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diff --git a/old/67640-0.txt b/old/67640-0.txt deleted file mode 100644 index 08ee682..0000000 --- a/old/67640-0.txt +++ /dev/null @@ -1,7296 +0,0 @@ -The Project Gutenberg eBook of The Tuberculosis Nurse, by Ellen N. La -Motte - -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world 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. If you are not located in the United States, you -will have to check the laws of the country where you are located before -using this eBook. - -Title: The Tuberculosis Nurse - Her Function and Her Qualifications; A Handbook for Practical - Workers in the Tuberculosis Campaign - -Author: Ellen N. La Motte - -Contributor: Louis Hamman - -Release Date: March 16, 2022 [eBook #67640] - -Language: English - -Produced by: Richard Tonsing and the Online Distributed Proofreading - Team at https://www.pgdp.net (This file was produced from - images generously made available by The Internet Archive) - -*** START OF THE PROJECT GUTENBERG EBOOK THE TUBERCULOSIS NURSE *** - - - - - - The Tuberculosis Nurse - Her Function and Her Qualifications - A Handbook for Practical Workers in the Tuberculosis Campaign - - - By - - Ellen N. La Motte, R.N. - - Graduate of Johns Hopkins Hospital; Former Nurse-in-Chief of the - Tuberculosis Division, Health Department of Baltimore - - Introduction by - - Louis Hamman, M.D. - - Physician in Charge, Phipps Tuberculosis Dispensary, Johns Hopkins - University - - - G. P. Putnam’s Sons - New York and London - =The Knickerbocker Press= - - 1915 - - - - - COPYRIGHT, 1915 - BY - ELLEN N. LA MOTTE - - _Second Impression_ - - - =The Knickerbocker Press, New York= - - - - - TO - - MARY E. LENT - - MY FRIEND - - - - - INTRODUCTION - - -To tuberculosis, more than to any other infectious disease, the parable -of the seed and the soil is strictly applicable. Without the tubercle -bacillus there can be no tuberculosis, but for tuberculosis to develop, -many factors of great complexity and as yet but little understood must -facilitate the implantation of the bacillus and augment its growth. It -is true that though we may emphasize the rôle of the bacillus, still we -cannot completely ignore those personal factors that contribute to make -the infection fruitful, and likewise though we focus our attention upon -individual resistance, still we cannot keep out of sight the invader -that is being resisted. The two viewpoints meet and run together, but -are sufficiently separate to lead to different methods in our efforts to -eradicate tuberculosis. - -On the one hand are those who direct their efforts toward the -annihilation of the tubercle bacillus. We are sufficiently instructed -about the life history and habits of this organism to lay our plans upon -a firm, scientific basis—a basis so firm and at first sight so simple -and so plausible that over-enthusiasm led to predictions that have been -sadly disappointed. The principles are sound indeed, but in practice -their application has met with insuperable difficulties. These -obstructions have sharpened our wits to find new avenues that now -promise a more ready approach to the goal. To put the matter briefly, -the tuberculosis campaign of the past fifteen years has taught us two -important lessons: first, that the tuberculous cannot be isolated in -their homes; second, that they cannot be cured in or out of sanatoria. I -am shocked myself to read these bald statements, particularly the -second, and still I am convinced that they are true. Some patients can -be isolated in their homes, and many patients recover from tuberculosis -and remain well. Tuberculosis is very amenable to treatment and under -proper conditions the results of treatment are very gratifying. The -difficulty is that the proper conditions are in most instances wanting, -and when they are absent sanatorium recovery is almost invariably -followed, after a brief period, by relapse. The records of cases with -tubercle bacilli in the sputum establish this fact. Concerning the value -of statistics of cases without tubercle bacilli in the sputum I -entertain the gravest doubt. While I am heartily in favour of treating -such patients, the personal equation enters too largely into the -diagnosis to give the results convincing value as evidence of the -lasting benefits of treatment. Experience has taught me that the -educational value of sanatoria has been grossly exaggerated, and that -this value is of small account in a broad plan of prevention. Our -present knowledge, fortified by the costly experience of the past -fifteen years, forces us to believe that the most direct and effective -way of dealing with the tubercle bacillus is to isolate as many advanced -consumptives as is possible. The hospital, perhaps supplemented by -colonies, is the rational method of procedure. Other factors are of -importance; all other factors are, but this is the fundamental and -essential factor in the campaign. - -On the other hand are those who direct their efforts towards cultivating -the soil. Reliable studies inform us that ninety per cent. of the human -race is tuberculosis infected, and that infection occurs at a very early -age, so that at twelve years few children have escaped it. Relatively a -small number of those infected subsequently become tuberculous, so that -something more than infection is necessary for tuberculosis to develop. -What this something is we do not know. Time, manner, frequency, and -intensity of infection play an important part. Apparently too there is a -wide personal variation in susceptibility. To just what this personal -factor is due we are not in a position to say, but certain general facts -known about the distribution of tuberculosis afford us a clue to its -interpretation. Tuberculosis, like most infectious diseases, thrives -under the conditions that poverty induces. Inadequate housing -facilities, insufficient food, filth, and sordid care are a few of -these. If, as all must admit, the tubercle bacillus is more or less -ubiquitous and few escape contact with it, then an important part of our -campaign of prevention will be the raising of personal resistance so -that when infection occurs it may be successfully overcome. Here is the -field for wide social activity. Everything that makes for higher -standards of living and for improved personal hygiene is a valuable arm -against tuberculosis. Housing laws, child-labour laws, the wage -question, municipal recreation centres, the liquor question, social -service in all its departments, vacation lodges, open-air schools, -factory inspection, and so on and so on, are all indirectly valuable -anti-tuberculosis agitation. - -It is not my purpose to discuss the relative merits of the various -phases of the anti-tuberculosis campaign. The death-rate from -tuberculosis is falling steadily and rapidly, and it has fallen most -rapidly in just those centres where the campaign has been vigorously -pushed on a broad basis. Which phase of the work is responsible for the -decrease or deserves the greatest credit, it is impossible to conclude -from a study of available evidence. The same statistics are interpreted -by one, for instance Cornet, as evidence of the efficiency of sputum -prophylaxis; by another, for instance Hoffman, as evidence of the -influence of improved economic conditions; by yet another, for instance -Newsholme, as evidence of the value of hospitals for advanced cases; and -finally by many, for instance Fränkel, as evidence of the undisputed -value of all three factors. Which factor one emphasizes will depend -largely upon one’s training and the field of activity in which one is -engaged. - -Being a physician and by training accustomed to view problems from a -medical standpoint, it is natural that I should emphasize the attacks -upon the bacillus. As I have said, it seems to me to be firmly -established that the most efficient, the most direct, and the cheapest -way to enforce isolation and prevent infection is by hospital -segregation of cases of advanced pulmonary tuberculosis. While early -diagnosis, sanatorium treatment, and education are valuable features of -the campaign, their value will be but slight if this one essential -feature is neglected. Indeed I am inclined to see the chief value of -economic improvement in the indirect influence this improvement -exercises upon the facility for infection. With economic advance the -æsthetic value of general and personal hygiene grows apace, and the -dictates of ordinary cleanliness offer a very strong barrier to -infection. Poverty itself does not produce tuberculosis, but the -conditions that poverty fosters do, and the advantages of better living -reside not so much in an improved personal fitness as in the eradication -of the conditions that facilitate infection. This view is in accord with -what we have learned of other infections. Plague has been notoriously a -scourge to the poor. To improve living conditions lessens plague, and -this general fact was known before we learned that cleanliness produced -results indirectly by eliminating rats. Malaria has always been -particularly prevalent amongst labourers living in unprotected huts. To -improve living conditions reduces malaria, but we gain the result more -surely and directly by an intelligent campaign against mosquitoes. -Unfortunately, we are not sufficiently instructed about tuberculosis to -pick out of the whole mass of ills that poverty entails those few -essential features that control infection. Perhaps some day we will, and -then we shall be able to manage the social campaign more efficiently and -economically. For instance, we are quite at sea to know what -prophylactic use to make of the firmly grounded fact that tuberculosis -infection establishes a strong resistance to reinfection. Upon an -analogous principle rests the conquest of smallpox by vaccination. No -doubt this immunity reaction has an important influence upon the -development of tuberculosis, but as yet we know too little about it to -control it and use it to advantage in our fight with the disease. - -In the anti-tuberculosis campaign the nurse must look to medical science -for the plan and inspiration of her work. Her attitude in the -tuberculosis campaign must always conform to the medical attitude, -although she may and indeed has added valuable material for building up -this attitude. It is because this intimate relation exists that I have -briefly outlined the medical impression of the tuberculosis campaign. It -is quite natural that it should represent at the same time the nurse’s -attitude. My object was to point out the numerous factors concerned in -the anti-tuberculosis crusade, their interrelation, and the quite -natural and necessary specialization that must occur. The field of the -nurse and particularly the municipal nurse is circumscribed, but it is -large enough to engage all her energy and devotion. It is not necessary -nor even desirable that she should diffuse her interest and energy over -the adjoining fields. - -For more than ten years Miss La Motte and I have been engaged in working -at the same problems, from the same broad though different personal -viewpoint. Our work has brought us into almost daily contact. I -acknowledge, with gratitude, the many valuable suggestions that I have -borrowed from her experience, and in reading her book I note with the -greatest satisfaction what I believe to be evidence of influence from -the experience I have gained. It is a pleasure to find that after years -of arduous work we agree at least upon what is the fundamental problem -of the tuberculosis campaign, namely—institutional care of the advanced -cases of pulmonary tuberculosis. I think it is right and proper that -Miss La Motte has made this fact the guiding principle of her book, and -that she has shown the relation of nursing activity to its furtherance, -and that she has held all other phases of tuberculosis work subservient -to it. To avoid misunderstanding it may be necessary to point out that -other features of the anti-tuberculosis campaign have been merely -touched upon or entirely ignored. This apparent slight is not offered, I -am sure, as a reflection upon the value of these features; they are -omitted simply to accentuate more boldly the dominant idea of the -nurse’s work. - -Another noteworthy feature of the book is the purely personal and local -character of the experience presented. It details the problems that have -offered themselves here in Baltimore, how these problems have been met, -and how an effective nursing staff has been built up, first under -private and then under municipal control. What has been accomplished -abroad and in other localities in this country is not considered. In a -way this is a disadvantage, for the book loses somewhat in breadth and -erudition. However, I am convinced that what may be lost in this respect -is more than compensated for by the gain in force and conciseness. After -all, the fundamental problems are the same everywhere, and though local -conditions will necessitate adjustment of details, still I believe the -adjustment will be stimulated and facilitated more by a spirited account -of what has been done under specific conditions than by a colourless -review of the whole field of activity. - -No doubt many will find personal views expressed with which they -disagree. This is unavoidable before such a frank and radical -presentation of the situation. One is impressed by the honesty and -enthusiasm of the book, but some may wish that certain of the -statements, and particularly some strictures, had been a little -mollified. The book will be interesting and helpful and, what is more -important, stimulating to all engaged in tuberculosis work. All the -better if some parts of it cause surprise and opposition,—we will then -review more critically our own attitude. - - LOUIS HAMMAN, M.D., - Physician-in-Charge, Phipps Tuberculosis - Dispensary, Johns Hopkins Hospital. - - - - - PREFACE - - -During eight successive years the writer has been engaged in special -tuberculosis work, first as field nurse of the Visiting Nurse -Association of Baltimore, later as organizer and director of the -Tuberculosis Division of the Baltimore Health Department. Entering the -field in the pioneer days of 1905, she has seen the work pass through -the struggling stages of private enterprise into the well organized, -almost automatic grooves of the city machinery. This continuity of -service has been an experience of unique value. During this period we -have walked into and backed out of many blind alleys or “No -Thoroughfares,” and have acquired wisdom through the loss of infinite -time, effort, and money. Although the material for the following pages -was gathered in Baltimore, and is therefore, strictly speaking, of a -local character, yet since practically all of the conditions indicated -or dealt with are common to all towns and cities, this need not limit -the application of the ideas and principles set forth. - -It is also hoped that though the work of tuberculosis nursing is dealt -with chiefly as done under the auspices of a Visiting Nurse Association, -or as part of the work of a City Health Department, what is here -presented will be of value to nurses working under private associations, -and to private associations themselves. Therefore, in presenting this -book to the public—to nurses, physicians, social workers, -anti-tuberculosis associations, and all those engaged in public health -work—the writer has two objects in view. First, to offer a working model -by which any community can gain some idea as to how to organize and -conduct tuberculosis work; second, to offer conclusions, gained through -practical experience, as to the nurse’s part in the anti-tuberculosis -campaign. - -The object of the anti-tuberculosis campaign is the eradication of -tuberculosis. Our experience has been to prove that the simplest and -most direct method of controlling this disease is through the -segregation—the voluntary segregation—of the distributor, and that to -remove the patient from an environment where he is dangerous to one -where he is harmless is the function of the public health nurse. This is -her chief and foremost duty, and all others are subsidiary to it. - -The writer wishes to express her appreciation and deep indebtedness to -those friends and fellow-workers who have given her guidance and -assistance during these years of service. These are: Mary E. Lent, -Superintendent of the Visiting Nurse Association of Baltimore, and Susan -Edmond Coyle, “lay member” of that Association; Dr. Louis Hamman, -Physician-in-Charge of the Phipps Dispensary, Johns Hopkins Hospital; -Dr. Samuel Wolman, First Assistant to the Phipps Tuberculosis -Dispensary; Dr. Gordon Wilson, Physician-in-Charge of the Maryland -University Dispensary and of the Municipal Tuberculosis Hospital; Dr. -Martin F. Sloan, Superintendent of Eudowood Sanatorium; Dr. Victor F. -Cullen, Superintendent of the Maryland Tuberculosis Sanatorium; and my -Chief, Dr. Nathan R. Gorter, Health Commissioner of Baltimore. - - ELLEN N. LA MOTTE. - - London, 4 June, 1914. - - - - - CONTENTS - - - CHAPTER I - - PAGE - Statement of the Case—Beginning the Work—Reaching the - Patients—Supervision of the Work—Necessity for Experienced - Nurses 1 - - - CHAPTER II - - The Nurse’s Training—Health—Hours Off Duty—Afternoons - Off—Character 11 - - - CHAPTER III - - Salary—Increase of Salary—Carfare—Transportation—Telephone—Vacation— - Sick Leave—Uniforms—Badges 20 - - - CHAPTER IV - - Object of Work—Districts—Hours on Duty—Number of Daily Visits—The - Nurse’s Office—Lunch and the Noon Hour—Bags—Prophylactic - Supplies—Cups, Fillers, and Napkins—Disinfectant—Waterproof - Pockets—Books of Instruction—Stocking the Bag and Distributing - Supplies—Nursing Supplies 33 - - - CHAPTER V - - Records and Reports—The Patient’s Chart—The Card Index—Nurse’s - Daily Report Sheet—Weekly and Monthly Reports—Examination of - Charts—Taking the Patient’s History 48 - - - CHAPTER VI - - Finding Patients and Building up the Visiting List—Increasing the - Visiting List—Social Workers—Dispensaries—Patients’ Families and - Friends—Nurses’ Cases—Physicians 61 - - - CHAPTER VII - - The General Practitioner and the Public Health—Responsibility of - the Private Practitioner in Tuberculosis—Impossibility of - Fulfilling this Obligation—Failure because of the Nature of - Tuberculosis—Failure because of the Personal Equation 74 - - - CHAPTER VIII - - The Nurse in Relation to the Physician—Municipal Control of - Infectious Diseases—The Nurse’s Difficulties—A Waiting - Game—Undiagnosed Cases—The Nurse’s Responsibility to the Ethical - Practitioner Only 87 - - - CHAPTER IX - - Obtaining a Diagnosis—The General Dispensary—Sputum - Examinations—Tuberculin Tests—Registration of Cases 105 - - - CHAPTER X - - Prevention of Tuberculosis—Sources through which Calls are - Received—Entering the Home—Telling the Truth to the - Patient—Truth for the Family—Disposal of Sputum—Danger of - Expired Air—Isolation of Dishes—Linen, Household and - Personal—Disinfectant and Other Supplies—Phthisiphobia 117 - - - CHAPTER XI - - Inspection of the House—The Patient’s Bedroom—Porches—Gardens and - Tents—Flat Roofs—Clothing and Bedclothing—Artificial - Heat—Rest—Fresh Air—Food—Cooking—The Bedridden Patient 136 - - - CHAPTER XII - - Care of the Family—Examination of the Family—Taking Patients to - Dispensaries—Children—Tuberculosis in Children—Open-Air - Schools—The Danger of Sending Patients to the Country 154 - - - CHAPTER XIII - - Disinfection of Houses—Value of - Fumigation—Formaldehyde—Housecleaning—Burning and - Sterilizing—Boiling—Carpets, Rugs, and Mattings—Painting, - Papering, and Whitewashing—Temporary Removals—Vacant - Houses—Concessions—Compulsory Cleaning 169 - - - CHAPTER XIV - - The Tuberculosis - Dispensary—Equipment—Medicines—Hours—Consideration for - Patients—Function of the Dispensary—The Physician’s Service—The - Physician’s Qualifications—The Physician and the Patient—Duties - of the Nurse—Tuberculin Classes—The Nurse in Home and - Dispensary—The Nurse as a Community Asset 184 - - - CHAPTER XV - - The Nurse in Relation to the Institution—Reports Made to the - Institution—Procuring Patients for it—The Value of the - Sanatorium—Sanatorium Outfit—Return from the Sanatorium—Work for - the Arrested Case—Light Work—Outdoor Work 203 - - - CHAPTER XVI - - Hospitals for Advanced Cases—The Careful Consumptive—Chief Duty of - the Nurse—Responsibility of the Institution—Home Care of the - Advanced Case—Exceptions to Institutional Care—Compulsory - Segregation 218 - - - CHAPTER XVII - - The Problem of Relief-Giving—The Relief-Giver—Co-operation between - Agent and Nurse—General Rules for Nurses and Agents—Conditions - of Asking for Relief—Wrong Conditions of - Relief-Giving—Incidental Assistance—Withdrawal of Relief—Milk - and Eggs 230 - - - CHAPTER XVIII - - Home Occupations of Consumptives—Sewing and Sweatshop - Work—Food—Milk and Cream—Lunch Rooms and Eating-Houses—Laundry - Work—Boarding and Lodging-Houses—Miscellaneous Occupations—The - Consumptive Outside the Home—Cooks—Personal Contact in the - Factory—Supervision Outside the Home 252 - - - CHAPTER XIX - - Municipal Control of Tuberculosis—The Danger of “Political” - Control—“Politics” in Co-operating Divisions of the Health - Department—Results in Baltimore—Tuberculosis and Poverty 273 - - - - - The Tuberculosis Nurse - - - - - CHAPTER I - - Statement of the Case—Beginning the Work—Reaching the - Patients—Supervision of the Work—Necessity for Experienced Nurses. - - -=Statement of the Case.= Pulmonary tuberculosis is a communicable -disease, transmitted from person to person by means of the tubercle -bacilli contained in the sputum of infected patients, or in the breath -expired during paroxysms of coughing. The bacilli thus liberated, find -their way into the system of another individual, either through the -respiratory or alimentary tract, or both. The enormous prevalence of -tuberculosis is due to the fact that its infectious nature was not -recognized until 1882 when Koch discovered the bacilli. Since that time -it has been classed as a transmissible disease, and during the past ten -years a vigorous effort has been made to eradicate it. This agitation is -popularly known as the anti-tuberculosis campaign, and associations for -the suppression of tuberculosis have sprung up in all parts of the -country. So far, no serum or vaccine has been found by which this -disease may be controlled, as was the case when smallpox and diphtheria -were checked. The sole way of overcoming it is to overcome the ignorance -concerning its nature, its transmissibility, and the means by which it -is spread. - -At the beginning of the campaign it was believed that simple education -along these lines was all that was needed to obtain results. These -results were expected to follow as soon as the patient was informed of -the nature of his disease, and how to avoid spreading it, and as soon as -those in contact with him were given like information and taught how to -avoid infection. Ten years ago, in the optimism of the moment, -tuberculosis was freely proclaimed a “curable” disease; so that together -with the campaign of prevention went a campaign of teaching the patient -how to become a “cured,” or as we now call it, an arrested, case. The -mechanics of cure were equally simple—rest, fresh air, and food were all -that was needed, provided the disease was taken in the early stages. And -all that was necessary for “cure,” just as all that was necessary for -prevention, was to tell the patient what to do, and those about him what -to do, and the thing was done. This is the theory upon which the work -was founded, and in theory this is still a sound principle upon which to -continue it. Unfortunately, a series of unlooked for conditions -interposed themselves between this theory and our ability to put it into -practice. At the time when the crusade was begun these conditions were -not recognized, and it is only through long study of the situation, from -its social, economic, and legal as well as clinical aspects that we get -some idea of the difficulties and complexities of the task before us. - -In the first place, tuberculosis is largely a disease of the poor—of -those on or below the poverty line. We must further realize that there -are two sorts of poor people—not only those financially handicapped and -so unable to control their environment, but those who are mentally and -morally poor, and lack intelligence, will power, and self-control. The -poor, from whatever cause, form a class whose environment is difficult -to alter. And we must further realize that these patients are surrounded -in their homes by people of their own kind—their families and -friends—who are also poor. It is this fact which makes the task so -difficult, and makes the prevention and cure of a preventable and -curable disease a matter of the utmost complexity. - -People of this sort, however, constitute almost the entire -problem—otherwise the situation would be so simple that the word problem -would not apply. - -This is why “cure” is not the solution of the matter. Too few people are -cured, in comparison to the numbers annually infected, to make any -impression on a disease of such wide prevalence. The sanatorium, -valuable as it may be for certain cases, is of little use to those who -relapse upon return to an environment they will not or cannot control. -This is also why mere instruction in preventive measures, unaccompanied -by effective isolation, is barren of results. - -Experience has taught us the unsatisfactory nature of so-called cures, -and the futility of that prevention which allows the distributor of -tuberculosis to remain at large in the community and heedless of his -obligations. Hence we must look to segregation as the only reasonable -course to pursue. If segregation can be obtained in the home, well and -good. If not, then we must look to the institution to provide the proper -care. This segregation, most of it voluntary, some of it enforced, is -the only way to do preventive work on a scale large enough to count. To -this end, we need dispensaries where the disease may be recognized and -diagnosed, nurses to visit the patients in their homes, and hospitals -for advanced cases, the function of the nurse being to teach patients -and their families the necessity for segregating the former in -hospitals. - -=Beginning the Work.= Let us suppose that a certain community, town or -country, suddenly becomes aware of tuberculosis in its midst, and in -consequence wishes to get rid of it. It is but a fraction of the -community which is enlightened enough for this, but from this nucleus -must come all that awakening of public sentiment needed to facilitate -the campaign. To estimate the number of tuberculous persons in any -locality, multiply the yearly tuberculosis death-rate by five or -ten—authorities differ as to the exact figures. The result will be the -approximate number of those afflicted. The public press will help in -disseminating this information, which is the basis from which we must -work. Since the beginning of the campaign, newspapers have been -wonderfully helpful allies in giving wide publicity to facts concerning -tuberculosis. As a result of this newly aroused interest, an -Anti-Tuberculosis Society may be created, and into its fold are gathered -all those willing to help in the work, each with his dollar. Lectures, -exhibits, open-air speaking, lantern-slide exhibitions, meetings in -churches and others held before various societies are given in various -parts of the town, and in this way information about tuberculosis is -spread far and wide. - -There are two classes of the community, however, that must be -reached—those who have tuberculosis and those who have not. The people -who go to lectures and exhibits belong chiefly to the latter class. -Frequently, of course, the sick ones find their way in, in an endeavour -to learn something which may be helpful to them; unfortunately, they are -able to take away but little, and the little they do get they often -misapply. We recall the case of a man who went to a tuberculosis -exhibit, and learned that fresh air was good. As a result, he walked -several miles a day in order to get it, and nearly killed himself. He -had succeeded in learning one important fact—that fresh air was -valuable—but another, of equal importance, that exercise was harmful, -had escaped him. - -To make the undertaking succeed, it is necessary to reach both the sick -and the well, since that strong, intelligent public opinion, which is -the motive force behind all new movements, must be aroused among the -sick as well as among the healthy. But as we have seen, the former are -not those who go largely to lectures, so they must be reached through -some other means. The most effective way of reaching them is through the -employment of a special nurse, who shall give eight hours a day, week in -and week out, to visiting in the homes where tuberculosis exists, and -giving instruction adapted to each individual case. By this means the -people most in need of assistance are reached without loss of time and -effort, and case after case is uncovered. This is shooting straight for -the bull’s-eye—namely, the infected home from which tuberculosis is -spread. - -There may be laws on the statute books compelling doctors to notify the -local health authorities of their tuberculosis cases, but these laws are -not lived up to. Nor will the establishment of a hospital for advanced -cases bring these patients to light; neither will the sanatorium, nor -even the special tuberculosis dispensary. The surest and most effective -way of unearthing them is through the visiting nurse. Therefore the -nebulous plans of the newly formed anti-tuberculosis association may -well crystallize themselves into a decision to put such an effective -agent into the field. - -=Supervision of Work.= After this decision has been made, the question -arises, by whom is the nurse to be directed? Is she to be placed under -the local health department, under a dispensary, under the charity -organization society, or under the visiting nurse association, if such -an organization exists in the town? If supported by a church or special -association of some sort, should not the governing board of such -organization direct her work? Or is she to be a free lance and manage -herself? - -Unless taken over by the local health department (which in that case -becomes responsible for her salary and expenses incurred in the work), -the nurse should be affiliated with the Visiting Nurse Association, -rather than with any lay organization. Better results will be obtained -if her work is directed by a superintendent of nurses who is accustomed -to dealing with and judging nurses, and familiar with their duties along -technical lines. The credit of supporting the nurse would still rest -where it belonged—with the church, with the anti-tuberculosis -association, or whatever group of people might be responsible for her -maintenance,[1] but this arrangement would relieve the lay organization -of much responsibility, for no matter how good their intentions, such a -group cannot direct nursing work as well as this can be done by one -qualified for the purpose. Another advantage gained by placing the new -nurse with the Visiting Nurse Association is that it keeps together the -various branches of public health service, and the tuberculosis nurse -realizes more fully than she otherwise might, how completely her own -specialty is interlocked with and dependent upon other forms of social -activity. - -Footnote 1: - - For five years the Maryland Tuberculosis Association supported five - nurses, which it placed under the management of the Superintendent of - the Visiting Nurse Association of Baltimore. - -There is still another advantage in placing the new nurse with the -established organization, for then a nurse may be selected with regard -to her ability alone, leaving it to the Superintendent of Nurses to give -her the necessary careful training in social work, and the proper -supervision. - -If there is no Visiting Nurse Association in the community, under whose -auspices the new special nurse may be placed, the lay organization will -have to do the best it can. In this event, it will be absolutely -necessary to select a nurse thoroughly trained in social work, and since -the number of women with this equipment falls far short of the demand, a -delay of some duration may take place. This delay is always borne with -great impatience by the newly formed group of people, anxious in their -enthusiasm to attack the tuberculosis problem at once. Yet policy would -counsel postponing the undertaking until a suitable person can be found, -for it is usually a fatal mistake to begin new work with an -inexperienced worker. Moreover, a situation which has existed for years -may be tolerated a few months longer without undue alarm as to -consequences. - -If it is impossible to obtain a nurse fully trained in public health -work, the community may select a good nurse and send her for a few -months’ experience to some well recognized centre of public health work, -such as New York, Chicago, Boston, Baltimore, etc. The money thus spent -will prove a valuable investment to a community thus far-seeing, and an -ample return will be manifest in the efficiency of the nurse’s work. - -A wrong start in choosing a nurse has driven many an enthusiastic -organization into deep waters, and caused trouble and misunderstanding -of a most grievous sort. In several instances, the local campaign -against tuberculosis has come to a disappointed end; in others, public -interest has been so antagonized and repelled that the movement received -a check from which it did not recover for several years. - - - - - CHAPTER II - - The Nurse’s Training—Health—Hours off Duty—Afternoons off—Character. - - -=Training.= One of the first qualifications of the nurse should be -proper training. She should be a graduate of a first-class general -hospital, which gives a three-years’ course. In States where -registration is established, she should be a registered nurse as well. -This means that she has passed the examinations set by the State Board -of Examiners for Nurses, and has attained at least the minimum degree of -efficiency prescribed by that body. Of course, it is well if she far -exceeds this minimum, but she must not fall below it in any case. - -It is sometimes said that a woman trained in a sanatorium or special -tuberculosis hospital will make as good a tuberculosis nurse as one who -has been trained in all branches of nursing work. This claim is often -made by those sanatoriums which seek to find positions for their -ex-patients, to whom they have given a more or less sketchy training and -a diploma. Needless to say, if a community undertakes to support a -nurse, it should procure the best that can be found. There is no economy -in employing a half-trained woman. In social work the nurse occupies a -unique position in the patient’s household—she must be able not only to -gain but to retain the family’s confidence, and this cannot be done by a -half-educated woman, not sure of herself and unable to carry conviction -to her hearers. - -=Health.