere and Moreland, page 6.
+
+[11] Not absolutely necessary: may get along with graduated cylinder and
+syringe.
+
+[12] See previous footnote.
+
+                                 (END)
+
+       *       *       *       *       *
+
+                       Transcriber's Amendments
+
+Transcriber's Note: Blank pages have been deleted. Paragraph formatting
+has been made consistent. The publisher's inadvertent omissions of
+important punctuation have been corrected.
+
+Other changes are listed below. The listed source publication page number
+also applies in this reproduction except possibly for footnotes since they
+have been moved.
+
+   Page          Change
+
+   7  the acute inflamatory[inflammatory] at the beginning,
+   9  systematic treatment was underaken[undertaken].
+   9  Bodingon of Sutton, Coldfield[Sutton Coldfield], England,
+  10  The fundimental[fundamental] principle
+  19  fit to make to a printed questionaire[questionnaire].
+  23  who visits the physican[physician]
+  28  Tuberculosis Sanitarium is extending sanatorum[sanatorium] care
+  35  [Split first footnote into two.]
+  36  in the shelter of a strong windbrake[windbreak].
+  43  makes a family, ordinnarily[ordinarily]
+  58  [Split first footnote into two.]
+  58  Hyperdermic[hypodermic] needle suited to the syringe
+  62  absence of conclusive symptons[symptoms] or signs,
+  62  (thourough[thorough][et seq.] study of the case,
+  63  all other methods of diagnosis were thouroughly[thoroughly]
+  63  from a diameter of 10 millimeters in [the] average case
+  66  [Added (END).]
+
+On page 50 of the original publication, the following portion of a
+paragraph has two extraneous lines here marked in brackets:
+
+  All of the cooking was done by the teacher. Careful attention to
+  [is given. Children are weighed once in two weeks. Instruction]
+  [is chiefly practical. Instruction in gardening is given twice a week]
+  general cleanliness and hygiene of the teeth was insisted upon.
+  Individual drinking cups and tooth brushes were provided. The
+  children took turns in washing dishes, setting the table and helping....
+
+The extraneous lines are duplicates of lines further up the page and have
+been deleted.
+
+       *       *       *       *       *
+
+
+
+
+
+End of Project Gutenberg's Nurses' Papers on Tuberculosis :, by Various
+
+*** END OF THIS PROJECT GUTENBERG EBOOK NURSES' PAPERS ON TUBERCULOSIS : ***
+
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+
+<pre>
+
+The Project Gutenberg EBook of Nurses' Papers on Tuberculosis :, by Various
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Nurses' Papers on Tuberculosis :
+       read before the Nurses' Study Circle of the Dispensary
+              Department, Chicago Municipal Tuberculosis Sanitarium
+
+Author: Various
+
+Release Date: November 23, 2011 [EBook #38090]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK NURSES' PAPERS ON TUBERCULOSIS : ***
+
+
+
+
+Produced by Bryan Ness, Henry Gardiner and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+file was produced from images generously made available
+by The Internet Archive/American Libraries.)
+
+
+
+
+
+
+</pre>
+
+
+<div class="center" style="width: 25em; margin: auto; border: solid 1px; padding: 1em;">
+Transcriber's Note: The original publication has been replicated faithfully except as listed
+<a href="#Changes" name="Start" id="Start">here</a>. Obscured letters in
+the original publication are indicated with {?}.
+</div>
+
+<hr class="ChapterTopRule" />
+<!--001.png-->
+
+
+
+
+<h1 style="line-height: 2em;">
+<small>Dispensary Department Bulletin No. 1</small><br />
+NURSES' PAPERS<br />
+<small>ON</small><br />
+TUBERCULOSIS
+</h1>
+
+<div class="c2" style="padding-top: 3em; line-height: 1.5em;"><small>PUBLISHED BY THE</small><br />
+CITY OF CHICAGO<br />
+MUNICIPAL TUBERCULOSIS SANITARIUM<br />
+<small>SEPTEMBER 1914</small><br />
+</div>
+
+<!--002.png-->
+
+<hr class="ChapterTopRule" />
+<div class="c2">CITY OF CHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM</div>
+
+
+<div class="c3" style="padding-top: 2em;">STAFF OF NURSES<br />
+<span style="font-size: 0.8em;">&mdash;OF THE&mdash;</span><br />
+DISPENSARY DEPARTMENT</div>
+
+
+<div class="center">
+<dl>
+  <dt><span class="smcap">Rosalind Mackay</span>, R. N., Superintendent of Nurses</dt>
+  <dt>&nbsp;</dt>
+  <dt><span class="smcap">Anna G. Barrett</span></dt>
+  <dt><span class="smcap">Barbara H. Bartlett</span></dt>
+  <dt><span class="smcap">Olive E. Beason</span></dt>
+  <dt><span class="smcap">Ella M. Bland</span></dt>
+  <dt><span class="smcap">Kathryn M. Canfield</span></dt>
+  <dt><span class="smcap">Mabel F. Cleveland</span></dt>
+  <dt><span class="smcap">Elrene M. Coombs</span></dt>
+  <dt><span class="smcap">Margaret M. Coughlin</span></dt>
+  <dt><span class="smcap">Stella W. Couldrey</span></dt>
+  <dt><span class="smcap">Emma W. Crawford</span></dt>
+  <dt><span class="smcap">Fannie J. Davenport</span></dt>
+  <dt><span class="smcap">Roxie A. Dentz</span></dt>
+  <dt><span class="smcap">C. Ethel Dickinson</span></dt>
+  <dt><span class="smcap">Anna M. Drake</span></dt>
+  <dt><span class="smcap">Mary E. Egbert</span></dt>
+  <dt><span class="smcap">Maude F. Ess{?}</span></dt>
+  <dt><span class="smcap">Sara D. Faroll</span></dt>
+  <dt><span class="smcap">Mary Fraser</span></dt>
+  <dt><span class="smcap">Augusta A. Gough</span></dt>
+  <dt><span class="smcap">Frances M. Heinrich</span></dt>
+  <dt><span class="smcap">Laura K. Hill</span></dt>
+  <dt><span class="smcap">Isabella J. Jensen</span></dt>
+  <dt><span class="smcap">Emma E. Jones</span></dt>
+  <dt><span class="smcap">Letta D. Jones</span></dt>
+  <dt><span class="smcap">Jeanette Kipp</span></dt>
+  <dt><span class="smcap">Elsa Lund</span></dt>
+  <dt><span class="smcap">Mary Macconachie</span></dt>
+  <dt><span class="smcap">Josephine V. Mark</span></dt>
+  <dt><span class="smcap">Isabel C. McKay</span></dt>
+  <dt><span class="smcap">Anna V. McVady</span></dt>
+  <dt><span class="smcap">Annie Morrison</span></dt>
+  <dt><span class="smcap">Katherine M. Patterson</span></dt>
+  <dt><span class="smcap">Laura A. Redmond</span></dt>
+  <dt><span class="smcap">Grace M. Saville</span></dt>
+  <dt><span class="smcap">Beryl Scott</span></dt>
+  <dt><span class="smcap">Florence T. Singleton</span></dt>
+  <dt><span class="smcap">Mabelle Smith</span></dt>
+  <dt><span class="smcap">Florence A. Spencer</span></dt>
+  <dt><span class="smcap">Harriett Stahley</span></dt>
+  <dt><span class="smcap">Genevieve E. Stratton</span></dt>
+  <dt><span class="smcap">Annabel B. Stubbs</span></dt>
+  <dt><span class="smcap">Alice J. Tapping</span></dt>
+  <dt><span class="smcap">Olive Tucker</span></dt>
+  <dt><span class="smcap">Elizabeth M. Watts</span></dt>
+  <dt><span class="smcap">Mary C. Wright</span></dt>
+  <dt><span class="smcap">Mary C. Young</span></dt>
+  <dt>&nbsp;</dt>
+  <dt><span class="smcap">Karla Stribrna</span>, Interpreter.</dt>
+</dl>
+</div>
+
+
+<div class="c3" style="padding-top: 2em;">BOARD OF DIRECTORS</div>
+
+<div class="center">
+<table  width="300" border="0" cellpadding="4" cellspacing="0" summary="">
+<tr><td align="left"><span class="smcap">Theodore B. Sachs</span>, M. D.,</td><td align="right">President</td></tr>
+<tr><td align="left"><span class="smcap">George B. Young</span>, M. D.,</td><td align="right">Secretary</td></tr>
+<tr><td align="left"><span class="smcap">W. A. Wieboldt</span>.</td></tr>
+</table></div>
+
+<div class="c3" style="padding-top: 2em;">GENERAL OFFICE</div>
+
+<div class="center">105 West Monroe Street<br />
+<span class="smcap">Frank E. Wing</span>, Executive Officer.
+</div>
+
+<hr class="ChapterTopRule" />
+<!--004.png-->
+
+<div class="figcenter" style="width: 700px; padding: 2em 2em;">
+<img src="images/frontispiece.png" width="700" height="470" alt="Group photo of nursing staff."
+title="" />
+<span class="caption">FIELD NURSES, DISPENSARY DEPARTMENT
+CHICAGO MUNICIPAL TUBERCULOSIS
+SANITARIUM</span></div>
+
+<p><!--005.png--></p>
+
+<hr class="ChapterTopRule" />
+
+
+
+
+<div class="c2" style="line-height: 2em;">
+<small>Dispensary Department Bulletin No. 1</small><br />
+NURSES' PAPERS<br />
+<small>ON</small><br />
+TUBERCULOSIS
+</div>
+
+<div class="c4" style="line-height: 1.5em; padding-top: 1em;">
+READ BEFORE THE<br />
+<span class="large">NURSES' STUDY CIRCLE</span><br />
+OF THE<br />
+DISPENSARY DEPARTMENT<br />
+CHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM
+</div>
+
+
+<div class="c5" style="padding-top: 1em; line-height: 1.5em;">
+PUBLISHED BY THE<br />
+<span class="large">CITY OF CHICAGO<br />
+MUNICIPAL TUBERCULOSIS SANITARIUM</span><br />
+105 WEST MONROE STREET<br />
+SEPTEMBER 1914
+</div>
+<!--006.png-->
+
+<hr class="ChapterTopRule" />
+
+
+
+
+<h2>CONTENTS</h2>
+
+
+<div class="center">
+<table border="0" cellpadding="4" cellspacing="0" summary="">
+<tr><td align="left">&nbsp;</td><td align="right" style="font-size: 0.8em;">PAGE</td></tr>
+<tr><td align="left">Introduction&mdash;Nurses' Tuberculosis Study Circle</td><td align="right"><a href="#Page_5">5</a></td></tr>
+<tr><td align="left">&nbsp;</td></tr>
+<tr><td align="left">Historical Notes on Tuberculosis</td><td align="right"><a href="#Page_7">7</a></td></tr>
+<tr><td align="center" colspan="2"> <span class="smcap">Rosalind Mackay</span>, R. N.</td></tr>
+<tr><td align="left">&nbsp;</td></tr>
+<tr><td align="left">Visiting Tuberculosis Nursing in Various Cities of the United States</td><td align="right"><a href="#Page_11">11</a></td></tr>
+<tr><td align="center" colspan="2"> <span class="smcap">Anna M. Drake</span>, R. N.</td></tr>
+<tr><td align="left">&nbsp;</td></tr>
+<tr><td align="left">Provisions for Outdoor Sleeping</td><td align="right"><a href="#Page_30">30</a></td></tr>
+<tr><td align="center" colspan="2"> <span class="smcap">May MacConachie</span>, R. N.</td></tr>
+<tr><td align="left">&nbsp;</td></tr>
+<tr><td align="left">Some Points in the Nursing Care of the Advanced Consumptive</td><td align="right"><a href="#Page_37">37</a></td></tr>
+<tr><td align="center" colspan="2"> <span class="smcap">Elsa Lund</span>, R. N.</td></tr>
+<tr><td align="left">&nbsp;</td></tr>
+<tr><td align="left">Open Air Schools in This Country and Abroad</td><td align="right"><a href="#Page_44">44</a></td></tr>
+<tr><td align="center" colspan="2"> <span class="smcap">Frances M. Heinrich</span>, R. N.</td></tr>
+<tr><td align="left">&nbsp;</td></tr>
+<tr><td align="left">Notes on Tuberculin for Nurses</td><td align="right"><a href="#Page_56">56</a></td></tr>
+</table></div>
+
+<hr class="ChapterTopRule" />
+<p><span class="pagenum"><a name="Page_5"
+id="Page_5">5</a></span></p><!--007.png-->
+
+
+
+<h2>NURSES' TUBERCULOSIS STUDY CIRCLE</h2>
+
+
+<p>It is well known that the gathering of facts and study of literature
+essential to the preparation of a paper on a certain subject is a very
+productive method of acquiring information. If the paper is to be
+presented to your own group of co-workers, and the subject covered by it
+represents an important phase of their work, or an analysis of some of its
+underlying principles, then there is a further incentive to do your best,
+as well as an opportunity for a general discussion which acts as a sieve
+for the elimination of false ideas and gradual formulation of true
+conceptions.</p>
+
+<p>Lectures on various phases of the work being done by a particular group of
+people are very important. Papers by the workers themselves are, however,
+greatest incentives to study and self-advancement.</p>
+
+<p>With this view in mind, I suggested the organization of a Tuberculosis
+Study Circle by the Dispensary Nurses of the Municipal Tuberculosis
+Sanitarium. The nurses chosen to present papers on particular phases of
+tuberculosis are given access to the library of the General Office of the
+Sanitarium; they are also given the assistance of the General Office in
+procuring all the necessary information through correspondence with
+various organizations and institutions in Chicago and other cities.</p>
+
+<p>As the program stands at present, the Nurses' Study Circle meets twice a
+month. At one of these meetings a lecture on some important phase of
+tuberculosis is given by an outside speaker, and at the next meeting a
+paper is read by one of the nurses. At all of these meetings the
+presentation of the subject is followed by general discussion. The program
+since January, 1914, was as follows:</p>
+
+<p>January 9th, 1914&mdash;"Historical Notes on Tuberculosis," by Miss Rosalind
+Mackay, Head Nurse, Stock Yards Dispensary of the Municipal Tuberculosis
+Sanitarium.<span class="pagenum"><a name="Page_6"
+id="Page_6">6</a></span><!--008.png--></p>
+
+<p>January 23rd, 1914&mdash;"Channels of Infection and the Pathology of
+Tuberculosis," by Professor Ludwig Hektoen of the University of Chicago.</p>
+
+<p>February 13th, 1914&mdash;"Visiting Tuberculosis Nursing in Various Cities of
+the United States," by Miss Anna M. Drake, Head Nurse, Policlinic
+Dispensary of the Municipal Tuberculosis Sanitarium.</p>
+
+<p>March 13th, 1914&mdash;"Provisions for Outdoor Sleeping," by Miss May
+MacConachie, Head Nurse, St. Elizabeth Dispensary of the Municipal
+Tuberculosis Sanitarium.</p>
+
+<p>March 27th, 1914&mdash;"What Should Constitute a Sufficient and Well Balanced
+Diet for Tuberculous People," by Mrs. Alice P. Norton, Dietitian of Cook
+County Institutions.</p>
+
+<p>April 10th, 1914&mdash;"Some Points in the Nursing Care of the Advanced
+Consumptive," by Miss Elsa Lund, Head Nurse of the Iroquois Memorial
+Dispensary of the Municipal Tuberculosis Sanitarium.</p>
+
+<p>May 15th, 1914&mdash;"Open Air Schools in This Country and Abroad," by Miss
+Frances M. Heinrich, Head Nurse of the Post-Graduate Dispensary of the
+Municipal Tuberculosis Sanitarium.</p>
+
+<p>May 29th, 1914&mdash;"Efficient Disinfection of Premises After Tuberculosis,"
+by Professor P. G. Heinemann, Department of Bacteriology, University of
+Chicago.</p>
+
+<p>The organization of the Tuberculosis Study Circle among the nurses of the
+Dispensary Department of the Municipal Tuberculosis Sanitarium, calling
+forth the best efforts of the nurses in getting information on various
+phases of tuberculosis for presentation to their co-workers in an
+interesting manner has, no doubt, stimulated the progress of our entire
+nursing force. The first five papers presented by the nurses are given in
+this series. The pamphlet is published with the idea of attracting the
+attention of other organizations to this method of stimulating more
+intensive study among their nurses.</p>
+
+<div class="right">
+<span class="small">THEODORE B. SACHS, M. D., President &nbsp; &nbsp; &nbsp; <br />
+Chicago Municipal Tuberculosis Sanitarium.</span>
+</div>
+
+<hr class="ChapterTopRule" />
+<p><span class="pagenum"><a name="Page_7" id="Page_7">7</a></span></p>
+<!--009.png-->
+
+
+
+
+<h2>HISTORICAL NOTES ON TUBERCULOSIS</h2>
+
+
+<div class="c3">By ROSALIND MACKAY, R. N.</div>
+
+<div class="center">Head Nurse, Stock Yards Dispensary of the Chicago Municipal Tuberculosis
+Sanitarium.</div>
+
+
+<p>So far as our information goes, pulmonary tuberculosis has always existed.
+It is, as Professor Hirsch remarks, "A disease of all times, all
+countries, and all races. No climate, no latitude, no occupation, forms a
+safeguard against the onset of tuberculosis, however such conditions may
+mitigate its ravages or retard its progress. Consumption dogs the steps of
+man wherever he may be found, and claims its victims among every age,
+class and race."</p>
+
+<p>Hippocrates, the most celebrated physician of antiquity (460-377 B. C.),
+and the true father of scientific medicine, gives a description of
+pulmonary tuberculosis, ascribing it to a suppuration of the lungs, which
+may arise in various ways, and declares it a disease most difficult to
+treat, proving fatal to the greatest number.</p>
+
+<p>Isocrates, also a Greek physician and contemporary of Hippocrates, was the
+first to write of tuberculosis as a disease transmissible through
+contagion.</p>
+
+<p>Aretaeus Cappadox (50 A. D.) describes tuberculosis as a special
+pathological process. His clinical picture is considered one of the best
+in literature.</p>
+
+<p>Galen (131-201 A. D.) did not get much beyond Hippocrates in the study of
+tuberculosis, but was very specific in his recommendation of a milk diet
+and dry climate. He held it dangerous to pass an entire day in the company
+of a tuberculous patient.</p>
+
+<p>During the next fifteen centuries, a period known as the Dark Ages and
+characterized by most intense intellectual stagnation, little was added to
+the knowledge of pulmonary tuberculosis. In the seventeenth century
+Franciscus Sylvius brought out the relationship between phthisis and
+nodules in the lymphatic glands. This was the first step toward accurate
+knowledge of the pathology of tuberculosis.</p>
+
+<p>Richard Morton, an English physician, wrote, in 1689, of the wide
+prevalence of pulmonary tuberculosis, and recognized the two types of
+fever: the acute inflammatory at the beginning, and the <span class="pagenum"><a name="Page_8"
+id="Page_8">8</a></span><!--010.png-->hectic
+at the
+end. He also recognized the contagious nature of the disease and
+recommended fresh air treatment. He believed the disease curable in the
+early stages, but warned us of its liability to recur. Morton taught that
+the tubercle was the pathological evidence of the disease.</p>
+
+<p>In 1690, Leeuwenhoek, a Dutch lens maker, started the making of short
+range glasses which resulted later in the modern microscope, making
+possible the establishment of the germ theory of disease, including the
+establishment of that theory for tuberculosis.</p>
+
+<p>Starck, whose observations and writings were published in 1785 (fifteen
+years after his death), gave a more accurate description of tubercles than
+had ever been given before, and showed how cavities were formed from them.</p>
+
+<p>Leopold Auenbrugger introduced into medicine the method of recognizing
+diseases of the chest by percussion, tapping directly upon the chest with
+the tips of his fingers. The results of his investigations were published
+in a pamphlet in 1761. This new practice was ignored at first, but after
+the work of Auenbrugger was translated he attained a European reputation
+and a revolution in the knowledge of diseases of the chest followed.</p>
+
+<p>Boyle recognized in miliary tubercle, as it was afterwards called by him,
+the anatomical basis of tuberculosis as a general disease, and, in 1810,
+published the results of one of the most complete researches in pathology.
+He described the stages in the development of the disease, using miliary
+tubercle as its starting point. He opposed the theory that inflammation
+caused tuberculosis and declared hemorrhage a result and not a cause of
+consumption.</p>
+
+<p>Laennec discovered one of the most important, perhaps, of all methods of
+medical diagnosis&mdash;that of auscultation. By means of the stethoscope,
+which he invented in 1819, he recognized the physical signs and made the
+first careful study of the healing of tuberculosis; he gave also one of
+the best accounts of the sputum of the consumptive. He believed that every
+manifestation of the disease in man or animals was due to one and the same
+cause.</p>
+
+<p>Up to this time the views which were held concerning the infectious nature
+of tuberculosis were not based upon direct experiment, but in 1843 Klenke
+produced artificial tuberculosis by inoculation. He injected tuberculous
+matter into the jugular vein of a rabbit, and six months later found
+tuberculosis of the liver and lungs. He did not continue, however, his
+researches; so they were soon forgotten.</p>
+
+<p>To Villemin, a French physician, belongs the immortal fame of being the
+first to show the essential distinction in tuberculosis <span class="pagenum"><a name="Page_9"
+id="Page_9">9</a></span><!--011.png-->between
+the virus
+causing the disease and the lesion produced by it. By inoculating animals,
+he demonstrated that tuberculosis is a specific disease caused by a
+specific agent. His paper presented in 1865 before the Academy of Medicine
+in France contained a detailed account of his experimental investigations.
+This was a most remarkable contribution to scientific medicine.</p>
+
+<p>It remained for Robert Koch in 1882, after years of painstaking
+investigation, to announce to the world the discovery of a definite
+bacillus as the causative agent in all forms of tuberculous lesions. Koch
+isolated, cultivated outside the body, described and differentiated the
+infective organism of tuberculosis and proved that it could continue to
+produce the same lesions indefinitely. He showed the presence of the
+bacilli in all known tuberculous lesions and in tuberculous expectoration,
+and demonstrated the virulence in sputum which had been dried for eight
+weeks.</p>
+
+<p>Following directly upon the knowledge of the cause of tuberculosis came
+the recognition of its curability, and the proper means of its prevention.
+Although good food and fresh air have always been considered of importance
+in the treatment of the disease, it was not until the middle of the
+nineteenth century that anything like systematic treatment was undertaken.</p>
+
+<p>Dr. George Bodingon of Sutton Coldfield, England, wrote an essay in 1840
+advocating fresh air treatment. He denounced the common hospital in large
+towns as a most unfit place for consumptive patients, and established a
+home for their care, but met with so much opposition that it was soon
+closed.</p>
+
+<p>In 1856, Hermann Brehmer wrote a thesis on the subject which has been the
+foundation of our modern treatment. He opened a small sanatorium in 1864.
+Five years later he established the sanatorium at Goerbersdorf, in
+Silesia, which eventually became the largest in the world. He advocated
+life in the open air, abundant dietary and constant medical supervision.
+He believed that the heart of the large majority of consumptives is small
+and undeveloped, and that this predisposes them to the disease. In
+accordance with this theory he put a great deal of emphasis on exercise in
+the treatment of his patients. He built walks of various grades on the
+grounds of his sanatorium and installed a system of walking exercise.
+Patients began with the lowest grade, gradually accustoming themselves to
+ascend to the highest. Brehmer was himself a consumptive, and was cured by
+the method he so firmly believed in.</p>
+
+<p>Dr. Dettweiler, who opened the second sanatorium in Germany, at
+Falkenstein, near Frankfort, was also a consumptive, having developed
+<span class="pagenum"><a name="Page_10"
+id="Page_10">10</a></span><!--012.png-->tuberculosis
+during the arduous campaign in the Franco-Prussian War in
+1871. He entered the Goerbersdorf Sanatorium as a patient, becoming later
+an assistant of Brehmer. Dr. Dettweiler laid great emphasis upon rest in
+treatment.</p>
+
+<p>In 1888, Dr. Otto Walther opened his famous sanatorium at Nordrach in the
+Black Forest, in Germany.</p>
+
+<p>The first sanatorium for the care of the consumptive in the United States
+was opened at Saranac Lake by Dr. Edward L. Trudeau in 1884. He was the
+pioneer of the sanatorium treatment in this country, and an example of
+what a man, although tuberculous himself, can do for his fellow men. In
+1874, a seemingly helpless invalid, he made his home in the Adirondack
+Mountains. A little more than twenty-five years ago he became the founder
+of a village now crowded with tuberculous patients. The Saranac Lake
+institution, which began with one small cottage, has since developed into
+the best known sanatorium in this country.</p>
+
+<p>In 1891, Dr. Herman Biggs posted the first anti-spitting ordinance in the
+street railway cars of New York.</p>
+
+<p>Dr. Lawrence Flick brought about the formation of the first
+anti-tuberculosis society in 1892, and in 1894 the City of New York
+adopted a law to enforce notification and registration.</p>
+
+<p>Dr. Philip of Edinburgh was the first to systematically and completely
+organize the anti-tuberculosis campaign. In 1887 he inaugurated that new
+institution, the anti-tuberculosis dispensary, which has since rendered
+such inestimable service. The fundamental principle of the Edinburgh
+system is that the disease should be sought out in its haunts.</p>
+
+<p>The first dispensary in the United States was opened in New York in 1904,
+modeled after the Edinburgh system. About the same time came the Open Air
+Schools&mdash;Charlottenburg establishing one in 1904 and Providence, R. I.,
+following in 1908. The first Day Camp in the United States was opened in
+1905 in Boston. New Jersey established the first Preventorium for Children
+at Farmingdale in 1909. All this naturally led to better provision for
+advanced cases; sanatoria for hopeful cases at small cost; factory
+inspection; and, in some countries, industrial colonies for arrested
+cases.</p>
+
+<p>The tuberculosis patient of today presents a hopefulness previously
+undreamt of. The outlook is brighter with promise than ever before, and we
+have every reason to look forward to a steady reduction in the mortality
+rate from this dread disease; but the extinction of tuberculosis will be
+achieved only when the social and economic problems have been solved.</p>
+
+<hr class="ChapterTopRule" />
+<p><span class="pagenum"><a name="Page_11"
+id="Page_11">11</a></span><!--013.png--></p>
+
+
+
+
+<h2>VISITING TUBERCULOSIS NURSING IN VARIOUS CITIES OF THE UNITED STATES</h2>
+
+<div class="c3">By ANNA M. DRAKE, R. N.</div>
+
+<div class="center">Head Nurse, Policlinic Dispensary of the Municipal Tuberculosis
+Sanitarium.</div>
+
+
+<div class="subleader">BALTIMORE</div>
+
+<p>In 1903, the first visiting tuberculosis nurse was assigned in Baltimore
+to follow up patients of the Johns Hopkins Hospital Out-patient
+Department. Her duties were varied as are the duties of the present day
+tuberculosis nurse. She was to instruct patients in the use of sunlight
+and fresh air and was allowed to furnish them with special diet in the
+shape of milk and eggs. She investigated home conditions and helped
+improve sleeping quarters. She placed patients in sanatoria, or brought
+them back to the dispensary for treatment. She gave bedside care to
+advanced cases, if she could not get them into hospitals, and applied to
+relief organizations for help in solving the problems of the family. From
+time to time other nurses of the Baltimore Visiting Nurse Association were
+assigned to the work, other dispensaries and agencies began referring
+cases to be followed up, and the work grew to such proportions as to be
+almost unmanageable for a private organization.</p>
+
+<p>In 1910, the Tuberculosis Division of the Baltimore Health Department was
+organized. It began its activities with a corps of fifteen nurses and a
+visiting list of 1,617 patients turned over to it by the Baltimore
+Visiting Nurse Association. The object of the Tuberculosis Division was to
+bring under the supervision of the Health Department all persons in the
+city suffering with pulmonary tuberculosis. Ambulatory cases were to be
+given advice and instruction; advanced cases, bedside care, if needed, or
+hospital care, if available. At present, it is upon the advanced cases, as
+well as those who are in contact with them, that the nurses of the
+Tuberculosis Division concentrate their efforts. The Staff at present
+consists of a Superintendent and sixteen Field Nurses. The city is
+<span class="pagenum"><a name="Page_12"
+id="Page_12">12</a></span><!--014.png-->divided
+into sixteen districts, a nurse being assigned to each district.