= Next to thorough training, the health of the nurse is of -utmost importance. All nurses should be examined before they undertake -tuberculosis work. This should be done for two reasons: first, for the -obvious reason of protecting the nurse herself; secondly, for the -protection of the work. There is already sufficient prejudice against -tuberculosis work, and it is well not to increase it by having a nurse -break down soon after going on duty. In Baltimore, all applicants are -examined by a specialist before they are accepted. Note that this is -done by a specialist, and that the applicant is not permitted to go to -her own “family physician” who may or may not be able to make a proper -examination. The candidate is given a choice of several specialists, to -any one of whom she may go. The report of her physical condition, mailed -to the superintendent, determines her eligibility from the standpoint of -health. In this way, the responsibility is assumed by those most capable -of assuming it, and neither the health of the nurse nor the prestige of -the work is jeopardized. - -After the preliminary examination, it is well for the nurse on duty to -be re-examined every six months. If suspicious symptoms present -themselves, this should be done oftener. Part of the superintendent’s -duties are to watch the health of her workers, and keep a sharp look-out -for suspicious symptoms—symptoms which the nurse herself may be unaware -of or afraid to acknowledge. Each nurse, however, should assume the -responsibility for her own health; she should remember that she is -dealing with a highly infectious disease, and that it behooves her to -keep in as good physical condition as possible. Nurses with a -predisposition to tuberculosis should not undertake this work. - -The question often arises as to whether this visiting work is suitable -employment for arrested cases—for nurses who have had tuberculosis and -recovered. It is not suitable. It is far too hard and trying, for it -must be done day in and day out, at all seasons and in all weathers, and -involves severe physical strain. For that reason it is not proper -occupation for one whose health is in any way precarious. The danger of -relapse is too great. Nor should this work be done by those who are -afraid of tuberculosis. If fear of tuberculosis develops after a nurse -goes on duty, she should be released at once. Under such circumstances -she cannot do good work, while to persuade her to remain on duty, -contrary to her instincts, is a responsibility too grave for any one to -assume. - -=Hours off Duty.= At this point we should like to speak of the nurse’s -hours off duty, though strictly speaking they are not within our scope. -As a rule, the hours on duty are eight—from 9 a.m. till 5 p.m., with an -hour in the middle of the day for lunch. This is a long day, and at the -end of it, any woman is in a condition of mental and physical fatigue. -The constant nervous strain occasioned by contending with the ignorance -and stubbornness which a nurse must encounter, is particularly wearing. - -The hours off duty are for recuperation from the day’s toil, and if this -recuperation is insufficient, it will manifest itself in various ways. A -tired nurse is of no use as a teacher—she cannot cope successfully with -the obstinate wills of her patients, nor with the trying demands of the -daily routine. Moreover, a physically tired person is one who offers -ready soil for the development of tuberculosis. These two facts must be -constantly borne in mind. Therefore we should like to impress upon all -nurses who undertake this work that they must take excellent care of -themselves. Rest, sleep, and food are the three essentials to good -health, and any scheme of life which reduces these below a certain level -is bound to lead to disaster. - -No one condemns reasonable pleasures, and in no other work is relaxation -and recreation so much required, but one must be careful not to burn the -candle at both ends. It is no part of the superintendent’s duties to -regulate the life of her nurses outside of working hours, but when their -life off duty diminishes their working ability, she is then called upon -to interfere. Tuberculosis work is trying, serious, and difficult, and -demands a high degree of mental and physical strength and freshness. If -a nurse is not willing to give this, she should not undertake public -health work. - -=Afternoons Off.= Each nurse should be given one afternoon a week off -duty. It is more satisfactory to give this half-day in the middle of the -week, on Wednesday or Thursday, rather than on Saturday, at the week’s -end. In this way, the rest period breaks the long stretch of days, and -the nurse is enabled to rest before she becomes too tired. Sundays, of -course, should always be free. Under no consideration should the nurse -be subject to night calls and it is well to have this fact understood at -the outset of the work. A nurse cannot be on duty night and day both, -and certain rules should be established, regarding her hours on duty, -and be rigidly adhered to. - -=Character.= The questions of training and of health having been -satisfactorily answered, there remains a third great essential to be -considered—the question of personality. Social nursing differs from all -other branches of nursing, since in this specialty there is a wider -departure from the routine and mechanical duties which form so large a -part of nursing work. Those qualities which make a good institutional, -or a good private nurse, do not necessarily make a good social or public -health nurse. Something more is demanded. - -Broadly speaking, apart from professional training, the more highly -educated and cultivated the woman, the better will she be qualified. -This, one may say, would apply to all branches of the profession, but we -believe these qualities are more necessary in the tuberculosis nurse -than in the operating-room nurse, for example. The latter does work -which demands mechanical quickness and coolness; the former requires a -personality capable of dealing with human beings in all stages of -refractoriness, over whom she has no authority, but from whom she is -expected to obtain results. As every one knows, it is far easier to deal -with things than with people. - -The qualities of a teacher are requisite. No matter how well one may -know a subject, if one cannot present it clearly and impressively, small -progress will be made. Nor is it the patient alone that the nurse is -called upon to deal with. Her activities bring her into close relations -with physicians, social workers, politicians, boards of directors, and -“benevolent individuals” of all classes, whose interest and good-will it -is necessary to secure. She must be as well able to meet people of this -sort, as to teach the humblest patient in her district. - -Since this is social work, the so-called social virtues are a -necessity—and these exclude a bad temper or a quarrelsome disposition. -It is as essential to work in harmony with other social workers as with -the patients themselves—the two relationships are interdependent. - -Needless to say, a nurse who cannot get on with her patients is a -failure. No matter how experienced she may be, or how well trained, if -she cannot gain the confidence and friendship of her families she is -unfitted to deal with them. It frequently happens that for the first few -visits a family may be uncordial and suspicious, but within a short time -a well trained, sympathetic nurse should be able to change this attitude -into one of confidence and appreciation. A few, a very few families -remain unchangeable of course, but their number is so small that they -form a negligible quantity. - -Neither should a nurse fraternize with her patients. Through familiarity -she loses the personal dignity which means so much to her authority. -Authority is a term somewhat subtle in its definition—it means that hint -of power, of sureness, of knowledge, which enables one to speak with a -confidence which transmits itself to others, and compels them to accept -one’s point of view. A strong personality easily conveys this sense of -authority, but it may also be conveyed by a personality less strong, -when the nurse is well assured of her facts and cannot be caught -tripping. It is the hall-mark of the successful teacher—this ability to -impress her points upon others, and to make them see that what she -proposes is right, reasonable, and advantageous. - -It seems hardly necessary to speak of the qualities of honesty, loyalty, -and conscientiousness. When they are lacking, all or any one of them, -the nurse is useless. The nurse is alone in her district all day long, -from early morning till late in the afternoon, and she must be a woman -with a high sense of responsibility and worthy of her trust. Patience, -that despised virtue, is also an essential part of the nurse’s -equipment, for she must listen to long details of illness, and must be -willing to reiterate, over and over again, without show of annoyance, -the rules which have been needlessly and exasperatingly ignored. No one -knows better than the nurse the awful hiatus that exists between -preaching and practising—the glib promise and the broken pledge—but she -must never show her irritation. We have known many excellent nurses who -gave up this work because they could not stand discouragement of this -sort, and who had not vision enough to look into the future for results. - -This standard of requirements may seem high, but it is not impossible. -In fact, it is the minimum from which successful work can be expected. A -superintendent who has a choice of nurses will of course approximate it -as nearly as possible, in choosing her staff. The higher and finer the -type of woman, the more valuable she will be—probably in no other field -do fine instincts and fine feeling tell so strongly. - - - - - CHAPTER III - - Salary—Increase of Salary—Carfare—Transportation—Telephone—Vacation— - Sick-Leave—Uniforms—Badges. - - -=Salary.= A good nurse should command a good salary—she is worth it. -There is a tendency to underpay nurses even at the present day, because -of the tradition handed down from the Middle Ages, that nursing service -should be given largely as a matter of love or charity. A woman who -gives up her whole time to district nursing, doing highly specialized -work, should at the very least receive a living wage. Associations are -often asked to supply nurses at a salary of forty or fifty dollars a -month, and surprise and indignation have been expressed because such a -woman was not forthcoming. Salaries should be large enough to attract -and retain efficient women; a small salary does not attract desirable -applicants, as a rule, and this limits the field of selection. Large -sums are appropriated for hospitals, sanatoriums, dispensaries, and -physicians’ services, but retrenchment takes place when it comes to the -nurse. Her work seems to be the one point where economy prevails. - -In Baltimore, the staff nurses are paid seventy-five dollars a month, -and this is the very least that any woman should receive. A small town -or country community would doubtless have to pay more than this, -especially if it looks to the city for an experienced nurse. The reason -is simple enough—other things being equal and the character of work the -same, one would hardly expect a nurse to prefer an unknown locality, -away from home and friends, unless some extra inducement were offered. A -nurse might be willing to organize work in a small city, at a low -salary, for the sake of the experience. In that case, it is the -experience which offers the inducement. This once gained, however, she -would shortly be in a position to demand more salary or seek a wider -field of service. - -=Increase of Salary.= The question constantly arises whether or not it -is well to increase the salary of the staff nurse from year to year. If -she enters the work at seventy-five dollars a month for the first year, -is it well to increase this to eighty dollars a month for the second -year, eighty-five dollars the third, and so on till a definite maximum -has been reached? To this question there are two answers. - -Undoubtedly a nurse becomes more valuable as her experience ripens. Her -first six months on duty are largely spent merely in acquiring -rudimentary knowledge concerning her work. As she learns to know her -district, her patients, the doctors, the institutions, the social -workers, her value to the community increases. Each succeeding year, -therefore, which increases her knowledge of social conditions, should -make her in so far more valuable. It would seem but just, under these -conditions, that her remuneration should be raised accordingly. But at -this point there enters a factor which we must recognize. To specialize -in tuberculosis work makes peculiar demands upon one’s strength. Quite -apart from the physical strain, which is always great, it demands the -expenditure of a vast amount of nervous force, required in the constant -combat with opposition. For this reason it is peculiarly wearing and -exhausting. Also, by its nature, it tends to become monotonous. These -two factors—one of which tends to wear out the individual, the other to -make her indifferent and stale—make us hesitate to say that the nurse’s -value keeps increasing year after year. It undoubtedly does increase up -to a certain point, but after that point has been reached, it tends to -diminish. Such being the case, the obligation of raising the salary is -debatable. - -Two kinds of nurses are usually found on the staff. One is the ambitious -nurse, who comes for the experience and training, to fit herself for an -executive position elsewhere. To such a woman, the routine of field work -will not be desirable for long—not for more than a year or two, or until -she has gained enough experience to prepare herself for a wider field of -service. That point being reached, her executive ability will seek an -outlet in work where she herself may become the organizing and directing -force. To such a nurse, salary increase will offer no inducement, since -she will seek that increase through work which provides greater -opportunities and responsibilities. - -There is another sort of nurse on the staff however, who has no such -ambition; no executive ability, no desire to occupy any other than a -subordinate position. This one will never venture into a position of -responsibility, such as her experience might warrant, but prefers -instead the easier path, choosing to be guided rather than to guide. She -prefers to work under direction, rather than to direct others. To such, -an increase in salary would seem but a just reward for faithful service. -But, as we have said before, the monotony of tuberculosis work tends to -produce stale workers. There is danger, after a time, that the first -alertness and energy may wear off, the nurse may settle down into a rut, -and her daily task, though faithfully performed, tends to become one of -mechanical routine. - -One of the chief duties of the superintendent is to train new nurses, -and she should renew the personnel of her staff whenever the welfare of -the work demands a change. Sometimes, when a nurse shows flagging energy -and interest, sufficient stimulus may be given by removing her to -another district, where she will encounter new patients and new -problems, and so regain her old keenness and ability. When one once -becomes thoroughly tired of this work, however, it is unwise and futile -to attempt to continue it. Therefore, in the interest both of the nurse -and of her work, it does not seem wise to offer inducements for -prolonged service, unless the individual characteristics of any given -nurse make this wholly desirable. - -=Carfare.= In addition to salary, a reasonable sum of money should be -allowed for carfare. This allowance should vary in accordance with the -territory to be covered, those nurses who visit in smaller areas -naturally having a smaller allowance for the purpose. While economy in -this matter is always necessary, it must be remembered that undue -economy in carfare is wasteful of something still more important,—the -nurse’s time and strength. If she is obliged to walk long distances -between cases, this will greatly reduce the number of visits she can -make in a day. Moreover, she will spend so much energy in mere walking -that she will become too tired for effective teaching. Only fresh, -energetic people can teach; those who are physically tired are apt -unconsciously to let the obstinate patient have his own way. - -=Transportation.= In small towns and country districts the problem of -transportation is often a difficult one. There are either no street -cars, or their service is very restricted and inadequate. Under such -circumstances it will be necessary to provide the nurse with a horse and -runabout, especially if she is expected to cover a large territory. -Unless there is proper provision for transportation, it will be -impossible for her to visit the patients often enough to make any -impression,—her teaching will be laid on too thin to have much value. -And to depend upon haphazard, volunteer offers of transportation is -almost as bad as to expect her to make her rounds on foot. She should be -given proper facilities for going from case to case, and should be able -to plan a day’s work unhampered by any considerations as to if or how -she can reach her patients. - -=Telephone.= In making up the budget of necessary expenses, a reasonable -sum should be set aside for telephone calls. The nurse has constant -occasion to communicate with doctors, institutions, social workers, and -so forth, and this item of expense should not come out of her own -pocket. A careful weekly account of all expenditures, including -telephone calls and carfare should be rendered by her. - -=Vacation.= A vacation of at least one month should be given during the -year. Less than a month is not sufficient time in which to recover the -physical and nervous energy expended during the rest of the year. This -holiday should be taken all at one time, rather than split up into -shorter vacations, taken at intervals throughout the year. We all know -that a week or two is not sufficient time in which to restore a -thoroughly tired person; at the end of such a short period, one is just -beginning to feel rested, and there has been no margin left over for -amusement, which is a necessary part of all holidays. - -Strong emphasis must be laid on the fact that if a nurse expects to -return to her work and continue it successfully for another year, she -should use this vacation as a means of fitting herself for another -year’s close contact with an infectious disease. She should return to -work thoroughly rested, with her resistance increased by rest and -recreation, not lowered by injudicious use of this time off duty. - -=Sick-Leave.= While a nurse is supposed to be sufficiently well and -strong to go on duty every day, in all weathers and at all seasons of -the year, a reasonable allowance for illness should nevertheless be -made. Two weeks’ annual sick-leave is a good allowance. If a woman is -off duty for longer time than that, needless to say her work must suffer -and her patients must be neglected. If a nurse is constantly off duty -for small ailments, this shows that she is not strong enough to -undertake this arduous work. A fixed allowance for sick-leave, -therefore, will tend to work automatically, and will eliminate the -unfit, whose burden of work is otherwise added to that of the steady -working members of the staff. - -In the case of acute illness, such as typhoid fever or appendicitis, it -would be perfectly possible to appoint a substitute until the nurse was -able to resume her duties. If no time has been taken off for sick-leave -during the year, the two weeks should be added to the time granted for -vacation. If exceeded during the year, the salary for every day thus -lost should be deducted from the monthly salary. This procedure may seem -harsh, but with a large staff it is necessary. It places a double -incentive on keeping well, and nurses who would otherwise have been -thoughtless and careless as to their health, will take excellent care of -themselves, in order not to lose one day of their coveted vacation. - -In Baltimore, the municipality gives two weeks’ vacation, and two weeks’ -sick-leave. If the sick-leave is unused, a reasonable vacation is the -result. - -=Uniforms.= The question as to whether or not a nurse shall wear a -uniform is one which usually excites much discussion. The one or two -disadvantages of such a dress are more than offset by the numerous -reasons in its favour. Two objections are usually raised to wearing it: -by the nurse, because it makes her conspicuous; and by the patient, -because the uniform makes him a target for neighbourly gossip. - -Let us consider the first objection, that made by the nurse. A nurse -does not feel conspicuous when on duty in her district. Her busy, daily -routine, taking her in and out of homes where she is needed, soon causes -her to forget her personal appearance. A self-conscious woman is hardly -the right sort for this work. The only rub comes when she is off duty -and going to and from her district, but this cannot be held to -constitute a serious objection. - -As for the patient’s objection—he would be equally conspicuous if -regularly visited by any woman unknown to the neighbourhood, no matter -how attired. Prying eyes would recognize her as an alien, and the -neighbours would speculate accordingly. We have often heard of patients -who for fear of what the neighbours would say objected to being visited -by agents of the Charity Organization Society. Yet the agents of that -Organization wear no sort of uniform. The truth is, it is usually really -the visit itself which is objected to, rather than the costume of the -visitor—the costume merely serving as an excuse. On analysing the -objections of a group of patients who disliked the uniform, they were -found to be, without exception, patients who strongly resented every -suggestion made to them. Their one desire was to be let alone, to be as -careless as they chose. - -On the other hand, the advantages of the uniform are many. In the first -place, all effective care given to a consumptive has to include nursing -as well as teaching. Now, one can “educate” in a woollen dress, but one -certainly cannot give bed-baths in anything but a cotton dress, which -can be plunged into a tub and washed. And whether she enters the home to -give a bed-bath, or whether she goes in merely to distribute -prophylactic supplies, the fact remains that a nurse spends some eight -hours a day in contact with an infectious disease. Good technique -demands that she be dressed in washable material. - -In summer, a dress of washable material is not conspicuous. In winter, -it may be covered with a long coat. And if we admit that such a dress is -necessary, what objection can there be to making it of simple and -uniform design? A single nurse so arrayed looks neat and business-like; -a staff of nurses looks equally so. Moreover, uniformity of dress -suggests uniformity of method, standard, and character of work, and -hence inspires confidence. A staff of nurses, each one dressed according -to the hazard of her own fancy, would hardly create the same impression. - -In itself, the uniform is a protection to its wearer. It enables her to -go freely and without molestation into all kinds of tenements and -lodging houses, into side alleys and back streets. The well-known dress -surrounds her with recognition, affection, and respect. - -The uniform is also of value to the patients and to their friends. It -enables them to recognize the nurse as she passes, and to call upon her -as she goes by. - -The uniform worn in Baltimore consists of a plain shirtwaist suit, worn -with white linen collar and black necktie. The dress is made of blue -denim, such as is used for overalls. Denim of this sort has two sides, a -light and a dark; the dress is made up with the light side out, as in -washing it seems to “do up” better than the darker side. Black sailor -hats are worn, and in winter long, dark coats protect the dresses. This -uniform is not necessarily the last word as to what a uniform should be, -but it is simple and inexpensive, and the nurses look well in it. - -=Badges.= The staff of a municipal nursing force is usually provided -with badges to denote that they are connected with the Health -Department. These badges should never be worn conspicuously, although -they should be readily accessible. They are only occasionally needed, -however, as when entering some lodging or rooming houses, or houses of -prostitution, or other places where there may be marked opposition. To -show them when entering a private home would be bad policy. A nurse -usually enters a private house as a friend, but a public house she is -sometimes obliged to enter in her official capacity. In dealing with all -her patients, however, no matter where they are situated, the less show -made of officialdom the better. By the time her patient finds out that -she is connected with the Health Department, she should be already -firmly established as his friend, and then the discovery will have no -terrors. Indeed, at that stage, it very often enhances her value, and -patients often feel intense pride at being visited by the “city nurse.” - - - - - CHAPTER IV - - Object of Work—Districts—Hours on Duty—Number of Daily Visits—The - Nurse’s Office—Lunch and the Noon Hour—Bags—Prophylactic - Supplies—Cups, Fillers, and Napkins—Disinfectant—Waterproof - Pockets—Books of Instruction—Stocking the Bag and Distributing - Supplies—Nursing Supplies. - - -=Object of Work.= The object of tuberculosis nursing is the home -supervision of all persons suffering from pulmonary tuberculosis. This -supervision should include patients in all stages of the disease, and -not be limited to those who are in some particular stage, such as early, -in contradistinction to advanced, cases. No organization which expects -to do effective work should deal with one class of patients alone, since -the boundary lines between the different stages are constantly shifting; -the ambulatory case of to-day may be the bed-ridden case of to-morrow, -and _vice versa_, and any attempt to limit the nurse to one class or the -other would mean neglect of both. Unless the work is planned on such -inclusive lines, it will be necessary to place a second organization in -the field, to care for those cases which have been thrown out by the -first. Policy of this sort would mean a number of similar organizations, -duplicating and overlapping each other’s work at every turn. Thus, in -the same household, we should see the early, ambulatory patient -“advised” by the nurse of one organization, while the advanced, -bed-ridden, more infectious case is being bathed and cared for by the -nurse from another. Invidious comparisons would doubtless be made by the -family, with the decision in favour of “deeds, not words.” True, there -would be co-operation between these two societies,—which would mean, as -a rule, double work, duplication of visits, endless transferring of -cases backwards and forwards, and opening and closing of records. From -whatever point of view we consider it, this is a very poor plan of work, -and a wasteful method. The nurse should be in a position to follow the -fortunes of her patients for months and years. Any scheme which involves -transferring him to a stranger, from an old friend to a new, at the -moment when he slips from an early into a most infectious stage, is to -lose sight of him and of his family at a most critical time. - -Adequate supervision means that the nurse must teach, nurse, and ferret -out patients, and her patients must include advanced, early, and -suspicious cases. The care should be of two kinds—instruction as to the -nature of tuberculosis, with general teaching along the lines of -prevention and prophylaxis; as well as actual nursing service, rendered -to advanced and bed-ridden cases. The Baltimore nurses take charge of -all tuberculous patients, in whatever stage, and we feel that this is -the most effective way to carry on the work. - -=Districts.= A small town, of course, constitutes but one district in -itself. A larger town may be divided into two or three districts; a -city, into as many as may be necessary. The principles upon which the -work is conducted are the same in each case. The nurse is responsible -for every consumptive in her district, and her constant endeavour should -be to bring under supervision every case of tuberculosis that exists. -She must visit all patients referred to her—give them instruction, -prophylactic supplies, and nursing care; unearth suspicious cases and -send them to a physician for diagnosis; secure hospital or sanatorium -treatment for those who are eligible, and arrange all details connected -with their admission. To accomplish these duties, she must know the -physicians of her district, the dispensaries and institutions where she -may send her patients, the philanthropic or relief-giving agencies whose -aid is so often needed, and all social workers whose co-operation is -necessary for the furtherance of the work in hand. - -=Hours on Duty.= Eight hours should constitute the working day, from -eight or nine in the morning, till four or five in the afternoon. With a -large staff, the day will probably not begin till 9 A.M., while a single -nurse, in a small community, may prefer to begin earlier and so finish -earlier, especially in summer. It is a mistake to work overtime, no -matter how interested and enthusiastic one may be. A peculiarity of -tuberculosis work is its unending character—there is always more to do -than can be crowded into the longest day, and even after working ten, -twelve, fourteen hours, one would always feel that some important thing -was being left undone. It is well to recognize this fact in the -beginning, although the temptation to make “just one more” visit is -often hard to resist. The nurse who habitually works overtime only wears -herself out the faster, and in the end her patients will suffer through -her loss of health and energy. - -=Number of Daily Visits.= This is a variable factor, and depends in -great measure upon the size of the district, as well as the number of -patients it contains. The character of the service rendered also -determines the number of visits, as new patients and bed-ridden patients -always demand considerable time. If a nurse calls on ten patients in a -block, and finds none of them in, she naturally can make more visits -than when compelled to spend a long time in each house. As in everything -else, it is the quality that counts, rather than the quantity; the day -which shows few visits may have been spent more profitably than that on -which she scored a high total. There is no general rule as to a nurse’s -capacity, yet it is always well to suspect the value of a large total of -daily visits; if a nurse dashes in and out of a house, spending but a -few moments with her patients, she has probably done her work so -superficially that nothing has been accomplished. - -On the other hand, some nurses pay far too few visits because they have -no head for planning their work, but linger, past all necessity, over -unimportant details. To judge if a district is being properly visited, -the superintendent should know the district, and she should also know -her nurse’s capacity. To estimate the value of the day’s work by the -number of visits alone, is like those societies who reckon their value -by the number of pieces of literature they distribute, totally -regardless as to whether any of it bears fruit. - -Roughly speaking, each patient should be visited once a week; failing -this, once every ten days or two weeks. In a few exceptional instances, -this time between visits may be still further extended, but this should -happen only when the patient is doing extremely well, following all the -rules, and giving efficient and intelligent co-operation. There are not -many patients in this class—for the average, supervision to be adequate -must be frequent. - -Very ill patients, however, must be seen two or three times a week—every -day would not be too often, did the work permit. Unfortunately, if the -visiting list is large, these sick patients can be visited only at the -expense of other cases better able to take care of themselves. For this -reason, the visits to ambulatory patients may become as infrequent as -once every three weeks. If the visiting list grows so large that these -infrequent visits are all that the nurse can give, then her instruction -is laid on so thin as to be nearly worthless, a condition of affairs -which calls for another nurse. - -=The Nurse’s Office.= An office is a necessity for the nurse as a place -where she may keep her nursing and prophylactic supplies, and at which -she will report at certain hours of the day, say at 9 A.M., at lunch -time, and possibly again in the afternoon before going off duty. At -certain specified hours, therefore, it will be possible to reach her, -either in person or by telephone, and her office hours should be known -to doctors, social workers, patients, or to any who have need to call -upon her. In a small town or country district, there will of course be -only one office, but in a city it will be necessary to have several -branch offices, accessible to the nurses of the different districts. -These branch offices should be situated on the border lines of two or -three adjoining districts, so that one office may be used in common by -several nurses. In a city there is also the central office, from which -the superintendent directs the work, and where the staff nurses report -daily. - -In Baltimore[2] these branch offices are usually in the same building -which houses a branch of the Federated Charities, the branch office of -the Visiting Nurse Association, the Infant Welfare Association, and -other similar agencies. In this way, the various social workers learn to -know each other, and to secure close co-operation and understanding. The -different agencies, however, each have their separate rooms or offices. - -Footnote 2: - - Baltimore is divided into sixteen nursing districts, with eight branch - offices or sub-stations, for the use of the sixteen nurses. - -The nurse’s office should be simply but comfortably furnished. It is -used for several purposes—as a store room for supplies, and as a rest -room, where she takes her lunch and spends an hour off duty in the -middle of the day. The furniture should consist of a large writing -table, which may also be used for a dining table; chairs, a lounge or -couch, and a small gas stove or Bunsen burner for cooking simple meals. -If there is no available closet, there will have to be a commodious -cupboard for storing the prophylactic supplies. A large stock of these -must always be kept on hand, so that the nurse may refill her bag before -starting out again on her afternoon rounds. A telephone in the office, -or at least in the same building, is of course necessary. - -=Lunch and the Noon Hour.= It is not within the province of a -superintendent to dictate to her nurses as to what they shall eat. The -association, be it private or municipal, furnishes the office and the -hour, but the nurse must provide her own lunch and select it according -to her fancy. A word, however, in regard to this lunch. It should be as -nourishing as possible, and should consist of such wholesome food as -eggs, milk, cocoa, and so forth. If a nurse substitutes a pint of milk -for a cup of tea or coffee, she is wise. - -In addition to nourishing, wholesome food (in contradistinction to -unprofitable pie and buns from the neighbouring bakeshop), a short -period of relaxation on the lounge or couch is a wise way in which to -spend a portion of the noon hour. In dealing with tuberculosis, food and -rest are necessary to keep one strong and well, and no nurse can afford -to trifle with her health when engaged in this serious work. On no -account should the noon hour be cut short, no matter how little tired -she may be. Better work can be done if one is well fed and rested. - -=Bags.= The association which employs the nurse should also provide her -with the bag for carrying the supplies. The kind of bag needed is a much -discussed question. It should be strong, even though this necessitates -its being heavy. There is no other way out of it—for unless the bag has -the first qualification, strength, the weight of the supplies will soon -wear it out. Very light bags are not practical. - -The bags used in Baltimore are made somewhat like the ordinary Boston -bag, about fourteen inches long, and of good black leather. They weigh a -few more ounces than those used by other associations, but they last -longer. It must also be remembered that the bag used by the tuberculosis -nurse, no matter how heavy it is when she starts forth on her rounds, -grows lighter and lighter as she goes from house to house, leaving the -supplies. Thus, at the end of the day, when she is most tired, it is -practically empty. - -=Prophylactic Supplies.= The prophylactic supplies used for the patients -consist of tin sputum cups, cardboard fillers, paper napkins, waterproof -pockets, disinfectant, and books of instruction. The first three are of -primary importance. The Health Department of a community usually -provides these supplies, even when the nursing work is carried on by a -private association. Thus, in Baltimore, where for six years the -tuberculosis work was done by the Visiting Nurse Association, an -arrangement was entered into between this Association and the State -Board of Health, according to which, the latter paid for and provided -the supplies which the nurses distributed. The only condition imposed -was that each case should be reported to the Health Department, and that -the Health Department should be constantly advised as to the number of -cases under supervision. If no such arrangement is possible, then the -private association supporting the nurse must be put to the additional -expense of buying the supplies. - -It is impossible to make the patients themselves pay for them. -Naturally, they consider them a nuisance and a bother, and it is -difficult enough to persuade them to use them, even when given free. The -cost is not great, however. - - Tin sputum cups, (in lots of 5000) 7 cents apiece. - Fillers, (in lots of 1,000,000) $3.50 per thousand. - Paper napkins, (in lots of 5,000,000) $.55 per thousand. - Disinfectant, 10 cents a bottle. - Waterproof pockets 4 cents apiece. - Books of instruction 2 or 3 cents apiece. - -=Disinfectant.= The most expensive of the supplies is the disinfectant, -which is also probably the least valuable. That used in Baltimore is a -special preparation, consisting largely of creolin; it is put up in pint -bottles by one of the large wholesale drug houses. For use, it is -diluted in water, a tablespoonful to a pint, and used in wiping up -floors, furniture, and so forth. It is of necessity too dilute to have -much germicidal action, and the patients place far too much reliance -upon its odor—which, to the ignorant mind, is of prime importance. -Although we use this disinfectant, we prefer to teach our patients that -better results may be obtained by the lavish use of hot water, brown -soap, and a scrubbing brush, and that thorough cleaning of this kind is -of more value than the most malodorous drug ever dispensed. Disinfectant -to be of real use must be strong and powerful, and it is dangerous to -distribute such powerful drugs promiscuously. Several of our patients -have tried to commit suicide by drinking even the weak preparation that -we gave them. On the whole, we believe that an anti-tuberculosis society -would lose nothing by omitting disinfectant from its list of -prophylactic supplies, and better results could be obtained by -substituting a thorough grounding as to the value of soap and water. - -=Waterproof Pockets.= These are little calico bags, dipped in paraffin, -or some similar preparation which makes them fairly waterproof. These -are pinned inside the coat pocket, and the patient uses them as a -receptacle for his soiled napkins, when he is out on the street, or in -other places where he cannot carry his sputum cup. The napkins are -burned upon his return. - -=Books of Instruction.= These little books are more or less valuable, -but are by no means intended to take the place of the verbal instruction -which it is the nurse’s duty to give. They serve merely to refresh the -memory after she has gone. They can be procured at small cost through -the various anti-tuberculosis organizations, and most Boards of Health -print them for their own distribution. The best of them are inadequate. - -=Stocking the Bag and Distributing Supplies.= When the nurse starts -forth on her morning rounds, her bag should contain enough supplies for -the patients she proposes to call on. Each should be given enough to -last until her next arrival. It is sometimes possible to direct either -the patient himself, or some member of his family, to come to the office -and get a fresh stock whenever necessary. By putting this slight -responsibility on the family, it is made to realize how necessary are -these supplies, but it should not relieve the nurse of her obligation to -visit such a household, and keep it under as close observation as any -other case. If a nurse thus trains a certain number of patients to come -themselves for the supplies, she will be able to reserve the contents of -her satchel for those patients who cannot call for them, or who are too -indifferent to do so. - -Supplies should always be given out freely, and the patient should not -feel that he is put under any obligation by accepting them. They are -intended for his personal use and convenience, and he should be made to -realize this. Otherwise, some patients may hesitate to accept all that -they really need. If a patient needs four or five fillers a day, he -should unquestionably have them—otherwise he may practise small -economies which will mean unnecessary exposure for his family. On the -other hand, the nurse must see that the supplies are used for the -purpose intended—we have sometimes known handkerchiefs used as a -decoration for kitchen shelves, simply because the nurse had given away -far more than was necessary. - -=Nursing Supplies.= In addition to the prophylactic supplies, the bag -also contains a number of articles used in caring for bed-ridden or very -ill cases. Naturally, these articles are not given to the patients, but -are used from case to case, as necessity arises. They include a bottle -of alcohol, boracic ointment, talcum powder, gauze, adhesive strapping, -absorbent cotton, and a thermometer. The nurse should always carry an -apron, to be worn when doing any nursing work. - -The most common dressing is that of bedsores; many patients with -pleurisy have to be strapped; others have drainage tubes, which must be -taken out and cleaned. These extensive dressings are not those which the -nurse should properly be required to attend to, since a patient ill -enough to require an extensive dressing, is a patient who should be sent -to a hospital. Hospital accommodation, however, is unfortunately very -limited, and the nurse is often obliged to do these dressings while -waiting for a vacancy to occur. It is no part of the programme to keep -these advanced cases at home rather than in an institution; on the -contrary, the nurse must make every effort to get them away—but until -this can be accomplished, it is her duty to care for them at home. - - - - - CHAPTER V - - Records and Reports—The Patient’s Chart—Closing the Chart—The Card - Index—Nurse’s Daily Report Sheet—Weekly and Monthly - Reports—Examination of Charts. - - -=Records and Reports.= Every association, whether it be private or -municipal, supporting one nurse or fifty, should keep careful records -concerning its patients, and concerning its nurses’ work. These two sets -of records should dovetail and form a cross file; by looking at the -patient’s chart, one should be able to note the condition of each -individual case, and how often and on what dates he was visited. By -looking at the nurse’s record, one should be able to know exactly how -she had employed every moment of her day, and to see the number of -patients she had visited during the course of it. The patients’ charts -account for the patients—the nurse’s daily report accounts for her work -among them. - -=The Patient’s Chart.= Each patient should have a chart made out for him -at the moment when he is taken on the visiting list. This also applies -to suspects, or those for whom the diagnosis is not positive, but whom -the nurse is required to visit and care for. This also applies to those -moribund patients, who may live but a few hours after being reported, -and who die before a second visit can be made. Whether he has been on -the list a year or an hour, it is necessary to account for every patient -who passes under supervision, and to record the result in each case. -Unless this is done, accurately and promptly, it will be impossible to -estimate the amount of work, and its value to the community. - -The patient’s chart should contain name, sex, age, colour, address, -occupation, social status (married, single, or widowed), and a brief -history concerning the onset and progress of his disease. These charts -may be as simple or as elaborate as one desires. Herewith is submitted a -specimen chart, such as are used in Baltimore; they are not perfect, nor -the acme of all that is or might be desirable in a record of this kind, -but they have proved simple and fairly satisfactory. There is much left -out which with advantage might have been added, but in this connection -it is well to remember that an elaborate and exhaustive history, one -demanding dozens of intimate details, is apt to alarm the patient -excessively. To collect exhaustive statistics would be valuable for the -sociologist, but to do so at the expense of the patients’ confidence and -trust would be to defeat the object of the work itself. - -[Illustration: Patient’s Chart. Cardboard, five by eight inches] - -[Illustration: Reverse side of Patient’s Chart, showing spaces for -recording visits. The Second Chart Sheets are similar to this, but alike -on both sides] - -The reverse side of this chart contains spaces in which each visit may -be recorded. Sometimes these charts are kept up for months and years, -and it is therefore necessary to have what are called second -sheets—alike on both sides, and resembling the reverse side of the first -sheet, which contains the patient’s history. These sheets are fastened -together, and the chart of a chronic case may thus record hundreds of -visits. Each nurse is responsible for keeping up the charts of all -patients under her supervision. The notes should be carefully recorded -at the end of each day’s work, for it is bad policy to let this charting -accumulate for even two or three days. The entries should be brief and -concise, and should describe the patient’s condition, or the work done -for him. - -Each nurse should have a filing box or drawer in which to keep these -charts; they should be arranged in alphabetical order, and kept at the -central office, where the superintendent may have ready access to them. -These charts are the property of the association, and under no -circumstances are to be removed from the central office. The nurse may -make her entries upon them either at the end of the day’s work, or -before she goes on duty the next morning. - -=Closing the Chart.= Patients are removed from the visiting list when -they die, or when they are discharged. They are discharged only for one -of three reasons—either they leave the city, or they move and their -address is lost, or they prove not to be tuberculous. When a patient -dies or is discharged, a suitable entry is made on his chart, which is -then turned in to the superintendent of nurses, or to whomever is -responsible for the records. If there is only one nurse, it is of course -her duty to file these closed histories. These records should be rich -mines of sociological information, and should contain valuable material -for those who have access to them, such as municipal authorities, -physicians, and social workers. Except for the access allowed to these, -the files should be confidential. - -=The Card Index.= All offices should contain a card index, giving the -name and address of each patient under supervision. Change of address -should always be noted, since it is only by means of this card index -that the particular chart desired can be referred to. For example: the -card index contains the names of some 3000 cases, all under supervision, -and each one having its own chart. The charts themselves, however, are -distributed among the filing boxes of several nurses. If particulars are -wanted concerning John Doe, it would be necessary to turn first to the -card index, find his address and the district in which he lives, and -then turn to the filing box of that district and take out the chart. If -it were not for the card index, it would be necessary to search through -all the filing boxes before finding the desired chart. - -[Illustration: Card, three by five inches, used in Card Index] - -As the discharged charts are handed in, the corresponding card in the -index is withdrawn and filed away in a drawer containing either the dead -or the discharged cases according to circumstances. This is a very -simple way of keeping records, and of balancing from day to day the -number of patients on the visiting list. This balance may be made every -week or every month, as desired, for it is a simple method and reduces -to a minimum the opportunities for mistakes in addition and subtraction. -Needless to say, no one but the superintendent or her secretary should -have access to, or touch these files in any way. - -=Nurse’s Daily Report Sheet.= Beside the patients’ charts, the nurse -must fill in a day sheet, or daily report of her work, to be handed to -the superintendent, or to whomever she is responsible. This sheet -accounts for her time and occupation all through the day. Beginning with -the time she goes on duty in the morning, she will record each visit to -each patient, the service rendered, and the time spent on him. She will -also record the time she reached her office for lunch, and the time she -left it for her afternoon rounds, also the hour at which she went off -duty for the day. A record of this kind means additional clerical work, -but how else is the nurse to account for her day? And be it noted, it is -always a satisfaction to the nurse to place on record the summary of her -day’s work. - -[Illustration: Nurse’s Daily Report Sheet, seven by nine inches] - -This daily report sheet is of great value to the superintendent: without -it, there is no way in which she can estimate either the quality or the -quantity of each nurse’s work. A glance at the report will show whether -the day has been light or heavy; it will show the number of new patients -and ill patients, and how many bed-baths and dressings were given; how -much time was spent in calling on doctors, dispensaries, social workers, -and so forth, and arranging houses for fumigation. In short, a record of -this kind shows the day’s work at a glance, and is the only way in which -it can be satisfactorily accounted for, and if necessary verified. - -[Illustration: Day Sheet, used for summarizing the day’s work. From this -sheet the weekly and monthly reports are made out] - -True, this information may be obtained by going over the charts one by -one, and verifying the records made upon them. But this is a clumsy and -laborious way of doing it. If a nurse has two hundred charts in her box, -and pays fifteen visits a day, it would be necessary to search through -the whole boxful of charts in order to find the fifteen cases visited. A -day sheet therefore, is not only a simple and practical way of recording -a day’s work, but it is a protection both to the nurse and the work -itself. - -=Weekly and Monthly Reports.= From her daily report sheet, the nurse -should make up a weekly or monthly report, to be turned in at specified -intervals. This weekly or monthly balance sheet should be presented to -the superintendent, or to the officers of the association to whom the -nurse is responsible. Herewith is given a sample of the monthly report -cards used in Baltimore, but again attention is called to the fact that -these are not the last word in desirability. In using them as models, -they would of course be altered to meet local needs or conditions, and -enlarged or changed to suit other requirements. These monthly reports -should be carefully filed away; they are needed for the construction of -the annual report, and it may be necessary to refer to them on other -occasions. - -[Illustration: Card, four by six inches, used for summarizing the weekly -and monthly reports] - -=Examination of Charts.= One of the duties of the superintendent is to -examine the patients’ charts from time to time, to see how well the -nurses do the clerical work, which is quite as important as the visiting -itself. By carefully examining the charts, the superintendent is able to -call the nurse’s attention to any lapses in them—incomplete histories, -long intervals between visits, and so forth. If, for any reason, the -nurse allows considerable time to elapse between her visits to a -patient, the reasons for this should be fully noted on his chart. For -example: some one wants to know when Mrs. Jones was last visited. On -looking at the chart, we find the last visit was made on June first—and -it is now August first. A two-months’ gap between visits looks like -careless and inattentive work. The nurse, being questioned, however, is -able to give a satisfactory explanation—Mrs. Jones had gone to pick -berries, leaving the city the first of June, and not due to return till -the first of September. This important fact, however, should have been -noted on the chart, since it is almost as careless not to have made this -entry, as it would have been to neglect the patient for so long a time. -If a chart is to have any value, it should tell its own story, briefly -and clearly. - -These charts, therefore, should be examined every two or three weeks. It -is the duty of the superintendent to go over these records, just as it -is her duty to make rounds from time to time among the patients, and -visit them in their homes. This is done by the superintendent, not in a -spirit of distrust or suspicion, but because she is the person -responsible for the work, and it is her duty to oversee it, and bring it -to its highest degree of efficiency. - - - - - CHAPTER VI - - Finding Patients and Building up the Visiting List—Increasing the - Visiting List—Social Workers—Dispensaries—Patients’ Family and - Friends—Nurses’ Cases—Physicians. - - -=Finding Patients and Building up the Visiting List.= The first thing -for a nurse to do when she begins her work in a new community is to find -the patients she is to instruct and care for. And the question naturally -arises; how are these patients to be discovered? - -The campaign of propaganda concerning the need of tuberculosis work has -aroused the interest of people of all classes. The funds to support the -nurse are evidence of this. But the people who pay the bills are not -those who can produce the patients. To get in touch with the patients, -it is necessary to approach people of another class, those whose work -brings them in contact with the very poor. For, as a rule, in beginning -tuberculosis work, it is only patients of the poorest class who find -their way to the nurse’s visiting list. Later, as the work becomes more -firmly established, and better known and understood, her visiting list -will include not only the poor, but those in well-to-do and comfortable -circumstances. - -The Board of Managers of the new association may interest themselves in -finding the patients, but in the end it is the nurse herself upon whom -this responsibility rests. Upon her initiative and ability depends the -success of the work. Her first step, therefore, should be to call upon -all those who can in any way be of service, and who can direct her to -the patients she is anxious to reach. She should call upon the -physicians of the community, the dispensaries and hospitals (if there -are any), social workers, such as the agents of charitable associations; -priests, clergymen, and all those who come into contact with the -suffering and the destitute. Her visits should be made in person, since -a personal interview makes a stronger appeal to the memory of the busy -man than the most convincing letter or the most eloquent report. This -involves one great reason why the nurse should be thoroughly equipped in -character and training; the colourless, uneducated, unconvincing woman -carries with her no conviction, and inspires no confidence either in -herself, or in what she proposes to do. A physician may well hesitate -about turning over his patients to a woman who is unable to put her case -before him. - -It may be that considerable time will thus have to be spent in calling -upon all those likely to know of tuberculous patients, and therefore -able to furnish the nurse with the necessary names and addresses. That -the response is not great should cause no discouragement. As we have -said elsewhere, the tuberculosis death-rate, multiplied by five, will -give a conservative estimate of the number of tuberculous individuals in -a community. It is the nurse’s duty to unearth them. They exist—she must -find them, and the greater the obstacles, the greater the incentive to -overcome them. The total result of a two or three weeks’ campaign may be -a mere handful of cases reluctantly handed over by a few physicians, and -a few undiagnosed suspects, reported by an earnest priest. In this way -the visiting list is begun. - -=Increasing the Visiting List.= To increase the visiting list—that is, -to bring under her care an increasingly larger proportion of the total -number of tuberculous patients, even though the list becomes so large -and unwieldy that she cannot manage it, should be the ambition of every -tuberculosis nurse. At present, in every city in the country, there is -so much undiscovered and unreported tuberculosis, that the failure of -the nurse to increase the visiting list is an indication of poor work, -not an indication that a full round-up has been made of all those -suffering from this disease. This is especially true in a new community; -a small or stationary visiting list is a sure sign, not necessarily of -lazy or unconscientious work, but at least that the undertaking is being -managed by someone who does not know how. - -To illustrate this: A nurse is sent to a certain house, to see a -specified patient. She does her work well—gives him a bed-bath, shows -the family what to do, and makes considerable impression along lines of -general hygiene. As far as it goes, her work is satisfactory and good. -Another nurse, however, sent into this same house, would not only do all -these things equally well, but, in addition, she would discover that the -patient’s wife was coughing and probably infected, while his old mother, -retired in the chimney-corner, was in even worse plight than the patient -himself. These suspects, therefore, she sends to the dispensary, where -her suspicions are confirmed by the doctor’s findings. Thus, if a -community possesses a nurse of the first type, it may rejoice to find -the amount of tuberculosis so small. If, on the other hand, it has a -woman of the second type, it will become alarmed and anxious at the -increasing number of patients who need care and control. - -Nothing should diminish the enthusiasm for gaining new patients. The -mere fact that a nurse has more than she can manage should never deter -her from continually trying to find more. More patients, more patients, -and even then, more patients, should be her constant aim—and then the -chances are that she has not found all that exist. In Baltimore, when -pioneer work was begun under the Visiting Nurse Association, that -organization had a visiting list of some 1700 consumptive patients, -divided among five nurses. As five nurses represented the largest number -the Association could support, and as 1700 patients was only about -one-fourth of those who needed care and attention, some other method of -caring for the latter had to be devised. It was at this critical moment -that the Health Department was persuaded to assume the tuberculosis work -of the private association, and to incorporate it as part of the city -machinery. If the need for this transfer had never been proved, it is -hardly possible that the change would have been made. If the first -nurses had confined their visits to the patients they could reasonably -manage, and had refused to accept others, it would have been impossible -to prove how great the number of infectious patients was, and how -inadequate the care given them by the five struggling nurses of the -private association. Therefore, each community which undertakes -tuberculosis work should endeavour to unearth all the cases that exist, -if for no other reason than to show the size of the problem, and the -necessity of adequate measures for handling it. New patients, positive -and suspicious, should be sought for from every possible source. This is -better policy than to confine the work to the conscientious care of a -handful of manageable cases. - -=Social Workers.= The agents of the Charity Organization Society, or -similar associations, continually come across cases of tuberculosis. The -new nurse should canvass all these agencies, and ask that all cases of -this kind be referred to her. If a case is not positively diagnosed, -that should be no drawback to reporting it; while the agents of these -associations are laymen and therefore not able to make diagnoses, -laymen, nevertheless, are able to make very shrewd guesses. It is the -nurse’s duty to take charge of these doubtful cases, and get them -examined and diagnosed by the proper agencies. The mere fact that a -patient presents suggestive symptoms makes it all the more urgent that -he be examined as soon as possible, and lack of positive diagnosis -should be no reason for the agent to withhold, or for the nurse to -refuse to take charge of, such a case. To visit a suspect does not -necessarily classify him as a consumptive, while not to visit him might -be to deprive him of assistance at a most critical time. - -In finding cases, extensive co-operation should be invited; almost every -one whose work brings him into contact with numbers of people, knows one -or two among them who are tuberculous. Thus settlement workers, school -teachers, school attendance officers, juvenile court officers, -clergymen, Salvation Army workers, and so forth, are all people whose -aid and interest should be solicited. It makes no difference whether or -not the case is positively diagnosed—any sick person, with the symptoms -of a consumptive, is a person whose case should be looked into. It is -the nurse’s business to obtain the diagnosis. - -=Dispensaries.= If there is a hospital or dispensary (not necessarily a -tuberculosis dispensary), the nurse should visit these institutions and -ask to have all positive and suspicious cases referred to her. Since the -patients who come to these places are usually those of the poorer -classes, the doctors will not be likely to object to giving their names -to the nurse. Indeed, they may be glad to accept the assistance she -offers. One visit to these institutions, however, is not enough. Every -week or two the nurse must present herself and renew her request for -patients—she must not trust to the busy physician to report them by -letter or telephone. Even when tuberculosis work is conducted on a large -scale, as in Baltimore, it is always part of the nurse’s duty to visit -these institutions regularly, to remind the doctors of their existence -and of their unquenchable desire for more patients. - -=Patients’ Families and Friends.= After the nurse is well established, -and her position in the community recognized and assured, she will find -that a certain number of new cases are referred to her through the -families and friends of those already on her visiting list. This is a -high tribute, and should be valued accordingly. She should not rely -entirely upon this voluntary assistance, however, but from time to time -should question her patients, and find out whether they have any friends -who are ill, who would like to be visited. Surprising revelations often -follow. There was in Baltimore one old coloured woman who took special -pride in discovering patients, and who made an indefatigable agent in -hunting up cases in the neighbourhood. The accuracy of her diagnosis was -wonderful—her son had died of tuberculosis, so she knew all the -symptoms, and she did not refer us to a single case, which, upon -examination, failed to be tuberculous. We must remember that while in -its early stages tuberculosis is difficult to detect, when it is so -advanced that a layman can recognize it, in nine times out of ten he is -right. And as these advanced cases are the chief distributors of the -disease, the alert nurse should be keen to learn of these patients -through any source that presents itself. Of course many calls from such -sources send one on mere wild-goose chases, but it is better to go on a -dozen fruitless errands, than to overlook one real case of tuberculosis. - -=Nurse’s Cases.= A large proportion of her cases will be unearthed by -the nurse herself. In Baltimore, the nurses themselves discover nearly -thirty-three per cent. of the cases under supervision. Thus, on being -sent to see a certain patient, before her visit is over the nurse may -discover one or two others of the family whose condition is such as to -call for immediate examination. The nurse should look with suspicion -upon every member of a household which has been exposed to tuberculosis. -The prolonged and intimate contact which is necessary for the -transmission of this disease has unfortunately, in most families, -existed for months before her arrival. The nurse should be particularly -keen in questioning the parents of tuberculous children since it is from -the parents that most children contract this disease. - -=Physicians.= In considering the various sources from which patients are -recruited, we have purposely left until the last that which most people -would have deemed the first and most important source of all, namely, -the physicians of a community. While the medical profession has blazed -the way, and has indicated the paths along which the work must be -carried on, it is unfortunately only the greater men in the profession -who have done this. The others, through ignorance, through indifference, -or through that spirit which according to Dr. Cabot makes medicine “the -greatest profession, the meanest of trades,” have succeeded in placing -effective if temporary barriers in the path of the anti-tuberculosis -worker. The rigid adherence to the old Hippocratic oath, by which the -physician was sworn to keep inviolate the confidence of his patient, and -to place foremost the welfare of the individual, has for the most part -been very nobly lived up to. This oath, however, antedates our knowledge -concerning infectious and communicable disease. With the knowledge as to -the nature of transmissible diseases, there has come a change in medical -ethics, a change manifested by laws in which the welfare of the -community is placed above that of the individual. We see this reflected -in the regulations governing diphtheria, smallpox, scarlet fever, and so -forth—diseases which are distinctly the concern of the community, as -well as of the patient himself. But with tuberculosis, which has but -recently become recognized as a communicable disease, we find a halting -reluctance to consider anything but the rights of the individual. This -feeling is particularly strong among physicians of an older generation, -hold-overs from a passing régime. To such as these the nurse is nothing -less than an impertinence. Even if physicians of this sort are unable to -see their patients oftener than once or twice a year, or know them to be -in need of supplies which the nurse will gladly furnish, they refuse to -call upon her, and consider her advent as intolerable. - -Again, there are physicians who do not object to the nurse on this -score, but who resent her as a subtle menace to their practice. They -feel that if a layman is able to preach rest, fresh air, and food, and -distribute prophylactic supplies, that the ground will be cut out from -under them, and that they will lose a chronic and fairly lucrative class -of patients. As a matter of fact, the physician who preaches this simple -doctrine has nothing to fear from the tuberculosis nurse—if her words -echo his they only add force. - -There are other physicians, however, who have received an inferior -medical education; they are neither sure of themselves, nor able to -diagnose tuberculosis until it is in an advanced state. These object to -the nurse on the ground, implied rather than expressed, that she is -supervising and criticizing their work, and this self-consciousness -often takes the form of a violent antagonism. It is always the badly -trained physician who fears the well-trained nurse. - -Furthermore, there are certain practitioners who frankly exploit their -patients. They may be competent enough but they are in medicine to make -a living, and are often brutally unethical as to how this is done. If -through self-interest it seem best to them to withhold from the patient -the nature of his disease, they do not hesitate to do so, regardless of -the danger to which others may be exposed. By a strange paradox, the -same profession which gives us the noblest, the most unselfish workers -in the interests of public health, also gives us its most implacable -enemies. - -However, the new nurse must call upon all the physicians of the -community, and endeavour to obtain their assistance and support. But, -for the reasons mentioned, she must not be discouraged if she is not -always cordially received by them. There will always be among them many -who are enlightened and progressive, and who will assist generously in -the anti-tuberculosis campaign. If a community can boast of only one or -two such men, even, success is assured. And later on, as the nurse -progresses quietly in her work, she will come into contact with other -doctors, who promise her aid, but ignore their promises because they -think she is trying to steal away their patients. As it gradually dawns -on them that this is not the case, their opposition will wear off. To -conquer this prejudice as soon as possible is part of the nurse’s work. - -Furthermore, the community itself should not be daunted if the -physicians as a body do not endorse the prospect of a tuberculosis -nurse. This prejudice against public health nursing is the common -experience in all cities where visiting work has been established, but -it gradually wears off as the nurse is able to demonstrate her value. -Little by little the doctors are won over, as they begin to realize that -she is not a rival but an assistant. In Baltimore, our experience has -been that those physicians who were at first our worst opponents have -now become our staunchest and warmest friends. - - - - - CHAPTER VII - - The General Practitioner and the Public Health—Responsibility of - the Private Practitioner in Tuberculosis—Impossibility of - Fulfilling this Obligation—Failure because of the Nature of - Tuberculosis—Failure through the Personal Equation. - - -=The General Practitioner and the Public Health.= Roughly speaking, we -may say that the medical profession is divided into three or four -branches—private practice, hospital or laboratory work, and public -health service. A man who takes up one of these branches is not -necessarily interested in or equipped for another. While all physicians -are supposed to have approximately the same medical education, and -therefore to be interested in those measures which tend to raise and -improve the standard of public health, it is only those who are most -keenly interested in this work who have made it a special study. For it -must be remembered that public health work is as much a specialty and -calls for as much training and ability along certain lines as laboratory -work, or the administration of an institution. This being so, a man who -goes in for it does so because he is more interested in it than in -private practice, or in research work. And the converse of this is also -true. The selection of one field rather than another is a matter of -individual taste or inclination. Yet curiously enough, the State does -not take note of this fact. It places certain obligations upon all -members of the medical profession, and expects them all to live up to -the responsibilities thus arbitrarily imposed. - -=Responsibility of the Private Practitioner in Tuberculosis.