+Each nurse is responsible for the care of all cases of tuberculosis in her
+district.</p>
+
+<p>In 1912, the Tuberculosis Division opened two municipal tuberculosis
+dispensaries. These dispensaries receive patients on alternate days from 3
+to 5 p. m., nurses in districts nearest the dispensaries alternating for
+clinic duty. Other dispensaries are the Phipps Tuberculosis Dispensary at
+Johns Hopkins' Hospital, and the University of Maryland Hospital
+Tuberculosis Dispensary.</p>
+
+<p>The problems which chiefly concern the Tuberculosis Division in its
+efforts to control the spread of tuberculosis in Baltimore are the failure
+of physicians to report cases to the Department of Health until the
+patient is in a dying condition, and the inadequate provision for hospital
+care of advanced cases. These conditions are particularly marked in the
+case of colored patients, who are found going in and out of homes,
+restaurants, and laundries, as cooks, waitresses and servants of various
+kinds, as long as they are able to drag themselves about.</p>
+
+<p>The nurses of the Tuberculosis Division are graduate nurses and are
+registered. They are paid $75 a month, with car fare and telephone
+expenses, and are allowed two weeks' vacation with pay. They are not
+required to take a Civil Service examination, but are carefully selected
+with a view to obtaining women of a high grade of efficiency. They wear
+uniforms of blue denim with simple hats and coats, but not of uniform
+design. Each nurse wears under the lapel of her coat a badge reading
+"Nurse&mdash;Baltimore Health Department," which she uses on occasions. The
+nurses report to the Superintendent each morning at 8:30 to hand in
+reports of the previous day's work, to stock their bags, and to receive
+new work for the day. At noon each nurse reports at her branch office, of
+which there are seven, each situated on border lines of adjoining
+districts. An hour is spent at the branch office for lunch and rest, for
+receiving telephone calls and for restocking the bags for afternoon
+rounds. The nurse leaves her district at four o'clock to attend to about
+an hour's clerical work, which is usually done at home.</p>
+
+<p>The average number of patients per nurse is 212, about four per cent of
+whom are bed cases. These bed patients are visited two or three times a
+week, while ambulatory cases are visited on an average of twice a month.
+During the year 1912 the sixteen nurses made 72,058 visits for instruction
+and nursing care.</p>
+
+
+<div class="subleader">NEW YORK</div>
+
+<p>The oldest tuberculosis clinic in New York City is connected with the New
+York Nose, Throat and Lung Hospital; it was established <span class="pagenum"><a name="Page_13"
+id="Page_13">13</a></span><!--015.png-->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.</p>
+
+<p>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, <span class="pagenum"><a name="Page_14"
+id="Page_14">14</a></span><!--016.png-->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:</p>
+
+<div class="ots1">a. Tuberculous patients must be segregated in a separate class.</div>
+
+<div class="ots1">b. Home supervision of all cases by a graduate nurse especially
+assigned for this purpose must be maintained.</div>
+
+<div class="ots1">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.</div>
+
+<p>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.</p>
+
+<p>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:</p>
+
+<div class="ots1">(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.</div>
+
+<div class="ots1">(2) Special children's clinics should be established wherever
+the size of the clinic warrants it.</div>
+
+<div class="ots1">(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.</div>
+
+<div class="ots1">(4) The physician should use the nurse's report of home
+conditions as a basis for advising patients.</div>
+
+<div class="ots1">(5) Patients refusing to attend the proper dispensary shall be
+dismissed as delinquent and reported to the Health Department.</div>
+
+<div class="ots1">(6) All supervising nurses should be affiliated with some local
+relief organization in order to better organize the relief work
+of the clinic.</div>
+
+<div class="ots1">(7) The home of every patient should be visited at least once a
+month.</div>
+
+<div class="ots1">(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.<span class="pagenum"><a name="Page_15"
+id="Page_15">15</a></span><!--017.png--></div>
+
+<div class="ots1">(9) A uniform system of record keeping should be used by nurses
+in order to facilitate the compiling of monthly reports.</div>
+
+<div class="ots1">(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.</div>
+
+<div class="ots1">(11) There should be at least one nurse for every 100 patients
+on the clinic register.</div>
+
+<div class="ots1">(12) Sputum cups, or a proper substitute, should be furnished to
+patients to take home.</div>
+
+<div class="ots1">(13) Paper or gauze handkerchiefs should be given to each
+patient on entrance to the clinic.</div>
+
+<div class="ots1">(14) No cuspidors should be used.</div>
+
+<div class="ots1">(15) Sanitary fountains or sanitary drinking cups should be
+provided.</div>
+
+<div class="ots1">(16) Gowns with sleeves should be worn by physicians. Nurses
+should wear gowns with sleeves or washable uniforms while on
+duty in the dispensary.</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class="pagenum"><a name="Page_16"
+id="Page_16">16</a></span><!--018.png-->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.</p>
+
+<p>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.</p>
+
+
+<div class="subleader">BOSTON</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class="pagenum"><a name="Page_17"
+id="Page_17">17</a></span><!--019.png-->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.</p>
+
+<p>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.</p>
+
+<p>Boston tuberculosis nurses do not wear uniforms. They are paid $900 a
+year, with no increase for length of service or efficiency.</p>
+
+
+<div class="subleader">BUFFALO</div>
+
+<p>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:</p>
+
+<div class="ots1">(1) A dispensary maintained by the Buffalo Charity Organization
+Society.</div>
+
+<div class="ots1">(2) The Erie County Hospital for advanced cases.</div>
+
+<div class="ots1">(3) A day camp, with a capacity of thirty patients, supported by
+a group of women.</div>
+
+<div class="ots1">(4) One visiting nurse supplied by the District Nursing
+Association.</div>
+
+<p>The present facilities are:</p>
+
+<div class="ots1">(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.</div>
+
+<div class="ots1">(2) The J. N. Adam Memorial Hospital for early cases, capacity
+125, supported by the city.</div>
+
+<div class="ots1">(3) The Municipal Hospital for the care of advanced cases,
+supported by the city.</div>
+
+<div class="ots1">(4) The Erie County Hospital, as before.</div>
+
+<div class="ots1">(5) Tuberculosis Division of the Department of Health with two
+tuberculosis inspectors and six visiting tuberculosis nurses.<span class="pagenum"><a name="Page_18"
+id="Page_18">18</a></span><!--020.png--></div>
+
+<div class="ots1">(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.</div>
+
+<div class="ots1">(7) Two open air schools, with another promised.</div>
+
+<div class="ots1">(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.</div>
+
+<div class="ots1">(9) Teachers soon to be appointed for the education of
+tuberculous children.</div>
+
+<div class="ots1">(10) The trades unions organized to promote the campaign among
+their own members in a unique organization.</div>
+
+<div class="ots1">(11) The whole community alert to the menace of tuberculosis,
+willing to shoulder the community burden and to assume the
+community responsibility.</div>
+
+<p>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,&mdash;"No uncared for tuberculosis in Buffalo in 1915."</p>
+
+
+<div class="subleader">PHILADELPHIA AND PENNSYLVANIA</div>
+
+<p>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 <span class="pagenum"><a name="Page_19"
+id="Page_19">19</a></span><!--021.png-->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."</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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:</p>
+
+<div class="blockquot"><p>"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.</p>
+
+<p>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 <span class="pagenum"><a name="Page_20"
+id="Page_20">20</a></span><!--022.png-->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.</p>
+
+<p>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."</p></div>
+
+<p>A similar plan is in operation at the other two State Department Clinics
+in Philadelphia.</p>
+
+<p>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:</p>
+
+<div class="ots1">(1) An efficient training school for tuberculosis nurses,
+affording the opportunity of hospital and dispensary training.</div>
+
+<div class="ots1">(2) A course of lectures on tuberculosis given to the nursing
+profession at large.</div>
+
+<div class="ots1">(3) Intensive home work among tuberculous families.</div>
+
+<p>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.<span class="pagenum"><a name="Page_21"
+id="Page_21">21</a></span><!--023.png--></p>
+
+
+<div class="subleader">PITTSBURGH</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Pittsburgh, then, has in all twenty visiting tuberculosis nurses, under
+three separate and distinct organizations.</p>
+
+
+<div class="subleader">CLEVELAND</div>
+
+<p>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 <span class="pagenum"><a name="Page_22"
+id="Page_22">22</a></span><!--024.png-->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.</p>
+
+<p>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.</p>
+
+<p>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."</p>
+
+<p>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.</p>
+
+<p>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.<span class="pagenum"><a name="Page_23"
+id="Page_23">23</a></span><!--025.png--></p>
+
+<p>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.</p>
+
+
+<div class="subleader">DETROIT</div>
+
+<p>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.</p>
+
+
+<div class="subleader">MILWAUKEE</div>
+
+<p>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.</p>
+
+
+<div class="subleader">ST. LOUIS</div>
+
+<p>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.</p>
+
+
+<div class="subleader">ATLANTA</div>
+
+<p>Atlanta, Ga., has a staff of four nurses and a dispensary under the
+Atlanta Anti-Tuberculosis and Visiting Nurse Association. They <span class="pagenum"><a name="Page_24"
+id="Page_24">24</a></span><!--026.png-->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.</p>
+
+<hr style="width: 45%;" />
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<div class="subleader">CHICAGO</div>
+
+<p>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).</p>
+
+<p>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 <span class="pagenum"><a name="Page_25"
+id="Page_25">25</a></span><!--027.png-->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.</p>
+
+<p>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.</p>
+
+<p>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:</p>
+
+<div class="ots1">(a) Early diagnosis of tuberculosis.</div>
+
+<div class="ots1">(b) Control of tuberculosis by means of personal instruction and
+home visits.</div>
+
+<div class="ots1">(c) Education of the community in the necessity of further
+development of the dispensary and nursing systems.</div>
+
+<div class="ots1">(d) Spread of the gospel of fresh air and "right living."</div>
+
+<p>Dispensaries were opened during the latter part of 1907 as follows:</p>
+
+<div class="ots1">(1) Jewish Aid Society Tuberculosis Clinic in existence since
+1900; joined the Chicago Tuberculosis Institute, December 13th,
+1907.</div>
+
+<div class="ots1">(2) Olivet Dispensary, May 15, 1907; transferred to Policlinic
+in December of same year.</div>
+
+<div class="ots1">(3) Central Free Dispensary at Rush Medical College, November
+16th.</div>
+
+<div class="ots1">(4) Northwestern Tuberculosis Dispensary, November 21st.</div>
+
+<div class="ots1">(5) Hahnemann Tuberculosis Dispensary, December 9th.</div>
+
+<div class="ots1">(6) Policlinic Tuberculosis Dispensary, December 13th.</div>
+
+<div class="ots1">(7) West Side Dispensary at the College of Physicians and
+Surgeons, December 17th.</div>
+
+<p>The South West Dispensary was opened in August, 1909.</p>
+
+<p>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 <span class="pagenum"><a name="Page_26"
+id="Page_26">26</a></span><!--028.png-->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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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:</p>
+
+<div class="ots0">(1) Nurses are classified into:</div>
+
+<div class="ots1"><b>Grade II. Field Nurse</b></div>
+
+  <div class="ots2">Group C: $900.00</div>
+
+  <div class="ots2">Group B (At least one year's service in lower group): $960.00</div>
+
+  <div class="ots2">Group A (At least one year's service in next lower group): $1080.00</div>
+
+<div class="ots1"><b>Grade III. Head Nurse</b></div>
+
+  <div class="ots2">Group B: $1200.00</div>
+
+  <div class="ots2">Group A (At least one year's service in lower group): $1320.00</div>
+
+<p><span class="pagenum"><a name="Page_27"
+id="Page_27">27</a></span></p><!--029.png-->
+
+<div class="ots1"><b>Supervising Nurse</b></div>
+
+  <div class="ots2">Group B: $1440.00</div>
+
+  <div class="ots2">Group A (At least one year's service in lower group): $1560.00</div>
+
+<div class="ots1"><b>Grade IV. Superintendent of Nurses</b></div>
+
+  <div class="ots2">Group D: $1920.00</div>
+
+  <div class="ots2">Group C (At least one year's service in lower group): $2100.00</div>
+
+  <div class="ots2">Group B (At least one year's service in next lower group): $2280.00</div>
+
+  <div class="ots2">Group A (At least one year's service in next lower group): $2400.00</div>
+
+<div class="ots0">(2) Civil Service examinations for all of the above positions render
+possible the selection of the best candidates.</div>
+
+<div class="ots0">(3) Efficiency of the nursing force is stimulated by conferences
+of various groups of nurses:</div>
+
+<div class="ots3">(a) Weekly conferences of junior nurses.</div>
+
+<div class="ots3">(b) Weekly conferences of head nurses.</div>
+
+<div class="ots3">(c) Conferences of the entire nursing force twice a
+month.</div>
+
+<div class="ots3">(d) A well organized system of lectures on various
+phases of tuberculosis by authorities.</div>
+
+<div class="ots3">(e) Bi-monthly meetings of the Nurses' Tuberculosis
+Study Circle, the proceedings of which are published
+in this pamphlet.</div>
+
+<div class="ots0">(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.</div>
+
+<div class="ots0">(5) Nurses wear uniforms beginning with the middle of October of
+this year (1914).</div>
+
+<div class="ots0">(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.
+</div>
+
+<p>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.</p>
+
+<p>We look into the future with confidence. The Chicago Municipal
+Tuberculosis Sanitarium, with its 900 beds and its comprehensive <span class="pagenum"><a name="Page_28"
+id="Page_28">28</a></span><!--030.png-->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.</p>
+
+<div class="figcenter" style="width: 309px;">
+<img src="images/deco_01.png" width="309" height="169" alt="Decoration." title="" />
+</div>
+
+<p><span class="pagenum"><a name="Page_29"
+id="Page_29">29</a></span><!--031.png--></p>
+
+<div class="center">
+<table border="0" cellpadding="4" cellspacing="0" summary="">
+<tr><td align="center">CITY</td><td align="center">POPULATION 1910 CENSUS</td><td align="center">PRIVATE OR PUBLIC FUNDS</td><td align="center">NUMBER OF NURSES</td><td align="center">AVERAGE NUMBER OF PATIENTS PER NURSE</td><td align="center">BEDSIDE CARE</td><td align="center">UNIFORMS</td><td align="center">YEARLY SALARY</td></tr>
+<tr><td align="center">New York</td><td align="center">4,767,000</td><td align="center">Public (city)</td><td align="center">158</td><td align="center">About 125</td><td align="center">Yes</td><td align="center">No</td><td align="center">$900.00 average</td></tr>
+<tr><td align="center"></td><td align="center"></td><td align="center">Private</td><td align="center">102</td><td align="center"></td><td align="center"></td><td align="center"></td><td align="center"></td></tr>
+<tr><td align="center">Chicago</td><td align="center">2,185,000</td><td align="center">Public (city)</td><td align="center">50</td><td align="center">135</td><td align="center">Yes</td><td align="center">Yes</td><td align="center">$900.00 to $1,320</td></tr>
+<tr><td align="center">Philadelphia</td><td align="center">1,549,000</td><td align="center">Public (state)</td><td align="center">12</td><td align="center">Varies</td><td align="center">Yes</td><td align="center">Yes</td><td align="center">$900.00</td></tr>
+<tr><td align="center"></td><td align="center"></td><td align="center">Private</td><td align="center">4</td><td align="center">150</td><td align="center">No</td><td align="center">No</td><td align="center">$720.00 to $900.00</td></tr>
+<tr><td align="center">St. Louis</td><td align="center">687,000</td><td align="center">Private</td><td align="center">7</td><td align="center">100</td><td align="center">Yes</td><td align="center">Yes</td></tr>
+<tr><td align="center">Boston</td><td align="center">671,000</td><td align="center">Public (city)</td><td align="center">25</td><td align="center">100 to 180</td><td align="center">Yes</td><td align="center">No</td><td align="center">$900.00</td></tr>
+<tr><td align="center">Cleveland</td><td align="center">561,000</td><td align="center">Public (city)</td><td align="center">24</td><td align="center">300</td><td align="center">Yes</td><td align="center">Yes</td><td align="center">$720.00 to $1,020.00</td></tr>
+<tr><td align="center">Baltimore</td><td align="center">558,000</td><td align="center">Public (city)</td><td align="center">16</td><td align="center">212</td><td align="center">Yes</td><td align="center">Yes</td><td align="center">$900.00</td></tr>
+<tr><td align="center">Pittsburgh</td><td align="center">534,000</td><td align="center">Public (city)</td><td align="center">4</td><td align="center"></td><td align="center">No</td><td align="center">No</td><td align="center">$900.00</td></tr>
+<tr><td align="center"></td><td align="center"></td><td align="center">State</td><td align="center">10</td><td align="center">100</td><td align="center">No</td><td align="center">No</td><td align="center">$840.00</td></tr>
+<tr><td align="center"></td><td align="center"></td><td align="center">Private</td><td align="center">6</td><td align="center">Yes</td><td align="center">Yes</td><td align="center">$300.00</td></tr>
+<tr><td align="center">Detroit</td><td align="center">466,000</td><td align="center">Public (city)</td><td align="center">10</td><td align="center">100</td><td align="center">Yes</td><td align="center">Yes</td><td align="center">$1,000</td></tr>
+<tr><td align="center">Buffalo</td><td align="center">424,000</td><td align="center">Public (city)</td><td align="center">6</td><td align="center">125</td><td align="center">Yes</td><td align="center">No</td><td align="center">$720.00</td></tr>
+</table></div>
+
+<hr class="ChapterTopRule" />
+<p><span class="pagenum"><a name="Page_30"
+id="Page_30">30</a></span></p><!--032.png-->
+
+
+
+
+<h2>PROVISIONS FOR OUTDOOR SLEEPING</h2>
+
+<div class="c3">By MAY MacCONACHIE, R. N.</div>
+
+<div class="center">Head Nurse, St. Elizabeth Dispensary of the Chicago Municipal Tuberculosis
+Sanitarium.</div>
+
+
+<p>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.</p>
+
+
+<h3>The Fresh Air Room.</h3>
+
+<p>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.</p>
+
+<p>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.<span class="pagenum"><a name="Page_31"
+id="Page_31">31</a></span><!--033.png--></p>
+
+
+<h3>Window Tents</h3>
+
+<p>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.</p>
+
+<p><span class="smcap">Knopf Window Tent.</span> The Knopf window tent<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a> 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.</p>
+
+<p><span class="smcap">Allen Window Tent.</span> The Allen window tent<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a> is on the same order as
+Knopf's, the difference being chiefly in size. The <span class="pagenum"><a name="Page_32"
+id="Page_32">32</a></span><!--034.png-->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.</p>
+
+<p><span class="smcap">Box Window Tent.</span> 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.</p>
+
+<p><span class="smcap">Aerarium.</span> Dr. Bull's aerarium<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a> 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.</p>
+
+<p>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.</p>
+
+
+<h3>Tents</h3>
+
+<p>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 <span class="pagenum"><a name="Page_33"
+id="Page_33">33</a></span><!--035.png-->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.</p>
+
+<p><span class="smcap">Gardner Tent.</span> The Gardner tent<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a> 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.</p>
+
+<p><span class="smcap">Tucker Tent.</span> 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&mdash;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.</p>
+
+<p><span class="smcap">La Pointe Tent.</span> 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.