= In the -pursuit of his calling, the private practitioner comes into contact with -certain diseases which by their nature are a matter of public as well as -private concern. In so far, therefore, he is expected to interest -himself in the general welfare of the community, but there is no way of -compelling him to do this. The State grants him a licence to practice -medicine, and in exchange for this licence or permission, he is expected -to serve the State more or less gratuitously. At best, it is volunteer -service, and therefore intermittent and unsatisfactory. That the State -expects this service is shown by laws referring to transmissible -diseases, the notification of births and deaths, and other matters which -in one sense belong to his private business, but which in another sense -are part of his public responsibility. - -Physicians who have no taste for research work are not forced to -undertake it, nor are they coerced into any other line of service. Yet -the State obliges those who are least inclined, as well as the others, -to assume a graver responsibility; care of the public health. It takes -no account of the many reasons which may prevent their doing this, or -prevent their willingness to assume any part of this responsibility. It -is thrust upon them just the same, but the expected results are not -forthcoming. The State, therefore, is in the position of making an -unfair demand upon the private practitioner, and at the same time -relying upon an unfulfilled requirement for the security of the public -health. In regard to tuberculosis, there are certain regulations which -all physicians are supposed to comply with, no matter how little -interested they may be in public welfare, or how unwilling to consider -any other than their personal interests. These laws require, first, that -all cases of tuberculosis be registered with the local or state health -department, since in dealing with a transmissible disease it is -necessary to learn its distribution and prevalence. Second, the -physician in charge of a tuberculous patient must give this patient full -prophylactic supplies, and teach him how to use and dispose of them. -These supplies are furnished free of charge by the Health Department, so -that the physician is under no expense in distributing them. Third, all -houses vacated by a consumptive, either through death or removal, must -be reported to the Health Department for fumigation. If these -regulations could have been thoroughly complied with, they would -doubtless have insured a system of complete and satisfactory supervision -of tuberculosis. As it is, most of our large cities have found it -necessary to place special workers in the field, to give exactly the -same supervision and control which these regulations were designed to -secure. The private practitioner, endowed with special education, -special opportunity, and special authority, has not used these -endowments, or else has used them to so slight an extent that the -community has received no benefit. - -If the physicians of a community have been able to diagnose -tuberculosis, and have been required by law to report it, why has it -become necessary to establish municipal dispensaries for this purpose? -Can the dispensary physician make a better diagnosis? Or is he more -willing to fill in a blank and report the case? - -And if the physicians, required by law to instruct and keep careful -watch over their consumptive patients, had been able to do this, why has -it become necessary to place tuberculosis nurses in the field, designed -to give just such service? Is the special nurse better fitted to explain -the nature and danger of the disease? Is she a more efficient -distributor of prophylactic supplies? To all these questions there -should be but one answer—there is, or should be, no difference between -the two. The private practitioner should be as well able to make a sure -diagnosis as the municipal physician. He should be as ready to report -the case. The private practitioner should be as capable a teacher, as -careful a distributor of supplies, as alive to the danger of -tuberculosis as the municipal nurse. The only difference between these -two groups of people is that one acts and the other does not—or acts in -such intermittent and irregular manner as to be productive of no -results. And it is because of this lack of action on the part of the -physicians in private practice, their failure to recognize, report, -teach, and continually supervise consumptive patients, that our cities -are placing the care of tuberculosis under municipal control. The care -of tuberculosis is gradually being withdrawn from the man in private -practice, and placed in the hands of specialists, who devote their -entire time to the welfare of the community. And although now as always -the latter solicit the support of the private physician, if he withholds -his co-operation they can do without him, and reach their goal through -other means. - -=Impossibility of Fulfilling this Obligation.= We may ask why the -private practitioner is being supplanted by municipal control. -Undoubtedly he once held the key of the tuberculosis situation, as he -holds it of many other problems involving the public health. He is being -supplanted for two reasons: because of the peculiar nature of -tuberculosis, and because of the failure of the medical profession to -act as a united whole. - -=Failure because of the Nature of Tuberculosis.= Let us first consider -the nature of the disease. Tuberculosis is a prolonged, chronic disease, -which may be drawn out over a period of months or years. The patient has -many ups and downs, being sometimes so ill that he places himself under -the care of a physician, sometimes so much better that he does not see a -doctor for months. We have known patients who have not been to a -physician for years, yet during that time they were infectious cases, as -proved by sputum examination. During a hiatus of this kind, how can we -possibly hold the doctor responsible for the tuberculous patient? How -can we hold him responsible for the conduct, training, and surroundings -of a case he never sees? Undoubtedly a very large number of patients -pass completely from under the observation of their physicians, and are -utterly lost to them. With the best intentions in the world, the private -practitioner cannot follow and supervise a disease of this character, -not acute, but chronic and ambulatory in nature. If he attempted this, -it would leave him little time for anything else. - -Nor can we assume that the patient who closes his account with one -doctor necessarily places himself in the hands of another. He frequently -drifts along without any medical advice whatsoever, and only seeks it -again when his symptoms become alarming. These facts alone, exclusive of -all other considerations, show the necessity for centralized control of -these ambulatory patients. - -Tuberculosis is largely a disease of the poor, as we have remarked -before. A poor consumptive must consider the spending of every dollar, -and the doctor’s fee is a matter of grave importance. For this reason, -the patient will pay just as few visits to the physician as he possibly -can. A doctor who sees a case only once or twice may well hesitate to -pronounce it tuberculosis, and may wish to keep the patient under -observation for a time, but the poverty of the patient prevents this. - -Again, patients of the poorer classes continually change their doctors. -Unlike people in more fortunate circumstances, they have no one -physician to whom they always turn when in trouble. To such as these, -the “family doctor” is unknown. Their fickle interest is attracted by -the newest shingle, and they pay a visit or two to its owner and they -depart. We knew one patient who visited five different doctors within -the week. Small wonder that the doctor forgets these patients—mere -transients—and that, even if he has time to diagnose them, he does not -consider himself their physician, or responsible for them in any way. It -is for just such cases, however—those patients who come into fleeting -and haphazard relation with their physician, that municipal control is -required. It is no reflection upon the private practitioner that he has -failed to make headway against tuberculosis. It simply proves that -people with this disease must be watched and cared for by those who are -able to devote their entire time to it. - -So much for the disease itself, and for the sociological and -psychological conditions which complicate it, and make it a matter which -cannot be handled successfully by the man in private practice. For no -matter how conscientious he may be, or how willing to assume the full -responsibility imposed by the State, he cannot do this when the patients -refuse him the opportunity. He cannot follow them up at the expense of -his private obligations. While the State expects service from those whom -it licenses to practise, it does not expect the impossible. - -=Failure through the Personal Equation.= We must now consider the second -reason for removing tuberculosis from private into public control. For -while the nature of the disease itself explains in large measure why it -cannot be dealt with by the private practitioner, that is not the entire -explanation. And here we must put the blame where it belongs—at the door -of the physician himself. - -When we think of the medical profession, we unconsciously think of its -finest members—not only of the leaders in thought and achievement, but -the numbers of highly educated, advanced, efficient, and conscientious -men who form so large a part of it. In thinking of these, however, we -are apt to overlook men of another sort, who are less well equipped, or -who are imbued with commercialism, yet who are none the less members of -this great profession. Yet even the least of these is armed, and has the -sanction of the State in bearing these arms, which may be used either -against a common enemy, or in a guerilla warfare in behalf of his own -interests. The wide diversity among its individual members is the reason -why the medical profession has been unable to act as a united whole in -the warfare against tuberculosis. - -In the first place, all physicians, no matter how well they may be -trained, are not necessarily good teachers. No matter how keenly aware -of the danger of tuberculosis, they are often unable to impress it upon -their patients. Again, the busy physician has usually too little time to -be a careful teacher. When conscious of a crowded waiting-room, or of -the urgency of his next call, he is unable to give any but the most -superficial and hurried instructions about the nature of tuberculosis, -or the use of the prophylactic supplies. He does not realize that that -which is obvious to him is frequently unintelligible to those less -enlightened. We have often found patients possessing bundles of -prophylactic supplies, given conscientiously enough, but without -sufficient instruction to enable them to fold the fillers or to dispose -of them afterwards. We recall one such case, where the doctor had given -his patient a package of supplies, but had hurried off without opening -the bundle or explaining its contents. A week later, we found the -package still unopened. The patient, however, had torn a small hole in -the wrapper, through which opening he had seen enough to convince -himself that the strange objects within were no concern of his. We do -not mean to say that no physicians are good teachers, but we do say that -even where they are, and are moreover highly conscientious men, that -they frequently give inadequate instruction to the patients under their -charge, because they are too busy. - -There is another class of practitioners, who, while willing enough, are -nevertheless unable to contribute much towards the anti-tuberculosis -campaign. These are the men whose education is limited, who are unable -to recognize tuberculosis until it is advanced, and even then hesitate -to commit themselves. The patient under these circumstances has ample -opportunity to infect others, to say nothing of losing his own life into -the bargain. No amount of conscientiousness, of integrity, and of honest -intention can compensate for lack of skill. Indeed, many men of this -sort come perilously near the border-line of quackery. Yet the State has -granted them a licence, though thereby it entrusts them with obligations -which they cannot fulfil. - -We have spoken before of the unethical practitioner, who, while -competent enough, feels himself under no obligation to protect the -community from an infectious disease. There is sometimes a reason for -this indifference, this failure to tell the patient he has tuberculosis, -and to inform those who surround him of their danger. This reason is -because many a patient is afraid to know the truth about his condition. -If the physician tells him he has tuberculosis, he at once changes his -doctor and seeks another who will give a more comforting diagnosis. -Thus, the struggling physician, to whom this may mean the loss of -livelihood and prestige, is forced to a decision between self-interest -and the interest of a community which he learns to despise, because it -has forced him to dishonesty. We grow cynical about the welfare of those -who force us to trim our ideals. - -We have tried thus briefly to review the main reasons why tuberculosis -is emphatically a disease which should be removed from private practice -and placed under municipal control. On the one hand, this is necessary -because of the nature of the disease, since ambulatory patients cannot -be followed except by those able to devote their whole time to it. On -the other hand, it is necessary because of the wide diversity within the -ranks of the medical profession. The greater number of private -practitioners are either too busy, too intent on earning a living, too -indifferent, or too poorly educated to assume effective supervision of -an infectious disease which requires masterful handling. And since they -themselves have not been able to deal with this great issue, they should -not object to placing it in the hands of those qualified to do so. The -greatest contribution that the private physician can make to the -anti-tuberculosis campaign, is to do what he can to hasten the advent of -full municipal controls. - - - - - CHAPTER VIII - - The Nurse in Relation to the Physician—Municipal Control of Infectious - Diseases—The Nurse’s Difficulties—A Waiting Policy—Undiagnosed - Cases—The Nurse’s Responsibility to the Conscientious Physician - Only. - - -=The Nurse in Relation to the Physician.= In the foregoing chapter, we -have seen that the task of preserving and improving the public health is -one which rests, theoretically, on the medical profession as a whole. As -a matter of fact, however, this task is assumed only by certain members -of the profession. We have pointed out the reasons for this—that -physicians vary greatly as to personal character, ability, and ideals. -In the field of public health, the nurse finds herself in contact with -physicians of all classes. Some are able, high-minded, and skilful, and -whether working as public officials or private practitioners, have -nevertheless the same end; improvement of the public health. Others have -standards quite the reverse. This brings us to the question: When the -nurse’s duties bring her in contact with men of the latter class, how is -she to meet the situation? In what relation does she stand to these men? -What shall be her attitude to them, as regards her work? They are not -numerous fortunately, but there are enough to constitute a serious -problem, and one which sooner or later the nurse must face. This -question will also have to be faced by those who are responsible for the -nurse, and for her work. - -In our opinion, the answer is simple enough—or, rather it will be, -twenty years hence. For at present, public opinion is in a transition -state and needs moulding. The nurse should work under the direction of, -and in co-operation with, all those physicians who, whether as public -officials or private practitioners, are working for a higher standard of -public welfare. To all such, without discrimination, the public health -nurse is the faithful, efficient, and tireless ally. But to all those -other physicians who have no such aims or desires, the nurse stands in -but remote and casual relation. The old teaching that she is the -handmaiden of the doctor is gone. Both are now co-workers in the field -of public health. The nurse still carries out the doctor’s orders, but -there is this difference—she discriminates as to doctors. As a public -servant, she obeys the orders of the municipal authorities, or of the -private practitioner when the object of both is the same, that is, the -welfare of the community. But she is not responsible to those physicians -who try to defeat this object. - -For this reason, the nurse can do more effective work if she is -connected with the Health Department, since it is the Health Department -of a city which must formulate standards of efficiency, and clothe its -employees with authority to carry them out. The authority of the Health -Department physicians should be superior to that of any private -physician, should there be any conflict of opinion between them. - -If the nurse cannot be established in connexion with the local Health -Department, she will yet be responsible to a group of public-spirited -citizens, which group will undoubtedly include many advanced and -enlightened physicians. This group of people will represent advanced -public opinion on the subject of tuberculosis, and the authority which -the nurse gets from them will be of almost equal value to that which she -would get from the municipality. Municipal authority, or the authority -of enlightened public opinion, is a dangerous thing to oppose. - -=Municipal Control of Infectious Diseases.= In the case of smallpox, -diphtheria, or scarlet fever, the private practitioner attends the -patient under the immediate supervision of the Health Department. Thus, -in diphtheria and scarlet fever, he notifies the Department of each case -that comes under his notice. A municipal physician is at once sent to -take cultures from the patient’s throat, as well as from all the other -members of the household. He placards the house, and instructs the -family in such preventive measures as shall insure their safety and that -of the community. The patient is then left in the charge of the original -physician, who notifies the Health Department when, in his opinion, the -infection is over. His opinion, however, is verified by the municipal -physician, who takes another series of throat cultures, and ascertains, -quite independently, whether or no the danger is past. If it is, he -orders the placard taken down, and arranges for the fumigation of the -house. - -In the case of smallpox much more drastic measures are observed. The -patient is summarily removed to quarantine, and all those who have come -in contact with him are vaccinated and kept under observation for a -definite period. In this way the strong hand of authority protects the -community from infection—the private physician has been merely the means -of calling attention to the danger. The time will come, indeed it is -rapidly approaching, when enlightened public opinion will demand this -same care in the matter of tuberculosis. By reason of the chronic nature -of the disease, the care given must include long-continued supervision, -extending if need be, over months and years. This supervision will be -given by municipal physicians and nurses. Furthermore, the private -practitioner will no more resent this, nor consider it interference with -his private business, than he resents municipal care of smallpox or -scarlet fever. The readjustment of the point of view is necessarily -slow, but it is coming, none the less. Those of us on the firing line, -however, who daily witness the loss and sacrifice due to this slow -readjustment, cannot but wish for revolution instead of evolution in -medical ethics. - -In this chapter, however, we must deal with the situation as it exists -to-day. The infectious nature of tuberculosis has become known -comparatively recently, hence we find ourselves confronted with a -delicate and difficult situation, as must always be the case when public -opinion is evolving. To-day if a private physician forbids a nurse to -visit his patient (and for nurse, read also Health Department), the -present status of public opinion will usually uphold him in his -decision. It is for us, therefore, to find out the reasons which prompt -him to this decision, and to lay them frankly before the public, and let -the public pass judgment. In no other way can opinion be altered, or can -we gain for tuberculosis the same supervision and control that we have -obtained for the other infectious diseases. - -=The Nurse’s Difficulties.= Let us take a few examples of the -difficulties the nurse meets. A boy of fifteen had been diagnosed by the -Phipps Dispensary as a moderately advanced case, and the nurse was asked -to follow him up. On her first visit, the patient’s mother refused to -let the nurse enter, saying that her son had since called in a private -physician, who assured him that the dispensary diagnosis was all -nonsense. The dispensary man had counselled rest; the newcomer told the -mother to buy her son a bicycle and let him take all the exercise he -could. This treatment was followed out, and, still acting on the -physician’s advice, the nurse was refused admission to the house. The -mother was friendly enough when they met on the street, and she even -permitted the nurse to stop and inquire for her son, always cheerfully -replying that he was doing well. Useless as they were, the nurse -continued these visits, since she was anxious to see the outcome of the -case. Finally, one day six months later, the mother threw open the door, -and in deep distress, begged the nurse to come in. “Do what you can for -my boy,” she pleaded, and led the way to an upper bedroom, where the -young fellow was lying in a moribund condition. A few days later he -died. The mother bitterly accused herself for her folly in refusing the -disinterested advice of the dispensary physician, and her grief, -remorse, and opinions were given wide circulation in the neighbourhood. -At no time during his illness had instruction been given as to the -nature and danger of the disease, and not until a week before death did -the attending physician admit that something was seriously wrong. In -consequence of this wrong diagnosis, the boy lost his life, and the -physician’s reputation was damaged. Apparently he had not taken into -sufficient consideration the risk of contradicting a diagnosis that came -from such an expert source. - -In this particular case, it was impossible for the nurse to force her -way in, or to do anything except await developments. As it happened, -there was no one in the family likely to become infected, since the -patient had no brothers or sisters, no one except his mother with whom -he came in contact. The sacrifice of this boy to the ignorance, -obstinacy, jealousy, or stupidity of the local physician proved a -striking object lesson to the neighbourhood. The bereaved and indignant -mother was a factor in forming public opinion in this particular -vicinity. - -Another case is that of a woman who had in her employ a favourite -coloured servant, whom she suspected to be tuberculous. Accordingly, she -sent for the nurse, asking her to take all necessary steps towards -getting the case diagnosed. As the patient was too ill to go to a -dispensary and could not afford a doctor, the nurse brought a specimen -of sputum to the laboratory of the Health Department, where it was -proved positive. So far, all was clear going. The patient was given her -prophylactic supplies, put to bed in a clean, airy room, and the nurse -called daily to give her a bath and such attention as she required. This -should have been a hospital case, but at that time the hospital was -crowded and there was no available bed. One day, when the nurse called -as usual, she found the patient suddenly become very impudent. She was -lying in a room with all windows closed, and a coal oil stove in full -blast; no supplies were in sight and the patient was expectorating at -random over the floor. This change had occurred because the patient had -taken some of the money given by her employer, and had called in a -“private doctor,” who declared she had nothing but a passing cold. He -also told her the supplies were nonsense, and that he could cure her in -two or three weeks. Furthermore, this physician himself came down to the -Health Department, and forbade the nurse to continue her visits, and all -“interference” with his case. A few days later, the employer also came -to the Health Department, in considerable heat, and wished to know why -the nurse was neglecting her duty. The explanation was satisfactory, and -a visit to her servant amply corroborated the statements that had been -made. This woman had been paying her servant full wages while off duty, -as well as providing her with many little luxuries and necessities. She -was therefore in a position to dictate the terms upon which she would -continue this assistance, and these terms did not include visits from a -physician of the calibre of the man now in attendance. In every case, -however, it is not so easy to obtain the whip-hand of the situation. - -In these two instances, there was little danger of spreading the -infection, since neither patient was in close contact with children, or -other persons likely to contract the disease. The young boy suffered an -early death, while the coloured woman suffered personal inconvenience -and discomfort, due to lack of nursing, care, and attention. In neither -case, however, was there danger to other people. Whenever other people -are involved, it is less easy to stand by and do nothing, while waiting -for that slow change in public sentiment which shall give one the right -to interfere. Thus, a physician diagnosed a case as tuberculous, and -asked the nurse to take charge of the patient, telling her that he had -carefully examined all the other members of the family, and found them -in apparently good condition. He added, however, that he had been -dismissed as soon as he had told the family the disease from which the -patient was suffering. For this reason, he feared the nurse would find -difficulty in entering the home. His fears were only too well grounded. -The family had straightway called in another doctor, who calmed their -anxiety by denying the previous diagnosis. He also advised them to turn -away the nurse, which they did. - -The patient lived some eight months after this, during which time she -was given no supplies, no instructions of any sort, and the family were -kept in ignorance of the nature of her illness. When she died, the nurse -as agent of the Health Department went to the house to arrange for the -fumigation. The front door was opened by a young girl obviously -tuberculous—the nurse was struck with her appearance; further search -revealed still another member of the household who presented suggestive -symptoms. In their distress, the family turned to the nurse and asked -for advice and assistance, and she at once referred them to the -physician who had diagnosed the original patient, eight months ago. The -family obediently presented themselves to him, and he found that three -more members had become infected. Since they were all in the early -stages, it is probable that they had become infected during the last few -months of the patient’s life—during which time not one precautionary -measure had been observed. The day will surely come when the possibility -of treating tuberculosis lightly, at the option of the attending -physician, will not be allowed. Public sentiment will finally insist -upon full municipal control, which will do away with such malpractice -and sacrifice of human life. - -=A Waiting Policy.= As matters stand to-day, we can do nothing but -accept the situation as we find it, and do the best that circumstances -will permit. Which brings us to the question of the hour—What is to be -done if the physician refuses to let the nurse visit his patient? Is she -to accept his dismissal and turn away, or is she to continue her visits -in spite of his objections, on the ground that the patient is hers as -well as his? - -If the case is a positive one, diagnosed on unquestionable authority, -and if the nurse has been sent by a dispensary, the Federated Charities, -or through some other disinterested source, she should be readily able -to gain admission. Having gained this, she should be able to hold her -own against all comers. As a rule, it is the opposition she encounters -before, rather than after her first visit, which determines her ability -to do her work in the home. Once in the home, however, it should make -little difference whether or not the patient changes doctors. If he -does, she should continue her visits as usual—her knowledge of his -condition makes it advisable to hang on to the family at all costs. If -this change brings a friendly doctor, he will not object to the nurse. -If it brings a prejudiced one, she should do nothing to excite his -hostility. Thus, if the new doctor denies the presence of tuberculosis, -it may become necessary for her to seem to assent to this opinion—for a -time she may have to visit merely in the capacity of a friend, offering -no advice, and distributing no supplies. She must be careful not to -antagonize the family, for after all, it is the family, at the doctor’s -instigation, which is able to turn her out. Thus, when they triumphantly -tell her that the patient no longer has consumption, she should not -contradict them. Time will do it for her. She may express pleasure at -the happy change, and ask for permission to stop in now and then, in -passing, in the capacity of an old acquaintance. This request will -seldom be denied, and at all costs she must keep in touch with the -family which now, more than ever, needs her supervision and aid. She -must stand by, ready to give this as soon as it is wanted. During this -time it will be very hard to wait, to see the patient relax all -vigilance, and to see the family recklessly exposed. But this waiting -policy will pay in the end. As we have said elsewhere, the consumptive -changes doctors more often than any other class of patients, and the -nurse must realize this, and be ready to follow him through the -vicissitudes which these changes involve. She must avoid all criticism -when the family is fallen upon evil times, and be ready to uphold and -encourage them when they are fallen upon good times. - -=Undiagnosed Cases.= In the matter of suspected or undiagnosed cases, -there is greater difficulty. In these cases the nurse has nothing to go -on but her own keen observation of symptoms, therefore the physician in -charge may make it very difficult for her to continue her visits. He can -withhold his diagnosis, ignorantly or wilfully, and there is nothing to -do but to accept this state of affairs. As before, the nurse must -quietly hold on to the case, saying nothing that can possibly imply -criticism or involve her in difficulty with the doctor. Time must be -trusted to clear the situation—either the patient will get better, or he -will get so much worse that a diagnosis may be forthcoming. Or else he -may change doctors. When a nurse is visiting a case in charge of one -doctor, she must be exceedingly careful never to advise another or to -suggest a dispensary. All this involves infinite waste of time and loss -of life, but as matters stand to-day, there is no other course to -pursue. When a nurse is visiting a case of this kind—it may be one who -presents every symptom of tuberculosis, including even hemorrhage—she -must be particularly careful. She may call up the doctor, tell him that -she has been called to his case through such and such an agency (these -cases are usually referred by a layman) and ask if there are any orders -he would like carried out. She may also ask him to tell her the nature -of the disease. If he refuses, it is then a question of further -“watchful waiting.” If the patient is expectorating a great deal, she -may provide him with a sputum cup and other supplies, taking care, -however, never to use the word “tuberculosis” in connection with them. -She simply offers them as a convenience for a distressing symptom. We -have known patients of this kind who died after being ill for months, -most of the time being spent in bed. Meanwhile, they had extreme -emaciation, night sweats, fever, cough, profuse expectoration, even -hemoptysis, yet the death certificate read “bronchitis.” It is true, -that these patients may really have died of bronchitis; as nurses, we -cannot make diagnoses, therefore we have no right to question the -physician’s findings. But it is impossible for an intelligent nurse to -look on at a case of this kind without wishing it were possible to -obtain a second opinion. As public health nurses we cannot but object -that the last word on so serious a disease should be said by men whose -diagnoses we distrust. That the health of the community should be -endangered by even a few physicians of this sort,—either ignorant, or -dishonest, or both,—is grave commentary upon the medical ethics of the -day. It is a severe criticism on that “professional courtesy” which -forbids intervention, even by the health authorities, with a physician -who drives his trade at the community’s expense. The war against -tuberculosis cannot be fought to a successful finish until the public -refuses to countenance ethics of this sort. - -=The Nurse’s Responsibility to the Conscientious Physician Only.= In all -tuberculosis work, the nurse is singularly independent. When the patient -is in charge of the dispensary physician, or is in charge of a doctor in -sympathy with the tuberculosis movement, she may be said to be acting -under their orders. Or rather, there are no special orders, except in -individual instances, for the routine prescribed is always practically -the same. When a doctor reports a case, with the laconic statement, -“John Smith, such and such an address, usual thing,” he has fully stated -the situation. The doctor knows what should be done, and the nurse knows -what to do, and further words are unnecessary. Therefore, when for any -reason the patient gives up his doctor, the nurse can still continue to -supervise and direct. Months may pass before the patient revisits a -physician, and during these months the nurse is the only person in touch -with him. She also knows how to advise and direct those who are in -contact with him. When he finally calls upon a doctor again, her visits -still continue without a break—there should be nothing in her teaching -that is at variance with that of the newly arrived physician. The -chronic nature of tuberculosis makes this situation possible, and also -makes for the extremely independent position of the nurse. - -Whenever the physician is in the vanguard of the anti-tuberculosis -movement, he will recognize the nurse as an ally, not a rival. He will -know that she will make no attempt to supplant him with the patient, -since the chances are that she has been caring for the patient for -months before he, the doctor, has been called in. He will regard her, -therefore, as a highly efficient ally, who will relieve him of tiresome, -time-consuming details connected with the case. She will take charge of -routine matters that he has no time for, and thus set him free for -larger and more important tasks. - -If, on the contrary, the physician is one who exploits his patients, who -keeps the nature of the disease hidden, whether through ignorance or -design, and fails to give proper instruction as to its infectiousness, -then we must look for nothing but opposition and antagonism. We must -hear objections as to the nurse’s interference, to her uniform, to her -tactlessness, to her scaring the patient to death—and we must consider -the motives which underlie them. This brings us once more to the -question—under these circumstances, what is the nurse to do? Is she to -discontinue her visits, or is the value of her instruction to be -nullified by contradictory advice? Is a physician, who has consideration -for neither the patient nor the community to be allowed to jeopardize -both? - -To men of this stamp, the tuberculosis nurse owes nothing. Her business -is to do her duty, even when it brings her to cross-purposes with them. -She has been taught her work by the most advanced and progressive -members of the medical profession, and in the homes of patients she is -but carrying out the orders of these abler men. That they themselves may -have no direct connection with the patient does not alter the situation. -She is their agent, not the agent of the hold-overs from a passing -régime. Therefore, we look to the former to establish their agent, the -public health nurse, in a position of unassailable dignity and -authority. - - - - - CHAPTER IX - - Obtaining a Diagnosis—The General Dispensary—Sputum - Examinations—Tuberculin Tests—Registration of Cases. - - -=Obtaining a Diagnosis.= As we all know, it is not the business of the -nurse to make diagnoses, but it is emphatically her business to select -cases which should be diagnosed, and to send them where this may be -done. Therefore, if a community supports a tuberculosis nurse it will -also find it necessary to establish a place where she may send her -patients for examination—a special dispensary for the recognition of -pulmonary tuberculosis. If there is no such dispensary, in charge of a -capable physician, she may find it exceedingly difficult to obtain a -diagnosis for her patients, without which her hands are tied. She cannot -preach fresh air and prophylaxis to a person who has nothing but a -“heavy cold,” no matter how serious may be the symptoms in connection -with it. If the physician in charge of such a case is unable or -unwilling to make a diagnosis, it is necessary to have some court of -appeal to which the patient may be sent the moment he gives up his -doctor or his doctor gives him up. As we have said before, the nurse -must never influence a patient to change his doctor—on the contrary, she -must be exceedingly punctilious in this regard—but when the patient is -fickle and inconstant in his allegiance, she must take advantage of the -opportunities offered to send him where he may be skilfully examined. -The question of the special dispensary will be treated more fully in -another chapter—here it is simply our purpose to show the need of such a -place. - -In a community which is beginning tuberculosis work, there are usually a -few physicians who will generously volunteer their services in examining -suspected cases. The nurse, however, will feel some hesitation in -accepting these kindly offers, since to take full advantage of them -would be to swamp these physicians with a class of patients which would -leave them but little time for their private practice. These offers, -however, may well be utilized in the formation of a special dispensary, -since the same men would doubtless be equally willing to examine -patients at some central locality. No matter how humble the quarters, -how imperfect the equipment, it is necessary to establish as soon as -possible a special place where these patients may be freely examined -without any sense of intrusion or of incurred obligation. - -=The General Dispensary.= In many cities, general dispensaries exist for -the treatment of minor medical and surgical diseases. It is possible to -send tuberculous patients to these dispensaries, and to get them -examined and diagnosed, but as a rule this is not satisfactory. These -general dispensaries are usually crowded, and the physicians in charge -are unable to give sufficient time to the protracted, careful -examination which the consumptive requires. However, failing a special -dispensary, the nurse must take advantage of these general clinics and -accept all the help they are able to give. - -=Sputum Examinations.= In many States, the local or State Departments of -Health maintain laboratories for the examination of sputum. The nurse as -well as the doctor should be allowed the privilege of sending specimens -for examination. If the findings are positive, the result is a diagnosis -from which there can be no appeal. The difficulty with this means of -diagnosis, however, is that many specimens are negative upon first -examination. It may require repeated examinations to find the bacilli, -or before their continued absence may be considered evidence that the -patient is not tuberculous. Dr. Victor F. Cullen, Superintendent of the -Maryland Tuberculosis Sanatorium, writes: - -“We had one case that was examined sixty-seven times before tubercle -bacilli were found, and this was a far advanced case, with both lungs -involved from top to bottom, and cavities in each lung. - -“We have at the present time (September 14, 1914) a patient in the -Sanatorium, with both lungs diffusely involved, with a huge cavity in -her left lung, expectoration about two boxes daily, whose sputum was -examined twenty-four times, with only three positive findings. - -“These advanced cases with a lot of bronchial secretion are usually the -ones in which it is difficult to find tubercle bacilli in one or two -examinations.” - -The nurse, therefore, should send in specimens frequently, every week or -so, and should never be satisfied with a negative report. As we have -said before, finding the bacilli is proof positive that the patient has -tuberculosis, but not finding them is no proof to the contrary. -Countless lives have been sacrificed by considering a negative return as -evidence that the patient was not tuberculous. - -The nurse should carry in her satchel specimen bottles for collecting -sputum. These bottles are provided by the Health Department. If the -nurse has been called to a patient by the Federated Charities, or -through some similar source, or if the patient is one whom she herself -has discovered, she may send the specimen to the laboratory on her own -initiative. But if the patient is already under the care of a physician -who has not made a diagnosis, the nurse may call upon him and ask if she -may take such a specimen to be examined. This courtesy will doubtless -ensure better co-operation and understanding, but if the physician -refuses, the nurse is then in an awkward position. In a short time she -will learn the various physicians of her district, those whom she may -call upon, and those whom she may not, and she will learn to exercise -considerable discretion concerning them. - -Valuable as these sputum examinations may be in the case of a positive -finding, they should never take the place of a careful physical -examination. It is only when this examination is not to be had, when the -diagnosis can be obtained in no other way, that the nurse will be -obliged to rely upon sputum examinations alone in dealing with her -patients. A positive sputum should confirm the diagnosis made by -physical examination—it is not, or should not be, the only means of -obtaining this diagnosis. Therefore, the fact that a Health Department -is equipped to make sputum examinations should never for a moment -supplant the dispensary, in charge of a specialist or expert. A -specialist is able by auscultation, percussion, and an ear finely -trained to detect changes in the breath sounds, and to recognize -tuberculosis weeks before the diagnosis is confirmed by sputum findings. -In this way it is possible to place a patient under treatment long in -advance of the time when the average physician would have recognized the -disease—an advantage to the patient and to the community as well. - -=Tuberculin Tests.= There are two tuberculin tests commonly used, which -enable the specialist to diagnose doubtful cases. These are the eye and -the skin test. Strictly speaking, the public health nurse has nothing to -do with these tests, since they are entirely within the realm of the -physician, but she should at least understand their significance. The -Von Pirquet, or Skin Test, consists of inoculating the forearm with a -drop of tuberculin of a certain strength. A positive reaction is -manifest by a slight redness appearing within twenty-four hours and this -may persist for a day or two, after which it disappears. This test has -no value in the case of adults, since all adults are supposed to possess -some slight tuberculous focus, and therefore a reaction has no -significance. In the case of children, however, a positive skin test has -some value. Children are not as a matter of course supposed to possess -tubercular foci, and a positive reaction would therefore indicate that -they have become infected. A reaction, however, gives no indication as -to the location of the focus—it only proves its existence. - -The Calmette, or Eye Test, has more importance. A drop of tuberculin is -placed inside the lower eyelid of one eye, and if a reaction occurs, it -does so within twenty-four hours. The conjunctiva becomes slightly red -and inflamed, which condition persists for a day or two and then -disappears. In adults as well as children, this is a positive indication -of tuberculosis—not necessarily of a mere latent focus, but of a -possible lesion which must be watched and guarded against. It gives no -indication, however, of the location of the lesion. - -These tests are useful to specialists in helping them to highly refined -diagnoses. Dr. Hamman, however, questions the validity of these -extremely early diagnoses, unless they are confirmed by sputum findings. -If the bacilli are not found the diagnosis rests entirely with the -examiner, and is therefore dependent upon the personal equation. - -=Registration of Cases.= Most States have laws which require the -notification of infectious diseases, including tuberculosis. This means -that all physicians are required to report their cases of tuberculosis -to the Health Department, filling in a card, more or less complex, in -which is set forth the patient’s name, age, address, occupation, and the -duration and stage of the disease. In Baltimore, the nurses also are -allowed to register their tuberculous patients in this way, with the -city as well as the State Health Department. The card used is the same -as that used by the physicians, but with this difference—since a nurse -is unable to make a diagnosis herself, she is required to place in the -corner of the card the name and address of the physician or dispensary -responsible for the diagnosis. In this way the authorities are enabled -to know how many patients are under the nurses’ supervision, and the -sources of the diagnosis. - -Many of these registration cards are duplicates, the case having already -been registered by the attending physician, or the dispensary. If they -are not duplicates, it is necessary to have the official registration in -the handwriting of the physician himself—it is often needed when trouble -arises over the fumigation of houses, and so forth. There is nothing -official or authoritative about the nurse’s registration cards—these -merely call attention to the fact that certain patients are under her -supervision, attended by such and such a doctor. In most cases, the -diagnosis given is a verbal one. Should any difficulty arise, this -verbal diagnosis would not be valid, although it furnishes an excellent -basis from which to instruct the patient and his family. Therefore the -nurse’s registration card, if it is not a duplicate, serves to call -attention to the fact that a certain physician is in charge of a case -which he has not reported. The Health Department at once writes and asks -him to report, and in this way the diagnosis is officially recorded. - -In Maryland, the law calling for the registration of tuberculosis had -been on the statute books some years, but was generally disregarded. The -physicians failed to report their cases, and it was therefore impossible -to estimate the amount or distribution of tuberculosis. To do this was -the object of the law. How generally this regulation had been ignored -may be judged from the fact that in 1909, the year before the Baltimore -municipal nurses went on duty, the number of cases of tuberculosis -registered by physicians was only 919, while the deaths from -tuberculosis for that same year were 1400. In 1910, the first year that -the nurses were on duty, the cases registered jumped up to 3202, while -the deaths fell to 1234. This sudden increase in the registrations—an -increase of over three hundred per cent.—shows the stimulating effects -of a staff of active public health nurses. - -How necessary it is to have the diagnosis recorded in the physician’s -own handwriting may be judged by the following incident. There was a -coloured man on our list, referred to us by a private physician. This -patient was a model in a school of painting and drawing, and after a -time the Health Department was flooded with complaints concerning him. -These complaints came from pupils, who declared they were afraid to go -to the classes, because the patient coughed so violently and spat so -profusely. The students did not know he was tuberculous, but they -suspected it, and therefore asked us to look into the matter. Finding -that the man was one of our patients, we at once wrote to the directors -of this school, telling them of this, and of the complaints that had -been made against him. We further suggested that if he continued to pose -as a model he should use the prophylactic supplies that the nurse had -given him, and which he used faithfully enough in his own home. The -Directors, however, would not take our word for this; they sent the -patient to another physician, not the one who had originally examined -him. To this man, the darkey protested that he had never seen a doctor -in his life. The second physician declared that the patient did not have -tuberculosis, wrote a note berating us for our interference, and called -upon us for proof. A hurried search of the files brought forth the -original registration card, sent in by the physician who had first -diagnosed the case, and transferred it to the nurses of the Health -Department. This fact at once threw a different light upon the matter, -and we were able to uphold our contention. The first physician, however, -had completely forgotten this patient, and had it not been for his -registration card, on file at the office, we should have been in a very -disagreeable position. - -Since there is nothing authoritative about the nurse’s registration -card, she must be exceedingly careful never to register a case unless it -has been properly diagnosed. This information should be obtained from -the physician himself, whether in writing, verbally, or over the -telephone. She should never accept a third person’s word for the -diagnosis, no matter how accurate it may seem. For example, if a -patient’s mother tells the nurse that the doctor has just been in, and -said her son had tuberculosis, the nurse must not accept this statement -as sufficient. She must call upon the physician and ask him herself. -Again, suppose the nurse has sent a patient to the dispensary, and, -meeting him on the street an hour later, she learns that the doctor’s -verdict was consumption. She must not take the patient’s word for this, -obvious as its truthfulness may seem. It is necessary to be thus -punctilious, to prevent unpleasant occurrences from taking place. The -diagnosis of tuberculosis is too serious a matter to be accepted through -any such irresponsible medium as the patient or his family. - -To fill in the registration cards is the nurse’s work. To supervise -these cards, and note their correctness and accuracy, should be the work -of the superintendent of nurses, in whose name they should be signed. -This transaction is one of the most important tasks of the office, and -extreme care should be taken that non-tuberculous patients are not -registered by mistake. - - - - - CHAPTER X - - Prevention of Tuberculosis—Sources through Which Calls are - Received—Entering the Home—Telling the Truth to the Patient—Truth - for the Family—Disposal of Sputum—Danger of Expired Air—Isolation - of Dishes—Linen, Household and Personal—Disinfectant and Other - Supplies—Phthisiphobia. - - -=The Prevention of Tuberculosis.= The object of the nurse’s work is to -prevent the spread of tuberculosis—it is not to cure the disease. In -doing the preventive work, it often follows that the patient himself is -immensely benefited, and his disease apparently arrested. This arrest, -however, is incidental—it is not the real object of the work, which is -the protection of individuals as yet uninfected. In no other branch of -nursing is there so much misunderstanding, so much placing of the cart -before the horse, and so much emphasis laid on the wrong thing. Nurses -themselves when they first begin the work fail to recognize the real -issue, and think that it is the actual care of the patient which is the -thing to be considered. This is totally wrong—_we work through the -patient to gain our ends, but he himself is not the main object_. It is -necessary to grasp this fact firmly, and keep it constantly in mind. -This will not only prevent much disappointment and discouragement, but -it will lay the foundation for more intelligent work. - -On entering the home of the consumptive, the nurse has before her two -responsibilities, the family and the patient. The former is infinitely -larger and more important, since it is the family, as yet uninfected, -which must be protected from the patient, or source of the disease. -Instead of “family” substitute the word “community” and we have the crux -of the situation—the protection of the community from the danger to -which it is exposed. This protection may be accomplished largely through -care of the patient, but care of the patient, only, as such, is a -secondary matter. The vital and important concern is the welfare of his -family. To confuse these two issues, and put the patient first, and the -family, which means the community, second, would delay indefinitely the -result we hope to attain. As far as possible, the interests of the two, -patient and family, should be identical, but whenever a choice must be -made between them, the welfare of the community has the right of way. - -This is why effective tuberculosis work must place the emphasis on the -control of the last-stage cases, since it is the advanced case which is -of most danger to society. For example: we have two families, one of -which contains a moderately advanced case, whose outlook is favourable, -while the second contains a last-stage case with a hopeless prognosis. -Both patients are equally intractable; the nurse has but a limited time -at her disposal, and must choose between the two, since she cannot -divide her days equally between them. From the point of view of the -individual, care of the earlier case would better repay her time and -effort; from the standpoint of the greatest good to the greatest number, -she must concentrate her efforts on the advanced case, since it is this -one which is immediately dangerous. The earlier case is less of a menace -to those about him; his obstinacy and refusal to follow advice mean loss -of that precious time in which life and death are determined—but if he -chooses, however wilfully, to waste this time, it is his own loss after -all. It involves no one else. On the other hand, much more is involved -in the advanced case. Here the patient’s death is inevitable, but it can -be kept from occurring amid circumstances which would drag down others -with him. - -In the majority of cases, the death of the patient is the issue to be -expected, however much it may have been delayed or postponed—a result -saddening and discouraging to those whose previous training has been to -preserve life. What nurses are not trained to see, and what many of them -have neither imagination nor faith enough to see, is the number of lives -that are probably saved through the safeguarding of a dying individual. -It has been said that the world would be infinitely better off if every -consumptive in it could die to-day, since by this loss the people of -to-morrow would be saved. The nurse must cease to reckon in terms of -hundreds of patients—she must reckon in terms of the thousands who come -in contact with these patients. The amount that can be done to protect -these thousands is the standard by which the work must be judged a -failure or a success. If she bears this constantly in mind, she will not -become so easily discouraged. - -Therefore, to sum up once more: upon entering the home, the nurse’s -first care is the family, and her second is the patient himself. But it -is by working through the latter that the former may be reached. The -patient himself is the point of attack, and if in the ensuing pages he -becomes so prominent as to delude one into thinking that his welfare -alone is the final goal, he is only made prominent in order that we may -reach our goal more quickly. - -=Sources through Which Calls are Received.= The nurse goes to the -patient’s home, in the first instance, at the request of some one who -has sent her. This may be a physician, a dispensary, a neighbour, or she -may even go on her own shrewd suspicion that some one is ill. When the -door is opened to her knock, she must be careful how she explains her -coming. If a municipal nurse, she should never say that she has come -from the Health Department, for this conveys a suggestion of authority -which is often most alarming. Since the patient has been referred to the -Health Department from one of the sources just mentioned, it would be -more tactful to name the agency through which the call was received. - -When calls are anonymous, such as by letter or telephone message, or -when the sender gives his name but asks that it be withheld from the -patient, the task of gaining an entrance is often one of considerable -difficulty, and requires much strategy. Calls of this sort should never -be refused, since in this way many advanced cases are brought to light. -It is also a wholesome indication that the community is learning to take -an intelligent interest in an infectious disease, whose presence is -recognized as a menace. These cases can best be managed if the nurse -assumes the responsibility herself, saying that in a roundabout way she -has heard that there is illness in the house, and so has called to offer -her services. As a rule, her offer will be readily accepted, for a case -reported in this manner is usually advanced, and, as we have said -before, when the neighbours diagnose tuberculosis, they are frequently -right. - -=Entering the Home.= As a rule, when a nurse presents herself at a house -and explains her errand, the door is opened wide and she is cordially -asked in. In some instances, it is held half-shut, in a dubious manner, -and she is admitted with reluctance. Sometimes it is banged in her face. -It is a great satisfaction to gain an entrance into homes of the latter -class; to win the confidence of such patients is a victory worth having. -The surest formula for entering all homes is a broad smile; to stand on -the doorsteps and grin like a Cheshire cat disarms suspicion, and once -across the threshold, the victory is won. - -=Taking the Patient’s History.= The facts concerning the patient must be -gathered in his home, and they are of two kinds, those concerning his -physical and those concerning his social condition. The first thing to -be done is to establish a feeling of trust between the patient and the -nurse. As a rule, all patients are communicative, and a few adroit -questions will open a flood-gate of confidence from which can be -gathered full details concerning their personal and family affairs. This -gives the nurse much of the information which she needs not only for her -charts and records, but also in order to deal intelligently with each -case. For unless she understands the patient, and knows something of his -social and economic condition, she will not be able to give helpful -advice. But the nurse must also bear in mind that tuberculous persons -are frequently shy and sensitive, and it may be difficult to obtain -their true histories. They may be more ready to describe their physical -symptoms than their social condition, and facts about their employment, -hours, wages, life insurance, and so forth are not always forthcoming. -It is inadvisable to make notes in the presence of the patient, for -among the poorer classes there is a fear that their words, when noted in -a book, may in some mysterious manner be used against them. -Occasionally, in a matter of some importance, distrust may be quieted by -asking, “May I just write that down? The doctor will be interested in -that and I want to get it right,” but it is well to remember that -suspicions once aroused are difficult to quiet, and that for the welfare -of the community it is better to teach them to use their sputum cups, -than to antagonize them by too many questions. The nurse should get all -the facts the chart calls for, but with certain patients this may take -considerable time. At each succeeding visit she can ask another question -and a more intimate one, until she collects, little by little, all the -data she requires. But it is a mistake to keep on asking -questions—collecting statistics—at the expense of confidence and -good-will. - -It is true that when a patient goes to a dispensary, he is prepared to -answer many questions, but there is this difference—it is he who seeks -the dispensary. When the tables are reversed, when he is not the seeker -but the one sought, he must be handled carefully. There are of course -many patients to whom this does not apply, and who willingly volunteer -every detail of their lives, but these are not the majority. The others, -the more sensitive ones, make up three quarters of the visiting list. -The antagonizing of a patient by tactless questioning is an unfavourable -commentary on the method of handling him. - -=Telling the Truth to the Patient.= The most difficult of the nurse’s -duties, and the saddest, is to tell the patient the nature of his -disease. Yet this must be done, for unless he knows from the very -beginning, it is impossible to exact from him that intelligent -co-operation upon which rests his sole hope. Only on the rarest -occasions is there any justification for withholding this knowledge. If -a patient has but a few more days to live, or if a hopeless case is -surrounded by scrupulous care and attention, this information may, if it -seems best, be withheld. But these are exceptional instances. To hide -the truth from an early or moderately advanced case would be criminal. -Apart from the first shock, people are never really injured by being -told the truth, and we all know of hundreds of cases in which lives have -been ruthlessly sacrificed through the policy of silence. - -The truth need not necessarily be brutal—it can be made full of hope, -interest, and encouragement. In her efforts to encourage the patient, -however, the nurse must be exceedingly careful never to use the word -“cure.” Tuberculosis is never cured in the sense that typhoid fever is -cured, for example. At best, it is only arrested—that is, brought to a -standstill, to a point where the destruction of the lung tissue goes no -farther. Thus, if a person loses one or two fingers from a hand, a cure -would imply that these lost fingers could be made to grow again. The -lung tissue destroyed by tuberculosis can not be replaced or renewed any -more than lost fingers can be renewed. Yet a lung, in spite of this -loss, is still able to serve its owner well and enable him to lead a -useful and happy life, just as a hand which has lost a finger or two may -still be a fairly useful hand, and serve its owner well. This -distinction between arrest and cure must be made perfectly clear to the -patient, and he must also be taught that whether the arrest of the -disease is temporary or permanent depends in large measure upon himself. -His improvement depends upon his thorough understanding of his illness, -and upon his ability or willingness to co-operate as to treatment. -According to Dr. Minor,[3] it is not so much what a patient has in his -lungs, as what he has in his head; namely, common-sense, which -determines his recovery. Therefore to keep a patient in the dark -concerning his condition, and yet expect him, without knowing the -reason, to do over and over again the tiresome routine things necessary -to improvement, is to expect the impossible. - -Footnote 3: - - Dr. Charles L. Minor, Asheville, North Carolina. - -In making the best of things, the nurse must never over-encourage the -patient. A half-starved, overworked person, suddenly put on a régime of -fresh air, rest, and abundant food, will often make surprising -advances—up to a certain point. This improvement may be so marked that -it will raise false hopes of its continuance and the nurse must never -jeopardize her reputation and the confidence imposed in her, by -extravagant statements as to what may be accomplished. The overconfident -patient mistakes temporary improvement for permanent cure. Tuberculosis -is like a concealed enemy, crouched and ready to spring the moment one -turns one’s back, and it requires constant vigilance to guard against -it. If this fact could be securely drilled into the patients, there -would probably be fewer relapses. - -=Truth for the Family.= If now and then an exception may be made in -informing the patient of his condition, there are no conceivable -circumstances under which this knowledge should be withheld from his -family. The significance and danger of tuberculosis must be fully -explained to all who are exposed to it. It is the “family” who -constitute public opinion as far as the patient is concerned, and we -must depend upon it to keep the patient up to the standard of living -which means his improvement and their protection. The nurse should fully -explain the situation to some older, responsible member of the -household. This can best be done out of the patient’s presence. She must -speak very plainly, using words within the comprehension of her hearers, -so that they cannot fail to grasp her meaning. The patient needs this -knowledge in order to get better—the family need it in order to protect -themselves. It is a sad fact, but a frank appeal to the selfish instinct -is usually productive of better results than one made upon higher -grounds. Both points should always be made, but the instinct of -self-preservation may be aroused with less prodding than is needed to -awaken rudimentary altruism. - -=Disposal of Sputum.= The nurse has by this time prepared the way for -the prophylactic supplies, which she carries in her bag. These consist -of a tin cup, fillers, paper napkins, disinfectant, and so forth. She -must teach the patient how to use and dispose of them, as well as their -advantages—the latter reason not being always apparent to the ambulatory -case. She must teach that danger to himself and others lies in the -sputum coughed up from his sick lungs, and that the simplest way to -receive it is in the little tin cup, whose waterproof filler can easily -be burned. To the advanced case, with profuse expectoration, these -light, convenient little cups are a great improvement over the household -spittoon, which should be banished at once. Bed patients, or those too -weak to raise even this light cup to their lips, may be taught to -expectorate into the paper napkins, of which they should be given a -large supply. A simple way of disposing of these napkins is to pin to -the bedclothes a large paper bag (such as are used for groceries), into -which they may be thrown. Failing a paper bag, a cornucopia made of -newspaper will answer the purpose, the object being to let the patient -himself place this infective material in a receptacle which can be -burned in its entirety, without its contents being handled by anyone -else. - -The problem of destroying sputum cups and their contents is often -difficult. The proper and only sure way is to burn them, and no other -course should be considered. Yet in summer, when many patients have no -coal fires, but merely gas or oil stoves, many difficulties arise. Under -such circumstances the patient may wrap his cup in a newspaper, place it -in a galvanized iron bucket, and then set it on fire. This is a -nuisance, as well as somewhat dangerous, and since these fillers and -their contents are hard to burn, the simpler method of throwing them in -the gutter becomes an irresistible temptation. To see that these fillers -are properly destroyed requires constant supervision and instruction and -is one of the most important of the nurse’s duties. - -The patient should destroy the fillers himself—they should be handled by -no other member of the family, unless of course he is too weak and ill -to do it. Even when very ill, however, it is nearly always possible for -him to remove the filler from the cup and place it in a newspaper, which -is then rolled up by someone else and carried out to the fire. Needless -to say, the nurse must teach those who touch or handle this cup how -important it is to wash their hands thoroughly afterwards. - -=Danger of Expired Air.= After giving him the tin cup and fillers, the -nurse must then give the patient a supply of paper napkins, and explain -their purpose. These are primarily intended to hold over the mouth when -coughing. The nurse must explain that bacilli are liberated in great -numbers during these coughing attacks, and that it is harmful to live in -a room filled with these invisible organisms. Most patients, knowing -themselves to be infected, are indifferent to the welfare of those about -them. Therefore, in trying to make him careful, the nurse will have to -appeal to his selfish instincts, and show that what is bad for other -people is equally bad for him, and so diminishes his chances of -improvement. - -It is comparatively easy to instruct a patient in the use of his sputum -cup, but to obtain any sort of carefulness in this equally grave -matter—liberation of bacilli in the expired air—is well-nigh impossible. -This is partly due to the nature of the disease—in its most infectious -stages, the patient is so racked with paroxysms of coughing, that it is -impossible for him to keep his mouth covered, or to think of anything -except his own sufferings. - -On the street, these paper napkins may be used to spit into, the patient -carrying them home again in the waterproof pocket pinned inside his -coat. Fine details of this sort are difficult to insist upon, -however—the convenience of the street and of the gutter making a -stronger appeal than any newly acquired æsthetic valuations. This is of -minor importance, however; the real danger lies in the home. - -=Isolation of Dishes.= The consumptive should have special dishes -provided for him, which should never be used by any other member of the -household. If the family can afford it, they should buy dishes of a -special pattern, unlike those in general use, since in this way the -chances of mixing them are greatly lessened. Otherwise, constant care -must be taken to keep them apart. The patient’s dishes should stand on -their own corner of the shelf, be washed in a separate dishpan, and -dried with a special towel. Once a week, for general cleanliness’ sake, -they should be boiled. Any dish which may have got mixed with them, or -has inadvertently been used by the patient, should be boiled before -being used again in the household. The patient need not necessarily know -that his dishes are isolated, since details of this kind are explained -to the family rather than to the sick man. - -If he is a bed patient, it is an easy matter to isolate his dishes, -without his knowledge; when he is up and about, it is much harder. -Patients are particularly sensitive about this, and some families, -rather than risk hurting the feelings of the invalid, prefer to boil the -dishes after every meal. This adds so much to the work of the busy -household that after a time all attempts at isolation are dropped. This -matter calls for considerable vigilance on the part of the nurse. - -=Linen, Household and Personal.