+<span class="pagenum"><a name="Page_34"
+id="Page_34">34</a></span><!--036.png--></p>
+
+<p><span class="smcap">Army Tent.</span> 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.</p>
+
+<p><span class="smcap">Tent Cot.</span> 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.</p>
+
+<p><span class="smcap">Knopf's Half Tent.</span> Another simple arrangement is Knopf's half tent.<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a> 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.</p>
+
+
+<h3>Sleeping Porches</h3>
+
+<p>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.</p>
+
+<p>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.<span class="pagenum"><a name="Page_35"
+id="Page_35">35</a></span><!--037.png--></p>
+
+<p><span class="smcap">Ordinary Porches.</span><a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a> 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.</p>
+
+<p>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.</p>
+
+<p><span class="smcap">Porch de Luxe.</span> 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<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a>
+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.</p>
+
+<p><span class="smcap">Sleeping Cabin.</span> 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.<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a></p>
+
+<p><span class="smcap">Knopf's Star-Nook.</span> Another arrangement is Knopf's "Star-nook."<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">[9]</a> 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 <span class="pagenum"><a name="Page_36"
+id="Page_36">36</a></span><!--038.png-->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.</p>
+
+
+<h3>Roofs</h3>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<hr style="width: 45%;" />
+
+<p>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.</p>
+
+<hr class="ChapterTopRule" />
+<p><span class="pagenum"><a name="Page_37"
+id="Page_37">37</a></span><!--039.png--></p>
+
+
+
+
+<h2>SOME POINTS IN THE NURSING CARE OF THE ADVANCED CONSUMPTIVE</h2>
+
+<div class="c3">By ELSA LUND, R. N.</div>
+
+<div class="center">Head Nurse, Iroquois Memorial Dispensary of the Chicago Municipal
+Tuberculosis Sanitarium.</div>
+
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class="pagenum"><a name="Page_38"
+id="Page_38">38</a></span><!--040.png-->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.</p>
+
+<p>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, <span class="pagenum"><a name="Page_39"
+id="Page_39">39</a></span><!--041.png-->because
+of the low vitality of the
+patient and the need of frequent care.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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:</p>
+
+<div class="subleader"><b>1. Infirmary of Eudowood Sanatorium, Towson, Maryland.</b></div>
+
+<div class="blockquot"><p>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 <span class="pagenum"><a name="Page_40"
+id="Page_40">40</a></span><!--042.png-->iron
+bucket, in which it is
+carried, with the others, to the incinerator.</p></div>
+
+<div class="subleader"><b>2. North Reading (Mass.) State Sanatorium.</b></div>
+
+<div class="blockquot"><p>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.</p></div>
+
+<div class="subleader"><b>3. Montefiore Home Country Sanitarium, Bedford Hills, N. Y.</b></div>
+
+<div class="blockquot"><p>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.</p></div>
+
+<div class="subleader"><b>4. House of the Good Samaritan, Boston, Mass.</b></div>
+
+<div class="blockquot"><p>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.</p></div>
+
+<div class="subleader"><b>5. Chicago Fresh Air Hospital.</b></div>
+
+<div class="blockquot"><p>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.</p></div>
+
+<p>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.</p>
+
+<p>The following methods and solutions are employed in the treatment of
+laryngeal tuberculosis in various institutions:<span class="pagenum"><a name="Page_41"
+id="Page_41">41</a></span><!--043.png--></p>
+
+<div class="subleader"><b>North Reading (Mass.) State Sanatorium.</b></div>
+
+<p>The following are used as <i>gargles</i>:</p>
+
+<p>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).</p>
+
+<p><i>Sprays</i> used at this institution are as follows:</p>
+
+<p>Spray No. 1. Menthol spray in proportion of fifteen grains of menthol to
+one ounce of alboline.</p>
+
+<p>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).</p>
+
+<p>Heroin spray. From one to three grains of heroin to one ounce of water.</p>
+
+<p>Cocaine spray. From one-half to two per cent, usually before meals, for
+dysphagia.</p>
+
+<p>For <i>local applications</i>: Argentide, 1 to 200; argyrol, 10%; iodine,
+potassium iodide and glycerine; heroin powder applied dry to ulcerations;
+orthoform powder applied dry.</p>
+
+<div class="subleader"><b>Montefiore Home Country Sanitarium, Bedford Hills, N. Y.</b></div>
+
+<p>In the <i>routine treatment</i> 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.</p>
+
+<p>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.</p>
+
+<div class="subleader"><b>Eudowood Sanatorium, Towson, Md.</b></div>
+
+<p>At the Eudowood Sanatorium, Towson, Maryland, the following procedure is
+used in the treatment of tuberculous ulcers of the larynx:</p>
+
+<p><i>Topical applications</i> of lactic acid, 15 to 50%, followed by a spray
+composed of 20 grains of menthol to 1 ounce of liquid alboline.</p>
+
+<p>A <i>spray</i> of 2% cocaine is used as often as is necessary to relieve the
+pain.</p>
+
+<p>Insufflation of orthoform powder, or the patient is directed to slowly
+dissolve an orthoform lozenge in his mouth.<span class="pagenum"><a name="Page_42"
+id="Page_42">42</a></span><!--044.png--></p>
+
+<p>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.</p>
+
+<p>In laryngeal complications, semi-solid diet is generally more easily
+swallowed. This is facilitated by a reclining position. Cold compresses
+give some relief.</p>
+
+<div class="subleader"><b>Chicago Fresh Air Hospital</b></div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Cold packs are also used to give temporary relief, but they are not
+recommended as being very reliable.</p>
+
+<hr style="width: 45%;" />
+
+<p>Authorities differ regarding the proper <i>diet</i> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The contents of the bag, which should be lined with washable, removable
+lining, should include: Alcohol, tr. iodine, green soap, <span class="pagenum"><a name="Page_43"
+id="Page_43">43</a></span><!--045.png-->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.</p>
+
+<p>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.</p>
+
+<hr style="width: 45%;" />
+
+<p>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.</p>
+
+<div class="figcenter" style="width: 311px;">
+<img src="images/deco_02.png" width="311" height="131" alt="Decoration." title="" />
+</div>
+
+<hr class="ChapterTopRule" />
+<p><span class="pagenum"><a name="Page_44"
+id="Page_44">44</a></span><!--046.png--></p>
+
+
+
+
+<h2>OPEN AIR SCHOOLS IN THIS COUNTRY AND ABROAD</h2>
+
+<div class="c3">By FRANCES M. HEINRICH, R. N.</div>
+
+<div class="center">Head Nurse, Post-Graduate Dispensary of the Chicago Municipal Tuberculosis
+Sanitarium.</div>
+
+
+<p>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.</p>
+
+<p>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 <span class="pagenum"><a name="Page_45"
+id="Page_45">45</a></span><!--047.png-->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.</p>
+
+<p>During its first year the Charlottenburg School was open for only three
+months, but upon publication of the first report of the results
+accomplished it was decided to keep the school open a longer period. The
+desire to open other schools of similar type spread rapidly throughout
+Germany, as well as the rest of Europe and other parts of the world.</p>
+
+<p>Probably the best argument for maintaining such schools was not only the
+physical benefit derived, but the actual advance made by the children in
+their studies, although they spent less than half as much time on school
+work as did their companions in the regular schools, not only fully
+maintaining their standing, but ever surpassing their companions in the
+regular classes. Through results obtained from this first experiment in
+Charlottenburg came the resolve on the part of school authorities of other
+cities to inaugurate Open Air Schools in their respective localities, and
+in less than three years the movement had spread to England, where, in
+1907, London opened her first school, modeled after that of
+Charlottenburg.</p>
+
+<p>The same remarkable results obtained during the first season here, as in
+the three years previously reported from Charlottenburg, awakened such
+popular enthusiasm that towns and cities in different parts of England
+began to plan for similar schools in the communities most needing them.</p>
+
+<p>Meanwhile, the movement spread to the United States. In 1908, one year
+after England had established her first Open Air School, this country
+opened its first Open Air School in Providence, Rhode Island. Although
+Providence has the distinction of priority in this matter, the school
+inaugurated by Providence was not, strictly speaking, the first Open Air
+School established on American territory, as a school of this type was
+opened in 1904 in San Juan, Porto Rico, by L. P. Ayres, now Associate
+Director of the Department of Hygiene of the Russell Sage Foundation, at
+that time Superintendent of Schools for Porto Rico. The San Juan school
+was an experiment. It was built to accommodate 100 children. It was simple
+in its arrangements; it had a floor and roof but no sides. Venetian blinds
+were provided to keep out rain and the too direct sunlight. The school was
+designed for children of no particular class, but was established in the
+endeavor to demonstrate <span class="pagenum"><a name="Page_46"
+id="Page_46">46</a></span><!--048.png-->that
+the regime which has proven beneficial for
+weak and ailing children will also benefit those that are strong and
+seemingly healthy. The results demonstrated fully the correctness of this
+idea. The children greatly preferred the outdoor classes, and even the
+teachers were most anxious to be assigned to outdoor work. Since then at
+least one more school of similar type has been opened in Porto Rico.</p>
+
+<p>Before showing what the United States has done in this very important
+movement, it might be interesting to learn how Germany and England have
+further developed their program, as the work done in these countries,
+particularly in Germany, served as the basis of the Open Air School
+movement in this country in the initial stages of its development.</p>
+
+<p>For the past fifteen years Germany has carried on medical inspection of
+schools in a very thorough and efficient manner. This has drawn special
+attention to backward children. These children are treated there in
+special classes and sometimes in special schools. The quantity of
+instruction given them is reduced and every endeavor is made to increase
+its effectiveness. The classes are taught by capable teachers and the
+children have the benefit of suitable dietary, bathing and other hygienic
+provisions.</p>
+
+<p>In Charlottenburg, in 1904, there were a large number of backward children
+who were about to be removed from the ordinary elementary schools to
+special classes. When examined, it was found that many of them were in a
+debilitated condition owing to anaemia, or various other ailments in an
+incipient stage. This circumstance afforded an ideal opportunity for the
+co-operation of the teacher and the school physician in devising and
+operating, for such children, an Open Air School. The general school
+regime was modified to meet the educational and physical needs of these
+children, the treatment consisting, as above stated, of abundance of fresh
+air, pleasant and hygienic surroundings, careful supervision, wholesome
+food and judicious exercise. The ordinary school work was modified to meet
+the individual condition of children; the hours of teaching were cut in
+two and the classes so reduced that no teacher had more than twenty-five
+pupils under her care. The site chosen for the first school in
+Charlottenburg was a large pine forest on the outskirts of the town. The
+sum of $8,000 was granted by the municipality for carrying out the plan,
+and inexpensive but suitable wooden buildings were erected. At first
+ninety-five children were admitted to the school, but later the number was
+increased to 120, and still later to 250. These children were mainly
+anaemic or suffering from slight pulmonary, heart or <span class="pagenum"><a name="Page_47"
+id="Page_47">47</a></span><!--049.png-->scrofulous
+conditions. Those suffering from acute or communicable diseases were
+rigidly excluded. Of the five buildings erected, three were plain sheds
+about 81 feet long and 18 feet wide, one of them being completely open on
+the south side and closed on the other sides, of sufficient size to
+shelter during rainy weather about 200 children. The other two sheds
+contained five classrooms and a teachers' room. These were closed in on
+all sides, provided with heating arrangements, and used for classrooms
+during very cold or unpleasant weather, only one of the buildings was
+fitted with tables and benches intended for meals, or for work in
+inclement weather. This building was open on all sides. All over the
+school grounds, which were fenced in, there were small sheds open on all
+sides, fitted with tables and benches to accommodate from four to six
+children. These served as shelters. There were small buildings for shower
+baths, kitchen and a separate shed where the wraps of the boys and girls
+were kept. In these were individual lockers which contained numbered
+blankets for protection against cold, and waterproofs against rain.</p>
+
+<p>The children in this school report at a little before 8 a. m. and leave at
+a quarter of 7 p. m. For breakfast they are given a bowl of soup and a
+slice of bread and butter. Classes commence at 8 o'clock and continue with
+an interval of five-minutes' rest after each half hour. At 10 a. m. the
+children receive one or two glasses of milk and a slice of bread and
+butter. After this they play, perform gymnastic exercises, do manual work
+or read. Dinner is served at 12:30 p. m. and consists of about three
+ounces of meat, with vegetables and soup. After dinner the children rest
+or sleep for two hours on folding chairs. At 3 p. m. comes more class work
+and at 4 p. m. milk, rye bread and jam is given. The rest of the afternoon
+is given over to informal instruction and play. The last meal consists of
+soup, bread and butter, after which the children are dismissed. Some walk
+home; some use street cars. In case of the very poor children the city
+pays the fare, while the transportation is furnished for others through
+the generosity of the street car company. The expense of the feeding is
+borne by the municipality, in the case of those who can not pay, and, for
+the others, is defrayed in part or whole by the parents.</p>
+
+<p>The work of the school physician consists of careful examination,
+treatment and supervision of these children. Attention is principally
+directed to heart, lungs and general condition with respect to color,
+muscular and flesh development. Weight and measurements are taken every
+two weeks, and at the end of the school period the children are very
+carefully examined and condition compared with that noted upon their
+admission.<span class="pagenum"><a name="Page_48"
+id="Page_48">48</a></span><!--050.png--></p>
+
+<p>The regime covers such important phases of hygiene as suitable clothing,
+attention to daily habits, bathing, giving of warm baths for those who are
+anaemic and nervous, and of mineral baths for those who are scrofulous.
+Bathing plays a very important part. All of the children receive two or
+three warm shower baths a week. A trained nurse is in attendance.</p>
+
+<p>The educational, physical and moral results obtained are remarkable. There
+is a great improvement in their behavior, especially with regard to order,
+cleanliness, self-help, punctuality and good temper. This is undoubtedly
+due to their removal, during practically all of their waking hours, from
+the influences of the street life to the more wholesome influences of the
+school. The children are taught to regard themselves as members of a large
+family, are trained to assist in the daily work and are taught to be
+helpful and considerate of each other.</p>
+
+<p>This, in detail, is the regime of the first Open Air School conducted in
+Germany.</p>
+
+<p>The number of Open Air Schools at present in Germany is at least ten, with
+an attendance of approximately 1,500.</p>
+
+<hr style="width: 45%;" />
+
+<p>In England the Open Air Schools were made possible through the work of the
+local educational authorities and co-operation of dispensaries for
+treatment and care of tuberculous children.</p>
+
+<p>As in other countries, general legislation for the control of tuberculosis
+has had considerable bearing on the Open Air School situation in England.
+Among the legislative acts should be mentioned:</p>
+
+<div class="blockquot"><p>(a) The Act of 1911 providing building grants for the
+establishment of sanatoria, dispensaries and other auxiliary
+institutions.</p>
+
+<p>(b) Compulsory notification of tuberculosis, etc.</p></div>
+
+<p>Notification of tuberculosis, for instance, besides bringing to notice of
+the school medical officer cases of tuberculosis which might otherwise not
+come before him until a late period, serves in many cases to keep him
+informed as to "contact cases"&mdash;cases of children in contact with
+communicable tuberculosis.</p>
+
+<p>At Burton-on-Trent a system was instituted for periodical examination of
+school children who are either members of a family in which there is or
+has been a case of pulmonary tuberculosis, or who are attending school
+while residing in houses in which there is an existing case of this
+disease. All notified cases of tuberculosis are visited by the Assistant
+Medical Officer of Health, who is also Assistant School Medical Officer,
+and the names of any children <span class="pagenum"><a name="Page_49"
+id="Page_49">49</a></span><!--051.png-->living
+in the house, or related to the
+case, are ascertained, together with the school they are attending. These
+names are entered in a special register and when the pupils of a school,
+at which any of these children are attending, are examined, a special
+examination is made of the latter. This examination is repeated two or
+three times a year.</p>
+
+<p>In another part of England a special letter is sent to the occupants of
+all houses from which the disease has been notified, calling attention to
+the special importance of early detection of tuberculosis in children, and
+asking that the children should be brought to the school clinic for
+examination.</p>
+
+<p>In Lancashire the Medical Inspector calls on the Medical Officer of Health
+and obtains a list of names of persons suffering from tuberculosis, so
+that the children, if of school age, may be examined.</p>
+
+<p>At Newcastle-on-Tyne all children exposed at any time to infection are
+kept under observation and re-examined. The re-examination continues even
+after fatal termination of the tuberculosis case with which the child was
+in contact.</p>
+
+<p>Under the Finance Act of 1911 a sum of about $500,000 was especially
+appropriated for providing what are known as "Sanatorium Schools" for
+children suffering from pulmonary or surgical tuberculosis. These schools
+are known as the Residential Open Air Schools of Recovery, and the need of
+such schools for children requiring more continuous care than is provided
+at a day Open Air School is becoming widely recognized. Many children of
+the type already mentioned can not be satisfactorily treated unless they
+can be taken completely away, for a time, from their home environment.
+Such treatment as is needed for many of these children is not and can not
+be offered in the ordinary hospital and certainly not at their homes.</p>
+
+<p>The designs and arrangements of the Residential Open Air School of
+Recovery are very attractive. They are well equipped to fulfill their
+function. The children, received between the ages of seven and twelve
+years, are those suffering from anaemia, debility, or slight heart
+lesions. Cases of active tuberculosis are barred. No child is received for
+a shorter period than three months, and this period may be prolonged on
+the recommendation of the Medical Officer.</p>
+
+<p>The children rise at 7 a. m. and retire at 6:30 p. m. Those who are able,
+make their own beds and do some of the domestic work. The diet is liberal,
+with abundance of milk and eggs. Careful attention is given to inculcating
+habits of personal and general hygiene. All children receive a daily bath.
+Careful attention is <span class="pagenum"><a name="Page_50"
+id="Page_50">50</a></span><!--052.png-->paid
+to the teeth, tonsils and adenoids. All these
+conditions must be attended to before admission. Beyond this, very little
+treatment is given. Children are weighed once in two weeks. Instruction is
+chiefly practical. Instruction in gardening is given twice a week and
+other occupations taught are raffia work, plasticine modeling, cardboard
+modeling, brush work and needle work.</p>
+
+<p>The number of Open Air Schools at present in England is at least
+thirty-five, with an attendance of at least 2,500. Forty-two other cities
+are listed as carrying on some form of open air education.</p>
+
+<hr style="width: 45%;" />
+
+<p>In the United States the Open Air School movement, from its inception, has
+been closely connected with the general anti-tuberculosis movement.</p>
+
+<p>The credit of establishing the first Open Air School in America belongs,
+as previously stated, to Providence, Rhode Island, where the work was
+begun in January, 1908. The school was opened in a brick school house in
+the center of the city. A room on the second floor was chosen and
+remodeled by removing part of the south wall. For the wall thus removed
+windows were substituted. These extended from near the floor to the
+ceiling, with hinges at the top and with pulleys so arranged that the
+lower ends could be raised to the ceiling. The desks were placed in front
+of the open windows in such a manner that the children received the fresh
+air at their backs and the light over their shoulders. Suitable clothing
+was provided for cold weather and, in case of necessity, soapstone foot
+warmers were used.</p>
+
+<p>The school was started as an ungraded school and ten pupils were enrolled
+at the time of its opening, the number later increasing to twenty-five.
+Practically all children were selected by the visiting nurse of the local
+League for the Suppression of Tuberculosis from infected homes under her
+supervision. In a few instances children with moderately advanced lesions
+were admitted.</p>
+
+<p>The children reported at 9 a. m. and a recess was given at 10:30, when
+they were served soup. At noon they had a light lunch of pudding served
+with cream, hot chocolate or cocoa made entirely with milk. Some of the
+children brought additional food from home. All of the cooking was done by
+the teacher. Careful attention to general cleanliness and hygiene of the
+teeth was insisted upon. Individual drinking cups and tooth brushes were
+provided. The children took turns in washing dishes, setting the table and
+helping <span class="pagenum"><a name="Page_51"
+id="Page_51">51</a></span><!--053.png-->to
+serve. Children were dismissed at 2:30 p. m. They were
+provided with car tickets by the League for the Suppression of
+Tuberculosis, some for traveling both ways, some for one way only,
+depending upon the means of the family. During school session light
+gymnastic exercises were given and proper methods of breathing taught. In
+the spring they had a garden to work in.</p>
+
+<p>The Providence school is at present a part of the general school system.
+The school supplies and teacher's salary are furnished by the Board of
+Education. Food and carfare are supplied by the League for the Suppression
+of Tuberculosis. A physician is delegated by the League and one of the
+regular Medical Inspectors of the city schools works in co-operation with
+him.</p>
+
+<p>Providence has at present two schools, with an attendance of forty. One
+more Open Air School and two roof classes may be provided by the Board of
+Education in 1914. In addition, the Providence League for the Suppression
+of Tuberculosis conducts a Preventorium for thirty children at the
+Lakeside Preventorium, Rhode Island.</p>
+
+<hr style="width: 45%;" />
+
+<p>Boston started its first Open Air School in July, 1908. The work was
+carried on by the Boston Association for the Relief and Control of
+Tuberculosis. The school was located at Parker Hill, Roxbury. The same
+regime was followed as in previously reported schools. No formal
+instruction, however, was attempted at first. The school was simply a day
+camp. The benefit derived by the children in the first open air camp for
+children led the Association to ask the Boston School Board to co-operate
+with them in converting the camp into an outdoor school. This was agreed
+to, the School Board supplying teacher, desks, books, etc., the
+Association furnishing the necessary clothing, food, a nurse, attendants,
+home instruction and medical services. The same schedule was followed here
+as in the other Open Air Schools. General and personal hygiene was
+insisted upon. The school was kept open Saturdays and during the holidays.
+The children who were able paid ten cents a day to help defray the cost of
+food. In case they could not afford this, the money was supplied by some
+charity organization. While the combined public and private support had
+proved satisfactory, it seemed best, for many reasons, to reorganize the
+school so that it would be entirely under municipal authority, and this
+has since been done. At the present time the school is maintained by the
+Boston Consumptives' Hospital and the Boston School Board. The hospital
+furnishes transportation, food, etc., while the School Board gives school
+supplies, books, desks, etc., <span class="pagenum"><a name="Page_52"
+id="Page_52">52</a></span><!--054.png-->and
+pays the salaries of the teachers. The
+children are selected by the school physicians, the type considered being
+the anaemic, poorly nourished, those with enlarged glands, or
+convalescents. Cases of active tuberculosis are not admitted.</p>
+
+<p>Boston has at present fifteen Open Air Schools, with a total enrollment of
+about 500 children.</p>
+
+<hr style="width: 45%;" />
+
+<p>The first school established in New York City was started under the
+auspices of the Department of Education and was located on the ferryboat
+Southfield, which was maintained as an outdoor camp for tuberculous
+patients by Bellevue Hospital. It was through the special desire of the
+children who were patients at the camp that the school was started, for
+they banded together one day and informed the doctor that they wanted to
+have a teacher and attend school. When their action was reported to the
+Board of Education it was felt that such an unusual plea should be given a
+favorable response, and in December, 1908, the school on the ferryboat was
+made an annex of Public School No. 14.</p>
+
+<p>This school, except for its location, does not differ from other schools
+of similar type. The Board of Education pays the teacher and furnishes the
+school supplies. Food and clothing are supplied by the hospital. The
+school is an ungraded one and the number of children taught by one teacher
+averages thirty.</p>
+
+<p>Four more Open Air Schools have since been established, three on
+ferryboats and one on the roof of the Vanderbilt Clinic at West Sixtieth
+street. Officially, all these schools are considered to be annexes of the
+regular public schools.</p>
+
+<p>In October, 1909, $6,500 was granted to the Board of Education by the
+Board of Estimate and Apportionment for the purpose of remodeling rooms in
+some of the public schools for use as Open Air Rooms. A special conference
+was held in December of that year by medical and school authorities to
+decide how best to remodel, furnish and equip these new rooms for this
+purpose; also how the children should be chosen for these classes.</p>
+
+<p>It was decided that the maximum number of children admitted to any one
+open air classroom should not exceed twenty-five, the children to be
+chosen by the director of the tuberculosis clinic nearest the school and
+the school principal. No child was to be assigned to the room until the
+parents' permission had been secured in writing. Children moving from one
+district to another were to be followed up and cared for in the new
+district. No special rule was adopted defining the physical condition
+entitling the child to admission. Each case was to be considered
+individually, <span class="pagenum"><a name="Page_53"
+id="Page_53">53</a></span><!--055.png-->and
+the only definite rule was that no open case of
+tuberculosis should be admitted. The minimum temperature of the room was
+50 degrees F. The rooms, wherever possible, were to be located on the
+third floor. The first of these open air classes was established in April,
+1910. Such popular interest was awakened by the inauguration of these
+classes that, as a direct result, a special privilege was granted by the
+Commissioners of Central Park permitting children of the kindergarten
+classes of the public schools to pursue their studies in the open air in
+Central Park.</p>
+
+<p>At present New York has thirty-three Open Air Schools and Open Window
+Rooms, with a total enrollment of at least 1,000.</p>
+
+<hr style="width: 45%;" />
+
+<p>Chicago's first Outdoor School for Tuberculous Children was inaugurated as
+a result of the joint co-operation of the Chicago Tuberculosis Institute
+and the Board of Education. This school was opened during the first week
+of August, 1909, on the grounds of the Harvard School at Seventy-fifth
+street and Vincennes Road. The Board of Education assigned a teacher to
+the school and furnished the equipment, while the Tuberculosis Institute
+supplied the medical and nursing service, selected the children and
+provided the food.</p>
+
+<p>Except during inclement weather, the children occupied a large shelter
+tent in which thirty reclining chairs were placed. Meals were served in
+the basement of the school building, where a gas range, cooking utensils
+and tables were installed for this special purpose.</p>
+
+<p>The nurse, who was assigned by the Tuberculosis Institute on half-time
+attendance, visited the school each afternoon, took daily afternoon
+temperatures, pulse and respiration, looked after the general physical
+condition of the children, made weekly records of their gain or loss in
+weight and did instructive work in the home of each pupil.</p>
+
+<p>Of the thirty children selected, seventeen had pulmonary tuberculosis, two
+had tubercular glands, and eleven were designated as "pre-tuberculous."
+None of the children had passed to the "open" or infectious stage. On
+admission two-thirds of the children showed a temperature of from 99 to
+100.2 degrees.</p>
+
+<p>The daily program was similar to that already described for the Providence
+and Boston Schools. The school was kept open for a period of only one
+month, with excellent results. During this time the thirty children made a
+net gain of 115 pounds in weight, and at the close of the period
+practically all of them showed a normal temperature, with their general
+condition greatly improved.<span class="pagenum"><a name="Page_54"
+id="Page_54">54</a></span><!--056.png--></p>
+
+<p>It is needless to say that the experiment created a great deal of local
+interest in the problem of better school ventilation. Those who had the
+success of the movement most intimately at heart realized, however, that
+the undertaking lacked the element of permanency and that the results
+accomplished by it lacked that degree of conclusiveness which would attend
+the same results if secured through the operation of an all-the-year-round
+school.</p>
+
+<p>The opportunity to demonstrate the effectiveness of such an
+all-the-year-round school was realized in the Fall of 1909 by a grant from
+the Elizabeth McCormick Memorial Fund to the United Charities for the
+purpose of conducting such a school on the roof of the Mary Crane Nursery
+at Hull House. This school was opened by the United Charities in October
+with twenty-five carefully selected children, and was conducted throughout
+the following winter and spring with the co-operation of the Board of
+Education and the Chicago Tuberculosis Institute. During the same winter
+the Public School Extension Committee of the Chicago Women's Club,
+co-operating with the Board of Education, established two classes for
+anaemic children in open window rooms&mdash;one in the Moseley and one in the
+Hamline School. Here the regular regime was broken by a rest period, and
+lunches of bread and milk were served twice each day. "Fresh Air Rooms,"
+in which the windows were thrown wide open and the heat cut off, were also
+established for normal children in several rooms in the Graham School. No
+attempt was made here to furnish lunches and no rest period was provided.</p>
+
+<p>There were, then, during the school year of 1909 and 1910, three distinct
+classes of children cared for by three distinct agencies&mdash;the classes for
+normal children in the low temperature rooms at the Graham School; anaemic
+children, with rest period and two lunches, in the Moseley and Hamline
+Open Window Rooms, and the Roof School for Tuberculous Children, with
+specially provided clothing, sleeping outfits, three meals a day and
+medical and nursing attendance, at the Mary Crane Nursery.</p>
+
+<p>The same condition existed throughout the following year&mdash;1910-11&mdash;with
+the addition of one Open Air School on the roof of the municipal bath
+building on Gault Court, given rent free by the City Health Department,
+and two Open Window Rooms for anaemic children in the Franklin School, all
+maintained by the Elizabeth McCormick Memorial Fund.</p>
+
+<p>In 1911 the Elizabeth McCormick Memorial Fund assumed the responsibility
+for all the open air school work carried on in the <span class="pagenum"><a name="Page_55"
+id="Page_55">55</a></span><!--057.png-->Chicago
+Public
+Schools, and began the standardization of methods which should be employed
+in the conduct of such schools.</p>
+
+<p>Through the initiative of the Elizabeth McCormick Memorial Fund the
+Chicago Open Air School work has been rapidly developed during 1912 and
+1913, the program being along the line of additional roof schools for
+tuberculous children and an increasing number of open window rooms for
+anaemic children and children exposed to tuberculosis. In all this work
+the Elizabeth McCormick Memorial Fund has had the co-operation of the
+Board of Education, the Chicago Tuberculosis Institute and the Municipal
+Tuberculosis Sanitarium. The Board of Education has supplied teachers and
+furnished rooms wherever there has been a distinct demand for such a
+provision. During the past two years the Municipal Sanitarium has made
+appropriations aggregating $12,000 to pay the cost of food for these
+schools, in addition to furnishing the necessary nursing service.</p>
+
+<p>At the present time four Roof Schools and sixteen Open Window Rooms, with
+an enrollment of 500 pupils, are being maintained.</p>
+
+<p>For full information concerning the Chicago Open Air School movement, see
+"Open Air Crusaders," January, 1913, edition, published by the Elizabeth
+McCormick Memorial Fund, 315 Plymouth Court, Chicago; or write Mr. Sherman
+C. Kingsley, Director, Elizabeth McCormick Memorial Fund, for more recent
+developments.</p>
+
+<hr style="width: 45%;" />
+
+<p>Space will not permit a statement of the development of the Open Air
+Schools in other cities in the United States since this movement was
+started in 1908. It is, however, encouraging to note what has been
+accomplished and the comprehensive plans which are being made to further
+this great movement for the good of the future citizens of America.</p>
+
+<div class="figcenter" style="width: 415px;">
+<img src="images/deco_03.png" width="415" height="84" alt="Decoration." title="" />
+</div>
+
+<hr class="ChapterTopRule" />
+<p><span class="pagenum"><a name="Page_56"
+id="Page_56">56</a></span><!--058.png--></p>
+
+
+
+
+<h2>NOTES ON TUBERCULIN FOR NURSES</h2>
+
+<div class="center blockquot">VARIETIES OF TUBERCULIN&mdash;THEORIES OF TUBERCULIN REACTION&mdash;TUBERCULIN
+TESTS.</div>
+
+<div class="c4">By THEODORE B. SACHS, M. D.</div>
+
+
+<h3 style="padding-top: 1em;">VARIETIES OF TUBERCULIN AND METHODS OF PREPARATION</h3>
+
+<div class="ots0"><span class="smcap">Old Tuberculin</span>&mdash;T. Announced by Koch in 1890.</div>
+
+<div class="ots3">Tubercle Bacilli of human origin.</div>
+
+<div class="ots3">Grown on beef broth containing 5% glycerine, 1% peptone,
+sodium chloride; growths 6 to 8 weeks.</div>
+
+<div class="ots3">Sterilized by steam one-half hour.</div>
+
+<div class="ots3">Evaporated (at a temp. not higher than 70° C.) to <sup>1</sup>&frasl;<sub>10</sub> its volume.</div>
+
+<div class="ots3">Filtered.</div>
+
+<div class="ots3"><sup>1</sup>&frasl;<sub>2</sub>% carbolic acid added. Let stand.</div>
+
+<div class="ots3">Filtered (porcelain filter).</div>
+
+<div class="ots2">Old Tuberculin contains:</div>
+
+<div class="ots3">1. 40 to 50% glycerine (a small percentage of glycerine is
+evaporated)</div>
+
+<div class="ots3">2. 10% of peptones or albumoses</div>
+
+<div class="ots3">3. Toxic secretions of the tubercle bacilli into the culture fluid,
+or such of them as are soluble in 50% glycerine</div>
+
+<div class="ots3">4. Substances extracted from the bacterial bodies by the alkaline
+broth during the process of boiling and evaporation.</div>
+
+<div class="ots2">Appearance and Characteristics:</div>
+
+<div class="ots3">1. A clear brown fluid</div>
+
+<div class="ots3">2. Of syrupy consistency</div>
+
+<div class="ots3">3. Mixes with water in all proportions without producing any
+turbidity</div>
+
+<div class="ots3">4. Keeps indefinitely, but not advisable to use brands older than
+one year.</div>
+
+<p><span class="pagenum"><a name="Page_57"
+id="Page_57">57</a></span></p><!--059.png-->
+
+<div class="ots0"><span class="smcap">Boullion Filtrate</span>&mdash;B. F. Denys&mdash;1907.</div>
+
+<div class="ots3">Method of preparation same as Old Tuberculin, with the exception
+of subjection to heat;</div>
+
+<div class="ots3">B. F. is a filtered, unconcentrated culture.</div>
+
+<div class="ots3">Contains less peptone and less glycerine than Old Tuberculin.</div>
+
+<div class="ots3">Contains no substances extracted from tubercle bacilli by heat.</div>
+
+<div class="ots3">Some toxic substances may be more active (not having been subjected
+to heat).</div>
+
+<div class="ots0"><span class="smcap">Tuberculin Ruckstand</span> (Residue)&mdash;T. R. Announced by Koch in
+1897.</div>
+
+<div class="ots3">Ground, dried tubercle bacilli.</div>
+
+<div class="ots3">Distilled water added.</div>
+
+<div class="ots3">Centrifugalization.</div>
+
+<div class="ots3">Supernatant fluid removed (not to be used).</div>
+
+<div class="ots3">Sediment dried and ground; distilled water added; centrifugalization.</div>
+
+<div class="ots3">Fluid removed and <i>set aside</i>.</div>
+
+<div class="ots3">Sediment dried and ground again; distilled water added; centrifugalization.</div>
+
+<div class="ots3">Fluid removed and set aside.</div>
+
+<div class="ots3">Sediment dried and ground, etc., as above.</div>
+
+<div class="ots3">The process continued until water takes up the sediment, then
+all the fluids set aside (except the first one) mixed together.</div>
+
+<div class="ots3">Glycerine 20% added.</div>
+
+<div class="ots3">The mixture is T. R.</div>
+
+<div class="ots3">Koch was prompted by the following consideration in bringing out T. R.: He
+thought that the Old Tuberculin conferred only a toxic immunity, not
+bacterial. T. R. was supposed to confer bacterial immunity.</div>
+
+<div class="ots3">Each 1 cc. of T. R. contains 10 milligrams of dried bacilli.</div>
+
+<div class="ots0"><span class="smcap">Bacillen Emulsion</span>&mdash;B. E. Announced by Koch in 1901.</div>
+
+<div class="ots3">Finely powdered tubercle bacilli&mdash;<sup>1</sup>&frasl;<sub>2</sub> gram.</div>
+
+<div class="ots3">50 cc. of water and 50 cc. of glycerine.</div>
+
+<div class="ots3">All mixed together&mdash;prolonged shaking.</div>
+
+<div class="ots3">B. E. is supposed to contain not only the extract of the body of the
+tubercle bacilli, as in T. R., but also its soluble products (which in the
+case of T. R. were discarded in setting aside the supernatant fluid).</div>
+
+<h3>THEORIES OF TUBERCULIN REACTION</h3>
+
+<div class="ots0"><i>a&nbsp;</i> <span class="smcap">Robert Koch</span> ascribes the tuberculin reaction to the increased necrotic
+process around the tubercle, the histological changes consisting
+of hyperaemia, exudation and softening.</div>
+
+<p><span class="pagenum"><a name="Page_58"
+id="Page_58">58</a></span></p><!--060.png-->
+
+<div class="ots0"><i>b&nbsp;</i> <span class="smcap">Ehrlich</span> considers the formation of antibodies an essential feature
+in the mechanism of reaction. Formation of antibodies takes place
+in the middle of the three layers encircling the tubercle, the layer
+damaged by toxins, but not yet rendered incapable of reaction.</div>
+
+<div class="ots0"><i>c&nbsp;</i> <span class="smcap">Wassermann</span> maintains that the antituberculin found in the tuberculous
+process draws the injected tuberculin out of the circulation
+to the tuberculous focus. The interaction that takes place between
+antituberculin and tuberculin results in formation of ferments
+which digest albumin, resulting in the softening of tissue.
+Absorption of softened tissue causes fever.</div>
+
+<div class="ots0"><i>d&nbsp;</i> <span class="smcap">Carl Spengler</span>&mdash;Toxins in the blood of the tuberculous are kept in
+check by antibodies. Injected tuberculin unites with antibodies,
+thus setting the toxins free. Result&mdash;autointoxication.</div>
+
+<div class="ots0"><i>e&nbsp;</i> <span class="smcap">Wolff-Eisner</span>&mdash;Bacteriolysin is present in the organism of the tuberculous,
+as result of previous infection; bacteriolysin sets free the
+potent substances of the injected tuberculin; this acts on the
+body and the tuberculous focus, producing a reaction.<a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">[10]</a></div>
+
+
+<h3>TUBERCULIN TESTS</h3>
+
+<div class="ots0">I. <span class="smcap">Subcutaneous</span> (hypodermic); introduced by Robert Koch in 1890.</div>
+
+<div class="ots0">II. <span class="smcap">Cutaneous</span>; introduced by Von Pirquet in 1907.</div>
+
+<div class="ots0">III. <span class="smcap">Conjunctival</span> (ophthalmic); introduced about the same time by
+Wolff-Eisner and Calmette in 1907.</div>
+
+<div class="ots0">IV. <span class="smcap">Percutaneous</span> (inunction or salve); introduced by Moro in 1908.</div>
+
+<div class="ots0">V. <span class="smcap">Intracutaneous</span> (needle track reaction); introduced as a test by
+Mantoux in 1909. Described previously by Escherich.</div>
+
+
+<h4>I. SUBCUTANEOUS TUBERCULIN TEST</h4>
+
+<div class="ots0">1. <span class="smcap">Apparatus and Solutions Necessary</span>:</div>
+
+<div class="ots1">Glass cylinder graduated to cc.</div>
+
+<div class="ots1">1 cc pipette graduated to <sup>1</sup>&frasl;<sub>10</sub> cc.<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">[11]</a></div>
+
+<div class="ots1">10 cc pipette graduated to <sup>1</sup>&frasl;<sub>10</sub> cc.<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">[12]</a></div>
+
+<div class="ots1">Hypodermic needle suited to the syringe.</div>
+
+<div class="ots1">Two or more <sup>1</sup>&frasl;<sub>2</sub> oz. bottles.</div>
+
+<div class="ots1"><sup>1</sup>&frasl;<sub>2</sub>% carbolic acid solution.</div>
+
+<div class="ots1">Normal salt solution.</div>
+
+<div class="ots1">1 cc. Old Tuberculin.</div>
+
+<p><span class="pagenum"><a name="Page_59"
+id="Page_59">59</a></span></p><!--061.png-->
+
+<div class="ots0">2. <span class="smcap">Preparation of Apparatus</span>:</div>
+
+<div class="ots1">Glass apparatus, syringe and needles boiled before use.</div>
+
+<div class="ots1">Some keep needles and syringe in 95% alcohol.</div>
+
+<div class="ots0">3. <span class="smcap">Making Solutions</span>:</div>
+
+<div class="center" style="margin-bottom: 1em;">
+<table border="0" cellpadding="4" cellspacing="0" summary="">
+<tr><td align="center">Tuberculin No. I:</td><td style="width: 5em;"> &nbsp; </td><td align="center">Tuberculin No. II:</td></tr>
+<tr><td align="center">Label one bottle</td><td> &nbsp; </td><td align="center">Another</td></tr>
+<tr><td align="center"><i>.1 cc. = 1 mg. T</i></td><td> &nbsp; </td><td align="center"><i>.1 cc. = .1 mg. T</i></td></tr>
+</table></div>
+
+<div class="center" style="margin-bottom: 1em;">
+<table border="0" cellpadding="4" cellspacing="0" summary="">
+<tr><td align="left">No. I:</td><td align="left">Put 0.1 cc. T in bottle No. I</td></tr>
+<tr><td align="left">&nbsp;</td><td align="left">Add 9.9 cc. of <sup>1</sup>&frasl;<sub>2</sub>% carbolic acid solution</td></tr>
+<tr><td align="left">No. II:</td><td align="left">Put 1 cc. of Tuberculin solution from No. I into bottle No. II</td></tr>
+<tr><td align="left">&nbsp;</td><td align="left">Add 9 cc. of <sup>1</sup>&frasl;<sub>2</sub>% carbolic solution</td></tr>
+</table></div>
+
+<div class="ots1">In making dilutions you may use your syringe instead of pipette.</div>
+
+<div class="ots1">Dilutions can be kept <i>one week</i> in a dark, cool place.</div>
+
+<div class="ots1">Discard turbid solutions.</div>
+
+<div class="ots0">4. <span class="smcap">Preparation of the Patient for the Test</span>:</div>
+
+<div class="ots1">Patient to keep quiet in bed, or reclining chair, for two or three
+days before injection.</div>
+
+<div class="ots1">Take temperature every two or three hours for two or three
+days (daytime).</div>
+
+<div class="ots1">If the test is to be applied, highest temperature should not be
+above 99.1 F, by mouth, according to Koch; not above 100 F,
+according to others.</div>
+
+<div class="ots1">Site of injection&mdash;back, below the level of the shoulder blades,
+alternately on the two sides.</div>
+
+<div class="ots1">Rub skin with ether or alcohol.</div>
+
+<div class="ots1">An exact record of physical signs, <i>just before injection</i>, should
+be made by the physician.</div>
+
+<div class="ots0">5. <span class="smcap">Time of Injection</span>:</div>
+
+<div class="ots1">Between 8 and 10 A. M. (Bandelier and Roepke).</div>
+
+<div class="ots1">Late in the evening, 9 or 10 P. M., or later (others).</div>
+
+<div class="ots0">6. <span class="smcap">Dose</span>:</div>
+
+<div class="ots1">According to Koch: Begin with  <sup>1</sup>&frasl;<sub>2</sub> mg., or 1 mg., according to
+condition of patient; give larger dose if no reaction. Order
+of increase: 1 mg.; 5 mg.; 10 mg. (last dose repeated if necessary).</div>
+
+<div class="ots1">Interval between injections: two or three days.</div>
+
+<div class="ots1">Present Usage: First dose in adults, <sup>1</sup>&frasl;<sub>2</sub> mg., or <sup>1</sup>&frasl;<sub>5</sub> mg., or smaller,
+according to physical condition.</div>
+
+<div class="ots2">First dose in children: <sup>1</sup>&frasl;<sub>10</sub> mg., or <sup>1</sup>&frasl;<sub>20</sub> mg., or even smaller.</div>
+
+<div class="ots2">Thus, in adults: <sup>1</sup>&frasl;<sub>2</sub>, or 1, 3, 5, 8, and rarely 10;</div>
+
+<div class="ots2">In children: <sup>1</sup>&frasl;<sub>10</sub>, <sup>1</sup>&frasl;<sub>2</sub>, 1, 3.</div>
+
+<p><span class="pagenum"><a name="Page_60"
+id="Page_60">60</a></span></p><!--062.png-->
+
+<div class="ots1">Loewenstein and Kaufmann's Scheme: Repetition of small dose,
+relying on exciting hypersensibility&mdash;<sup>2</sup>&frasl;<sub>10</sub> mg.; in 3 days,
+<sup>2</sup>&frasl;<sub>10</sub> mg.; in 3 days, <sup>2</sup>&frasl;<sub>10</sub> mg.; in 3 days, <sup>2</sup>&frasl;<sub>10</sub> mg.</div>
+
+<div class="ots1">Some use <sup>1</sup>&frasl;<sub>10</sub> mg., or <sup>3</sup>&frasl;<sub>4</sub>, or 1<sup>1</sup>&frasl;<sub>4</sub>, in same way.</div>
+
+<div class="ots1">This scheme is based on hypersensibility created by repetition of
+same dose in tuberculous subjects. Scheme not used at
+present.</div>
+
+<div class="ots1">Some advise single dose: 3 or 5 mg., (on the ground that gradual
+increase of doses creates tolerance).</div>
+
+<div class="ots0">7. <span class="smcap">Rules to Follow in Increasing Dose</span>:</div>
+
+<div class="ots1"><i>a</i> If no reaction with one dose, give a larger one next time,
+according to <i>b</i>.</div>
+
+<div class="ots1"><i>b</i> If temperature rises less than 1 degree F, repeat same dose;
+otherwise increase.</div>
+
+<div class="ots1"><i>c</i> Avoid large doses in cases of weakness, nervous temperament,
+children, etc. In a majority of cases smaller doses suffice.</div>
+
+<div class="ots0">8. <span class="smcap">After Injection</span>:</div>
+
+<div class="ots1"><i>a</i> Rest in reclining chair two or more days, unless severe reaction
+requires absolute rest in bed.</div>
+
+<div class="ots1"><i>b</i> Take temperature every 2 or 3 hours for 2 or 3 days.</div>
+
+<div class="ots0">9. <span class="smcap">General Reaction</span>:</div>
+
+<div class="ots1"><i>a</i> Rise of Temperature. Positive reaction, if temperature rises
+at least .5° C. (.9° F.), higher than previous highest temperature.</div>
+
+<div class="center" style="padding: 1em 1em;">
+<table border="0" cellpadding="4" cellspacing="0" summary="">
+<tr><td align="left" rowspan="3">Degree of reaction according to Bandelier and Roepke:</td>
+  <td align="left" style="border-left: solid black 1px;">Slight reaction if temp. rises to 38°&nbsp;C. or 100.4°&nbsp;F.</td></tr>
+<tr><td align="left" style="border-left: solid black 1px;">Moderate reaction if temp. rises to 39°&nbsp;C. or 102.2°&nbsp;F.</td></tr>
+<tr><td align="left" style="border-left: solid black 1px;">Severe reaction if temp. rises above 39°&nbsp;C. or 102.2°&nbsp;F.</td></tr>
+</table></div>
+
+<div class="ots1">Typical reaction temperature curve: Rapid rise, slower fall,
+normal temperature after 24 hours.</div>
+
+<div class="ots1">Rise begins, in average case, 6 to 8 hours after injection (may
+begin within 4 hours or be delayed for 30 hours).</div>
+
+<div class="ots1">Acme of rise in 9 to 12 hours.</div>
+
+<div class="ots1">Duration of reaction, 30 hours or longer.</div>
+
+<div class="ots1">Rise, acme and duration of reaction vary.</div>
+
+<div class="ots1"><i>b</i> Symptoms:</div>
+
+<div class="ots2">May begin with rigor or chilliness, followed by feeling of warmth.</div>
+
+<div class="ots2">Following symptoms may be present:</div>
+
+<div class="ots3">Malaise, giddiness, severe headache, pain in limbs, pain in
+affected organ, palpitation, loss of appetite, nausea, vomiting,
+thirst, sleeplessness, lassitude, etc.; in short, a general feeling
+of "illness."</div>
+
+<div class="ots2">With fall of temperature&mdash;disappearance of symptoms.</div>
+
+<p><span class="pagenum"><a name="Page_61"
+id="Page_61">61</a></span></p><!--063.png-->
+
+<div class="ots0">10. <span class="smcap">Reaction at Point of Injection</span>: Area of redness, swelling,
+tenderness; important as indicative of sensitiveness, pointing to
+probable general reaction with repetition or increase of dose.</div>
+
+<div class="ots0">11. <span class="smcap">Focal Reaction</span>: Reaction at site of process, due to congestion
+around it.</div>
+
+<div class="ots1">Focal reaction is demonstrable by:</div>
+
+<div class="ots2"><i>a</i> Change in physical signs; breath sounds, resonance,
+appearance of rales, etc.</div>
+
+<div class="ots2"><i>b</i> Localizing symptoms, pointing to location of the tuberculous
+process.</div>
+
+<div class="ots3">Lungs&mdash;increase of cough, sputum, appearance of bacilli,
+pain in chest, etc.</div>
+
+<div class="ots3">Kidney&mdash;pain in the region of kidney, changes in urine
+findings, etc.</div>
+
+<div class="ots3">Joint&mdash;swelling, tenderness, etc.</div>
+
+<div class="ots3">Lupus&mdash;redness and exudation.</div>
+
+<div class="ots1">Focal reaction is an important feature of the subcutaneous tuberculin
+test; it permits localization of the disease in a certain
+percentage of cases.</div>
+
+<div class="ots1">Physical examination, sputum examination, urinalysis, etc., are
+very important <i>during the course of the reaction</i>.</div>
+
+<div class="ots0">12. <span class="smcap">Contraindications</span>:</div>
+
+<div class="ots1">Subcutaneous tuberculin test should not be employed in:</div>
+
+<div class="ots1">1. Cases with temperature above 100° F, by mouth
+(99.1° F, by mouth, according to Koch).</div>
+
+<div class="ots1">2. Cases in which the clinical history and physical signs make
+the diagnosis certain (presence of tubercle bacilli in the
+sputum render, of course, any other test unnecessary).</div>
+
+<div class="ots1">3. Cases of recent haemoptysis.</div>
+
+<div class="ots1">4. Grave conditions, as severe heart disease, nephritis, marked
+arteriosclerosis, etc.</div>
+
+<div class="ots1">5. Convalescence from acute infectious diseases, typhoid fever,
+pneumonia, etc.</div>
+
+<div class="ots0">13. <span class="smcap">Interpretation of the Positive Subcutaneous Tuberculin
+Reaction</span>:</div>
+
+<div class="ots1">Occurrence of reaction, following the subcutaneous tuberculin
+test, signifies the <i>existence of infection</i>; it does not signify
+that the individual is <i>clinically tuberculous</i>. To quote E. R.
+Baldwin, of Saranac Lake: "The tuberculin test is of very
+limited value in determining tuberculous <i>disease</i>; it is of
+extreme value in detecting tuberculous <i>infection</i>."</div>
+
+<div class="ots1">The test results in positive reaction in cases with latent as well as
+active processes.<p><span class="pagenum"><a name="Page_62"
+id="Page_62">62</a></span></p><!--064.png--></div>
+
+<div class="ots1">The decision as to the patient being clinically tuberculous (ill with
+tuberculosis) must rest on the consideration of the clinical history and
+the results of the physical examination.</div>
+
+<div class="ots1">It is maintained by some that the subcutaneous tuberculin reaction is
+<i>more rapid in onset</i> and <i>more marked in degree</i> in cases of <i>recent</i>
+infection. On the other hand, the test is negative in a certain proportion
+of far advanced cases.</div>
+
+<div class="ots1">Occurrence, then, of a subcutaneous tuberculin reaction does not indicate
+necessarily sanatorium or institutional treatment; neither does it
+absolutely indicate the necessity of tuberculin treatment. The decision
+rests on the consideration of all the clinical features of the case.</div>
+
+<div class="ots1"><i>In the absence of any symptoms or physical signs of disease</i>, a reaction
+should call for regulation of every day life, tending to increase the
+state of general resistance (improvement of nutrition, etc.) frequently
+without discontinuance of work.</div>
+
+<div class="ots1">The occurrence of reaction, <i>in the presence of slight symptoms or
+physical signs</i>, calls, according to individual condition, either for home
+treatment with or without discontinuance of work, or sanatorium treatment.</div>
+
+<div class="ots0">14. <span class="smcap">Indications for the Subcutaneous Tuberculin Test</span>:</div>
+
+<div class="ots1">The following considerations should guide its employment:</div>
+
+<div class="ots1">1. A thorough study of the history, thorough physical examination,
+examination of sputum (if any) give sufficient data for a
+reliable diagnosis in the vast majority of cases.</div>
+
+<div class="ots1">2. Cases, with uncertain symptoms or inconclusive physical
+signs, pointing to possible existence of tuberculous infection,
+may be treated as "suspicious" cases (without resorting to
+subcutaneous tuberculin test), the treatment consisting of rearrangement
+of mode of life, diet, work, etc., that would tend
+to increase of general resistance of the patient. This can and
+should be done in the vast majority of suspicious cases.</div>
+
+<div class="ots1">3. The subcutaneous tuberculin test is indicated in cases in which,
+in the absence of conclusive symptoms or signs, an absolutely
+positive diagnosis is desired; then the test should be applied,
+with the consent of the patient, <i>after all other methods of
+diagnosis are exhausted</i> (thorough study of the case,
+thorough physical examination, repeated examinations of
+sputum, etc).</div>
+
+<div class="ots1">4. The focal reaction (the reaction pointing to the seat of the
+disease) occurs in about <sup>1</sup>&frasl;<sub>3</sub>, or less, of the general reactions
+following the subcutaneous tuberculin test; this enhances the
+value of the test in some cases where a focal reaction would
+clear the diagnosis.</div>
+
+<p><span class="pagenum"><a name="Page_63"
+id="Page_63">63</a></span></p><!--065.png-->
+
+<p>Above all, the subcutaneous tuberculin test should be used rarely, and
+then only after all other methods of diagnosis were thoroughly applied.</p>
+
+
+<h4>II. CUTANEOUS TUBERCULIN TEST</h4>
+
+<div class="ots0">1. <span class="smcap">Synonyms</span>: Von Pirquet Test or Skin Test</div>
+
+<div class="ots0">2. <span class="smcap">Apparatus and Dilutions Necessary</span>:</div>
+
+<div class="ots1">Inoculation needle of Von Pirquet</div>
+
+<div class="ots1">Koch's Old Tuberculin (undiluted or
+dilutions according to method).</div>
+
+<div class="ots1">A centimeter tape measure (divided
+to <sup>1</sup>&frasl;<sub>10</sub> cm.) to measure reactions</div>
+
+<div class="ots1">Ether</div>
+
+<div class="ots1">Alcohol lamp</div>
+
+<div class="ots1">Medicine dropper</div>
+
+<div class="ots0">3. <span class="smcap">Application of Test</span>:</div>
+
+<div class="ots1">Inner surface of the forearm; clean the site with ether; place two drops
+of tuberculin 4 inches apart; stretch the skin and scrape off the
+epidermis (at a point midway between the two drops of tuberculin) by
+rotating the Von Pirquet needle between thumb and index finger, with
+slight pressure on the skin; repeat same through the two drops of
+tuberculin; let the tuberculin soak in for a few minutes. No dressing is
+necessary. The middle scarification is the control test. One tuberculin
+and one control test may suffice. A separate needle should be used for the
+control test.</div>
+
+<div class="ots1">After each inoculation, clean the needle of tuberculin and heat the point
+red hot in the alcohol flame before applying it again.</div>
+
+<div class="ots0">4. <span class="smcap">Reaction</span>:</div>
+
+<div class="ots1">Gradual elevation and reddening of skin around the point of tuberculin
+inoculation, beginning in 3 hours or later; the reaction (papule) well
+developed, generally, in 24 hours and most distinct in 48 hours after
+inoculation.</div>
+
+<div class="ots1">Size of papule varies from a diameter of 10 millimeters in the average
+case to 20 mm. occasionally, and 30, rarely (Bandelier and Roepke).</div>
+
+<div class="ots1">At the end of 48 hours the swelling and redness subside gradually, with
+the subsequent bluish discoloration of the skin, remaining for various
+periods of time, and slight peeling of the epidermis. Individual reactions
+vary in degree of redness, elevation, size, contour of the border, etc.
+All these points should be observed and recorded.</div>
+
+<div class="ots1">Time of inspection&mdash;24 and 48 hours after inoculation.</div>
+
+<div class="ots1">Single inspection&mdash;best time in 48 hours.</div>
+
+<div class="ots0">5. <span class="smcap">Cause of Reaction</span>:</div>
+
+<div class="ots1">Interaction between inoculated tuberculin and the antibodies
+(bacteriolysins, according to Wolff-Eisner) present in the skin of a
+tuberculous individual; interaction results in hyperaemia and exudation
+(papule).</div>
+
+<p><span class="pagenum"><a name="Page_64"
+id="Page_64">64</a></span></p><!--066.png-->
+
+<div class="ots0">6. <span class="smcap">Interpretation of Reaction</span>:</div>
+
+<div class="ots1">Occurrence of positive reaction signifies presence of a tuberculous focus
+somewhere in the body. No indication as to activity or location of the
+focus.</div>
+
+<div class="ots1">A negative reaction in adults (especially if repeated) signifies
+non-existence of tuberculosis (unless great deterioration of health, far
+advanced process, or tolerance to tuberculin established by tuberculin
+treatment).</div>
+
+<div class="ots1">A positive reaction in children under two years of age signifies,
+generally, active tuberculous process; with the advance of age the
+determination of active tuberculous processes by means of cutaneous
+tuberculin test becomes impossible.