= All linen, including clothing and bed -linen that has been used by the patient, should be boiled before it is -washed. There seems to be some prejudice against this previous boiling, -as the family are apt to maintain that it makes it more difficult to get -the linen clean afterward. The nurse should overcome their objections, -and emphasize the necessity for the utmost caution in regard to this -infective material. - -=Disinfectant and Other Supplies.= At a later visit, the disinfectant -may be given, as well as the waterproof pockets and books of -information. During the first visit, it is better to give only the most -important of the supplies—the tin cup, fillers, and napkins—and to save -the rest for another time. For on her first visit the nurse is a -stranger—later, she becomes a friend. Therefore she will make better -headway if on her first appearance she does not burden the family with -too much instruction and too much detail. It is better to say too little -than too much, better to leave something unsaid until the next time, -rather than overwhelm those she visits with a mass of advice which they -cannot assimilate. Her first visit has been made as the bearer of -distressing news, no matter how gently and carefully it may have been -broken, and the distress and confusion which often arise fill the minds -of her hearers to the exclusion of nearly everything else. - -During her later visits, she will have ample opportunity to say all that -should be said—and at each succeeding call she will find that much of -what she said the time before has been forgotten, misapplied, or -altogether ignored. Tuberculosis work means the constant and incessant -repetition of the same thing, trying by every device imaginable to point -the way, to make an impression, to obtain some slight degree of -carefulness which may mean the protection of other people. - -=Phthisiphobia.= People frequently reproach the nurse with the fact that -her teaching tends to alarm the patient and his family, and to produce a -community phthisiphobia which works great hardship in individual cases. -As far as the community is concerned, fear of tuberculosis is a good, -wholesome sentiment, and infinitely preferable to ignorance and -indifference. We cannot have too much of a public opinion which declines -to be exposed to this disease, and which will therefore provide the -machinery to cope with it. As far as the family is concerned, we have -never been able to produce _enough_ fear of tuberculosis. It would -greatly facilitate the campaign if the first feeling of alarm and -apprehension could become permanent, instead of very transitory and -fleeting. Tuberculosis is so slow and insidious in its onset,—there is -nothing spectacular, by which we can demonstrate to the ignorant mind -the relation between cause and effect, exposure and infection,—that the -educational method alone is inadequate to deal with the situation. If -the alarmed patient and his household could or would continue the -preventive measures which at first so strongly appeal to them, and which -in the beginning they apply with boundless enthusiasm, we should have -comparatively little difficulty. But the disease is chronic and slow; -the scare wears off, and the cry of “Wolf, Wolf” loses its value. And -then follows a relaxation of prophylactic measures. Each time the nurse -must stir them up anew—encourage, threaten, alarm, coax, bribe,—do -everything in her power to awaken them from their mental apathy and -drowsiness, which, as in morphia poisoning, precedes death. - - - - - CHAPTER XI - - Inspection of the House—The Patient’s Bedroom—Porches—Gardens and - Tents—Flat Roofs—Clothing and Bedclothing—Artificial - Heat—Rest—Fresh Air—Food—Cooking—The Bedridden Patient. - - -=Inspection of the House.= On her first visit the nurse must inspect -every room in the patient’s home, with a view to knowing what -possibilities it affords for treatment and isolation. Some contain no -facilities whatsoever; some but meagre ones, while in others may be -found excellent opportunities which the patient must be taught to use. -Before advising any change or rearrangement, several factors must be -considered: the stage of the disease, number in family, financial -condition, home surroundings and the institutional facilities of the -community. The course to be taken depends whether or not there is a -hospital, or whether or not the patient must wait some time before -admission. The first object is the protection of the family, but all -those measures which bring this about, offer at the same time the -maximum advantage to the patient himself. To remove him to an -institution is the best way to accomplish both ends. If this cannot be -done, the nurse must endeavour to secure conditions in the home which as -nearly as possible approach those of an institution. The closer this -approximation, the greater the gain to both patient and those who -surround him. - -=The Patient’s Bedroom.= The first thing to be considered is the -patient’s bedroom, or sleeping quarters. He should have this room to -himself, sharing it with no one. If this cannot be arranged, he should -at least have a bed to himself. This bed, and that of the other person, -or persons, should be placed at opposite ends of the room, and as far -apart as possible. - -The more windows in the room the better; these should be kept open to -their fullest extent. In some houses, where the windows are small, it is -often possible to lift out the entire sash, thereby admitting more air. -The bed should be placed directly at the window, so that the patient may -lay his pillow on the window sill if he chooses. He should be instructed -to sleep facing the opening, in order to get all the air he can. The -nurse should rearrange the furniture as she wishes it, otherwise -misunderstandings may occur. If the family object to her moving it but -promise to do this themselves, she must be careful to inspect the room -again on her next visit, to see that this has been properly done. Even -with families that have been under supervision a long time, it is well -to inspect the bedrooms occasionally, for the patient’s bed always has a -tendency to retreat into a remote corner of the room, especially in -winter. - -The floor should be bare, and this, together with all other plane -surfaces should be washed several times a week with hot water and soda. -Great caution must be exercised in making a sanitary sick-room, but, in -her enthusiasm to produce ideal conditions, the nurse must remember that -articles used for months by the patient, and suddenly banished from his -proximity, may be very deadly elsewhere. In advising that carpets and -curtains be removed, she must be careful what becomes of them. If -germ-laden carpets are sold, or given to the neighbour next door, they -would better remain where they are. Poor people find it hard to -withstand the temptation to sell or give away serviceable articles, -which is of course but natural, but the nurse must be on guard against -such occurrences. - -To have an ideal sick-room, there is no necessity for its being -depressing by its bleak ugliness, or bare and dismal as a cell. Washable -muslin curtains may be permitted, and there is no objection to pictures -and ornaments in moderation. It is bad enough to have tuberculosis, -without penalizing the patient by removing from him all those little -treasures which give him pleasure and harm no one. - -In selecting a good room for the patient, the nurse may find it -necessary to have him exchange with some other member of the household. -In this event, great care must be taken that the room vacated by the -patient is thoroughly cleaned and disinfected before being occupied by -anyone else. There are also circumstances which render it unwise to make -this exchange: for example, say that we have a moderately advanced case, -whose improvement is doubtful. He is occupying a room with one -window—not ideal, but fair enough. There is also another room in the -house, containing several windows, altogether brighter and larger, but -occupied by three or four people, so far healthy and sound. To exchange -rooms under such conditions would be bad policy—it would be of little -advantage to the patient himself, while the other people would be -subjected to overcrowding and bad ventilation, which would decidedly -lower their resistance. Those in prolonged, intimate contact with a -consumptive must not be allowed to reduce their vitality in any way. - -To arrange a good sanitary room for a patient does not in the least mean -that he will use it. Such a room would doubtless appear well in a -photograph, illustrating the “before and after” phases of the nurse’s -activity, but this does not necessarily mean that the patient is -isolated and harmless. He will probably use his nice room for sleeping -purposes only, and it is what he does with the remainder of his time -that counts. He comes into contact with the household at meals, in the -evenings, and on innumerable other occasions, and the consciousness of -an immaculate bedroom should not lessen the nurse’s anxiety about the -kitchen, the living-room, and the family sofa. There is where the danger -lies. - -=Porches.= In some houses we find a porch readily available for the -patient’s use, where he can sleep and spend most of his daylight hours. -It is sometimes difficult to induce him to make use of it, however. We -must also remember that there is a great difference in porches. Some are -narrow, unroofed, exposed to sun and wind, have disagreeable outlooks, -for instance, as on unsavoury alleys, and in other ways are unfit to be -used as living-rooms. They should be used, of course, whenever -practicable, since undoubtedly the patient will get more air, and more -constantly changing air, than if he sleeps indoors. Yet it is well to -realize that a place where the patient is unsheltered, uncomfortable, -and where he cannot sleep or have a quiet mind, is often far less -valuable than a good bedroom which may give him all of these -necessities. - -Patients in well-to-do circumstances can equip their porches admirably, -both with awnings and with canvas screens. These latter should roll up -from the floor, rather than down from the roof. Screens and awnings can -be made to order by any awning or sail maker; the price varies with -their construction, from about five dollars upward. To teach a patient -to use a porch for sleeping and also to use it as a living-room should -be the nurse’s constant endeavour. Even an ideal porch is like an ideal -bedroom—only valuable if it is used. - -=Gardens and Tents.= Many houses have little yards or gardens, easily -adaptable for open-air living. A tent may be erected for sleeping -purposes, if the space is large enough and the family can afford it. -Women and children are usually afraid to sleep under such exposed -conditions, and in consequence refuse to make use of what would -otherwise be an excellent opportunity. These gardens may be used during -the day, however, and the patient made comfortable in a reclining chair -or lounge. But excellent as they appear theoretically, the extremes of -our climate, excessive heat and cold, often make them unpractical for -the consumptive’s use. Under such circumstances, these little back yards -often become anything but ideal places in which to “take the cure.” - -=Flat Roofs.= We also find flat roofs or sheds attached to certain -houses in the tenement districts. These sometimes offer excellent -conditions for long hours out-of-doors, and may also be used as -sleeping-porches. The nurse must be alert to seize all opportunities -which present themselves, and to teach her patients to utilize them. - -=Clothing and Bedclothing.= In her effort to teach her patient to sleep -out-of-doors, and to spend most of his waking time there, the nurse must -remember that in winter this is impossible, if he is insufficiently -clad. The vitality of the consumptive is always below par, consequently -he needs much more clothing than would a healthy person under the same -conditions. It is impossible to expect patients to remain out-of-doors -if they are cold and uncomfortable, and before insisting upon open-air -treatment the nurse must see that it is possible for them to take it. If -they lack the necessary clothing—underwear, blankets, sweaters, -overcoats—these may be procured through some charitable association. It -is a part of the nurse’s duties to arrange for this assistance, the -question of which will be dealt with in a later chapter. - -=Artificial Heat.= In addition to extra clothing, artificial heat is -nearly always necessary, and this may be procured by means of hot-water -bottles, hot bricks, stove lids, and so forth. The clothing itself may -be sufficiently warm, and a hot brick may be all that is necessary to -keep the patient in the yard, rather than in the kitchen. The patient -must learn to live in the open-air—and the family must also learn that -their safety lies in keeping him there, and is well worth the trouble of -filling a hot-water bottle now and then. A hot kitchen is the worst -place in the world for a coughing consumptive—and a coughing consumptive -is the worst thing in the world for a hot kitchen—and the inhabitants -thereof. It is fortunate that the rule works both ways, so that both -sides may be appealed to. - -=Rest.= The three things necessary to improvement are rest, fresh air, -and food. Not one alone, nor two alone, but all three together, if -results are to be obtained. It is very difficult to impress upon the -patient that rest is not exercise, and that nothing is as bad for him as -exertion. He instinctively associates fresh air with exercise, and does -not realize that fresh air and rest is the combination required. If a -physician is in charge of the case, he of course would direct the amount -of exercise to be taken, but if, as often happens, there is no doctor in -attendance, the nurse must use her own knowledge of what is best. In a -sanatorium the usual rule is that all patients with more than 99 degrees -of fever shall stay in bed. After a hemorrhage, absolute rest is of -course indicated. - -Therefore the nurse should try to induce her patients to rest as much as -possible—not to walk about, or to drag themselves to a park, and so tire -themselves out. Exertion increases fever, and this will counteract what -benefit might have been gained through the fresh air. They should be -taught to sit comfortably in their gardens, on their front sidewalks, on -their porches, at their open windows. Best of all, they should go -upstairs to their bedrooms, and lie at full length on the bed placed -next to the open window. By thus emphasizing the importance of -rest—synonymous in this case with outdoor rest—the nurse is not only -giving sound advice to her patient, but she is protecting the community -from the ambulatory consumptive. - -Whenever possible, the patient should be induced to remain in bed -permanently. The sooner the weary, advanced case gives up his painful -wanderings, stops dragging himself from his own to his neighbour’s -kitchen, or to the hospitable bar, the better for him and for the -community. If he were to go to bed in a hospital, instead of at home, -greater still would be the gain. The part of the community constituted -by his family would be freed from danger, while he himself would be -adequately cared for. Again we are struck by the coincidence of what is -best for the patient being also best for those who surround him. - -=Fresh Air.= Fresh air is the second great essential in the treatment of -tuberculosis, and every patient should be taught to spend as many hours -as possible out-of-doors. The nurse must explain in words of one -syllable why this is necessary—that clean, pure air contains life-giving -oxygen, and that to breathe it entails little exertion on the part of -the sick lungs. On the other hand, impure air contains no upbuilding -principle, but greatly taxes the lungs and makes breathing difficult. -Outdoors, every breath of air is clean and pure; indoors, especially in -a closed room, one is soon reduced to rebreathing expired air, with all -its impurities. Just as tainted meat or spoiled fruit or vegetables are -unwholesome, and bad for the stomach and general system, so is impure -air harmful to the lungs and general health. One organ surely deserves -as much consideration as another. And when the lungs become impaired -through disease, it is still more necessary to take care of them. They -need to be strengthened in every way, in order to defy the inroads of -tuberculosis. The nurse must make her points clear and emphatic; if the -patient takes an intelligent interest in his treatment, it will become -less irksome. - -But it is not enough to tell the patient why he needs fresh air—the -nurse must show him how to get it. He is singularly helpless and unable -to recognize such ways for himself. Also she must overcome his -objections and bring him to her way of thinking. Thus, he objects to his -porch because it is shaky, or because it may only be reached by passing -through another person’s room. Investigation may prove the shakiness -imaginary, or at least not dangerous, while the other person may be only -too willing to let his room be used as passageway to this desirable -goal. Again, he objects to sitting in the yard, or on the sidewalk, or -even at his window, for fear of what the neighbours may say. It should -be pointed out that his health is more important than their -comments—whatever they may or may not be—and that his interest, not -theirs, should come first. The nurse must plan every little detail; she -must select his chair or sofa; must show how he can be warmly tucked up, -and sit out of the wind or sun, as the case may be. She must teach the -family about the hot brick and how to place it at the patient’s feet—or -two hot bricks, if need be. It is not enough to say: Do thus and so—she -must herself demonstrate how the thing is done. The consumptive is sick -and helpless and needs constant reassuring. If he belongs to the very -poor, he has little to do with, and is so ignorant that he cannot make -the most of what he has. This teaching is one of the chief duties of the -nurse. - -=Food.= The third great essential in the trilogy is food. The patient’s -diet is of the utmost importance, since his ability to take and -assimilate nourishing food determines his ability to build up enough -resistance to cope with tuberculosis. Generally speaking, he should be -encouraged to eat every kind of nourishing food that he can digest—for -tuberculosis does not call for a special diet as does typhoid or -diabetes. Anything which specifically disagrees with him should, of -course, be excluded. The question of food values must be considered; -with the poor, this requires careful teaching and explanation. The nurse -should point out the difference between food which merely fills the -stomach, and food which nourishes and upbuilds. In the first class may -be instanced cabbage, turnips, doughnuts, pies—all highly esteemed by -the poor, and cheap and indigestible. In the second class are meat, -eggs, milk, fish, rice, beans, hominy, oatmeal, and so forth. Some of -these nourishing foods—rice, beans, hominy, oatmeal—are no more -expensive than cabbage and pie. The family should be taught the -difference. Very harmful and indigestible are the products of the corner -bakery, the penny candies, the enormous pickles, and the copious strong -brews of tea and coffee which form so large a part of the dietary of -those near the poverty line. Considerable money is spent on these -things—often money enough to provide a wholesome meal, if the family but -knew how to discriminate. In planning a patient’s diet, the nurse will -have to do as much exclusive as inclusive propaganda. - -It is not necessary to insist on milk and eggs, certainly not in the -abnormal quantities which a few years ago were considered indispensable -in the treatment of tuberculosis. If a patient likes these and can -afford them, well and good, but they need by no means be made the staple -article of diet. This rich and highly concentrated food has a tendency -to cause indigestion, and since this is one of the gravest and most -distressing complications of tuberculosis, it must be prevented at all -costs. A patient unable to digest his food has but slim chance of -increasing his vitality, and little hope of improvement. Therefore, in -advising raw eggs, the nurse must be very careful; one or two a day will -be sufficient, over and above the regular meals. - -Milk should be substituted for tea and coffee. Three or four glasses a -day will be enough, and even that may be too much if the patient eats -well of other things. In place of raw milk, it may be peptonized, -malted, given hot, made into junket, taken in cocoa, or as one of the -flavoured milkshakes, or turned into clabber or buttermilk. These -varieties of milk are good for advanced patients, who may also be given -egg albumen, flavoured with lemon, orange, ginger ale, grape juice, and -so forth. The family must be taught to make these little innovations, in -the ordinary diet, and instruction in these is part of the nurse’s work. - -By careful supervision and attention, the nurse can procure a very -satisfactory dietary, one both nourishing and digestible. Three good -meals a day, with a little nourishment between meals and at bedtime (a -glass of milk or its equivalent), will be found quite satisfactory. If a -doctor is in attendance, he will of course arrange such diet as he -thinks best, but if the nurse is left to herself, she will not overstep -the boundaries if she advises some such plan as we have outlined. - -As we have said, indigestion is one of the most frequent complications -of tuberculosis. In some cases this can be overcome or relieved by -advising rest in the reclining position for an hour before, and -immediately following meals. If the patient lies flat on the bed or -lounge, this will be more effective that if he sits in a rocking-chair. - -=Cooking.= Cooking and the preparation of food also require supervision, -for, especially among the poor, dense ignorance of these important -matters prevails. Through improper cooking, wholesome, excellent food is -often turned into something quite the reverse, indigestible and -injurious to a high degree; or, if not ruined, it may lose so much of -its food value as to be practically worthless. Thus, a hard-boiled egg -or a fried egg (especially if fried on both sides) is less easy to -digest than a soft-boiled one. A good piece of meat may have its entire -value removed by overcooking. All nurses have had training in dietetics, -and this special knowledge is of immense value in public health work, -where for the most part they come in contact with a class of people -whose ignorance of culinary matters is profound. - -=Alcohol.= The question of giving alcohol frequently arises in this -work. If a doctor is in attendance, he will prescribe it or not as he -chooses. But if the nurse alone is in charge of the case, and the matter -is left to her decision, we feel that the ruling of the Phipps -Dispensary of the Johns Hopkins Hospital is a wise one to follow—no -alcohol for the consumptive under any circumstances. This means that -there shall be no eggnogs, made with brandy, sherry, rum, etc.; no -sherry with raw eggs—no indulgence in wine, beer, or alcoholic -stimulants of any sort. - -=The Bedridden Patient.= When the patient is confined to bed, the -nurse’s task becomes easier. Isolation, therefore better protection to -the family, is more readily secured than when he wanders from room to -room, leaving a trail of germs behind him. It is well to exclude from -the sick-room every one except those in actual attendance upon the -patient; this is especially necessary in the case of children, to whom -the danger is greatest. Neighbours and friends should also be excluded, -and if they refuse to consider the risk, the plea for exclusion should -be made on the ground that visitors are disturbing and harmful to the -patient. - -In the sick-room we sometimes find the young children of neighbours, -whose mothers are all unconscious of the danger to which they are -exposed. If through sheer indifference, the patient’s family does not -exclude these children, it would then become the nurse’s duty to seek -out their parents and warn them. When a patient’s household becomes -indifferent to community welfare, the nurse should then extend her -teachings farther afield—into the next house or block if need be—and try -to protect others who are unknowingly exposed to infection. - -In brief, these are the duties of the nurse in the home of the patient. -At her first visit, she cannot say everything she wishes, but later it -will be possible to do so. In many cases, the household will be -suspicious, antagonistic, or not inclined to want her, so that she must -feel her way cautiously, step by step. It may take two, three, four, or -even a dozen visits to accomplish her object, and before she can drive -her points home with the requisite vigour. When the situation is acute, -and the danger great, it is difficult and discouraging to make haste -slowly, yet this policy will pay in the end. It is better to proceed -cautiously with an uneasy family, winning them gradually from point to -point, than to arouse their resentment by an impatient enthusiasm which -sees no wisdom in delay. - -In dealing with patients, the nurse must speak plainly; it will not do -to insinuate or imply. What she has to say must be said -straightforwardly, in simple words adapted to the intelligence of her -hearers. The situations one encounters in this work are often sad and -trying to a degree, and it would be far easier to insinuate a -disagreeable or painful thing than to speak out plainly. The nurse who -cannot express herself clearly, forcibly, and convincingly will get poor -results. She must be able to meet prejudice with reason, to impose her -view upon another, and to convince the ignorant that what she says is -right. - -There is an old fable which all public health nurses should remember—the -old story of the Wind and the Sun, who both tried to remove the -Traveller’s cloak. The Wind tried first, and he blew and blustered, but -his frantic efforts only made the Traveller clutch it tighter. And then -the Sun tried. He shone, blandly, warmly, gently, and in a few moments -off came the cloak. It is the method of the Sun, rather than of the -Wind, which usually wins out. - - - - - CHAPTER XII - - Care of the Family—Examination of the Family—Taking Patients to - Dispensaries—Children—Tuberculosis in Children—Open-Air - Schools—The Danger of Sending Patients to the Country. - - -=Care of the Family.= We have already said that the first consideration -is the patient’s family, or those individuals who come in contact with -him. Therefore, as soon as he himself is under satisfactory supervision, -the nurse must turn her attention to the other members of the household -who need her even more. A majority of the nurse’s patients are either -advanced or last-stage cases, many of them having a history extending -over months or perhaps even years of illness. If during this time the -nature of the disease has been unknown; or known, and no precautions -have been taken, there is great likelihood that other members of the -family have also become infected. To discover these suspicious cases and -get them examined and under treatment as soon as possible, is one of the -nurse’s first responsibilities. Next, she must give careful attention to -those other members of the family who so far have apparently escaped. -She must not over-alarm or frighten them, but she must keep before them -the fact that they are in close contact with a highly infectious -disease, and that whatever lowers their resistance, increases in like -manner their chances of contracting it. They must employ every means in -their power to raise their vitality to a point where they cannot be -reached. An infectious disease does not, as a rule, gain entrance into a -constitution strong enough to resist it. - -To this end, the nurse should pay particular attention to the personal -hygiene of the exposed family. Their bedrooms and sleeping quarters -should receive as careful consideration as do those of the patient. -Every one in the house should be taught the value of fresh air, and the -necessity of sleeping with wide-open windows; the measures needed to get -people well are equally necessary to keep them well. - -The family also needs careful instruction as to food and rest: food, -nourishing and well cooked; rest, which should at least mean that at the -end of a day’s work they do not exhaust their vitality in crowded -poolrooms, dance halls, and saloons. The need of recreation is one of -the fundamental needs of mankind, but there is a difference between that -which refreshes and that which undermines the constitution. Whether this -fatigue comes from work, play, or excesses of any kind, it is usually -the worn-out individual who first succumbs to exposure. In all -households there is great need for instruction along these lines. There -are weary, indifferent parents, and heedless boys and girls whose -ignorance of personal hygiene is profound. The fact that much of this -teaching falls on apparently stony ground shows the need for redoubled -effort—which will in time bear fruit. Those in contact with tuberculosis -must be continually on their guard against it—disease does not, as a -rule, attack those who are in sound health. - -In this preventive work, the nurse will be greatly aided if she knows -what agencies she can call upon to reinforce her instruction. She must -be familiar with all the forces of social service, and know how to reach -them, and how to place her families in touch with them. Just as she must -have sufficient knowledge of dietetics to suggest rice as a substitute -for cabbage, bread instead of pie; so must she understand the social -agencies within call, and know what substitutes they offer for the -things that she condemns. A great gain will have been made if instead of -the poolroom, the young boy can be given the Settlement club or -gymnasium; or instead of the saloon dancehall, the young girl can be -offered that of the schoolroom or the church. The aim should not be to -deprive, but to substitute. Preventive work consists largely in teaching -how to substitute the harmless for the harmful, the healthful for the -unhealthful. In some communities, no such agencies exist; in others, -they are inadequate to the needs they try to fill. But if they exist, -they should be called upon. - -=Examination of the Family.= Every person constantly exposed to -tuberculosis should be examined periodically, whether or not he presents -symptoms. The nurse should endeavour to get all members of the patient’s -household examined. This is sound in theory, but not always feasible in -practice, especially when there are a large number of patients under -supervision. When one is working with small numbers, with ten, twenty, -or a hundred families, it might be possible to get every member of these -households examined, but when one is working with large numbers it -becomes proportionately difficult. In Baltimore some 5000 consumptives -are annually dealt with by the Tuberculosis Division; if every one of -these patients comes in contact with five other persons—a most modest -estimate—that would give us a total of 25,000 people to bring forward -for physical examination. This task would swamp our dispensaries and -leave no time for anything else. After all, it is the positive rather -than the potential cases which are a menace to the community. Thus, -however much we may advocate the need for general examination of all -exposed persons, this course has its drawbacks when it comes to actual -practice. The best we can do is to get the suspicious cases examined. -The examination of those who have no symptoms would furnish interesting -statistics, but they are hardly dangerous enough to the community to -warrant the outlay of time and energy. - -To induce a patient to be examined often requires weeks or months of -effort and persuasion. The less the apparent necessity, the more -difficult it often becomes. If a person has no symptoms he will not go, -and if he has symptoms, he is afraid to go, to a physician. Therefore, -whenever it is possible to get exposed persons examined, well and good; -when this is not possible, the nurse may confine her efforts to those -with suspicious symptoms. One of the foremost requisites in this work is -the ability to distinguish between essentials and unessentials, and -having made the distinction, to concentrate on the most important. - -=Taking Patients to Dispensaries.= Unless the nurse has abundance of -time and a very light district, it is not well that she should spend -time in taking reluctant patients to a dispensary for examination. To do -this, means to give up from one to several hours, which she can ill -afford to spend in this manner. Nor is it necessary to waste her expert -service in this way—it is always possible to find some one willing to -take these patients, some friendly visitor, settlement worker, or even a -kindly, intelligent neighbour. - -=Children.= It is conceded nowadays that people usually become infected -with tuberculosis in the first ten or twelve years of life, or during -childhood. The disease itself may or may not develop in later life, -according to the circumstances or environment in which the individual is -placed. It may light up later, if his resistance becomes lowered, or he -is reinfected, and cannot carry the extra load. For this reason, it is a -vastly important thing to protect children from infection, as well as to -protect those exposed in childhood from later undue strain. - -The children the nurse sees are usually those in contact with a -tuberculous father or mother. What is gained if we teach the parent to -sleep alone, and spend part of the time away from them, yet permit him -at other times to remain in close contact with the children? -Intermittent contact, repeated often enough, is as bad as constant -contact. If a mother nurses, feeds, cooks for, and handles her child, -there are untold opportunities of infection. If the parent is -intelligent and unselfish, it may be possible to bring about a relative -degree of carefulness, and a minimum exposure, but there is no such -thing as adequate carefulness while these conditions continue. Among the -very poor, where it is impossible to regulate living conditions, there -is practically no doing away with the danger of infection. - -Whenever the parents are sick, selfish, or ignorant; when the children -are undisciplined and uncontrolled, and where the grind of poverty has -reduced ethics to the most primitive basis, one cannot expect much. When -a child is in constant contact with a tuberculous individual, no matter -how careful that individual may try to be, there is always some danger. -By the very nature of his disease, a consumptive cannot be a hundred per -cent. careful. An adult living in contact with tuberculosis may be able -to resist it, a child has infinitely less chance. - -The only way to ensure absolute safety for the child is to remove it -from the danger, or to remove danger from it. Either the child must be -removed from the house, or the patient must be removed from the house, -it makes little difference which. The patient may be sent to an -institution, or the child may be sent to a relative, to the country, to -a neighbour, or to one of the child-saving agencies that are to be found -in most communities. We are aware that in advocating this policy we are -advocating what is called by the unthinking “breaking up the home,” as -if tuberculosis had not long ago preceded us in this. Sending away the -parent or the child is merely a belated effort to save what is left of -the home. - -Whenever an institution is possible, the patient should go there. In -many communities, however, there are no such facilities, or else their -capacity is limited. In this case, the child is the one to be removed. -This often becomes a matter of extreme difficulty, since it is hard to -overcome the parent’s very natural resistance. In urging this -separation, we are making a choice between two lives—one already doomed, -and the other which may be saved from a similar fate. - -=Tuberculosis in Children.