+</div>
+
+<h4>III. CONJUNCTIVAL TUBERCULIN TEST</h4>
+
+<div class="ots0">1. <span class="smcap">Synonyms</span>: Eye Test; Ophthalmic Test; Wolff-Eisner's Test; Calmette's
+Test.</div>
+
+<div class="ots0">2. <span class="smcap">Apparatus and Dilutions Necessary</span>:</div>
+
+<div class="ots1">1 cc. pipette graduated to <sup>1</sup>&frasl;<sub>10</sub> cc.</div>
+
+<div class="ots1">10 cc. pipette graduated to <sup>1</sup>&frasl;<sub>10</sub> cc.</div>
+
+<div class="ots1">10 cc. glass cylinder</div>
+
+<div class="ots1">Medicine dropper</div>
+
+<div class="ots1">Koch's Old Tuberculin</div>
+
+<div class="ots1"><sup>1</sup>&frasl;<sub>2</sub>% and 1% dilution of Old Tuberculin in
+.85% sterile normal salt solution.</div>
+
+<div class="ots1">To make 1% dilution, add .1 cc. Old Tuberculin to 9.9 cc. of diluent.</div>
+
+<div class="ots0">3. <span class="smcap">Application of Test</span>:</div>
+
+<div class="ots1">Patient sitting, with head thrown back</div>
+
+<div class="ots1">Lower eyelid drawn slightly down and toward the nose&mdash;to form
+a small pouch of the lid;</div>
+
+<div class="ots1">One drop of 1% or <sup>1</sup>&frasl;<sub>2</sub>% instilled in that pouch and the lower
+lid moved up gently over the eye until the lids meet;</div>
+
+<div class="ots1">Eye kept closed for one minute or so.</div>
+
+<div class="ots0">4. <span class="smcap">Reaction</span>:</div>
+
+<div class="ots1">Onset in 12 to 24 hours (may begin earlier); acme in 24 to 36 hours;
+duration of reaction&mdash;3 to 4 days or even longer (in severe cases). Some
+reactions are of short duration. 3 grades of reaction, according to
+Citron:</div>
+
+<div class="ots1">1. Reddening of caruncle and palpebral (lid) conjunctiva.</div>
+
+<div class="ots1">2. More intense reddening, with involvement of ocular (eyeball)
+conjunctiva, and increased secretion.</div>
+
+<div class="ots1">3. Very intense reddening of the whole conjunctiva, with much
+fibrinous and purulent secretion, etc.</div>
+
+<p><span class="pagenum"><a name="Page_65"
+id="Page_65">65</a></span></p><!--067.png-->
+
+<div class="ots0">5. <span class="smcap">Time of Inspection</span>:</div>
+
+<div class="ots1">12 and 24 hours after instillation; then once a day.</div>
+
+<div class="ots0">6. <span class="smcap">Cause of Reaction</span>:</div>
+
+<div class="ots1">Hyperaemia and exudation resulting from interaction between <i>instilled
+tuberculin</i> and <i>antibodies in conjunctiva</i> (bacteriolysin, according to
+Wolff-Eisner).</div>
+
+<div class="ots0">7. <span class="smcap">Interpretation of Reaction</span>:</div>
+
+<div class="ots1">Wolff-Eisner maintains that positive conjunctival tuberculin reaction
+means <i>active</i> tuberculosis, a conclusion accepted by but a few.</div>
+
+<div class="ots0">8. <span class="smcap">Field of Application of Conjunctival Tuberculin Test</span>:</div>
+
+<div class="ots1"><i>Should not be used</i>; connected with <i>danger</i> to the eye.</div>
+
+<div class="ots1">Conjunctival test used very rarely at present.</div>
+
+<h4>IV. PERCUTANEOUS TUBERCULIN TEST</h4>
+
+<div class="ots0">1. <span class="smcap">Synonyms</span>: Salve Test; Moro Test.</div>
+
+<div class="ots0">2. <span class="smcap">Salve</span>: Equal parts of Old Tuberculin and anhydrous lanolin.</div>
+
+<div class="ots0">3. <span class="smcap">Application of Test</span>:</div>
+
+<div class="ots1">Site: abdominal wall below ensiform process, <i>or</i> breast below
+nipple, <i>or</i> inner surface of forearm.</div>
+
+<div class="ots1">Application: rub in with the finger (using moderate pressure) a
+small particle of salve about the size of a pea.</div>
+
+<div class="ots1">Rub it in into an area about 5 cm.; rub 1 minute.</div>
+
+<div class="ots0">4. <span class="smcap">Reaction</span>:</div>
+
+<div class="ots1">In 24 to 48 hours&mdash;<i>either</i> numerous small reddened spots which disappear
+in a few days, <i>or</i> numerous small nodules, <i>or</i> coalescing nodules on a
+red base, etc.</div>
+
+<div class="ots0">5. <span class="smcap">Interpretation of Reaction</span>:</div>
+
+<div class="ots1">Positive reaction is assumed to indicate existing tuberculous infection
+somewhere in the body; does not indicate that the process is active.</div>
+
+<div class="ots0">6. <span class="smcap">Field of Application of Percutaneous Tuberculin Test</span>:</div>
+
+<div class="ots1">The percutaneous tuberculin test fails in a large proportion of
+tuberculosis cases.</div>
+
+<div class="ots1">The test is used rarely at present.</div>
+
+<h4><span class="smcap">Lignieres Test</span></h4>
+
+<div class="ots1">A modification of the Moro Test</div>
+
+<div class="ots1">Instead of salve, a few drops of Old Tuberculin rubbed in.</div>
+
+<div class="ots1">Used rarely at present.</div>
+
+<p><span class="pagenum"><a name="Page_66"
+id="Page_66">66</a></span></p><!--068.png-->
+
+<h4>V. INTRACUTANEOUS TUBERCULIN TEST</h4>
+
+<div class="ots0">1. <span class="smcap">Synonyms</span>&mdash;Mantoux Test</div>
+
+<div class="ots0">2. <span class="smcap">Application of Test</span>:</div>
+
+<div class="ots1">Injection into skin (needle parallel to skin) of <sup>1</sup>&frasl;<sub>100</sub> mg. of
+Old Tuberculin (according to Mantoux).</div>
+
+<div class="ots0">3. <span class="smcap">Reaction</span>:</div>
+
+<div class="ots1">Onset in a few hours, well developed in 24 hours, acme in 48
+hours.</div>
+
+<div class="ots1">Reaction consists of a central nodule surrounded by a
+halo of redness.</div>
+
+<div class="ots1">This is the intracutaneous test as originally suggested by
+Mantoux.</div>
+
+
+<h3>CONCLUSIONS</h3>
+
+<p>Comparing the various tuberculin tests we find that:</p>
+
+<p>1 <i>The Subcutaneous Tuberculin Test</i> has the advantage of focal reaction,
+disclosing in a certain percentage of cases the seat of the disease.</p>
+
+<p>The subcutaneous test should, however, never be employed unless <i>as a last
+resort</i>, and then only after all other methods of diagnosis are exhausted
+and an absolute diagnosis is very essential.</p>
+
+<p>In the vast majority of suspected cases of tuberculosis, thorough study of
+the history of the case, combined with thorough physical examination,
+furnishes all the necessary data for diagnosis and an efficient plan of
+treatment.</p>
+
+<p>2 <i>The Cutaneous Tuberculin Test</i> is a very efficient diagnostic measure
+in children under two years of age in whom a positive cutaneous tuberculin
+reaction indicates active disease.</p>
+
+<p>Positive cutaneous tuberculin reaction in adults indicates existence of a
+tuberculous process, somewhere in the body; it does not indicate that the
+process is active.</p>
+
+<p>Negative cutaneous tuberculin reaction is one of the corroborative
+evidences of absence of tuberculosis, unless reaction is prevented by very
+advanced disease or tolerance to tuberculin established by tuberculin
+treatment.</p>
+
+<p>3 Thorough study of the history and thorough physical examination of each
+individual case are more important and should precede the application of
+any test.</p>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> For illustration, see Knopf, "Tuberculosis," Chap. IV, page
+67.</p></div>
+
+<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> See Carrington, "Fresh Air and How to Use It," Chap. II, page
+29.</p></div>
+
+<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> For illustration, see Carrington, "Fresh Air and How to Use
+It," Chap. II, page 37.</p></div>
+
+<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> For illustration, see Carrington, "Fresh Air and How to Use
+It," Chap. VIII, page 128.</p></div>
+
+<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> For illustration, see Knopf, "Tuberculosis," Chap. IV, page
+58.</p></div>
+
+<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> For illustration, see Carrington, "Fresh Air and How to Use
+It," Chap. VII, page 108.</p></div>
+
+<div class="footnote"><p><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a> See previous footnote.</p></div>
+
+<div class="footnote"><p><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">[8]</span></a> For illustration, see Journal of Outdoor Life, January 1914.</p></div>
+
+<div class="footnote"><p><a name="Footnote_9_9" id="Footnote_9_9"></a><a href="#FNanchor_9_9"><span class="label">[9]</span></a> For illustration, see Carrington, "Fresh Air and How to Use
+It," Chap. IV, page 55.</p></div>
+
+<div class="footnote"><p><a name="Footnote_10_10" id="Footnote_10_10"></a><a href="#FNanchor_10_10"><span class="label">[10]</span></a> For a diagrammatic presentation of Wolff-Eisner's theory,
+see "Tuberculin Treatment" by Riviere and Moreland, page 6.</p></div>
+
+<div class="footnote"><p><a name="Footnote_11_11" id="Footnote_11_11"></a><a href="#FNanchor_11_11"><span class="label">[11]</span></a> Not absolutely necessary: may get along with graduated cylinder and syringe.</p></div>
+
+<div class="footnote"><p><a name="Footnote_12_12" id="Footnote_12_12"></a><a href="#FNanchor_12_12"><span class="label">[12]</span></a> See previous footnote.</p></div>
+
+
+
+
+</div>
+
+<div class="center">(END)</div>
+
+<hr class="ChapterTopRule" />
+
+<div class="c3"><a name="Changes" id="Changes"></a>Transcriber's Amendments</div>
+
+<p>Transcriber's Note: Blank pages have been deleted. Paragraph formatting
+has been made consistent. The publisher's inadvertent omissions of
+important punctuation have been corrected.</p>
+
+<p>Other changes are listed below. The listed source publication page number
+also applies in this reproduction except possibly for footnotes since they
+have been moved.</p>
+
+<pre>
+Page           Change
+
+ 7  the acute inflamatory[inflammatory] at the beginning,
+ 9  systematic treatment was underaken[undertaken].
+ 9  Bodingon of Sutton, Coldfield[Sutton Coldfield], England,
+10  The fundimental[fundamental] principle
+19  fit to make to a printed questionaire[questionnaire].
+23  who visits the physican[physician]
+28  Tuberculosis Sanitarium is extending sanatorum[sanatorium] care
+35  [Split first footnote into two.]
+36  in the shelter of a strong windbrake[windbreak].
+43  makes a family, ordinnarily[ordinarily]
+58  [Split first footnote into two.]
+58  Hyperdermic[hypodermic] needle suited to the syringe
+62  absence of conclusive symptons[symptoms] or signs,
+62  (thourough[thorough][et seq.] study of the case,
+63  all other methods of diagnosis were thouroughly[thoroughly]
+63  from a diameter of 10 millimeters in [the] average case
+66  [Added (END).]
+
+On page 50 of the original publication, the following portion of a
+paragraph has two extraneous lines here marked in brackets:
+
+
+All of the cooking was done by the teacher. Careful attention to
+[is given. Children are weighed once in two weeks. Instruction]
+[is chiefly practical. Instruction in gardening is given twice a week]
+general cleanliness and hygiene of the teeth was insisted upon.
+Individual drinking cups and tooth brushes were provided. The
+children took turns in washing dishes, setting the table and helping....
+
+The extraneous lines are duplicates of lines further up the page and have
+been deleted.
+</pre>
+
+<div style="padding-top: 1em;"><a href="#Start">Start of text.</a></div>
+
+<hr class="ChapterTopRule" />
+
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
+End of Project Gutenberg's Nurses' Papers on Tuberculosis :, by Various
+
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+The Project Gutenberg EBook of Nurses' Papers on Tuberculosis :, by Various
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Nurses' Papers on Tuberculosis :
+       read before the Nurses' Study Circle of the Dispensary
+       Department, Chicago Municipal Tuberculosis Sanitarium
+
+Author: Various
+
+Release Date: November 23, 2011 [EBook #38090]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK NURSES' PAPERS ON TUBERCULOSIS : ***
+
+
+
+
+Produced by Bryan Ness, Henry Gardiner and the Online
+Distributed Proofreading Team at http://www.pgdp.net (This
+file was produced from images generously made available
+by The Internet Archive/American Libraries.)
+
+
+
+
+
+
+       *       *       *       *       *
+
+Transcriber's Note: The original publication has been replicated
+faithfully except as shown in the Transcriber's Amendments at the end of
+the text. Words in italics are indicated like _this_. Obscured letters in
+the original publication are indicated with {?}. Text emphasized with bold
+characters or other treatment is shown like =this=. Footnotes are located
+near the end of the text.
+
+       *       *       *       *       *
+
+
+
+
+                  Dispensary Department Bulletin No. 1
+
+                             NURSES' PAPERS
+
+                                   ON
+
+                              TUBERCULOSIS
+
+                            PUBLISHED BY THE
+                            CITY OF CHICAGO
+                  MUNICIPAL TUBERCULOSIS SANITARIUM
+
+                             SEPTEMBER 1914
+
+
+
+
+             CITY OF CHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM
+
+                             STAFF OF NURSES
+                               --OF THE--
+                          DISPENSARY DEPARTMENT
+
+             ROSALIND MACKAY, R. N., Superintendent of Nurses
+
+                            ANNA G. BARRETT
+                          BARBARA H. BARTLETT
+                            OLIVE E. BEASON
+                             ELLA M. BLAND
+                          KATHRYN M. CANFIELD
+                           MABEL F. CLEVELAND
+                            ELRENE M. COOMBS
+                          MARGARET M. COUGHLIN
+                           STELLA W. COULDREY
+                            EMMA W. CRAWFORD
+                           FANNIE J. DAVENPORT
+                             ROXIE A. DENTZ
+                           C. ETHEL DICKINSON
+                             ANNA M. DRAKE
+                             MARY E. EGBERT
+                             MAUDE F. ESS{?}
+                             SARA D. FAROLL
+                               MARY FRASER
+                            AUGUSTA A. GOUGH
+                           FRANCES M. HEINRICH
+                              LAURA K. HILL
+                           ISABELLA J. JENSEN
+                              EMMA E. JONES
+                             LETTA D. JONES
+                              JEANETTE KIPP
+                                ELSA LUND
+                            MARY MACCONACHIE
+                            JOSEPHINE V. MARK
+                             ISABEL C. MCKAY
+                             ANNA V. MCVADY
+                             ANNIE MORRISON
+                        KATHERINE M. PATTERSON
+                            LAURA A. REDMOND
+                            GRACE M. SAVILLE
+                              BERYL SCOTT
+                          FLORENCE T. SINGLETON
+                              MABELLE SMITH
+                           FLORENCE A. SPENCER
+                             HARRIETT STAHLEY
+                          GENEVIEVE E. STRATTON
+                            ANNABEL B. STUBBS
+                             ALICE J. TAPPING
+                               OLIVE TUCKER
+                            ELIZABETH M. WATTS
+                              MARY C. WRIGHT
+                              MARY C. YOUNG
+
+                       KARLA STRIBRNA, Interpreter.
+
+
+                           BOARD OF DIRECTORS
+
+                  THEODORE B. SACHS, M. D.,   President
+                  GEORGE B. YOUNG, M. D.,     Secretary
+                             W. A. WIEBOLDT.
+
+
+                             GENERAL OFFICE
+
+                         105 West Monroe Street
+
+                   FRANK E. WING, Executive Officer.
+
+
+[Illustration: FIELD NURSES, DISPENSARY DEPARTMENT CHICAGO MUNICIPAL
+TUBERCULOSIS SANITARIUM]
+
+
+
+
+                  Dispensary Department Bulletin No. 1
+
+                             NURSES' PAPERS
+
+                                   ON
+
+                              TUBERCULOSIS
+
+
+                             READ BEFORE THE
+
+                          NURSES' STUDY CIRCLE
+
+                                 OF THE
+
+                          DISPENSARY DEPARTMENT
+
+               CHICAGO MUNICIPAL TUBERCULOSIS SANITARIUM
+
+
+                            PUBLISHED BY THE
+                            CITY OF CHICAGO
+                   MUNICIPAL TUBERCULOSIS SANITARIUM
+                         105 WEST MONROE STREET
+                             SEPTEMBER 1914
+
+
+
+
+                                CONTENTS
+
+
+                                                                   PAGE
+
+  Introduction--Nurses' Tuberculosis Study Circle                     5
+
+  Historical Notes on Tuberculosis                                    7
+  ROSALIND MACKAY, R. N.
+
+  Visiting Tuberculosis Nursing in Various Cities of the United
+  States                                                             11
+  ANNA M. DRAKE, R. N.
+
+  Provisions for Outdoor Sleeping                                    30
+  MAY MACCONACHIE, R. N.
+
+  Some Points in the Nursing Care of the Advanced Consumptive        37
+  ELSA LUND, R. N.
+
+  Open Air Schools in This Country and Abroad                        44
+  FRANCES M. HEINRICH, R. N.
+
+  Notes on Tuberculin for Nurses                                     56
+
+
+
+
+                   NURSES' TUBERCULOSIS STUDY CIRCLE
+
+
+It is well known that the gathering of facts and study of literature
+essential to the preparation of a paper on a certain subject is a very
+productive method of acquiring information. If the paper is to be
+presented to your own group of co-workers, and the subject covered by it
+represents an important phase of their work, or an analysis of some of its
+underlying principles, then there is a further incentive to do your best,
+as well as an opportunity for a general discussion which acts as a sieve
+for the elimination of false ideas and gradual formulation of true
+conceptions.
+
+Lectures on various phases of the work being done by a particular group of
+people are very important. Papers by the workers themselves are, however,
+greatest incentives to study and self-advancement.
+
+With this view in mind, I suggested the organization of a Tuberculosis
+Study Circle by the Dispensary Nurses of the Municipal Tuberculosis
+Sanitarium. The nurses chosen to present papers on particular phases of
+tuberculosis are given access to the library of the General Office of the
+Sanitarium; they are also given the assistance of the General Office in
+procuring all the necessary information through correspondence with
+various organizations and institutions in Chicago and other cities.
+
+As the program stands at present, the Nurses' Study Circle meets twice a
+month. At one of these meetings a lecture on some important phase of
+tuberculosis is given by an outside speaker, and at the next meeting a
+paper is read by one of the nurses. At all of these meetings the
+presentation of the subject is followed by general discussion. The program
+since January, 1914, was as follows:
+
+January 9th, 1914--"Historical Notes on Tuberculosis," by Miss Rosalind
+Mackay, Head Nurse, Stock Yards Dispensary of the Municipal Tuberculosis
+Sanitarium.
+
+January 23rd, 1914--"Channels of Infection and the Pathology of
+Tuberculosis," by Professor Ludwig Hektoen of the University of Chicago.
+
+February 13th, 1914--"Visiting Tuberculosis Nursing in Various Cities of
+the United States," by Miss Anna M. Drake, Head Nurse, Policlinic
+Dispensary of the Municipal Tuberculosis Sanitarium.
+
+March 13th, 1914--"Provisions for Outdoor Sleeping," by Miss May
+MacConachie, Head Nurse, St. Elizabeth Dispensary of the Municipal
+Tuberculosis Sanitarium.
+
+March 27th, 1914--"What Should Constitute a Sufficient and Well Balanced
+Diet for Tuberculous People," by Mrs. Alice P. Norton, Dietitian of Cook
+County Institutions.
+
+April 10th, 1914--"Some Points in the Nursing Care of the Advanced
+Consumptive," by Miss Elsa Lund, Head Nurse of the Iroquois Memorial
+Dispensary of the Municipal Tuberculosis Sanitarium.
+
+May 15th, 1914--"Open Air Schools in This Country and Abroad," by Miss
+Frances M. Heinrich, Head Nurse of the Post-Graduate Dispensary of the
+Municipal Tuberculosis Sanitarium.
+
+May 29th, 1914--"Efficient Disinfection of Premises After Tuberculosis,"
+by Professor P. G. Heinemann, Department of Bacteriology, University of
+Chicago.
+
+The organization of the Tuberculosis Study Circle among the nurses of the
+Dispensary Department of the Municipal Tuberculosis Sanitarium, calling
+forth the best efforts of the nurses in getting information on various
+phases of tuberculosis for presentation to their co-workers in an
+interesting manner has, no doubt, stimulated the progress of our entire
+nursing force. The first five papers presented by the nurses are given in
+this series. The pamphlet is published with the idea of attracting the
+attention of other organizations to this method of stimulating more
+intensive study among their nurses.
+
+                            =THEODORE B. SACHS, M. D., President=
+                                Chicago Municipal Tuberculosis Sanitarium.
+
+
+
+
+                    HISTORICAL NOTES ON TUBERCULOSIS
+
+                       By ROSALIND MACKAY, R. N.
+
+        Head Nurse, Stock Yards Dispensary of the Chicago Municipal
+                       Tuberculosis Sanitarium.
+
+
+So far as our information goes, pulmonary tuberculosis has always existed.
+It is, as Professor Hirsch remarks, "A disease of all times, all
+countries, and all races. No climate, no latitude, no occupation, forms a
+safeguard against the onset of tuberculosis, however such conditions may
+mitigate its ravages or retard its progress. Consumption dogs the steps of
+man wherever he may be found, and claims its victims among every age,
+class and race."
+
+Hippocrates, the most celebrated physician of antiquity (460-377 B. C.),
+and the true father of scientific medicine, gives a description of
+pulmonary tuberculosis, ascribing it to a suppuration of the lungs, which
+may arise in various ways, and declares it a disease most difficult to
+treat, proving fatal to the greatest number.
+
+Isocrates, also a Greek physician and contemporary of Hippocrates, was the
+first to write of tuberculosis as a disease transmissible through
+contagion.
+
+Aretaeus Cappadox (50 A. D.) describes tuberculosis as a special
+pathological process. His clinical picture is considered one of the best
+in literature.
+
+Galen (131-201 A. D.) did not get much beyond Hippocrates in the study of
+tuberculosis, but was very specific in his recommendation of a milk diet
+and dry climate. He held it dangerous to pass an entire day in the company
+of a tuberculous patient.
+
+During the next fifteen centuries, a period known as the Dark Ages and
+characterized by most intense intellectual stagnation, little was added to
+the knowledge of pulmonary tuberculosis. In the seventeenth century
+Franciscus Sylvius brought out the relationship between phthisis and
+nodules in the lymphatic glands. This was the first step toward accurate
+knowledge of the pathology of tuberculosis.
+
+Richard Morton, an English physician, wrote, in 1689, of the wide
+prevalence of pulmonary tuberculosis, and recognized the two types of
+fever: the acute inflammatory at the beginning, and the hectic at the
+end. He also recognized the contagious nature of the disease and
+recommended fresh air treatment. He believed the disease curable in the
+early stages, but warned us of its liability to recur. Morton taught that
+the tubercle was the pathological evidence of the disease.
+
+In 1690, Leeuwenhoek, a Dutch lens maker, started the making of short
+range glasses which resulted later in the modern microscope, making
+possible the establishment of the germ theory of disease, including the
+establishment of that theory for tuberculosis.
+
+Starck, whose observations and writings were published in 1785 (fifteen
+years after his death), gave a more accurate description of tubercles than
+had ever been given before, and showed how cavities were formed from them.
+
+Leopold Auenbrugger introduced into medicine the method of recognizing
+diseases of the chest by percussion, tapping directly upon the chest with
+the tips of his fingers. The results of his investigations were published
+in a pamphlet in 1761. This new practice was ignored at first, but after
+the work of Auenbrugger was translated he attained a European reputation
+and a revolution in the knowledge of diseases of the chest followed.
+
+Boyle recognized in miliary tubercle, as it was afterwards called by him,
+the anatomical basis of tuberculosis as a general disease, and, in 1810,
+published the results of one of the most complete researches in pathology.
+He described the stages in the development of the disease, using miliary
+tubercle as its starting point. He opposed the theory that inflammation
+caused tuberculosis and declared hemorrhage a result and not a cause of
+consumption.
+
+Laennec discovered one of the most important, perhaps, of all methods of
+medical diagnosis--that of auscultation. By means of the stethoscope,
+which he invented in 1819, he recognized the physical signs and made the
+first careful study of the healing of tuberculosis; he gave also one of
+the best accounts of the sputum of the consumptive. He believed that every
+manifestation of the disease in man or animals was due to one and the same
+cause.
+
+Up to this time the views which were held concerning the infectious nature
+of tuberculosis were not based upon direct experiment, but in 1843 Klenke
+produced artificial tuberculosis by inoculation. He injected tuberculous
+matter into the jugular vein of a rabbit, and six months later found
+tuberculosis of the liver and lungs. He did not continue, however, his
+researches; so they were soon forgotten.
+
+To Villemin, a French physician, belongs the immortal fame of being the
+first to show the essential distinction in tuberculosis between the virus
+causing the disease and the lesion produced by it. By inoculating animals,
+he demonstrated that tuberculosis is a specific disease caused by a
+specific agent. His paper presented in 1865 before the Academy of Medicine
+in France contained a detailed account of his experimental investigations.
+This was a most remarkable contribution to scientific medicine.
+
+It remained for Robert Koch in 1882, after years of painstaking
+investigation, to announce to the world the discovery of a definite
+bacillus as the causative agent in all forms of tuberculous lesions. Koch
+isolated, cultivated outside the body, described and differentiated the
+infective organism of tuberculosis and proved that it could continue to
+produce the same lesions indefinitely. He showed the presence of the
+bacilli in all known tuberculous lesions and in tuberculous expectoration,
+and demonstrated the virulence in sputum which had been dried for eight
+weeks.
+
+Following directly upon the knowledge of the cause of tuberculosis came
+the recognition of its curability, and the proper means of its prevention.
+Although good food and fresh air have always been considered of importance
+in the treatment of the disease, it was not until the middle of the
+nineteenth century that anything like systematic treatment was undertaken.
+
+Dr. George Bodingon of Sutton Coldfield, England, wrote an essay in 1840
+advocating fresh air treatment. He denounced the common hospital in large
+towns as a most unfit place for consumptive patients, and established a
+home for their care, but met with so much opposition that it was soon
+closed.
+
+In 1856, Hermann Brehmer wrote a thesis on the subject which has been the
+foundation of our modern treatment. He opened a small sanatorium in 1864.
+Five years later he established the sanatorium at Goerbersdorf, in
+Silesia, which eventually became the largest in the world. He advocated
+life in the open air, abundant dietary and constant medical supervision.
+He believed that the heart of the large majority of consumptives is small
+and undeveloped, and that this predisposes them to the disease. In
+accordance with this theory he put a great deal of emphasis on exercise in
+the treatment of his patients. He built walks of various grades on the
+grounds of his sanatorium and installed a system of walking exercise.
+Patients began with the lowest grade, gradually accustoming themselves to
+ascend to the highest. Brehmer was himself a consumptive, and was cured by
+the method he so firmly believed in.
+
+Dr. Dettweiler, who opened the second sanatorium in Germany, at
+Falkenstein, near Frankfort, was also a consumptive, having developed
+tuberculosis during the arduous campaign in the Franco-Prussian War in
+1871. He entered the Goerbersdorf Sanatorium as a patient, becoming later
+an assistant of Brehmer. Dr. Dettweiler laid great emphasis upon rest in
+treatment.
+
+In 1888, Dr. Otto Walther opened his famous sanatorium at Nordrach in the
+Black Forest, in Germany.
+
+The first sanatorium for the care of the consumptive in the United States
+was opened at Saranac Lake by Dr. Edward L. Trudeau in 1884. He was the
+pioneer of the sanatorium treatment in this country, and an example of
+what a man, although tuberculous himself, can do for his fellow men. In
+1874, a seemingly helpless invalid, he made his home in the Adirondack
+Mountains. A little more than twenty-five years ago he became the founder
+of a village now crowded with tuberculous patients. The Saranac Lake
+institution, which began with one small cottage, has since developed into
+the best known sanatorium in this country.
+
+In 1891, Dr. Herman Biggs posted the first anti-spitting ordinance in the
+street railway cars of New York.
+
+Dr. Lawrence Flick brought about the formation of the first
+anti-tuberculosis society in 1892, and in 1894 the City of New York
+adopted a law to enforce notification and registration.
+
+Dr. Philip of Edinburgh was the first to systematically and completely
+organize the anti-tuberculosis campaign. In 1887 he inaugurated that new
+institution, the anti-tuberculosis dispensary, which has since rendered
+such inestimable service. The fundamental principle of the Edinburgh
+system is that the disease should be sought out in its haunts.
+
+The first dispensary in the United States was opened in New York in 1904,
+modeled after the Edinburgh system. About the same time came the Open Air
+Schools--Charlottenburg establishing one in 1904 and Providence, R. I.,
+following in 1908. The first Day Camp in the United States was opened in
+1905 in Boston. New Jersey established the first Preventorium for Children
+at Farmingdale in 1909. All this naturally led to better provision for
+advanced cases; sanatoria for hopeful cases at small cost; factory
+inspection; and, in some countries, industrial colonies for arrested
+cases.
+
+The tuberculosis patient of today presents a hopefulness previously
+undreamt of. The outlook is brighter with promise than ever before, and we
+have every reason to look forward to a steady reduction in the mortality
+rate from this dread disease; but the extinction of tuberculosis will be
+achieved only when the social and economic problems have been solved.
+
+
+
+
+   VISITING TUBERCULOSIS NURSING IN VARIOUS CITIES OF THE UNITED STATES
+
+                        By ANNA M. DRAKE, R. N.
+
+    Head Nurse, Policlinic Dispensary of the Municipal Tuberculosis
+                              Sanitarium.
+
+
+BALTIMORE
+
+In 1903, the first visiting tuberculosis nurse was assigned in Baltimore
+to follow up patients of the Johns Hopkins Hospital Out-patient
+Department. Her duties were varied as are the duties of the present day
+tuberculosis nurse. She was to instruct patients in the use of sunlight
+and fresh air and was allowed to furnish them with special diet in the
+shape of milk and eggs. She investigated home conditions and helped
+improve sleeping quarters. She placed patients in sanatoria, or brought
+them back to the dispensary for treatment. She gave bedside care to
+advanced cases, if she could not get them into hospitals, and applied to
+relief organizations for help in solving the problems of the family. From
+time to time other nurses of the Baltimore Visiting Nurse Association were
+assigned to the work, other dispensaries and agencies began referring
+cases to be followed up, and the work grew to such proportions as to be
+almost unmanageable for a private organization.
+
+In 1910, the Tuberculosis Division of the Baltimore Health Department was
+organized. It began its activities with a corps of fifteen nurses and a
+visiting list of 1,617 patients turned over to it by the Baltimore
+Visiting Nurse Association. The object of the Tuberculosis Division was to
+bring under the supervision of the Health Department all persons in the
+city suffering with pulmonary tuberculosis. Ambulatory cases were to be
+given advice and instruction; advanced cases, bedside care, if needed, or
+hospital care, if available. At present, it is upon the advanced cases, as
+well as those who are in contact with them, that the nurses of the
+Tuberculosis Division concentrate their efforts. The Staff at present
+consists of a Superintendent and sixteen Field Nurses. The city is
+divided into sixteen districts, a nurse being assigned to each district.
+Each nurse is responsible for the care of all cases of tuberculosis in her
+district.
+
+In 1912, the Tuberculosis Division opened two municipal tuberculosis
+dispensaries. These dispensaries receive patients on alternate days from 3
+to 5 p. m., nurses in districts nearest the dispensaries alternating for
+clinic duty. Other dispensaries are the Phipps Tuberculosis Dispensary at
+Johns Hopkins' Hospital, and the University of Maryland Hospital
+Tuberculosis Dispensary.
+
+The problems which chiefly concern the Tuberculosis Division in its
+efforts to control the spread of tuberculosis in Baltimore are the failure
+of physicians to report cases to the Department of Health until the
+patient is in a dying condition, and the inadequate provision for hospital
+care of advanced cases. These conditions are particularly marked in the
+case of colored patients, who are found going in and out of homes,
+restaurants, and laundries, as cooks, waitresses and servants of various
+kinds, as long as they are able to drag themselves about.
+
+The nurses of the Tuberculosis Division are graduate nurses and are
+registered. They are paid $75 a month, with car fare and telephone
+expenses, and are allowed two weeks' vacation with pay. They are not
+required to take a Civil Service examination, but are carefully selected
+with a view to obtaining women of a high grade of efficiency. They wear
+uniforms of blue denim with simple hats and coats, but not of uniform
+design. Each nurse wears under the lapel of her coat a badge reading
+"Nurse--Baltimore Health Department," which she uses on occasions. The
+nurses report to the Superintendent each morning at 8:30 to hand in
+reports of the previous day's work, to stock their bags, and to receive
+new work for the day. At noon each nurse reports at her branch office, of
+which there are seven, each situated on border lines of adjoining
+districts. An hour is spent at the branch office for lunch and rest, for
+receiving telephone calls and for restocking the bags for afternoon
+rounds. The nurse leaves her district at four o'clock to attend to about
+an hour's clerical work, which is usually done at home.
+
+The average number of patients per nurse is 212, about four per cent of
+whom are bed cases. These bed patients are visited two or three times a
+week, while ambulatory cases are visited on an average of twice a month.
+During the year 1912 the sixteen nurses made 72,058 visits for instruction
+and nursing care.
+
+
+NEW YORK
+
+The oldest tuberculosis clinic in New York City is connected with the New
+York Nose, Throat and Lung Hospital; it was established in 1894. In 1895,
+the Presbyterian Hospital established a special tuberculosis clinic. In
+1902, the Vanderbilt Clinic organized a special class for the treatment of
+tuberculosis. In 1903, Gouverneur and Bellevue Hospitals and, in 1904,
+Harlem Hospital added Tuberculosis Clinics. These were followed during the
+next few years by the establishment of many others. In 1906, when the
+Tuberculosis Relief Committee of the New York Charity Organization Society
+began its work among the tuberculous poor of the city, it met at every
+turn instances of overlapping and duplication in the work done by the
+various clinics. This lack of co-operation, with the resulting
+difficulties encountered by the Committee in its endeavor to efficiently
+administer its special tuberculosis fund, demonstrated the advisability of
+forming an organization having as its object the co-ordination of the work
+of the various tuberculosis clinics. In 1908, nine of these clinics and
+several allied philanthropic agencies were organized into the Association
+of Tuberculosis Clinics. Today there are 29 clinics, 14 philanthropic
+institutions and organizations, five departments of municipal and state
+government, six tuberculosis institutions, and numerous other institutions
+and organizations having special interest in tuberculosis work. Of the 29
+clinics, eleven are under the supervision of the Department of Health,
+three are connected with city hospitals, and the remainder are operated by
+private institutions. This voluntary association of private and municipal
+dispensaries, sharing equal responsibilities and acknowledging equal
+obligations, is a striking feature of tuberculosis work in New York and
+presents a unique example of co-operation.
+
+The task of standardizing the clinics was a difficult one. One clinic had
+ten rooms with every convenience. Another had one room and no
+conveniences. Some clinics made no provision for sputum beyond a cuspidor;
+others provided gauze or paper napkins when patients entered the room. Two
+clinics provided no drinking water; two had a metal water cooler in the
+waiting room; one provided sanitary drinking cups; and another had two
+enamel drinking cups chained to the wall. Some clinics had sanitary
+fountains; in others the nurse kept a glass on hand for the patients.
+Neither was there any uniformity in matters of dress. Nurses and doctors
+at some clinics wore ordinary street clothes. At other clinics, gowns or
+aprons, with or without sleeves, were worn. Three clinics occupied
+separate buildings of their own. Four clinics provided separate
+waiting-rooms for tuberculous patients. At one dispensary the tuberculous
+patients had the use of the general waiting room, there being no other
+clinics held at that time; other clinics made no distinction, tuberculous
+patients using the general waiting room in company with patients attending
+other clinics. After studying the conditions existing in the various
+clinics, it was decided that to belong to the association each clinic must
+subscribe to and comply with the following regulations:
+
+  a. Tuberculous patients must be segregated in a separate class.
+
+  b. Home supervision of all cases by a graduate nurse especially assigned
+     for this purpose must be maintained.
+
+  c. Each dispensary must serve a certain district, and all cases living
+     outside of this district must be transferred to the clinic serving
+     the district within which they live.
+
+Early in the history of the Association objection was made to this last
+rule by teachers of medicine, who held that it tended to deprive them of
+teaching material; but they soon fell in line with the other dispensaries
+when they saw the advantage it afforded them of improving their methods
+without loss of teaching material, and the further opportunity of securing
+home supervision.
+
+From time to time it has been necessary for the Association to adopt
+certain methods of procedure in the administration of the various clinics.
+The general policy of the Association is as follows:
+
+  (1) Each clinic should arrange for a physician to visit and treat in
+      their homes patients who are too ill to attend clinic, for whom
+      hospital care cannot be provided.
+
+  (2) Special children's clinics should be established wherever the size
+      of the clinic warrants it.
+
+  (3) Sputum of every patient should be examined once a month; patients
+      should be re-examined once a month, and the results entered on the
+      records.
+
+  (4) The physician should use the nurse's report of home conditions as a
+      basis for advising patients.
+
+  (5) Patients refusing to attend the proper dispensary shall be dismissed
+      as delinquent and reported to the Health Department.
+
+  (6) All supervising nurses should be affiliated with some local relief
+      organization in order to better organize the relief work of the
+      clinic.
+
+  (7) The home of every patient should be visited at least once a month.
+
+  (8) The classification of the National Association for the Study and
+      Prevention of Tuberculosis should be followed for recording stages
+      of disease and condition on discharge.
+
+  (9) A uniform system of record keeping should be used by nurses in order
+      to facilitate the compiling of monthly reports.
+
+  (10) The staff of physicians should be sufficient to allow at least
+      fifteen minutes for the examination of every new case, and at least
+      six minutes for every old case.
+
+  (11) There should be at least one nurse for every 100 patients on the
+      clinic register.
+
+  (12) Sputum cups, or a proper substitute, should be furnished to
+      patients to take home.
+
+  (13) Paper or gauze handkerchiefs should be given to each patient on
+      entrance to the clinic.
+
+  (14) No cuspidors should be used.
+
+  (15) Sanitary fountains or sanitary drinking cups should be provided.
+
+  (16) Gowns with sleeves should be worn by physicians. Nurses should wear
+      gowns with sleeves or washable uniforms while on duty in the
+      dispensary.
+
+That the Association found it necessary to make so many recommendations
+for the administration of the various clinics is evidence of the diverse
+systems, and in some instances, the entire lack of system, in vogue in
+some dispensaries. The salary of nurses in privately operated tuberculosis
+dispensaries averages about $75 per month; no standard uniform is in use.
+
+The first tuberculosis visiting nurse of the New York Department of Health
+was appointed March 1st, 1903. By January, 1910, the staff had grown to
+158, the Health Department becoming practically responsible for the home
+supervision of every registered case of tuberculosis in New York not under
+the care of a private physician or in an institution.
+
+The organization of the work of the new Health Department tuberculosis
+nurses has been based upon the district system in force among the
+Associated Clinics. In each clinic district a staff of Health Department
+nurses is maintained, charged with the sanitary supervision of cases of
+pulmonary tuberculosis in that district. They visit at least once a month
+all "at home" cases; that is, cases not regularly attending clinics, not
+in an institution, or not under a private physician's care. These nurses
+report daily at the tuberculosis clinic, which is used as a district
+headquarters, and there receive assignments. One nurse is detailed as
+Captain, or supervising nurse of the district, and acts as official
+intermediary between the clinic and the Department of Health. Each morning
+the nurse telephones to the Department of Health the daily report of her
+staff and of the clinic, and obtains information received at the
+Department regarding cases in the district. In case of death or removal of
+tuberculous patients from a home the district nurses order disinfection of
+the premises and bedding; they make arrangements for admission of patients
+to hospitals or sanatoria, investigate complaints made by citizens, see
+that regulations of the Department of Health regarding expectoration are
+observed, and use their authority to induce delinquent cases to resume
+attendance at the proper clinic. They also visit families of patients in
+hospitals at intervals. Each nurse keeps a complete index of all cases of
+pulmonary tuberculosis in her district, which is at all times accessible
+to nurses and physicians at the clinic.
+
+In the Department of Health clinics, the plan is as follows: a supervising
+nurse who does no district work, and several field nurses, each assigned
+to special duties on clinic days, such as registration room, throat room,
+examining rooms, etc. Field nurses are also responsible for the care of
+patients in their sub-districts, each nurse carrying an average of about
+125 patients on her visiting list at one time.
+
+
+BOSTON
+
+A staff of twenty-five nurses, working from the Out-patient Department of
+the Boston Consumptives' Hospital, has the supervision of all tuberculosis
+cases in their homes, and the follow-up work on all discharged sanatorium
+and hospital cases in the city of Boston.
+
+All cases of tuberculosis reported to the Health Department, whether under
+the care of a private physician or not, are visited at least once by a
+nurse from this staff, to see that they are carrying out a proper plan of
+isolation.
+
+The Boston Consumptives' Hospital Dispensary, centrally located, is open
+every morning and one or two evenings a week. Three or four nurses are on
+duty in the clinic each morning, taking histories, attending nose and
+throat room and preparing patients for examination. At the dispensary only
+a medical history of new patients is taken, the social history being
+obtained by the nurse on her first visit to the home. Pulse, temperature
+and weight are also taken at the dispensary, after which the patient waits
+his turn for examination. Each new patient is given an examination in the
+nose and throat room; old patients also, if necessary. After examination
+or treatment, all patients return to the general waiting room. From here
+each patient is called before the Chief of Clinic, who notes the general
+progress of the patient, the results of the last examination or any
+remarks recorded by the physician, and the report of home conditions as
+reported by the nurse. The Chief of Clinic advises the patient in
+accordance with the needs indicated. He makes no examinations, but sees
+each patient every time he comes to the clinic and is thus able to follow
+very carefully the progress of each patient and to advise such changes in
+treatment as may seem necessary.
+
+The city is divided into twenty-two districts, each nurse being
+responsible for the care of all tuberculous patients in her district. The
+number of patients cared for by each nurse is from 100 to 180. A very
+small percentage of bedside care is given; far advanced patients as a rule
+are sent to hospitals.
+
+Boston tuberculosis nurses do not wear uniforms. They are paid $900 a
+year, with no increase for length of service or efficiency.
+
+
+BUFFALO
+
+The purpose of the Buffalo Association for the Relief and Control of
+Tuberculosis has been to stimulate progress in fighting tuberculosis. It
+very modestly shares with the city officials and with private charities
+the credit for the work accomplished. All it claims for itself is that it
+has been able, and will continue, to "point the way." How thoroughly it
+has succeeded in this may be seen by the progress made since 1909 when the
+Buffalo Association made its first appeal for funds. At that time Buffalo
+had:
+
+  (1) A dispensary maintained by the Buffalo Charity Organization
+      Society.
+
+  (2) The Erie County Hospital for advanced cases.
+
+  (3) A day camp, with a capacity of thirty patients, supported by a group
+      of women.
+
+  (4) One visiting nurse supplied by the District Nursing Association.
+
+The present facilities are:
+
+  (1) A dispensary, open every day and one evening a week, with a nose
+      and throat clinic, and a dental clinic with a paid dentist in
+      attendance.
+
+  (2) The J. N. Adam Memorial Hospital for early cases, capacity 125,
+      supported by the city.
+
+  (3) The Municipal Hospital for the care of advanced cases, supported by
+      the city.
+
+  (4) The Erie County Hospital, as before.
+
+  (5) Tuberculosis Division of the Department of Health with two
+      tuberculosis inspectors and six visiting tuberculosis nurses.
+
+  (6) An Open Air Camp, with a capacity of from seventy to one hundred
+      patients, with a special department for children. Patients are kept
+      day and night. The camp has three resident trained nurses and one
+      interne, and is visited daily by the Association's paid medical
+      director.
+
+  (7) Two open air schools, with another promised.
+
+  (8) A City Hospital Commission, with a plan for the erection of a
+      pavilion for 500 advanced cases as the first of a general hospital
+      scheme.
+
+  (9) Teachers soon to be appointed for the education of tuberculous
+      children.
+
+  (10) The trades unions organized to promote the campaign among their own
+      members in a unique organization.
+
+  (11) The whole community alert to the menace of tuberculosis, willing to
+      shoulder the community burden and to assume the community
+      responsibility.
+
+The Dispensary is now operated by the Association for the Relief and
+Control of Tuberculosis, and the nurses are supplied by the Health
+Department. The nursing staff consists of a supervising nurse and six
+field nurses, the latter receiving $720 per year. They wear no uniform.
+They give a limited amount of bedside care, some member of the family
+being taught to properly care for the patient, if he cannot be sent to a
+hospital. Recently an additional nurse was engaged by the Association to
+follow up cases on whom no diagnosis has been made and who have not
+returned to the dispensary for re-examination. Since the Dispensary was
+opened in 1909, there have been over one thousand such cases. Many of
+these had suspicious signs when examined, but there has hitherto been no
+means of keeping in touch with them, as the nurses have been obliged to
+confine their attention to positive cases. One of the chief difficulties
+of the Buffalo campaign, as elsewhere, has been the fact that more than
+half of the cases have probably already infected others. This latest
+movement of the Association should anticipate this condition to a certain
+extent, and is one more means by which it is "blazing the trail" toward
+its goal,--"No uncared for tuberculosis in Buffalo in 1915."
+
+
+PHILADELPHIA AND PENNSYLVANIA
+
+In the General Appropriations Act of 1907 the Legislature of Pennsylvania
+granted to the State Department of Health, in addition to its regular
+budget, the sum of $400,000, "to establish and maintain, in such places in
+the State as may be deemed necessary, dispensaries for the free treatment
+of indigent persons affected with tuberculosis, for the study of social
+and occupational conditions that predispose to its development, and for
+continuing research experiments for the establishment of possible immunity
+and cure of said disease."
+
+Immediately after securing the above appropriation, the State Department
+of Health began to establish dispensaries throughout the state, one or
+more in each county. The staff of each dispensary consists of a chief, who
+is also county medical inspector, and a corps of assistant physicians and
+visiting nurses. There is a supervising nurse with one assistant at
+Harrisburg, who oversee and inspect the work of the staff nurses.
+
+The number of nurses in the dispensaries throughout the state varies from
+a nurse shared by another organization or a practical nurse giving part
+time, to from four to seven nurses in one dispensary. There are now more
+than 115 State Department Tuberculosis Dispensaries in Pennsylvania,
+Philadelphia having three.
+
+An idea of the general plan of the work may be gained from a description
+given of the State Department Dispensary No. 21, located in Philadelphia,
+by Dr. Francine:
+
+    "There are at present five nurses employed at Dispensary No. 21,
+    two of whom give their whole time to following up the return
+    cases from the State Sanatoria. As soon as the case is
+    discharged from the sanatorium, that information, with other
+    data regarding the condition on discharge, etc., is sent to us
+    at once. At the end of a stated period, if that case has not
+    been returned, the nurse looks it up, and gets it to come in.
+    The nurses make out detailed reports on all cases discharged
+    from the sanatoria, at periods of six months, whether our own
+    patients or not. These will be and are valuable for statistical
+    data. Practically all the data for reports as to subsequent
+    results in cases discharged from the sanatoria, which have
+    appeared in this country at least, have been made up from
+    information gleaned by writing the discharged patient and having
+    him fill out his own report. It does not tax the imagination
+    unduly to conclude which is the more accurate, the answers to
+    questioning by a trained worker (we have selected for this work
+    the two nurses who have been with us longest) who in addition
+    takes the temperature, pulse, etc., herself, and usually
+    succeeds in getting the patient back to the dispensary for at
+    least one re-examination; or such answers as a patient may see
+    fit to make to a printed questionnaire.
+
+    For the purpose of regular dispensary and inspection work, the
+    dispensary limits itself to receiving patients from certain
+    districts of the city, though as a state institution it is
+    impossible for the dispensary to refuse any case, no matter
+    where they live, if they insist upon treatment. Usually by a
+    little persuasion, however, we can get the patients to go to the
+    dispensary in their district, co-operating in this way with the
+    Phipps Institute of the University of Pennsylvania, the Gray's
+    Ferry State Dispensary, the Kensington Tuberculosis Dispensary
+    and the Frankford State Dispensary. The section of the city from
+    which we draw our cases is divided, for purposes of inspection
+    and Social Service Work, into three districts with a nurse
+    assigned to each, and this gives each of our nurses, roughly
+    speaking, about seventy-five patients per month to take care of.
+    These patients must be visited regularly every two weeks, which
+    gives the nurse at least one hundred and fifty visits a month to
+    pay, not including the visits to new cases.
+
+    Every new case which is admitted to the dispensary must be
+    visited within one week of the day of admission. The nurses come
+    in from their visiting work and report daily at 12:30 o'clock,
+    for one hour in the dispensary office, and new cases, according
+    to the district in which they live, are assigned to the nurse
+    having charge of that district. The advantage of having a nurse
+    report daily to the dispensary at a time when all the doctors
+    are there, lies in the fact that the doctor has thus the
+    opportunity of talking over with the nurse the new cases which
+    she is to visit and of making any suggestions which he has
+    gleaned from the history and examination of the patient. It is
+    thus possible for the nurses to visit the new cases in the
+    afternoon of the same day. The advantage of this close
+    co-operation between doctor and nurse must be at once apparent.
+    Further, each nurse is required to report to every physician one
+    morning a month, with the histories in hand of all the patients
+    of that particular doctor which are on her list. This is
+    valuable, because in no other way can the doctor get so thorough
+    an understanding of the home conditions and social problems of a
+    given patient as by talking the situation over directly and
+    personally with the nurse in charge."
+
+A similar plan is in operation at the other two State Department Clinics
+in Philadelphia.
+
+The best known tuberculosis dispensary in Philadelphia, conducted by a
+private organization, is the dispensary connected with the Henry Phipps
+Institute. This dispensary during the eleven years of its existence has
+contributed greatly to the standardization of tuberculosis dispensary
+work, not only in Philadelphia, but throughout the entire country.
+Connected with a scientifically conducted hospital for advanced cases,
+with its laboratories and other improved medical facilities, the
+Dispensary of the Henry Phipps Institute occupies a high place among the
+similar institutions of this country. The nursing staff of the Henry
+Phipps Dispensary consists of three visiting tuberculosis nurses, aided by
+two additional nurses (both colored) assigned by other organizations to
+work on the Phipps Dispensary staff, one by the Whittier Centre, and the
+other by the Pennsylvania Society for the Prevention of Tuberculosis. Some
+of the important features of the work of this dispensary in its relation
+to nurses are as follows:
+
+  (1) An efficient training school for tuberculosis nurses, affording the
+      opportunity of hospital and dispensary training.
+
+  (2) A course of lectures on tuberculosis given to the nursing profession
+      at large.
+
+  (3) Intensive home work among tuberculous families.
+
+Visiting tuberculosis work in Philadelphia is also done in connection with
+the Presbyterian Hospital Tuberculosis Clinic, St. Stevens Church
+Tuberculosis Clinic, and by the Visiting Nurse Society of Philadelphia.
+
+
+PITTSBURGH
+
+The Tuberculosis League Hospital of Pittsburgh was opened in 1907 for
+incipient and advanced cases, with a capacity of eighty beds. The League
+conducts at present a night camp, an open air school, a farm colony, a
+post-graduate course for nurses and tuberculosis clinics for medical
+students at its dispensary. There is also a post-graduate course in
+tuberculosis for nurses. The course requires eight months and nurses
+receive during that time $25 a month. Only registered nurses are accepted.
+The training is along the following lines: nursing advanced cases in
+hospital, open air school work, sanatorium care of early cases, service in
+dental, nose and throat clinics, and in the dispensary for ambulant cases,
+district nursing, service in baby clinics, educational work, and
+laboratory work. Patients discharged from the hospital, families of
+patients in the hospital, and cases reporting at various tuberculosis
+dispensaries, are given complete follow-up care by the nurses taking the
+course, thus giving them excellent training in public health work,
+especially that phase of public health nursing dealing with tuberculosis.
+At present there are nine nurses taking the course. The Dispensary of the
+Tuberculosis League employs six nurses.
+
+Pittsburgh has also a State Department of Health Tuberculosis Clinic, with
+ten nurses, each caring for from 90 to 100 patients per month. These
+nurses give a small percentage of bedside care and are not in uniform,
+except when on duty in the dispensary. They are paid $70 per month. The
+plan of work is similar to that of the Philadelphia State Dispensary.