= Although children become infected at an -early age, it is often most difficult to obtain a diagnosis for them. -The most competent specialist hesitates to pronounce a child tuberculous -until he has repeatedly examined it, and kept it under constant -observation—and even then he may prefer to call it “suspicious only.” By -the aid of the eye test and the skin test he may finally arrive at a -positive diagnosis, but even then, he may not be sure of the location of -the lesion. The child, therefore, though diagnostically a positive case, -is not necessarily an infectious one. - -All these doubts and difficulties in connection with the diagnosis of -tuberculosis in children serve to show that in a way this question may -be called a negligible one, negligible, that is to say, as a menace to -public health. It is important for the individual that a diagnosis be -made, in order to do intensive work in upbuilding his resistance, but he -is negligible as a distributor of infection. About ten per cent. of the -visiting list is made up of children. On entering a home where there are -two children, one tuberculous and one not, the nurse’s efforts should be -concentrated on separating the two—the emphasis being placed on the care -of the one as yet uninfected. - -The question frequently arises, Should these tuberculous children be -sent to school? Is it well for them as individuals, from the standpoint -of their own health, and is it well for those who are thrown in contact -with them? This decision rests solely with the physician, and can be -made by him alone. As far as danger to others is concerned, it must be -remembered that while a person may be tuberculous, he is not necessarily -infectious, and it is upon the infectiousness of a case that the danger -depends. - -It is difficult to care for these tuberculous children. Most nurses -become deeply distressed because of this. The children are frequently -undisciplined, and their parents often weak and lacking in self-control. -The nurse becomes discouraged and annoyed when she sees her directions -unheeded or disobeyed. But, after all, these cases constitute but a -minor part of the problem, and they are not patients who do much harm. -It is sad to stand by and see the individual throw away his chances, or -to see them thrown away for him—but this standing by is part of the -work. - -=Open-Air Schools.= During the past five or six years, open-air schools -or classrooms have been established in several of our large cities. This -is an excellent affirmative answer as to whether a tuberculous child -should attend school. At these places, careful, systematic attention is -given the child for several hours a day. Non-tuberculous children are -also admitted—they may be called pre-tuberculous, since they are anæmic, -run-down, undernourished children, who come from homes where -tuberculosis exists in active form. For such cases, the open-air school -does excellent preventive work, in raising the child’s resistance to a -point where it can cope with the exposure at home. These open-air -classes are always in charge of a physician and a nurse; their -management does not come within the range of this discussion, any more -than does that of the hospital or the sanatorium. - -The public health nurse must always take advantage of these schools, if -they exist, and must see that her children are sent there. She must -avail herself of every agency and of every opportunity which will -improve or secure the welfare of those under her charge. - -Schools of this kind are extremely valuable, but are not the solution of -the tuberculosis problem, any more than the sanatorium for the early -case is its solution. Both of these institutions deal with results, not -causes. To fight tuberculosis, we must strike deep at the cause—the -advanced case who scatters the disease. Open-air schools always make a -strong appeal to people—it is easy to obtain money to support them, and -easy for public sentiment to exaggerate their value in the -anti-tuberculosis campaign. Since the public mind generally grasps but -one idea at a time, it is not well to dissipate its facile interest on -side issues. When a community has established on adequate scale the -machinery for combating tuberculosis, it may then establish such -effective allies as the open-air school. But to bring them on first, -before the fundamentals, is to misdirect public sentiment, and to place -the cart before the horse. - -=The Danger of Sending Patients to the Country.= Sooner or later, the -nurse will be called upon to decide whether the tuberculous patient -shall be sent to the country. This will be urged by earnest, -well-meaning people—and sometimes by social workers who should know -better. Needless to say, this policy calls for strong condemnation. -Whatever good the patient himself might gain from going to the country, -must be offset by the fact that the disease is spread elsewhere. To -create new centres of infection is not the result at which the -tuberculosis campaign is aimed. - -In his own home, under immediate and constant supervision, it is -difficult to obtain from the patient anything better than relative -carefulness. To get even that requires unceasing vigilance and continual -training, both of the patient and of his family. Therefore, to free him -of this restraint by sending him to a distant farm, would mean his -immediate relapse into carelessness, and a danger to those among whom he -is quartered. To send a consumptive into another household is to send -him where he may infect other people. Pity for the patient should not -obscure our interest in his possible victims. - -Moreover, the welfare of the patient himself is not as a rule secured by -this method. These journeys to the “country” are usually to -out-of-the-way little farm-houses, with various shortcomings both as to -food and accommodation. They are often anything but satisfactory places -for a sick man; or, if they happen to possess advantages, the patient -may not know enough to use them. In making these statements, we are not -speaking entirely at random, or from general surmises as to -probabilities. A few years ago, we had on our visiting list some -fifty-five patients who went to the country for the summer. They were in -all stages of the disease, and it is well to note, in this connexion, -that it is usually the advanced case who is most anxious to get away. Of -the fifty-five cases, two were really benefited by their sojourn; -thirteen were temporarily improved, but lost it all within a few weeks -after their return; thirty-two came back to town worse than when they -went away, and eight died while in the country. - -Of these fifty-five removals, it is safe to assume that fifty-five -centres of infection were established in consequence. The families where -they were quartered were doubtless unaware of the nature of the disease, -or how to protect themselves in any way. Nor is it likely that any of -these fifty-five farm-houses were afterwards properly cleaned or -disinfected. It was of course impossible to follow the results in these -scattered centres of infection—remote counties of Maryland and -Virginia—but we succeeded in doing so in one instance out of the -fifty-five. In this case, the patient had gone to a farm in Virginia; as -a result of his visit, three members of a hitherto healthy family became -infected, all of whom have since died, as well as the original patient, -the “city boarder” who carried infection among them. - -Of course, if patients insist upon going to the country, nothing can -prevent them, although the nurse must do her best to dissuade them. One -patient who had a large airy room in town, decided that she would be -better off on a farm. She was questioned as to conditions at the farm, -and it transpired that she was to occupy an attic room, with one window, -and that this room was to be shared with three other people. It then -became an easy matter to dissuade her from going. It is not always thus -easy to deflect them. Should they insist, they should be given plentiful -supplies, and if the nurse can obtain the address of the family where -they are to stay, she should send full information as to the patient’s -condition. It is a regrettable fact, but when a patient is removed from -surroundings where his condition is known, he is apt to discard his -sputum cup and all other precautions by which he is rendered -conspicuous. - -We cannot be too emphatic in refusing to send consumptives to the -country. If a sanatorium or day camp is not available, they would better -remain in the city. If the patient has money, he cannot of course be -prevented from going. If he has no money, no appeal should be made for -funds to send him away. To ask for money for such use is a wrong the -public health nurse should have no hand in. Her business is to prevent -scattering infection, not to aid in it. - - - - - CHAPTER XIII - - Disinfection of Houses—Value of - Fumigation—Formaldehyde—House-Cleaning—Burning and - Sterilizing—Boiling—Carpets, Rugs, and Mattings—Painting, - Papering, and Whitewashing—Temporary Removals—Vacant - Houses—Compulsory Cleaning. - - -=Disinfection of Houses.= One of the most important of the nurse’s -duties is her arrangement for the fumigation and cleaning of premises -that have been vacated by a consumptive. This takes place after death, -or upon the patient’s removal to an institution, to another house, or to -another room in the same house. - -Since tubercle bacilli are not confined to the sputum, but are -discharged in great numbers during coughing attacks, and to a less -extent during sneezing, speaking, and so forth, a patient not confined -to one room, but who wanders freely about the house, scatters bacilli -everywhere. No matter how careful he may be about the sputum, the nature -of the disease makes it practically impossible to be equally careful -about the expired air. Moreover, these organisms do not die of -themselves, at the end of a few weeks. They are singularly tenacious and -persist for months, virulent and active. A case is recorded in which -they were found in a room six months after the patient’s removal, alive -and virulent enough to cause tuberculosis in guinea-pigs inoculated with -them. For this reason it takes drastic measures to rid a house of these -tenacious germs. - -In indicating the rooms to be fumigated, it is necessary to include all -those that have been occupied by the patient within the past six months. -If he dies in his bedroom, it is not enough to do merely that one room. -It is equally necessary to fumigate the kitchen, in which he sat until -two months ago; the parlour, where he spent a few hours a day, and the -second bedroom, to which he was now and then removed. All are infected, -and all need the utmost care to free them from germs. The family must be -taught why these rooms are dangerous, and made to understand the -necessity for full and complete disinfection. It is better to err on the -side of too much, rather than of too little care. - -In Baltimore, the actual fumigation is not done by the nurses, but by -the employees of the Fumigation Division of the Health Department. The -nurse indicates the rooms, instructs the family, and makes all the -preliminary arrangements, after which she reports the premises to the -fumigator, who disinfects them next day. It would be well if this -fumigation could be done by the nurses or by a special corps of nurses; -this would probably ensure more intelligent and conscientious work than -that which the average city employee bestows upon this important task. - -As a matter of routine, every death from pulmonary tuberculosis is -reported to the Tuberculosis Division; the nurse in whose district this -death has occurred then inspects the house and arranges for the -fumigation. Four times out of five the patient is already known to us -and already under supervision, which makes the duty easier than if he -were unknown. In either case, however, the nurse visits the home and -arranges all the details. - -In like manner, all patients who enter either hospital or sanatorium are -reported to the Health Department, the institutions furnishing their -names and addresses so that the fumigation may be attended to. When a -patient changes his address and moves to other quarters, the nurse is -the only one who knows of this change, hence it is her responsibility to -report these houses and see that they are fumigated. To arrange for all -these fumigations, whether after death or after removal, means that a -large amount of time is spent upon this work of trying to rid the -community of dangerous centres of infection. - -=Value of Fumigation.= The actual value of fumigation is a debatable -point. Under the best conditions, its efficacy is not a hundred per -cent.—far from it—while under unfavourable conditions, when poorly done, -its efficacy is so low as to be almost nil. The house whose cracks have -been improperly stopped, and the old house, with open chimneys, loose -windows, and apertures which cannot be closed, are not made safe by this -process. Under such conditions, fumigation not only fails to remove the -danger, but it produces a false sense of security. Unless properly done, -it were better not to do it at all. We should prefer instead to depend -upon vigorous house-cleaning, the use of hot water, soap, and the -scrubbing brush, and the destruction of all infective material. -Moreover, even under the best conditions, formaldehyde has no powers of -penetration. Its action is purely superficial, and only useful for plane -surfaces, such as walls, ceilings, and so forth. The most dangerous -articles, such as clothing, carpets, bedding, and the like, are totally -unaffected by it. We ought to stop teaching that fumigation alone will -clear up these infected houses and make them safe for future habitation. -The public has been misled as to the value of this measure, and allowed -to place far more reliance upon it than has been justified by -experience. It is high time for enlightenment. The most that can be said -for fumigation is that undoubtedly it kills _some_ germs—so many that it -is worth while to continue the practice of it, but too few to afford -adequate protection. It must be supplemented by other and more radical -measures. - -=Formaldehyde.= Formaldehyde in one of its preparations is the chemical -most generally used, and is more valuable than sulphur, which is now -discarded. In most cities, the Health Department attends to the -fumigation. In small towns or rural districts, where there is no -fumigating corps, formaldehyde is usually given upon application to the -local or State Board of Health. In some localities, especially in -country districts, there may be no appropriation for this disinfectant, -which the householder must then buy himself.[4] - -Footnote 4: - - There are many formaldehyde preparations on the market, simple and - easy to use, but these may be unobtainable. In this case, an effective - method is the combination of formaldehyde with potassium permanganate. - For a room containing 1000 cubic feet of air space (a room 10 feet - long, 10 feet wide, and 10 feet high), the amount needed is: Potassium - permanganate, oz. 111.; liquid formaldehyde, pint 1. Place the - formaldehyde in a large galvanized iron bucket (holding 8 to 10 - quarts), and drop the permanganate into it. The room should be left - closed for six hours; a longer time is unnecessary, a shorter time - ineffectual. All cracks, of course, should have been previously - stopped. - -Since fumigation is only a matter of six hours’ duration, it will cause -no great hardship or inconvenience to the family which for this short -period must be turned out of the house. Yet many people complain -bitterly over this trial, and raise every possible objection. They are -willing enough to have one room done, but refuse to allow more. The -nurse must explain that a six hours’ inconvenience is better than -risking health and life, and she should also explain that in insisting -upon fumigation the Health Department is neither arbitrary nor -vindictive. Fumigation is a rather costly affair, and this expense is -incurred, not to annoy but to protect the community. In winning over a -reluctant family she has a chance to do excellent educational work. It -is always better to secure their intelligent co-operation, even though -it take long and patient argument, than to end the discussion by -abruptly informing them that fumigation is compulsory, and will be done -whether desired or not. - -=House-Cleaning.= Fumigation must always be followed by most searching -and thorough house-cleaning, which important task must be done by the -family itself. All floors should be scrubbed with hot water containing -lye or soda solution and all washable surfaces should be likewise -treated. This includes furniture, doors, door knobs, windows, stairs, -banister rails, and so forth. The necessity for this house-cleaning -cannot be too strongly emphasized. - -=Burning and Sterilizing.= The most highly infective material is the -bedding, mattress, pillows, clothing, and so forth, which have been used -by the patient. Since these articles cannot be made safe by formaldehyde -fumigation, and since most of them cannot be washed and boiled, there -are but two methods of disposal. The most drastic and wasteful is to -burn them, yet this must always be advised unless we can offer the -alternative of sterilization under high pressure steam. To burn -infective material involves a loss which few people can afford, and they -are loth to make the sacrifice; most of these articles, while laden with -germs, are nevertheless serviceable and in good condition. To expect -that they will be burned, therefore, is to expect the impossible. If the -family consent to destroy certain articles, they reserve others, equally -unsafe for use. The only alternative is the municipal sterilizer, and -any community which expects to do effective preventive work must -establish this as a factor of first importance. - -In Baltimore there is such a sterilizer, and the use of it is very -simple. When the nurse arranges about the fumigation, she selects at the -same time whatever articles are to be sterilized—pillows, mattresses, -blankets, clothing, and so forth. These are then called for by the men -from the Fumigation Division. They are placed in large canvas bags, -inventoried, labelled, and carried to the sterilizer. Here they are -steamed and dried, and returned a day or two later in good condition. -The householder signs a receipt to this effect.[5] - -Footnote 5: - - Certain articles are ruined by sterilization, and the nurse must be - careful not to include these, or there will be a suit for damages. - Leather and furs, can never be steamed. Straw mattresses are also - injured. Nor is it possible to sterilize carpets and matting, because - of their bulk. The sterilizer should be reserved exclusively for - material which lends itself readily to treatment of this kind. In - selecting what is suitable, the nurse should exclude old and filthy - articles, which should be burned. - -Unfortunately, steam sterilizing plants are rare, and in most -communities the nurse will have to protect her patients in other ways. -As we have said before, the only alternative is burning, and this often -works great hardship on many families. With the very poor, the Federated -Charities may be called upon to supply new mattresses, etc., in place of -those that have been destroyed, and as a rule this response is prompt. -Yet there are many cases where the family is too poor to suffer this -loss, yet not poor enough to come within range of a charitable -association. These cases constitute a difficult problem—a problem that -is entirely solved only by the municipal sterilizer. - -Except through sterilization, there is no way in which these articles -may be made safe. Carbolizing will not do this, neither will sunshine. -Valuable as sunshine is, it is difficult to secure prolonged exposure, -especially in tenement districts. It is possible, of course, to take a -mattress apart and wash and boil the ticking; feathers or hair may be -sent to an upholsterer, who has means of steaming them. Pillows may be -put into a large wash-boiler, and boiled for half an hour, after which -they may be washed—it will take a week or more before they become -thoroughly dry and usable. All these alternatives involve a great outlay -of time and energy, and we cannot but feel sceptical as to the -thoroughness with which this cleaning is likely to be done. A family -which objects to parting with dangerous articles, and prefers risk to -inconvenience or deprivation, is hardly likely to be scrupulous as to -details of this character. - -In Baltimore, before the advent of the steam sterilizer, the amount of -material burned was never more than a third of the amount which should -have been burned. Still, under the circumstances, we were thankful to -have achieved this third. Since the establishment of the sterilizer, we -now succeed in getting over two thirds (70 per cent.) of the infective -material sterilized. This is a triumph for the nurse’s teaching, since -there is no law making sterilization compulsory. - -=Boiling.= Everything which can be boiled will of course be made safe, -whether these articles be of wool, linen, china, rubber, etc. Even -blankets may be boiled, although the family will object to this on the -ground that it shrinks them. The nurse must explain that not to boil -them may have consequences even more disastrous. The nurse must never -permit her patients to make indiscriminate bonfires, and wantonly -destroy harmless articles, or those which may readily be made so. We -know one family which destroyed a whole set of dishes, not from painful -association, but from a misdirected desire to do the right thing. For -this reason, the nurse must look over all articles carefully, giving -thoughtful counsel as to the proper disposition of each. - -=Carpets, Rugs, and Mattings.= As the sterilizer cannot be used for -carpets, rugs, and mattings, there is nothing to do but advise that -these articles be burned. As a rule, this destruction is agreed to with -more readiness than in the case of pillows and mattresses. - -=Painting, Papering, and Whitewashing.= Whenever possible, the rooms -used by a consumptive should be repapered, painted, or whitewashed as -the case may be. The more thorough and complete the measures taken to -eliminate tuberculosis, the greater the chances of success. It is a -costly disease, and costly measures, both as to money, energy, and time, -are required to get rid of it. Half-way methods are poor economy. - -=Temporary Removals.= The foregoing directions apply mainly to those -cases in which the patient has either died, or has been permanently -removed elsewhere. If his return is not expected (as when an advanced -case enters the hospital), the amount of cleaning, burning, repapering, -etc., would naturally be as great as that required after death. - -On the other hand, when his removal is but temporary and the patient -expects to return home after a few months, the amount of disinfection -would be considerably modified. When he enters a sanatorium, his house -must be fumigated and cleaned, so that for a few months at least the -family may be relieved of danger. Under such circumstances, it would not -be necessary to counsel the destruction of the mattress and bedding that -he is to use upon his return. Meanwhile, no other member of the family -should use these things, although in certain instances it is almost -impossible to prevent their doing so. For such cases the municipal -sterilizer is needed—indeed no community can make much headway against -tuberculosis until it provides a means of removing the danger without -causing loss to the individual. - -=Vacant Houses.= When a family’s removal leaves a vacant house, there is -naturally no one left to do the cleaning. The Health Department will do -the fumigation, but the more essential house-cleaning remains undone. -These houses often stand idle for weeks or months before finding a new -tenant. Even if it were possible to discover the landlord or owners (a -task which in itself would require a staff of employees), it is doubtful -whether they would clean these houses themselves, or notify their new -tenants of the need for extra vigilance. Legislation compelling -house-cleaning would be difficult to put through. The landlord feels -relieved of all responsibility when once the fumigation is accomplished, -and that this fumigation is not a hundred per cent. effective is no -concern of his. He, together with the general public, has been misled as -to its true value. Nor is thorough cleaning, painting, and papering an -expense that he would willingly incur. The question of the fumigated but -not necessarily safe house is one that causes considerable anxiety. We -feel that the only way to deal with it, is that the nurse keep these -vacant houses on her visiting list, so to speak, and watch for the time -when they are re-let. This entails considerable loss of time, which she -can ill afford to spare from her patients, but the information she can -give the new tenant will have distinct preventive value. She must tell -the newcomer that he has moved into a house in which there has been -tuberculosis, and that only by the most exact and painstaking efforts -can it be made safe. - -=Concessions.= In carrying out this important work, the nurse sometimes -becomes so enthusiastic that her common-sense gives way under the -strain. She wishes to carry her point, without fully realizing the -prejudices, ignorances, sometimes even the comfort, of the family she is -dealing with. After a death, she comes upon a household in a most upset, -distressed, and often irresponsible condition, and she must be very -gentle and patient in her relations with them. She must accomplish what -is necessary, without undue disturbance of their prejudices and -feelings. For example: Orthodox Jewish people observe a mourning period -of several days following death, during which time they wish to remain -undisturbed. Fumigation should be postponed until this time is past. A -few days’ delay will not injure the health of a family which has been -exposed to infection for months. By thus respecting their religious -customs, it will be possible to gain better co-operation as to cleaning -and so forth; co-operation which would have been jeopardized by riding -roughshod over their feelings and beliefs. - -Sometimes people raise objections because they have nowhere to go for -the six hours required for fumigation, during which time they must leave -the house. If there is no kindly neighbour to take them in, the nurse -may arrange with a Settlement or other social agency, to give them -shelter. We have often asked for hospitality in this way, and have -always met a ready response. Sometimes, if a house is a large one, it is -possible to have it fumigated in sections, a few rooms being done one -day, a few the next. - -=Compulsory Cleaning.= In most communities, fumigation is compulsory. -But there is no regulation whatever concerning the after-care of the -premises—the cleaning, sterilization, and destruction of infective -material. The relatively unimportant part is obligatory, while the -essential part is optional. And that this essential part is done, and -well done, depends almost entirely upon the teachings of the public -health nurse. - -If, however, the family remains obdurate, refusing to clean and -disinfect, nothing can be done. Since it is now generally acknowledged -that fumigation falls far short of what it was once expected to do, we -need laws making adequate disinfection compulsory; until such laws are -enacted, we can only rely on the ability of the nurse to teach the -necessity for cleaning and disinfecting. How valuable is this teaching -may be gathered from these figures (_Report_, 1913, Tuberculosis -Division of the Baltimore Health Department): “After death: houses -cleaned, 80 per cent.; bedding, etc., either burned or sterilized, 70 -per cent.” With adequate laws, the nurses would make even a better -showing. - - - - - CHAPTER XIV - - The Tuberculosis Dispensary—Equipment—Medicines—Hours—Consideration of - Patients—Function of the Dispensary—The Physician’s Service—The - Physician’s Qualifications—The Physician and the Patient—Duties of - the Nurse—Tuberculin Classes—The Nurse in Home and Dispensary—The - Nurse as an Asset to the Community. - - -=The Tuberculosis Dispensary.= No community can make definite progress -against tuberculosis until it establishes a place where suspicious -patients may be sent for examination and diagnosis. Unless this disease -be promptly and definitely recognized, it is impossible to give advice, -or take authoritative action concerning the treatment of the patient and -his family. If in connection with the dispensary there was also a corps -of municipal physicians, who could visit the patients in their homes, -and examine all suspects called to their attention, diagnoses could be -obtained even more promptly. As it is now, considerable interval often -elapses between the time when the patient is advised to go to a -dispensary and the time when he follows this advice. The existence of a -corps of visiting physicians would prevent such delays. The patient -would be allowed a reasonable time in which to present himself, at the -expiration of which period he would be sought out by the officer of the -municipality. This prompt recognition of tuberculosis would save the -community from an enormous amount of exposure. The time may yet come -when Departments of Health will see the wisdom of such measures. - -Until that time, the special dispensary represents the only means of -obtaining a diagnosis; it is the only place where patients may freely be -sent, and where an expert and frank opinion may be had. Such a -dispensary may be established in connection with the general dispensary -of a hospital, or by the local Health Department, or it may be supported -by the same group of people or association which supports the special -nurse. In Baltimore, we have had dispensaries of all three kinds, and -the nurses have worked in connection with each one, on exactly the same -terms. - -=Equipment.= The great tuberculosis dispensaries run in connection with -the large hospitals and medical schools are usually very completely and -elaborately equipped. They contain large waiting rooms, examining rooms, -special rooms for the giving of tuberculin, for X-ray examinations, for -throat examinations, for laboratory work, and so forth. All these are -needed in teaching centres, where it is necessary to collect certain -scientific data. But for the purpose of making an ordinary physical -examination a simpler equipment will do equally well. - -In Baltimore there are several small municipal dispensaries, all under -the control of, and managed by, the Department of Health. They are -situated in different parts of the city, readily accessible to the -patients of different localities. Each dispensary consists of two or -three rooms, which are in the same building which houses the Federated -Charities, and other social agencies. This arrangement has several -advantages, from the point of view of both economy and co-operation. To -have rented similar rooms in another building or in a private house -would have meant a much greater outlay of money, to say nothing of the -opposition encountered in obtaining the use of these rooms for -dispensary purposes. - -The furnishings of these little municipal dispensaries are extremely -simple, but they lack nothing of comfort and convenience. The outer or -waiting room contains two or three dozen chairs, or benches to -accommodate an equal number of people. A corner of this room is screened -off for the nurse’s table, where she keeps her charts and records, and -writes the patients’ histories. A couple of filing cabinets, a medicine -closet, and a pair of scales complete the outfit. - -[Illustration: Waiting Room in Municipal Dispensary] - -The inner, or examining room, is also simple and inexpensively -furnished. It is divided into several compartments by means of gas -piping, each compartment being large enough to hold a revolving stool -and a wicker lounge. Unbleached muslin curtains hang from these gas-pipe -rods, making several little cubicles in which the patients are examined. -It is thus possible for the doctor to examine a patient in one cubicle, -while another patient undresses in the adjoining one—an arrangement -which saves considerable time. Sheets, towels, and blankets complete the -necessary furnishings, which may be cheap or costly according to the -means available. The doctor’s table stands in one corner of this -examining room. - -This is not necessarily the last word as to what tuberculosis -dispensaries should be, but we have found the ones described practical. -No tuberculin tests are given here, and all sputum examinations are made -at the Health Department laboratory. - -=Medicines.= A supply of simple drugs is kept in the medicine closet. -This includes a few of the standard tonics, such as iron, quinine and -strychnia, nux vomica, gentian and alkali, and so forth; there are also -cough syrups, and heroin, codeine, cascara, etc. The tonics are usually -bought in large quantities, in gallon jugs, and in her leisure moments -the nurse pours them into four- or six-ounce bottles. If these bottles -are filled by the druggist, the expense is somewhat greater. This -medicine is given free of charge, although now and then a patient may -wish to make a small payment of ten cents or so. In themselves, these -drugs cannot be said to constitute treatment, yet it has been found -advisable to dispense them. Patients are so accustomed to being dosed, -that they have no faith in an institution which does not prescribe for -them. It is above all things necessary to make these dispensaries -popular, so that patients will freely seek them, and recommend them to -their friends. Only through wide publicity and extensive patronage can -they become effective factors in the fight against tuberculosis. - -[Illustration: Examining Room in Municipal Dispensary, showing the room -divided into cubicles, by means of gas-piping] - -=Hours.= The hours at which a dispensary is open will depend somewhat -upon its location, also upon whether or not the physician’s services are -volunteered; in the latter case, it will depend upon the time he is able -to give to it. If it is open in the morning, the workingman cannot -attend without losing a whole day from his work, nor are these hours -convenient for schoolchildren, or for the busy housewife who does most -of her work before noon. If the dispensary is open in the afternoon, all -three classes of patients may be accommodated; the workingman will lose -half, not an entire day, while women and children can attend with no -inconvenience at all. Afternoon hours, say from two till five, not only -permit patients to be examined by daylight instead of artificial light, -but the doctor will be further aided in his diagnosis by the presence or -absence of that characteristic symptom, an afternoon temperature. Night -clinics are necessary in certain localities, when they may be patronized -by men and women, employed during the day, who would otherwise be unable -to come to them.[6] - -Footnote 6: - - Night clinics are in existence in New York, Hartford, Boston, Chicago, - and other cities, and are well attended. - -=Consideration for Patients.