+
+The Department of Public Health of Pittsburgh employs four visiting
+nurses, who investigate home conditions and instruct patients reported to
+the department who are not under the close supervision of a private
+physician, the State Department Clinic, or the Tuberculosis League Clinic.
+The nurses are able to correlate, in a way, the work of the two
+dispensaries by assigning patients to the clinic in the district in which
+they live. They receive $75 per month and are not in uniform.
+
+Pittsburgh, then, has in all twenty visiting tuberculosis nurses, under
+three separate and distinct organizations.
+
+
+CLEVELAND
+
+In Cleveland, as in nearly every other city, the work of organizing the
+fight against tuberculosis was accomplished by private organizations, the
+Anti-Tuberculosis League and the Visiting Nurse Association. For a number
+of years the Health Department confined itself to keeping a card
+catalogue of reported cases. In 1910 sufficient funds were voted by the
+City Council to enable the establishment of a separate Bureau of
+Tuberculosis, whose duty should be the development of municipal
+tuberculosis work. This Bureau has taken over and gradually developed five
+dispensaries, with a staff of twenty-four visiting tuberculosis nurses,
+and paid physicians, besides the director and office force. The work in
+Cleveland is centralized in its Health Department.
+
+General dispensaries are required to refer all cases of tuberculosis to
+the tuberculosis dispensaries, and physicians are required to report all
+cases to the Health Department. On report cards and sputum blanks is the
+statement: "All cases of tuberculosis reported to the department will be
+visited by a nurse from this department unless otherwise requested by the
+physician." With very few exceptions the physicians are glad to have a
+nurse call, and every effort is made to co-operate with the physicians in
+handling the case.
+
+The city is divided into five districts, with a dispensary located in each
+district. Patients are treated only at the dispensary serving the district
+in which they live. "This plan prevents cases wandering from one clinic to
+another and enables the nursing force to do more intensive work in each
+district."
+
+Once a week the chief of the Bureau of Tuberculosis and the Superintendent
+of Nurses meet with each separate dispensary staff, and cases are
+carefully considered and work discussed. In addition, meetings of the
+active nursing staff are held, informal talks on tuberculosis being given,
+or the work of allied organizations studied, speakers coming from the
+Associated Charities, Department of Health, Settlement Houses, etc. Each
+nurse is held responsible for the handling of every individual case in her
+district. By thus making the nurse responsible, the interest in her work
+is increased and much better results are obtained. If the problem
+presented is one that will take more time and energy than the busy
+dispensary nurse can give, it is referred to a Special Case Committee.
+
+All dispensary cases are visited in the home within twenty-four hours
+after the first visit to the dispensary, where a complete history of the
+case is taken. The patient and family are instructed and each member urged
+to come to the clinic for examination. Homes where a death from
+tuberculosis has occurred are visited immediately, with the consent of the
+physician. The family is carefully instructed as to disinfection, and
+advised to go to the physician or dispensary for examination.
+
+Cleveland nurses wear uniforms. Each nurse carries about three hundred
+patients, a very small percentage being bed cases, usually not more than
+two patients at a time. Nurses receive $60 for each of the first three
+months; $65 for each of the next nine; $70 a month for the second year;
+the third year $80; and the fourth year $85.
+
+
+DETROIT
+
+The Detroit Board of Health maintains a staff of ten visiting tuberculosis
+nurses. They give a small percentage of bedside care, wear a uniform, and
+receive $1,000 per year. They work in connection with the Board of Health
+Dispensary and have the same general follow-up plan as other cities.
+
+
+MILWAUKEE
+
+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.
+
+[Illustration]
+
+  --------------------------------------------------------------------------
+  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.
+
+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 1x4-inch
+tongued and grooved boards supported eight inches above the ground on
+2x4-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
+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.
+
+During its first year the Charlottenburg School was open for only three
+months, but upon publication of the first report of the results
+accomplished it was decided to keep the school open a longer period. The
+desire to open other schools of similar type spread rapidly throughout
+Germany, as well as the rest of Europe and other parts of the world.
+
+Probably the best argument for maintaining such schools was not only the
+physical benefit derived, but the actual advance made by the children in
+their studies, although they spent less than half as much time on school
+work as did their companions in the regular schools, not only fully
+maintaining their standing, but ever surpassing their companions in the
+regular classes. Through results obtained from this first experiment in
+Charlottenburg came the resolve on the part of school authorities of other
+cities to inaugurate Open Air Schools in their respective localities, and
+in less than three years the movement had spread to England, where, in
+1907, London opened her first school, modeled after that of
+Charlottenburg.
+
+The same remarkable results obtained during the first season here, as in
+the three years previously reported from Charlottenburg, awakened such
+popular enthusiasm that towns and cities in different parts of England
+began to plan for similar schools in the communities most needing them.
+
+Meanwhile, the movement spread to the United States. In 1908, one year
+after England had established her first Open Air School, this country
+opened its first Open Air School in Providence, Rhode Island. Although
+Providence has the distinction of priority in this matter, the school
+inaugurated by Providence was not, strictly speaking, the first Open Air
+School established on American territory, as a school of this type was
+opened in 1904 in San Juan, Porto Rico, by L. P. Ayres, now Associate
+Director of the Department of Hygiene of the Russell Sage Foundation, at
+that time Superintendent of Schools for Porto Rico. The San Juan school
+was an experiment. It was built to accommodate 100 children. It was simple
+in its arrangements; it had a floor and roof but no sides. Venetian blinds
+were provided to keep out rain and the too direct sunlight. The school was
+designed for children of no particular class, but was established in the
+endeavor to demonstrate that the regime which has proven beneficial for
+weak and ailing children will also benefit those that are strong and
+seemingly healthy. The results demonstrated fully the correctness of this
+idea. The children greatly preferred the outdoor classes, and even the
+teachers were most anxious to be assigned to outdoor work. Since then at
+least one more school of similar type has been opened in Porto Rico.
+
+Before showing what the United States has done in this very important
+movement, it might be interesting to learn how Germany and England have
+further developed their program, as the work done in these countries,
+particularly in Germany, served as the basis of the Open Air School
+movement in this country in the initial stages of its development.
+
+For the past fifteen years Germany has carried on medical inspection of
+schools in a very thorough and efficient manner. This has drawn special
+attention to backward children. These children are treated there in
+special classes and sometimes in special schools. The quantity of
+instruction given them is reduced and every endeavor is made to increase
+its effectiveness. The classes are taught by capable teachers and the
+children have the benefit of suitable dietary, bathing and other hygienic
+provisions.
+
+In Charlottenburg, in 1904, there were a large number of backward children
+who were about to be removed from the ordinary elementary schools to
+special classes. When examined, it was found that many of them were in a
+debilitated condition owing to anaemia, or various other ailments in an
+incipient stage. This circumstance afforded an ideal opportunity for the
+co-operation of the teacher and the school physician in devising and
+operating, for such children, an Open Air School. The general school
+regime was modified to meet the educational and physical needs of these
+children, the treatment consisting, as above stated, of abundance of fresh
+air, pleasant and hygienic surroundings, careful supervision, wholesome
+food and judicious exercise. The ordinary school work was modified to meet
+the individual condition of children; the hours of teaching were cut in
+two and the classes so reduced that no teacher had more than twenty-five
+pupils under her care. The site chosen for the first school in
+Charlottenburg was a large pine forest on the outskirts of the town. The
+sum of $8,000 was granted by the municipality for carrying out the plan,
+and inexpensive but suitable wooden buildings were erected. At first
+ninety-five children were admitted to the school, but later the number was
+increased to 120, and still later to 250. These children were mainly
+anaemic or suffering from slight pulmonary, heart or scrofulous
+conditions. Those suffering from acute or communicable diseases were
+rigidly excluded. Of the five buildings erected, three were plain sheds
+about 81 feet long and 18 feet wide, one of them being completely open on
+the south side and closed on the other sides, of sufficient size to
+shelter during rainy weather about 200 children. The other two sheds
+contained five classrooms and a teachers' room. These were closed in on
+all sides, provided with heating arrangements, and used for classrooms
+during very cold or unpleasant weather, only one of the buildings was
+fitted with tables and benches intended for meals, or for work in
+inclement weather. This building was open on all sides. All over the
+school grounds, which were fenced in, there were small sheds open on all
+sides, fitted with tables and benches to accommodate from four to six
+children. These served as shelters. There were small buildings for shower
+baths, kitchen and a separate shed where the wraps of the boys and girls
+were kept. In these were individual lockers which contained numbered
+blankets for protection against cold, and waterproofs against rain.
+
+The children in this school report at a little before 8 a. m. and leave at
+a quarter of 7 p. m. For breakfast they are given a bowl of soup and a
+slice of bread and butter. Classes commence at 8 o'clock and continue with
+an interval of five-minutes' rest after each half hour. At 10 a. m. the
+children receive one or two glasses of milk and a slice of bread and
+butter. After this they play, perform gymnastic exercises, do manual work
+or read. Dinner is served at 12:30 p. m. and consists of about three
+ounces of meat, with vegetables and soup. After dinner the children rest
+or sleep for two hours on folding chairs. At 3 p. m. comes more class work
+and at 4 p. m. milk, rye bread and jam is given. The rest of the afternoon
+is given over to informal instruction and play. The last meal consists of
+soup, bread and butter, after which the children are dismissed. Some walk
+home; some use street cars. In case of the very poor children the city
+pays the fare, while the transportation is furnished for others through
+the generosity of the street car company. The expense of the feeding is
+borne by the municipality, in the case of those who can not pay, and, for
+the others, is defrayed in part or whole by the parents.
+
+The work of the school physician consists of careful examination,
+treatment and supervision of these children. Attention is principally
+directed to heart, lungs and general condition with respect to color,
+muscular and flesh development. Weight and measurements are taken every
+two weeks, and at the end of the school period the children are very
+carefully examined and condition compared with that noted upon their
+admission.
+
+The regime covers such important phases of hygiene as suitable clothing,
+attention to daily habits, bathing, giving of warm baths for those who are
+anaemic and nervous, and of mineral baths for those who are scrofulous.
+Bathing plays a very important part. All of the children receive two or
+three warm shower baths a week. A trained nurse is in attendance.
+
+The educational, physical and moral results obtained are remarkable. There
+is a great improvement in their behavior, especially with regard to order,
+cleanliness, self-help, punctuality and good temper. This is undoubtedly
+due to their removal, during practically all of their waking hours, from
+the influences of the street life to the more wholesome influences of the
+school. The children are taught to regard themselves as members of a large
+family, are trained to assist in the daily work and are taught to be
+helpful and considerate of each other.
+
+This, in detail, is the regime of the first Open Air School conducted in
+Germany.
+
+The number of Open Air Schools at present in Germany is at least ten, with
+an attendance of approximately 1,500.
+
+       *       *       *       *       *
+
+In England the Open Air Schools were made possible through the work of the
+local educational authorities and co-operation of dispensaries for
+treatment and care of tuberculous children.
+
+As in other countries, general legislation for the control of tuberculosis
+has had considerable bearing on the Open Air School situation in England.
+Among the legislative acts should be mentioned:
+
+    (a) The Act of 1911 providing building grants for the
+        establishment of sanatoria, dispensaries and other auxiliary
+        institutions.
+
+    (b) Compulsory notification of tuberculosis, etc.
+
+Notification of tuberculosis, for instance, besides bringing to notice of
+the school medical officer cases of tuberculosis which might otherwise not
+come before him until a late period, serves in many cases to keep him
+informed as to "contact cases"--cases of children in contact with
+communicable tuberculosis.
+
+At Burton-on-Trent a system was instituted for periodical examination of
+school children who are either members of a family in which there is or
+has been a case of pulmonary tuberculosis, or who are attending school
+while residing in houses in which there is an existing case of this
+disease. All notified cases of tuberculosis are visited by the Assistant
+Medical Officer of Health, who is also Assistant School Medical Officer,
+and the names of any children living in the house, or related to the
+case, are ascertained, together with the school they are attending. These
+names are entered in a special register and when the pupils of a school,
+at which any of these children are attending, are examined, a special
+examination is made of the latter. This examination is repeated two or
+three times a year.
+
+In another part of England a special letter is sent to the occupants of
+all houses from which the disease has been notified, calling attention to
+the special importance of early detection of tuberculosis in children, and
+asking that the children should be brought to the school clinic for
+examination.
+
+In Lancashire the Medical Inspector calls on the Medical Officer of Health
+and obtains a list of names of persons suffering from tuberculosis, so
+that the children, if of school age, may be examined.
+
+At Newcastle-on-Tyne all children exposed at any time to infection are
+kept under observation and re-examined. The re-examination continues even
+after fatal termination of the tuberculosis case with which the child was
+in contact.
+
+Under the Finance Act of 1911 a sum of about $500,000 was especially
+appropriated for providing what are known as "Sanatorium Schools" for
+children suffering from pulmonary or surgical tuberculosis. These schools
+are known as the Residential Open Air Schools of Recovery, and the need of
+such schools for children requiring more continuous care than is provided
+at a day Open Air School is becoming widely recognized. Many children of
+the type already mentioned can not be satisfactorily treated unless they
+can be taken completely away, for a time, from their home environment.
+Such treatment as is needed for many of these children is not and can not
+be offered in the ordinary hospital and certainly not at their homes.
+
+The designs and arrangements of the Residential Open Air School of
+Recovery are very attractive. They are well equipped to fulfill their
+function. The children, received between the ages of seven and twelve
+years, are those suffering from anaemia, debility, or slight heart
+lesions. Cases of active tuberculosis are barred. No child is received for
+a shorter period than three months, and this period may be prolonged on
+the recommendation of the Medical Officer.
+
+The children rise at 7 a. m. and retire at 6:30 p. m. Those who are able,
+make their own beds and do some of the domestic work. The diet is liberal,
+with abundance of milk and eggs. Careful attention is given to inculcating
+habits of personal and general hygiene. All children receive a daily bath.
+Careful attention is paid to the teeth, tonsils and adenoids. All these
+conditions must be attended to before admission. Beyond this, very little
+treatment is given. Children are weighed once in two weeks. Instruction is
+chiefly practical. Instruction in gardening is given twice a week and
+other occupations taught are raffia work, plasticine modeling, cardboard
+modeling, brush work and needle work.
+
+The number of Open Air Schools at present in England is at least
+thirty-five, with an attendance of at least 2,500. Forty-two other cities
+are listed as carrying on some form of open air education.
+
+       *       *       *       *       *
+
+In the United States the Open Air School movement, from its inception, has
+been closely connected with the general anti-tuberculosis movement.
+
+The credit of establishing the first Open Air School in America belongs,
+as previously stated, to Providence, Rhode Island, where the work was
+begun in January, 1908. The school was opened in a brick school house in
+the center of the city. A room on the second floor was chosen and
+remodeled by removing part of the south wall. For the wall thus removed
+windows were substituted. These extended from near the floor to the
+ceiling, with hinges at the top and with pulleys so arranged that the
+lower ends could be raised to the ceiling. The desks were placed in front
+of the open windows in such a manner that the children received the fresh
+air at their backs and the light over their shoulders. Suitable clothing
+was provided for cold weather and, in case of necessity, soapstone foot
+warmers were used.
+
+The school was started as an ungraded school and ten pupils were enrolled
+at the time of its opening, the number later increasing to twenty-five.
+Practically all children were selected by the visiting nurse of the local
+League for the Suppression of Tuberculosis from infected homes under her
+supervision. In a few instances children with moderately advanced lesions
+were admitted.
+
+The children reported at 9 a. m. and a recess was given at 10:30, when
+they were served soup. At noon they had a light lunch of pudding served
+with cream, hot chocolate or cocoa made entirely with milk. Some of the
+children brought additional food from home. All of the cooking was done by
+the teacher. Careful attention to general cleanliness and hygiene of the
+teeth was insisted upon. Individual drinking cups and tooth brushes were
+provided. The children took turns in washing dishes, setting the table and
+helping to serve. Children were dismissed at 2:30 p. m. They were
+provided with car tickets by the League for the Suppression of
+Tuberculosis, some for traveling both ways, some for one way only,
+depending upon the means of the family. During school session light
+gymnastic exercises were given and proper methods of breathing taught. In
+the spring they had a garden to work in.
+
+The Providence school is at present a part of the general school system.
+The school supplies and teacher's salary are furnished by the Board of
+Education. Food and carfare are supplied by the League for the Suppression
+of Tuberculosis. A physician is delegated by the League and one of the
+regular Medical Inspectors of the city schools works in co-operation with
+him.
+
+Providence has at present two schools, with an attendance of forty. One
+more Open Air School and two roof classes may be provided by the Board of
+Education in 1914. In addition, the Providence League for the Suppression
+of Tuberculosis conducts a Preventorium for thirty children at the
+Lakeside Preventorium, Rhode Island.
+
+       *       *       *       *       *
+
+Boston started its first Open Air School in July, 1908. The work was
+carried on by the Boston Association for the Relief and Control of
+Tuberculosis. The school was located at Parker Hill, Roxbury. The same
+regime was followed as in previously reported schools. No formal
+instruction, however, was attempted at first. The school was simply a day
+camp. The benefit derived by the children in the first open air camp for
+children led the Association to ask the Boston School Board to co-operate
+with them in converting the camp into an outdoor school. This was agreed
+to, the School Board supplying teacher, desks, books, etc., the
+Association furnishing the necessary clothing, food, a nurse, attendants,
+home instruction and medical services. The same schedule was followed here
+as in the other Open Air Schools. General and personal hygiene was
+insisted upon. The school was kept open Saturdays and during the holidays.
+The children who were able paid ten cents a day to help defray the cost of
+food. In case they could not afford this, the money was supplied by some
+charity organization. While the combined public and private support had
+proved satisfactory, it seemed best, for many reasons, to reorganize the
+school so that it would be entirely under municipal authority, and this
+has since been done. At the present time the school is maintained by the
+Boston Consumptives' Hospital and the Boston School Board. The hospital
+furnishes transportation, food, etc., while the School Board gives school
+supplies, books, desks, etc., and pays the salaries of the teachers. The
+children are selected by the school physicians, the type considered being
+the anaemic, poorly nourished, those with enlarged glands, or
+convalescents. Cases of active tuberculosis are not admitted.
+
+Boston has at present fifteen Open Air Schools, with a total enrollment of
+about 500 children.
+
+       *       *       *       *       *
+
+The first school established in New York City was started under the
+auspices of the Department of Education and was located on the ferryboat
+Southfield, which was maintained as an outdoor camp for tuberculous
+patients by Bellevue Hospital. It was through the special desire of the
+children who were patients at the camp that the school was started, for
+they banded together one day and informed the doctor that they wanted to
+have a teacher and attend school. When their action was reported to the
+Board of Education it was felt that such an unusual plea should be given a
+favorable response, and in December, 1908, the school on the ferryboat was
+made an annex of Public School No. 14.
+
+This school, except for its location, does not differ from other schools
+of similar type. The Board of Education pays the teacher and furnishes the
+school supplies. Food and clothing are supplied by the hospital. The
+school is an ungraded one and the number of children taught by one teacher
+averages thirty.
+
+Four more Open Air Schools have since been established, three on
+ferryboats and one on the roof of the Vanderbilt Clinic at West Sixtieth
+street. Officially, all these schools are considered to be annexes of the
+regular public schools.
+
+In October, 1909, $6,500 was granted to the Board of Education by the
+Board of Estimate and Apportionment for the purpose of remodeling rooms in
+some of the public schools for use as Open Air Rooms. A special conference
+was held in December of that year by medical and school authorities to
+decide how best to remodel, furnish and equip these new rooms for this
+purpose; also how the children should be chosen for these classes.
+
+It was decided that the maximum number of children admitted to any one
+open air classroom should not exceed twenty-five, the children to be
+chosen by the director of the tuberculosis clinic nearest the school and
+the school principal. No child was to be assigned to the room until the
+parents' permission had been secured in writing. Children moving from one
+district to another were to be followed up and cared for in the new
+district. No special rule was adopted defining the physical condition
+entitling the child to admission. Each case was to be considered
+individually, and the only definite rule was that no open case of
+tuberculosis should be admitted. The minimum temperature of the room was
+50 degrees F. The rooms, wherever possible, were to be located on the
+third floor. The first of these open air classes was established in April,
+1910. Such popular interest was awakened by the inauguration of these
+classes that, as a direct result, a special privilege was granted by the
+Commissioners of Central Park permitting children of the kindergarten
+classes of the public schools to pursue their studies in the open air in
+Central Park.
+
+At present New York has thirty-three Open Air Schools and Open Window
+Rooms, with a total enrollment of at least 1,000.
+
+       *       *       *       *       *
+
+Chicago's first Outdoor School for Tuberculous Children was inaugurated as
+a result of the joint co-operation of the Chicago Tuberculosis Institute
+and the Board of Education. This school was opened during the first week
+of August, 1909, on the grounds of the Harvard School at Seventy-fifth
+street and Vincennes Road. The Board of Education assigned a teacher to
+the school and furnished the equipment, while the Tuberculosis Institute
+supplied the medical and nursing service, selected the children and
+provided the food.
+
+Except during inclement weather, the children occupied a large shelter
+tent in which thirty reclining chairs were placed. Meals were served in
+the basement of the school building, where a gas range, cooking utensils
+and tables were installed for this special purpose.
+
+The nurse, who was assigned by the Tuberculosis Institute on half-time
+attendance, visited the school each afternoon, took daily afternoon
+temperatures, pulse and respiration, looked after the general physical
+condition of the children, made weekly records of their gain or loss in
+weight and did instructive work in the home of each pupil.
+
+Of the thirty children selected, seventeen had pulmonary tuberculosis, two
+had tubercular glands, and eleven were designated as "pre-tuberculous."
+None of the children had passed to the "open" or infectious stage. On
+admission two-thirds of the children showed a temperature of from 99 to
+100.2 degrees.
+
+The daily program was similar to that already described for the Providence
+and Boston Schools. The school was kept open for a period of only one
+month, with excellent results. During this time the thirty children made a
+net gain of 115 pounds in weight, and at the close of the period
+practically all of them showed a normal temperature, with their general
+condition greatly improved.
+
+It is needless to say that the experiment created a great deal of local
+interest in the problem of better school ventilation. Those who had the
+success of the movement most intimately at heart realized, however, that
+the undertaking lacked the element of permanency and that the results
+accomplished by it lacked that degree of conclusiveness which would attend
+the same results if secured through the operation of an all-the-year-round
+school.
+
+The opportunity to demonstrate the effectiveness of such an
+all-the-year-round school was realized in the Fall of 1909 by a grant from
+the Elizabeth McCormick Memorial Fund to the United Charities for the
+purpose of conducting such a school on the roof of the Mary Crane Nursery
+at Hull House. This school was opened by the United Charities in October
+with twenty-five carefully selected children, and was conducted throughout
+the following winter and spring with the co-operation of the Board of
+Education and the Chicago Tuberculosis Institute. During the same winter
+the Public School Extension Committee of the Chicago Women's Club,
+co-operating with the Board of Education, established two classes for
+anaemic children in open window rooms--one in the Moseley and one in the
+Hamline School. Here the regular regime was broken by a rest period, and
+lunches of bread and milk were served twice each day. "Fresh Air Rooms,"
+in which the windows were thrown wide open and the heat cut off, were also
+established for normal children in several rooms in the Graham School. No
+attempt was made here to furnish lunches and no rest period was provided.
+
+There were, then, during the school year of 1909 and 1910, three distinct
+classes of children cared for by three distinct agencies--the classes for
+normal children in the low temperature rooms at the Graham School; anaemic
+children, with rest period and two lunches, in the Moseley and Hamline
+Open Window Rooms, and the Roof School for Tuberculous Children, with
+specially provided clothing, sleeping outfits, three meals a day and
+medical and nursing attendance, at the Mary Crane Nursery.
+
+The same condition existed throughout the following year--1910-11--with
+the addition of one Open Air School on the roof of the municipal bath
+building on Gault Court, given rent free by the City Health Department,
+and two Open Window Rooms for anaemic children in the Franklin School, all
+maintained by the Elizabeth McCormick Memorial Fund.
+
+In 1911 the Elizabeth McCormick Memorial Fund assumed the responsibility
+for all the open air school work carried on in the Chicago Public
+Schools, and began the standardization of methods which should be employed
+in the conduct of such schools.
+
+Through the initiative of the Elizabeth McCormick Memorial Fund the
+Chicago Open Air School work has been rapidly developed during 1912 and
+1913, the program being along the line of additional roof schools for
+tuberculous children and an increasing number of open window rooms for
+anaemic children and children exposed to tuberculosis. In all this work
+the Elizabeth McCormick Memorial Fund has had the co-operation of the
+Board of Education, the Chicago Tuberculosis Institute and the Municipal
+Tuberculosis Sanitarium. The Board of Education has supplied teachers and
+furnished rooms wherever there has been a distinct demand for such a
+provision. During the past two years the Municipal Sanitarium has made
+appropriations aggregating $12,000 to pay the cost of food for these
+schools, in addition to furnishing the necessary nursing service.
+
+At the present time four Roof Schools and sixteen Open Window Rooms, with
+an enrollment of 500 pupils, are being maintained.
+
+For full information concerning the Chicago Open Air School movement, see
+"Open Air Crusaders," January, 1913, edition, published by the Elizabeth
+McCormick Memorial Fund, 315 Plymouth Court, Chicago; or write Mr. Sherman
+C. Kingsley, Director, Elizabeth McCormick Memorial Fund, for more recent
+developments.
+
+       *       *       *       *       *
+
+Space will not permit a statement of the development of the Open Air
+Schools in other cities in the United States since this movement was
+started in 1908. It is, however, encouraging to note what has been
+accomplished and the comprehensive plans which are being made to further
+this great movement for the good of the future citizens of America.
+
+[Illustration]
+
+
+
+
+                      NOTES ON TUBERCULIN FOR NURSES
+
+   VARIETIES OF TUBERCULIN--THEORIES OF TUBERCULIN REACTION--TUBERCULIN
+                                 TESTS.
+
+                      By THEODORE B. SACHS, M. D.
+
+
+           VARIETIES OF TUBERCULIN AND METHODS OF PREPARATION
+
+OLD TUBERCULIN--T. Announced by Koch in 1890.
+
+    Tubercle Bacilli of human origin.
+
+    Grown on beef broth containing 5% glycerine, 1% peptone, sodium
+      chloride; growths 6 to 8 weeks.
+
+    Sterilized by steam one-half hour.
+
+    Evaporated (at a temp. not higher than 70 deg. C.) to 1/10 its volume.
+
+    Filtered.
+
+    1/2% carbolic acid added. Let stand.
+
+    Filtered (porcelain filter).
+
+  Old Tuberculin contains:
+
+    1. 40 to 50% glycerine (a small percentage of glycerine is
+       evaporated)
+
+    2. 10% of peptones or albumoses
+
+    3. Toxic secretions of the tubercle bacilli into the culture fluid, or
+       such of them as are soluble in 50% glycerine
+
+    4. Substances extracted from the bacterial bodies by the alkaline
+       broth during the process of boiling and evaporation.
+
+  Appearance and Characteristics:
+
+    1. A clear brown fluid
+
+    2. Of syrupy consistency
+
+    3. Mixes with water in all proportions without producing any turbidity
+
+    4. Keeps indefinitely, but not advisable to use brands older than one
+       year.
+
+BOULLION FILTRATE--B. F. Denys--1907.
+
+    Method of preparation same as Old Tuberculin, with the exception of
+      subjection to heat;
+
+    B. F. is a filtered, unconcentrated culture.
+
+    Contains less peptone and less glycerine than Old Tuberculin.
+
+    Contains no substances extracted from tubercle bacilli by heat.
+
+    Some toxic substances may be more active (not having been subjected to
+      heat).
+
+TUBERCULIN RUCKSTAND (Residue)--T. R. Announced by Koch in 1897.
+
+    Ground, dried tubercle bacilli.
+
+    Distilled water added.
+
+    Centrifugalization.
+
+    Supernatant fluid removed (not to be used).
+
+    Sediment dried and ground; distilled water added; centrifugalization.
+
+    Fluid removed and _set aside_.
+
+    Sediment dried and ground again; distilled water added;
+      centrifugalization.
+
+    Fluid removed and set aside.
+
+    Sediment dried and ground, etc., as above.
+
+    The process continued until water takes up the sediment, then all the
+      fluids set aside (except the first one) mixed together.
+
+    Glycerine 20% added.
+
+    The mixture is T. R.
+
+Koch was prompted by the following consideration in bringing out T. R.: He
+thought that the Old Tuberculin conferred only a toxic immunity, not
+bacterial. T. R. was supposed to confer bacterial immunity.
+
+Each 1 cc. of T. R. contains 10 milligrams of dried bacilli.
+
+BACILLEN EMULSION--B. E. Announced by Koch in 1901.
+
+    Finely powdered tubercle bacilli--1/2 gram.
+
+    50 cc. of water and 50 cc. of glycerine.
+
+    All mixed together--prolonged shaking.
+
+B. E. is supposed to contain not only the extract of the body of the
+tubercle bacilli, as in T. R., but also its soluble products (which in the
+case of T. R. were discarded in setting aside the supernatant fluid).
+
+
+                    THEORIES OF TUBERCULIN REACTION
+
+_a_ ROBERT KOCH ascribes the tuberculin reaction to the increased
+      necrotic process around the tubercle, the histological changes
+      consisting of hyperaemia, exudation and softening.
+
+_b_ EHRLICH considers the formation of antibodies an essential feature in
+      the mechanism of reaction. Formation of antibodies takes place in
+      the middle of the three layers encircling the tubercle, the layer
+      damaged by toxins, but not yet rendered incapable of reaction.
+
+_c_ WASSERMANN maintains that the antituberculin found in the tuberculous
+      process draws the injected tuberculin out of the circulation to the
+      tuberculous focus. The interaction that takes place between
+      antituberculin and tuberculin results in formation of ferments which
+      digest albumin, resulting in the softening of tissue. Absorption of
+      softened tissue causes fever.
+
+_d_ CARL SPENGLER--Toxins in the blood of the tuberculous are kept in
+      check by antibodies. Injected tuberculin unites with antibodies,
+      thus setting the toxins free. Result--autointoxication.
+
+_e_ WOLFF-EISNER--Bacteriolysin is present in the organism of the
+      tuberculous, as result of previous infection; bacteriolysin sets
+      free the potent substances of the injected tuberculin; this acts on
+      the body and the tuberculous focus, producing a reaction.[10]
+
+
+                            TUBERCULIN TESTS
+
+I. SUBCUTANEOUS (hypodermic); introduced by Robert Koch in 1890.
+
+II. CUTANEOUS; introduced by Von Pirquet in 1907.
+
+III. CONJUNCTIVAL (ophthalmic); introduced about the same time by
+    Wolff-Eisner and Calmette in 1907.
+
+IV. PERCUTANEOUS (inunction or salve); introduced by Moro in 1908.
+
+V. INTRACUTANEOUS (needle track reaction); introduced as a test by Mantoux
+    in 1909. Described previously by Escherich.
+
+
+                     I. SUBCUTANEOUS TUBERCULIN TEST
+
+1. APPARATUS AND SOLUTIONS NECESSARY:
+
+    Glass cylinder graduated to cc.
+
+    1 cc pipette graduated to 1/10 cc.[11]
+
+    10 cc pipette graduated to 1/10 cc.[12]
+
+    Hypodermic needle suited to the syringe.
+
+    Two or more 1/2 oz. bottles.
+
+    1/2% carbolic acid solution.
+
+    Normal salt solution.
+
+    1 cc. Old Tuberculin.
+
+2. PREPARATION OF APPARATUS:
+
+    Glass apparatus, syringe and needles boiled before use.
+
+    Some keep needles and syringe in 95% alcohol.
+
+3. MAKING SOLUTIONS:
+
+         Tuberculin No. I:        Tuberculin No. II:
+
+         Label one bottle             Another
+
+         _.1 cc. = 1 mg. T_      _.1 cc. = .1 mg. T_
+
+  No. I  { Put 0.1 cc. T in bottle No. I
+         { Add 9.9 cc. of 1/2% carbolic acid solution
+
+         { Put 1 cc. of Tuberculin solution from
+  No. II { No. I into bottle No. II
+         { Add 9 cc. of 1/2% carbolic solution
+
+    In making dilutions you may use your syringe instead of pipette.
+
+    Dilutions can be kept _one week_ in a dark, cool place.
+
+    Discard turbid solutions.
+
+4. PREPARATION OF THE PATIENT FOR THE TEST:
+
+    Patient to keep quiet in bed, or reclining chair, for two or three
+      days before injection.
+
+    Take temperature every two or three hours for two or three days
+      (daytime).
+
+    If the test is to be applied, highest temperature should not be above
+      99.1 F, by mouth, according to Koch; not above 100 F, according to
+      others.
+
+    Site of injection--back, below the level of the shoulder blades,
+      alternately on the two sides.
+
+    Rub skin with ether or alcohol.
+
+    An exact record of physical signs, _just before injection_, should be
+      made by the physician.
+
+5. TIME OF INJECTION:
+
+    Between 8 and 10 A. M. (Bandelier and Roepke).
+
+    Late in the evening, 9 or 10 P. M., or later (others).
+
+6. DOSE:
+
+    According to Koch: Begin with 1/2 mg., or 1 mg., according to
+      condition of patient; give larger dose if no reaction. Order of
+      increase: 1 mg.; 5 mg.; 10 mg. (last dose repeated if necessary).
+
+    Interval between injections: two or three days.
+
+    Present Usage: First dose in adults, 1/2 mg., or 1/5 mg., or smaller,
+      according to physical condition.
+
+    First dose in children: 1/10 mg., or 1/20 mg., or even smaller.
+
+    Thus, in adults: 1/2, or 1, 3, 5, 8, and rarely 10;
+
+    In children: 1/10, 1/2, 1, 3.
+
+    Loewenstein and Kaufmann's Scheme: Repetition of small dose, relying
+      on exciting hypersensibility--2/10 mg.; in 3 days, 2/10 mg.; in 3
+      days, 2/10 mg.; in 3 days, 2/10 mg.
+
+    Some use 1/10 mg., or 3/4, or 1-1/4, in same way.
+
+    This scheme is based on hypersensibility created by repetition of same
+      dose in tuberculous subjects. Scheme not used at present.
+
+    Some advise single dose: 3 or 5 mg., (on the ground that gradual
+      increase of doses creates tolerance).
+
+7. RULES TO FOLLOW IN INCREASING DOSE:
+
+_a_ If no reaction with one dose, give a larger one next time, according
+to _b_.
+
+_b_ If temperature rises less than 1 degree F, repeat same dose; otherwise
+increase.
+
+_c_ Avoid large doses in cases of weakness, nervous temperament, children,
+etc. In a majority of cases smaller doses suffice.
+
+8. AFTER INJECTION:
+
+    _a_ Rest in reclining chair two or more days, unless severe reaction
+        requires absolute rest in bed.
+
+    _b_ Take temperature every 2 or 3 hours for 2 or 3 days.
+
+9. GENERAL REACTION:
+
+    _a_ Rise of Temperature. Positive reaction, if temperature rises at
+        least .5 deg. C. (.9 deg. F.), higher than previous highest temperature.
+
+    Degree of reaction according to Bandelier and Roepke: Slight reaction
+        if temp. rises to 38 deg. C. or 100.4 deg. F. Moderate reaction if temp.
+        rises to 39 deg. C. or 102.2 deg. F. Severe reaction if temp. rises above
+        39 deg. C. or 102.2 deg. F.
+
+    Typical reaction temperature curve: Rapid rise, slower fall, normal
+        temperature after 24 hours.
+
+    Rise begins, in average case, 6 to 8 hours after injection (may begin
+        within 4 hours or be delayed for 30 hours).
+
+    Acme of rise in 9 to 12 hours.
+
+    Duration of reaction, 30 hours or longer.
+
+    Rise, acme and duration of reaction vary.
+
+    _b_ Symptoms:
+
+        May begin with rigor or chilliness, followed by feeling of
+          warmth.
+
+        Following symptoms may be present:
+
+          Malaise, giddiness, severe headache, pain in limbs, pain in
+            affected organ, palpitation, loss of appetite, nausea,
+            vomiting, thirst, sleeplessness, lassitude, etc.; in short, a
+            general feeling of "illness."
+
+        With fall of temperature--disappearance of symptoms.
+
+10. REACTION AT POINT OF INJECTION: Area of redness, swelling,
+      tenderness; important as indicative of sensitiveness, pointing to
+      probable general reaction with repetition or increase of dose.
+
+11. FOCAL REACTION: Reaction at site of process, due to congestion around
+      it.
+
+    Focal reaction is demonstrable by:
+
+    _a_ Change in physical signs; breath sounds, resonance, appearance of
+        rales, etc.
+
+    _b_ Localizing symptoms, pointing to location of the tuberculous
+        process.
+
+        Lungs--increase of cough, sputum, appearance of bacilli, pain in
+          chest, etc.
+
+        Kidney--pain in the region of kidney, changes in urine findings,
+          etc.
+
+        Joint--swelling, tenderness, etc.
+
+        Lupus--redness and exudation.
+
+    Focal reaction is an important feature of the subcutaneous tuberculin
+        test; it permits localization of the disease in a certain
+        percentage of cases.
+
+    Physical examination, sputum examination, urinalysis, etc., are very
+        important _during the course of the reaction_.
+
+12. CONTRAINDICATIONS:
+
+    Subcutaneous tuberculin test should not be employed in:
+
+    1. Cases with temperature above 100 deg. F, by mouth (99.1 deg. F, by mouth,
+       according to Koch).
+
+    2. Cases in which the clinical history and physical signs make the
+       diagnosis certain (presence of tubercle bacilli in the sputum
+       render, of course, any other test unnecessary).
+
+    3. Cases of recent haemoptysis.
+
+    4. Grave conditions, as severe heart disease, nephritis, marked
+       arteriosclerosis, etc.
+
+    5. Convalescence from acute infectious diseases, typhoid fever,
+       pneumonia, etc.
+
+13. INTERPRETATION OF THE POSITIVE SUBCUTANEOUS TUBERCULIN REACTION:
+
+    Occurrence of reaction, following the subcutaneous tuberculin test,
+      signifies the _existence of infection_; it does not signify that
+      the individual is _clinically tuberculous_. To quote E. R. Baldwin,
+      of Saranac Lake: "The tuberculin test is of very limited value in
+      determining tuberculous _disease_; it is of extreme value in
+      detecting tuberculous _infection_."
+
+    The test results in positive reaction in cases with latent as
+      well as active processes.
+
+    The decision as to the patient being clinically tuberculous (ill
+      with tuberculosis) must rest on the consideration of the
+      clinical history and the results of the physical examination.
+
+    It is maintained by some that the subcutaneous tuberculin
+      reaction is _more rapid in onset_ and _more marked in degree_
+      in cases of _recent_ infection. On the other hand, the test is
+      negative in a certain proportion of far advanced cases.
+
+    Occurrence, then, of a subcutaneous tuberculin reaction does not
+      indicate necessarily sanatorium or institutional treatment;
+      neither does it absolutely indicate the necessity of
+      tuberculin treatment. The decision rests on the consideration
+      of all the clinical features of the case.
+
+    _In the absence of any symptoms or physical signs of disease_, a
+      reaction should call for regulation of every day life, tending
+      to increase the state of general resistance (improvement of
+      nutrition, etc.) frequently without discontinuance of work.
+
+    The occurrence of reaction, _in the presence of slight symptoms
+      or physical signs_, calls, according to individual condition,
+      either for home treatment with or without discontinuance of
+      work, or sanatorium treatment.
+
+14. INDICATIONS FOR THE SUBCUTANEOUS TUBERCULIN TEST:
+
+      The following considerations should guide its employment:
+
+      1. A thorough study of the history, thorough physical examination,
+           examination of sputum (if any) give sufficient data for a
+           reliable diagnosis in the vast majority of cases.
+
+      2. Cases, with uncertain symptoms or inconclusive physical signs,
+           pointing to possible existence of tuberculous infection, may be
+           treated as "suspicious" cases (without resorting to
+           subcutaneous tuberculin test), the treatment consisting of
+           rearrangement of mode of life, diet, work, etc., that would
+           tend to increase of general resistance of the patient. This can
+           and should be done in the vast majority of suspicious cases.
+
+      3. The subcutaneous tuberculin test is indicated in cases in which,
+           in the absence of conclusive symptoms or signs, an absolutely
+           positive diagnosis is desired; then the test should be applied,
+           with the consent of the patient, _after all other methods of
+           diagnosis are exhausted_ (thorough study of the case, thorough
+           physical examination, repeated examinations of sputum, etc).
+
+      4. The focal reaction (the reaction pointing to the seat of the
+           disease) occurs in about 1/3, or less, of the general reactions
+           following the subcutaneous tuberculin test; this enhances the
+           value of the test in some cases where a focal reaction would
+           clear the diagnosis.
+
+    Above all, the subcutaneous tuberculin test should be used
+      rarely, and then only after all other methods of diagnosis
+      were thoroughly applied.
+
+
+                      II. CUTANEOUS TUBERCULIN TEST
+
+1. SYNONYMS: Von Pirquet Test or Skin Test
+
+2. APPARATUS AND DILUTIONS NECESSARY:
+
+    Inoculation needle of Von Pirquet
+
+    Koch's Old Tuberculin (undiluted or dilutions according to method).
+
+    A centimeter tape measure (divided to 1/10 cm.) to measure reactions
+
+    Ether
+
+    Alcohol lamp
+
+    Medicine dropper
+
+3. APPLICATION OF TEST:
+
+    Inner surface of the forearm; clean the site with ether; place
+      two drops of tuberculin 4 inches apart; stretch the skin and
+      scrape off the epidermis (at a point midway between the two
+      drops of tuberculin) by rotating the Von Pirquet needle
+      between thumb and index finger, with slight pressure on the
+      skin; repeat same through the two drops of tuberculin; let the
+      tuberculin soak in for a few minutes. No dressing is
+      necessary. The middle scarification is the control test. One
+      tuberculin and one control test may suffice. A separate needle
+      should be used for the control test.
+
+    After each inoculation, clean the needle of tuberculin and heat
+      the point red hot in the alcohol flame before applying it
+      again.
+
+4. REACTION:
+
+    Gradual elevation and reddening of skin around the point of
+      tuberculin inoculation, beginning in 3 hours or later; the
+      reaction (papule) well developed, generally, in 24 hours and
+      most distinct in 48 hours after inoculation.
+
+    Size of papule varies from a diameter of 10 millimeters in the
+      average case to 20 mm. occasionally, and 30, rarely (Bandelier
+      and Roepke).
+
+    At the end of 48 hours the swelling and redness subside
+      gradually, with the subsequent bluish discoloration of the
+      skin, remaining for various periods of time, and slight
+      peeling of the epidermis. Individual reactions vary in degree
+      of redness, elevation, size, contour of the border, etc. All
+      these points should be observed and recorded.
+
+    Time of inspection--24 and 48 hours after inoculation.
+
+    Single inspection--best time in 48 hours.
+
+5. CAUSE OF REACTION:
+
+    Interaction between inoculated tuberculin and the antibodies
+      (bacteriolysins, according to Wolff-Eisner) present in the
+      skin of a tuberculous individual; interaction results in
+      hyperaemia and exudation (papule).
+
+6. INTERPRETATION OF REACTION:
+
+    Occurrence of positive reaction signifies presence of a
+      tuberculous focus somewhere in the body. No indication as to
+      activity or location of the focus.
+
+    A negative reaction in adults (especially if repeated) signifies
+      non-existence of tuberculosis (unless great deterioration of
+      health, far advanced process, or tolerance to tuberculin
+      established by tuberculin treatment).
+
+    A positive reaction in children under two years of age
+      signifies, generally, active tuberculous process; with the
+      advance of age the determination of active tuberculous
+      processes by means of cutaneous tuberculin test becomes
+      impossible.
+
+
+                   III. CONJUNCTIVAL TUBERCULIN TEST
+
+1. SYNONYMS: Eye Test; Ophthalmic Test; Wolff-Eisner's Test; Calmette's
+      Test.
+
+2. APPARATUS AND DILUTIONS NECESSARY:
+
+    1 cc. pipette graduated to 1/10 cc.
+
+    10 cc. pipette graduated to 1/10 cc.
+
+    10 cc. glass cylinder
+
+    Medicine dropper
+
+    Koch's Old Tuberculin
+
+    1/2% and 1% dilution of Old Tuberculin in .85% sterile normal salt
+      solution.
+
+    To make 1% dilution, add .1 cc. Old Tuberculin to 9.9 cc. of diluent.
+
+3. APPLICATION OF TEST:
+
+    Patient sitting, with head thrown back
+
+    Lower eyelid drawn slightly down and toward the nose--to form a small
+      pouch of the lid;
+
+    One drop of 1% or 1/2% instilled in that pouch and the lower lid moved
+      up gently over the eye until the lids meet;
+
+    Eye kept closed for one minute or so.
+
+4. REACTION:
+
+    Onset in 12 to 24 hours (may begin earlier); acme in 24 to 36 hours;
+      duration of reaction--3 to 4 days or even longer (in severe cases).
+      Some reactions are of short duration. 3 grades of reaction,
+      according to Citron:
+
+    1. Reddening of caruncle and palpebral (lid) conjunctiva.
+
+    2. More intense reddening, with involvement of ocular (eyeball)
+       conjunctiva, and increased secretion.
+
+    3. Very intense reddening of the whole conjunctiva, with much
+       fibrinous and purulent secretion, etc.
+
+5. TIME OF INSPECTION:
+
+    12 and 24 hours after instillation; then once a day.
+
+6. CAUSE OF REACTION:
+
+    Hyperaemia and exudation resulting from interaction between
+      _instilled tuberculin_ and _antibodies in conjunctiva_
+      (bacteriolysin, according to Wolff-Eisner).
+
+7. INTERPRETATION OF REACTION:
+
+    Wolff-Eisner maintains that positive conjunctival tuberculin
+      reaction means _active_ tuberculosis, a conclusion accepted by
+      but a few.
+
+8. FIELD OF APPLICATION OF CONJUNCTIVAL TUBERCULIN TEST:
+
+    _Should not be used_; connected with _danger_ to the eye.
+
+    Conjunctival test used very rarely at present.
+
+
+                   IV. PERCUTANEOUS TUBERCULIN TEST
+
+1. SYNONYMS: Salve Test; Moro Test.
+
+2. SALVE: Equal parts of Old Tuberculin and anhydrous lanolin.
+
+3. APPLICATION OF TEST:
+
+    Site: abdominal wall below ensiform process, _or_ breast below
+      nipple, _or_ inner surface of forearm.
+
+    Application: rub in with the finger (using moderate pressure) a small
+      particle of salve about the size of a pea.
+
+    Rub it in into an area about 5 cm.; rub 1 minute.
+
+4. REACTION:
+
+    In 24 to 48 hours--_either_ numerous small reddened spots which
+      disappear in a few days, _or_ numerous small nodules, _or_
+      coalescing nodules on a red base, etc.
+
+5. INTERPRETATION OF REACTION:
+
+    Positive reaction is assumed to indicate existing tuberculous
+      infection somewhere in the body; does not indicate that the process
+      is active.
+
+6. FIELD OF APPLICATION OF PERCUTANEOUS TUBERCULIN TEST:
+
+    The percutaneous tuberculin test fails in a large proportion of
+      tuberculosis cases.
+
+    The test is used rarely at present.
+
+
+                             LIGNIERES TEST
+
+    A modification of the Moro Test
+
+    Instead of salve, a few drops of Old Tuberculin rubbed in.
+
+    Used rarely at present.
+
+
+                    V. INTRACUTANEOUS TUBERCULIN TEST
+
+1. SYNONYMS--Mantoux Test
+
+2. APPLICATION OF TEST:
+
+    Injection into skin (needle parallel to skin) of 1/100 mg. of Old
+      Tuberculin (according to Mantoux).
+
+3. REACTION:
+
+    Onset in a few hours, well developed in 24 hours, acme in 48 hours.
+      Reaction consists of a central nodule surrounded by a halo of
+      redness.
+
+    This is the intracutaneous test as originally suggested by Mantoux.
+
+
+                              CONCLUSIONS
+
+Comparing the various tuberculin tests we find that:
+
+1 _The Subcutaneous Tuberculin Test_ has the advantage of focal reaction,
+disclosing in a certain percentage of cases the seat of the disease.
+
+The subcutaneous test should, however, never be employed unless _as a last
+resort_, and then only after all other methods of diagnosis are exhausted
+and an absolute diagnosis is very essential.
+
+In the vast majority of suspected cases of tuberculosis, thorough study of
+the history of the case, combined with thorough physical examination,
+furnishes all the necessary data for diagnosis and an efficient plan of
+treatment.
+
+2 _The Cutaneous Tuberculin Test_ is a very efficient diagnostic measure
+in children under two years of age in whom a positive cutaneous tuberculin
+reaction indicates active disease.
+
+Positive cutaneous tuberculin reaction in adults indicates existence of a
+tuberculous process, somewhere in the body; it does not indicate that the
+process is active.
+
+Negative cutaneous tuberculin reaction is one of the corroborative
+evidences of absence of tuberculosis, unless reaction is prevented by very
+advanced disease or tolerance to tuberculin established by tuberculin
+treatment.
+
+3 Thorough study of the history and thorough physical examination of each
+individual case are more important and should precede the application of
+any test.
+
+
+FOOTNOTES:
+
+[1] For illustration, see Knopf, "Tuberculosis," Chap. IV, page 67.
+
+[2] See Carrington, "Fresh Air and How to Use It," Chap. II, page 29.
+
+[3] For illustration, see Carrington, "Fresh Air and How to Use It," Chap.
+II, page 37.
+
+[4] For illustration, see Carrington, "Fresh Air and How to Use It," Chap.
+VIII, page 128.
+
+[5] For illustration, see Knopf, "Tuberculosis," Chap. IV, page 58.
+
+[6] For illustration, see Carrington, "Fresh Air and How to Use It," Chap.
+VII, page 108.
+
+[7] See previous footnote.
+
+[8] For illustration, see Journal of Outdoor Life, January 1914.
+
+[9] For illustration, see Carrington, "Fresh Air and How to Use It," Chap.
+IV, page 55.
+
+[10] For a diagrammatic presentation of Wolff-Eisner's theory, see
+"Tuberculin Treatment" by Riviere and Moreland, page 6.
+
+[11] Not absolutely necessary: may get along with graduated cylinder and
+syringe.
+
+[12] See previous footnote.
+
+                                 (END)
+
+       *       *       *       *       *
+
+                       Transcriber's Amendments
+
+Transcriber's Note: Blank pages have been deleted. Paragraph formatting
+has been made consistent. The publisher's inadvertent omissions of
+important punctuation have been corrected.
+
+Other changes are listed below. The listed source publication page number
+also applies in this reproduction except possibly for footnotes since they
+have been moved.
+
+   Page          Change
+
+   7  the acute inflamatory[inflammatory] at the beginning,
+   9  systematic treatment was underaken[undertaken].
+   9  Bodingon of Sutton, Coldfield[Sutton Coldfield], England,
+  10  The fundimental[fundamental] principle
+  19  fit to make to a printed questionaire[questionnaire].
+  23  who visits the physican[physician]
+  28  Tuberculosis Sanitarium is extending sanatorum[sanatorium] care
+  35  [Split first footnote into two.]
+  36  in the shelter of a strong windbrake[windbreak].
+  43  makes a family, ordinnarily[ordinarily]
+  58  [Split first footnote into two.]
+  58  Hyperdermic[hypodermic] needle suited to the syringe
+  62  absence of conclusive symptons[symptoms] or signs,
+  62  (thourough[thorough][et seq.] study of the case,
+  63  all other methods of diagnosis were thouroughly[thoroughly]
+  63  from a diameter of 10 millimeters in [the] average case
+  66  [Added (END).]
+
+On page 50 of the original publication, the following portion of a
+paragraph has two extraneous lines here marked in brackets:
+
+  All of the cooking was done by the teacher. Careful attention to
+  [is given. Children are weighed once in two weeks. Instruction]
+  [is chiefly practical. Instruction in gardening is given twice a week]
+  general cleanliness and hygiene of the teeth was insisted upon.
+  Individual drinking cups and tooth brushes were provided. The
+  children took turns in washing dishes, setting the table and helping....
+
+The extraneous lines are duplicates of lines further up the page and have
+been deleted.
+
+       *       *       *       *       *
+
+
+
+
+
+End of Project Gutenberg's Nurses' Papers on Tuberculosis :, by Various
+
+*** END OF THIS PROJECT GUTENBERG EBOOK NURSES' PAPERS ON TUBERCULOSIS : ***
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