= The first consideration of the dispensary -should be the comfort and welfare of the patients. We have known many -dispensaries where the first consideration was the experience of the -students or physicians, the patient being regarded merely as good -clinical material. In dispensaries connected with medical schools, which -are essentially used for teaching purposes, this condition is -unfortunately necessary, yet we cannot believe that it is necessary to -the extent to which it is sometimes carried. We have often known of -“interesting” cases being held up for hours, in order that they might be -examined by certain men, or groups of students; moreover, this -detention, prolonged examination, and exposure often took place when the -patient was very weak, when he lost his job through the delay, or when a -husband’s dinner, a nursing baby, or a houseful of children made such -detention intolerable. Patients often refuse to return to a large -dispensary on the ground that “they keep you all day, everyone in the -place examines you, and you get so tired and sick you have to stay in -bed for a week afterward.” This lack of consideration—failure to look -upon the patient as a human being—is what tends to make dispensaries -unpopular. We have known patients to come straight from such an -experience and deliver themselves into the hands of a quack. However -necessary it may be to use certain dispensaries as teaching centres, the -tuberculosis campaign demands clinics of another kind. If the -tuberculosis dispensary is to be a factor in the fight against this -disease, it cannot afford to be a training school as well—it should be -in charge of men already trained. - -=Function of the Dispensary.= It follows, then, that the function of the -municipal dispensary is of necessity different from that established for -teaching purposes. The larger dispensary serves a double purpose, the -little dispensary serves but one; it is an examining station for making -diagnoses. Here the patient should come as informally as he would to a -doctor’s office, and here he should be able to consult experienced men. -We feel that the informality of these little clinics constitutes their -strong point. The patients are not afraid of them, and their great -advantage lies in their social rather than their scientific value. They -are merely places where a communicable disease may be discovered at the -earliest possible moment. - -=The Physician’s Service.= If a community decides to establish a -dispensary, the first step must be to secure the services of a -physician. At first this may be voluntary, and many doctors will gladly -offer an hour or two of their time, once or twice a week. Should there -be great pressure of work, it may be possible to find several men -willing to offer their time. But however willingly and freely -offered—for most physicians are generous in response to calls of this -sort—it must be remembered that, after all, this service is gratuitous. -The busy physician will often be obliged to side-track his dispensary -obligations, in favour of urgent private calls. This is only to be -expected, yet too many such side-trackings are bad for the dispensary. -The patients lose confidence in it; it is discouraging for a roomful of -sick people to find no one to receive them. - -Experience teaches us to look askance at all volunteer work, no matter -how generously or sincerely offered. Under certain conditions it may -have to be accepted, but whenever possible, the physician in charge of -the dispensary should be paid. It is fairer to him, and fairer to the -patients. - -The Health Department of Baltimore has three special tuberculosis -dispensaries, each open twice a week, for two hours at a time. The -physician in charge is paid a good salary, and as a result, the -regularity of his attendance is in sharp contrast to that in certain -other dispensaries, where the work is done by well meaning but -overworked men who volunteer their services. Tuberculosis is a disease -that cannot be overcome by volunteer work or economical methods. - -=The Physician’s Qualifications.= The success of the dispensary depends -upon the ability and character of the physician in charge. He should be -able to make a diagnosis by means of auscultation and percussion, -without hesitating to commit himself until a sputum examination reveals -the bacilli.[7] For if finding the bacilli is to be the sole test by -which tuberculosis may be recognized, it would be possible for the nurse -to obtain specimens of sputum from her patients and submit them to the -laboratory direct—thus doing away with the doctor and proving the -dispensary superfluous. - -Footnote 7: - - See Chapter IX., page 109. - -Nor is this all. The physician must have a strong social sense, and be -able to inspire his patients with confidence. In no other work does the -personal character play so large a part, and this applies to the doctor -as well as to the nurse. One of our patients, enthusiastic in her praise -of one of the dispensary men, summed this up with homely accuracy: “He -couldn’t have been nicer to me if I’d paid him fifty cents in his -office.” - -=The Physician and the Patient.= After the patient has been examined, -the doctor carefully explains to him the nature of his disease, and the -precautions necessary. Since these directions must often be brief and -hurried, he will further add that he is sending a nurse to the patient’s -home, to act under his orders, and see that certain directions are -carried out. In this manner, the doctor prepares the way for the nurse’s -visit, and gives her an authority which greatly facilitates her work. -With this assistance, it is far easier to gain the patient’s confidence -than if it has been forgotten or withheld. The orders concerning the -patient are then given to the nurse, and if these include admission to -an institution, it is her duty to arrange all the necessary details, and -so relieve the physician of much time-consuming work. - -=Duties of the Nurse.= If a community has a special dispensary as well -as a special nurse, the nurse’s duties are twofold, and should include -not only the home supervision of the patients, but attendance at the -dispensary as well. She is the connecting link between the two. In this -way, her intimate knowledge of home conditions is placed at the -physician’s disposal, who is then able to give sounder advice and deal -more intelligently with his patients if he has some knowledge of their -environment. - -The nurse’s presence at the dispensary is often a considerable -assistance in persuading patients to come. Patients are often frightened -and shy, and dread the unknown, consequently it is better if the nurse -can give them the comforting assurance that she will be on hand to -welcome them. From her knowledge of their home conditions, she also -knows which cases can afford to wait, and which should be taken out of -turn and given immediate attention. It is thus possible to deal with -them in a personal and intelligent manner. Since at present the control -of tuberculosis lies largely with the patients themselves, and depends -almost wholly upon their good-will and co-operation, it is necessary to -establish this co-operation as firmly as possible. - -The duties of the nurse consist in taking the history of the patient; -taking his weight and temperature, and preparing him for physical -examination. If the patient is a woman, she must be present while this -examination is made. She also gives such drugs as may have been -prescribed. On his arrival, each patient receives a paper napkin to hold -over his mouth during coughing attacks, and to use for expectoration. A -special receptacle should be provided for these soiled napkins, and they -should afterwards be burned. The nurse should come to the dispensary -half an hour before it opens, in order to put it in readiness,—to take -out the charts and histories, attend to the drugs, place towels and -sheets in the examining rooms, and so forth. Whenever the clinic becomes -large enough to require it, it will become necessary to place the -clerical work in charge of a clerk. - -In these informal clinics considerable trouble is often caused by -patients who arrive just before closing time, and expect to be examined. -It is unwise to encourage this sort of tardiness, and a time limit -should be set and strictly adhered to. All patients arriving after a -specified hour should be directed to come another day, except such -patients as are recognized by the nurse as worthy of exception from this -rule. The most frequent offenders are not the patients who come from a -distance, but those who live just around the corner. Unless punctuality -be insisted upon, there will be endless overtime work for both doctor -and nurse. - -=Tuberculin Classes.= At some of the large dispensaries, selected cases -are formed into what are called Tuberculin Classes, and given special -treatment. These patients are very carefully chosen, both from a -financial as well as a physical standpoint, and intensive work, of a -curative rather than a preventive nature, is put upon them. The -treatment is carried out in their homes, where as nearly as possible -sanatorium conditions are attained. Unruliness, or failure to comply -with the regulations, means being dropped from the class. These patients -live on a carefully planned routine, carried out under close supervision -of both doctor and nurse. They report to the dispensary at certain -intervals, once a week or so, and there tuberculin is administered, -weights taken, and examinations made. Each patient keeps a little book -containing a daily record of his doings, including the number of hours -spent in the open-air, food—kind and amount, exercise, temperature, -cough, and other symptoms. This book is presented at each visit to the -dispensary, and the nurse also inspects it when she visits his home. -These class patients often do extremely well, and excellent results are -often obtained. Like all work of a curative nature, however,—in which -the subjects are carefully selected and as carefully rejected,—it deals -with so few people that it makes no real impression on the situation. -The tuberculosis problem is, what can be done for a thousand patients, -not for twenty. It is always possible to select a handful of cases and -maintain them indefinitely at a high level of health, by a considerable -outlay of money, energy, and time—an expenditure from which the -community as a whole derives little benefit. - -To establish a tuberculin class is purely a physician’s affair, and all -directions in regard to it come from the doctor himself. - -=The Nurse in Home and Dispensary.= When the staff is large and there -are several nurses, it may seem advisable, upon first consideration, to -assign one nurse solely to dispensary duty, and leave the others to work -in the homes. It is a better plan, however, to let all the nurses -combine service of both kinds, as the single nurse in the small -community must do. The intimate connection between home and dispensary -should never be broken—it is much too valuable. Moreover, as far as the -nurse herself is concerned, the monotony of dispensary work becomes -extremely wearing, and it is well to vary it with duty in the home. It -is a regrettable fact that a nurse confined to mere mechanical routine, -is apt to lose that fine understanding and sympathy which she needs in -her work, and which is always lost whenever human beings become merely -“cases.” - -In Baltimore this service is arranged in the following manner: There are -three Municipal Dispensaries, and one other clinic, managed on the same -lines, although not connected with the Health Department. These are -situated at the boundary lines of two or more adjoining districts, and -are thus accessible to the patients as well as the nurses of the -adjacent areas. All four clinics are served by certain nurses of the -Health Department, who are on duty on alternate days or alternate weeks, -as the case may be. Thus, the nurse from any one district is on -dispensary duty for two afternoons a week, every other week. This -deprives the home of her services to only a very slight extent—a -deprivation which is counter-balanced by her increased opportunities for -effective work. We should never advocate any greater curtailment of home -work, however, since the home, or centre of infection, is always the -chief point of attack. - -From another standpoint it is well that the nurses combine both kinds of -service. Through sickness or other reasons, it may become necessary to -substitute one nurse for another, and it is an advantage to have nurses -trained and able to relieve each other when necessary. - -=The Nurse as an Asset to the Community.= We have hitherto considered -the nurse as a public health nurse, or servant of the entire community. -Whether supported by public or private funds, whether connected with the -Health Department or a private association, we have considered her as -ready to answer all calls made upon her. We have regarded her as at the -service of all physicians, dispensaries, institutions, social workers, -and laymen, ready to respond to all calls without hesitation or -discrimination. Her unattachment to any claims but those of the -community as a whole gives her this broad field. - -If, however, her work be limited to the patients of any one institution, -association, or sect, she is no longer an asset to the community. For -example, if she is employed by a certain dispensary to visit its -patients only, her work is circumscribed. Her usefulness will be -restricted—her service will be valuable to the physicians of such an -institution, and she will collect data for their records, but her duties -will be localized for the good of the dispensary, rather than for -society as a whole. The same would be true if she be employed by a St. -Vincent de Paul Society to care for Catholic consumptives, or by a -Jewish organization to follow up Jewish patients—any arrangement through -which she visits one patient in a block, but refuses the case next door, -means a narrow field of service. She then becomes the nurse of an -institution, or a sect, rather than a public health nurse. The object of -her work is not the welfare of the community, but the welfare of certain -individual patients. Incidentally, her work may benefit the community, -but it falls far short of its possibilities. It must be supplemented by -new agencies, with the consequent duplication and waste of effort that -this always involves. - -Our experience in Baltimore will illustrate this point. In 1904, when -tuberculosis nursing was first organized, two nurses were placed in the -field. One was attached to the dispensary, of the Johns Hopkins -Hospital, the other placed in charge of the Visiting Nurse Association. -Between them the city was divided into halves, one nurse working in the -eastern, the other in the western portion of the town. The dispensary -nurse visited only patients who had been to the dispensary. The nurse of -the Visiting Nurse Association visited not only dispensary cases, but -_all patients reported from whatever source_. Thus, in East Baltimore, -if two consumptives lived in the same tenement, one a dispensary case -and the other under no supervision at all, only one of these two was -visited. In West Baltimore, both patients were cared for on equal terms. -At the end of a year, another nurse was added to the Visiting Nurse -Association staff, but not to the dispensary. The city was then -redivided, this time into thirds, and again the patients were cared for -under the same conditions. The dispensary nurse served the Johns Hopkins -Dispensary; the Visiting Nurses served the dispensary and the community -as well. Finally, in 1910, the tuberculosis work of the Visiting Nurse -Association was taken over by the city, thus creating a new municipal -department, the Tuberculosis Division of the City Health Department. At -that time the dispensary nurse gave up visiting in the homes of the -patients, and confined herself entirely to routine dispensary duties. -This left all visiting work to the Health Department nurses, who were as -punctilious in making reports to the dispensary as was the dispensary -nurse herself. By this arrangement, the Phipps, in common with every -other dispensary in the city, has had a large staff of nurses placed at -its disposal. Both the dispensaries and the community gain through this -co-operation. - - - - - CHAPTER XV - - The Nurse in Relation to the Institution—Reports Made to the - Institution—Procuring Patients for it—The Value of the - Sanatorium—Sanatorium Outfit—Return from the Sanatorium—Work for - the Arrested Case—Light Work—Outdoor Work. - - -=The Nurse in Relation to the Institution.= As the nurse is the -go-between from patient to physician, and from patient to dispensary, so -also does her service link together patient and institution. This, of -course, is only possible if she is a public health nurse—not if she is -the agent for one institution alone, or if she is employed to serve one -set of people instead of the community as a whole. Just as she should be -at the service of every physician, dispensary, and layman who chooses to -call upon her, so in like manner should she serve both hospital and -sanatorium. She will act as beater-up in the matter of sending patients -into these institutions; will arrange all details connected with their -admission, and finally, upon their discharge, will take them again under -her supervision and care. By this co-operation, the patient himself -profits, likewise the community, while the institutions are enabled to -keep in touch with their discharged cases, learn of their condition, -and, through the nurse’s reports, add to their histories and records -from time to time in a way which will greatly enhance their value. - -There is complete co-operation between the various institutions of -Baltimore and the nurses of the Health Department. Of the five -institutions near the city, four admit both early and late cases, while -one is for advanced cases only. Whenever a patient is admitted to or -discharged from one of these institutions, either hospital or -sanatorium, the Health Department is at once notified of the fact. -Following admission, the nurse visits the home and arranges for the -fumigation. Two thirds of the patients admitted are already known and -under supervision, but whether known or unknown, the visit is made and -fumigation arranged for in the usual manner. In homes where the patient -is unknown, the nurse often finds suspicious cases, which she sends for -examination and diagnosis. By means of this sharp look-out the visiting -list is considerably augmented. - -When the discharge of a case is reported, the patient may or may not -have been under previous supervision. If already on the visiting list, -the nurse merely resumes her visits. If not on the list, he is taken on -at once. Needless to say, the physician in charge of the institution -should prepare the way for the nurse’s coming, as should the physician -of the dispensary. If he forgets to do so, the nurse may have some -difficulty, especially with patients discharged in good condition, who -see no need for her services. When discharged in bad condition, the -reason is obvious enough, but in either case co-operation with the -institution is necessary. - -=Reports Made to the Institution.= The reports made to the institution -vary in accordance with the wishes of the physician in charge. Sometimes -they are informal, made on certain specified cases; sometimes they are -extensive and deal with large numbers of individuals. The value of these -reports is indicated by the following examples: Two months ago a young -girl was admitted as a paying patient, but she is now at the end of her -resources, which consisted of a small fund subscribed through -contributions of her fellow-workers. If she is to remain longer at the -sanatorium, she must be transferred to the free list. Or we find that a -young man, admitted erroneously to the free list, is in a position to -pay; in justice to the institution and those who perforce must accept -its hospitality, this patient should be transferred to the paying side. -Or we receive a letter from the superintendent, saying that a certain -patient has failed to arrive on the day specified, and asking us to look -into the matter. Upon investigation we may find that a death in the -family, an accident, or the lack of railway fare has been the cause of -his non-arrival. Provision for him to go can then be made—his place is -not forfeited, but held for him until a more favourable time. These -personal relations between the nurse and the institution bring a great -sense of cordial understanding and mutual good-will. - -The more extensive reports are managed as follows: Once a year, or -oftener if necessary, certain institutions send to the Health Department -a full list of their discharged patients, whom they wish looked up. The -names and addresses are written on separate slips of paper, which -contain a printed list of questions to be answered. These are -distributed among the nurses of the different districts, each nurse -being responsible for the patients in her own territory. Within a week -or ten days all the slips are filled in, and a full return made on all -cases submitted for investigation. This involves little extra work on -the part of the nurses, since in nearly every instance the patients are -already under supervision—and if through any oversight they are not, it -affords a means of finding them. The superintendents of the various -institutions find this a satisfactory way of keeping in touch with their -ex-patients, and we think that this work is well within the field of the -visiting nurse. Each gains by this co-operation—the Health Department, -which wishes to supervise all consumptive patients, and the institution, -which wishes accurate data for its reports. In effective social work the -keynote of success is reciprocity. - -=Procuring Patients for the Institution.= In still another way does the -nurse serve the institution and that is by procuring patients for it. -Large, well organized, and well equipped institutions have little -difficulty in filling their beds, but this is often the reverse with -those less known and less attractive. It takes much persuasion to induce -a sick man to leave his home, and it often takes still more to persuade -his family to let him go. To point out the necessity for institutional -care, and induce the patient to take advantage of this, is the chief -duty of the public health nurse. Only when she does this duty thoroughly -and well does the demand for hospital beds exceed the supply. For -example: in Baltimore, before the nurses went on duty, the large -hospital for advanced cases was never more than half full. The community -was not well enough educated to take advantage of it. Since the nurses -have been on duty, however, not only has this hospital been filled to -capacity, but the capacity itself has been enlarged to nearly -double—while a long waiting list is constantly maintained. A small -sanatorium was recently opened in Maryland, with a capacity of twenty -beds; at the end of five months, it had only five patients. The nurses’ -aid was solicited, and within a week it was full. This situation has -also occurred in other cities, which found themselves equipped with -excellent hospital accommodations, which the patients refused to make -use of. Co-operation between the institution and the municipal or -visiting nurses would doubtless have promptly remedied this state of -affairs. Incidentally we may observe, the better managed and more -comfortable the institution, the less difficulty there is in keeping it -full. It must offer substantial advantages over the home—attractions -which even the most ignorant and prejudiced must be trained to -appreciate. - -=The Value of the Sanatorium.= The sanatorium for the treatment of -hopeful cases is by no means as valuable as was at first expected. The -cure of tuberculosis is at best very problematical, and the sanatorium -is chiefly useful to those who can control their environment upon -discharge. Unless this can be done, treatment will be of little avail, -although it will delay the inevitable end. The patient who comes from -the alley and returns to the alley is foredoomed. And as most patients -come from the alley, figuratively speaking, and are afterwards obliged -to return to it, the results obtained by these sanatoriums are by no -means commensurate with the expense involved in maintaining them. -Whatever benefit is derived from them is for the individual, rather than -for the community. - -In the tuberculosis campaign, the sanatorium occupies a place of -secondary importance. We could fight quite as successfully without -it—possibly better, since the money devoted to the upkeep of these very -costly institutions could then be diverted to more radical purposes. -However, the sanatorium exists, and every patient should be given his -individual opportunity. It is usually more difficult to get a patient -into a sanatorium than into a hospital. The former is for early or -moderately advanced cases, who have a reasonable chance of improvement, -therefore it would seem a simple matter to induce them to go. Yet to -persuade a patient that he needs such treatment, especially when he -feels well and has few symptoms, is often a difficult task. The peculiar -psychology of the consumptive, his optimism and refusal to believe that -he has tuberculosis, is as well marked in the early as in the later -stages of the disease. On the other hand, the difficulty is often of an -economic nature. When the patient stops work, his income ceases, and -this often determines his refusal. This is why many patients work until -they drop in harness. Through the Charity Organization, or other similar -agencies, it is possible to solicit aid for a certain number of these -cases, and this must always be done. Such relief, however, is very -uncertain, and latent periods of considerable duration often intervene -between the time it is asked for and such time as it may be given. Even -when given, it very seldom approximates the wages that the patient -himself has been able to earn. Thus, a patient earns twenty dollars a -week; with luck, we may obtain for his family an income of eight or ten. -This is no reflection upon the Charity Organization Society, which has -probably pulled every conceivable wire in order to raise even that -amount—but it explains why the patient refuses the sanatorium and hangs -on to his job until he can work no longer. - -In many cases on the other hand, there is no question of poverty to -contend with—neither the wage-earner’s reluctance to stop work, nor the -mother’s unwillingness to leave a houseful of little children. Instead, -we must contend with ignorance, prejudice, and mental inertia—a moral -alley quite as dark as that of the slum. One of the most discouraging -features of this work is having to stand by and see the patient throw -away his chances. Tuberculosis waits for no one, and it requires not -only physical, but mental and moral strength to resist it. Before we can -remake and reconstruct a supine individual, the disease wins out in the -race. - -There is one consolation, however; hopeful cases are usually far less -dangerous than advanced ones. The refusal of sanatorium treatment is a -loss to the individual only. Furthermore, we have this grim solace—when -they finally consent to go, after weeks and months of delay, they do so, -too late to help themselves, it is true, but at a time when they are -most dangerous to other people. - -=Sanatorium Outfit.= When a patient enters a sanatorium, the nurse must -see that he is supplied with clothing heavy and warm enough for outdoor -living. If he has money, he should be instructed what to buy. If he has -none, these things must then be procured through some charitable -association. No patient should be permitted to enter a sanatorium unless -properly equipped, and frequently his decision against going is due to -lack of such equipment. - -In winter, he naturally requires much more than in summer. Roughly -speaking, his wardrobe should contain at least two changes of flannel -underclothing, a sweater, overcoat, woollen cap, woollen gloves, -overshoes, flannel night clothing, a dressing-gown, toilet articles, and -a hot-water bottle. Some institutions have a printed list of the -articles required, which is sent to the patient when his application is -accepted. A steamer rug is usually necessary, a cheap substitute for -which may be found in the large horse-blanket, sold in saddlery shops. - -=Return from the Sanatorium.= When a patient returns from a sojourn in -an institution, he may or may not be better, but he has certainly -received a liberal education in what to do, and how to take care of -himself. Often, however, he is totally unable to apply this knowledge, -or to adapt his home environment to his needs. So carefully is the -institutional life planned, and so smoothly does he fit into it, that he -has no conception of the time and thought that have gone into this -planning. When he comes home, he knows theoretically what to do, but in -comparison with the institution his home surroundings seem so poor and -so inadequate, that he becomes hopelessly bewildered and confused. It is -at this point that the nurse has her great opportunity. She teaches him -to apply what he has learned, and how he may approximate sanatorium -conditions and routine. She goes to work much as she does upon her first -visit to the home, but this time she is working in a soil already -ploughed. The patient himself may be almost as helpless, but he will -follow suggestions, and co-operate with an intelligent enthusiasm gained -through his sanatorium education. - -=Work for the Arrested Case.= When a patient returns from the sanatorium -able to work, the question of employment is a serious one. Our -experience has been that of Dr. Lyman:[8] as a rule, unless it is an -exceedingly injurious employment, it is better to let him return to his -former occupation than to seek a new one. He understands his old work, -and for this reason it will be easier for him than one to which he is -unaccustomed. The difficulty of finding suitable employment for arrested -cases, and the number of relapses that occur in consequence, serve once -more to emphasize the value of prevention rather than cure. - -Footnote 8: - - Dr. David R. Lyman, Wallingford, Connecticut. - -There is one point which must always be brought out. It is not so much -what the patient does with his working hours, as what he does with his -leisure hours, which determines his ability to hold his own. An arrested -case may work eight or ten hours a day, in office, factory, or shop, and -still remain well, provided he spends the remaining hours of the -twenty-four in a proper manner. The ex-sanatorium case, rejoicing in his -apparently restored health and in his regained liberty, feels that he -can resume life on exactly the same terms as before. This he can never -do. He has tuberculosis, and he always will have tuberculosis, although -it may be latent at the moment. The fact that it is quiescent does not -mean that it will not light up again at the slightest indiscretion. He -must bear this fact constantly in mind and order his life accordingly. -If he expects to work and remain well, he cannot burn the candle at both -ends, even in the mildest manner. He must forego late hours, moving -picture shows, poolrooms, saloons, dance halls—everything, no matter how -harmless in itself, which places an extra strain upon his vitality. At -the end of the day’s work he should rest quietly, preferably in the -open-air. Eight or ten hours’ sleep at night is a necessity. The most -critical time in a patient’s career is that which follows his return -from a sanatorium, and it is at this particular moment that the nurse’s -supervision and encouragement are so greatly needed. - -=Light Work.= Many patients return from the sanatorium, unable to work -at their former occupation, yet sufficiently strong to do “light work,” -if such a thing can be found. In my experience, suitable “light work” -for these cases has yet to be discovered. We all know of patients who -have been given easy positions as night watchmen, elevator-men, -corridor-men, office work, gardening, and so forth, and who have done -well at such employment. The number of such positions, however, is so -small and so out of proportion to the number of those who seek such -occupation that it forms no adequate answer to the question; what light -work can we find for the arrested case? Our present industrial system, -which produces the class of people from which the consumptive is so -largely recruited, also fails to provide proper employment for him after -his so-called recovery. The pressure of this system makes it -sufficiently difficult for an able-bodied man or woman to find work that -pays, or even any work at all, but to find such work for the handicapped -is almost impossible. Light work means light pay, and light pay means an -insufficiency of food, clothing, and shelter, all three of which are -needed for the maintenance of health. In these days when the physically -fit cannot always earn a living wage, what chance has the poor -consumptive? - -=Outdoor Work.= Another favourite fallacy is the advantage of outdoor -work for the returned patient. The sole value of outdoor work lies in -the opportunity to breathe fresh air, but this benefit may be more than -offset by the strain of long hours, exposure to heat, cold, and rain, -the lifting of heavy weights, and so forth. All these objections apply -to farm-work, driving delivery or freight waggons, the occupation of -motorman, conductor, and so forth. Now and then, patients undertake work -of this character and do well at it, but we cannot but believe that this -is in spite, of, rather than because of, their occupation. - -In summing up the nurse’s value to these discharged cases, we find her -able to give immense assistance at a most crucial period in the -patient’s life. By this help and advice, she can often prevent his -relapse, or at least delay it for a long time. Her supervision provides -incentive and encouragement, and her careful watchfulness, both of the -patient and his household, is of value in detecting further danger -signals. If, as too often happens, he is eventually swept under by -currents too strong for him, she is still on the spot, tried counsellor -and friend, to make safer and easier the downward path. - - - - - CHAPTER XVI - - Hospitals for Advanced Cases—The Careful Consumptive—Chief Duty of the - Nurse—Responsibility of the Institution—Home Care of the Advanced - Case—Exceptions to Institutional Care—Compulsory Segregation. - - -=Hospitals for the Advanced Case.= The crux of the tuberculosis problem -lies in the segregation of the advanced case. Until the distributor is -removed from his family, and separated from the intimate circle -surrounding him, we can make but little progress in the fight against -this disease. No community can protect itself from the ravages of -tuberculosis until it provides a place to which these advanced cases may -be sent. Not only do we need large special hospitals for these patients, -but we need special wards for consumptives in connection with every -general hospital which receives either city or State appropriations. -These special wards would be of even greater benefit to the community -than large special hospitals situated in the environs of a city, since -it would be easier to persuade a patient to enter an institution just -“round the corner” than to go to one far distant from his home. A dying -man dreads being separated from his family, and his family is equally -reluctant to part from him; furthermore, if a hospital is remote from -the city, his family can afford neither time nor carfare for frequent -visits. These facts play an important part in influencing a patient’s -decision, and due consideration should be accorded them. - -It would probably cost less to build and maintain special wards in -connection with hospitals already existing than to erect and support an -entirely new institution. The greatest objection to special wards is -that the coughing of the consumptives is disturbing to the other -patients, but if the ward is sufficiently isolated (a separate building, -if the hospital is planned on the cottage system) this objection would -not apply. Furthermore, these wards would offer good teaching centres, -where both doctors and nurses could learn more about pulmonary -tuberculosis than the average hospital teaches to-day. - -In attempting to secure ground for the erection of a tuberculosis -hospital, there is usually great opposition from laymen. They are not -only afraid of tuberculosis, but they fear the depreciation of property -which may arise in the vicinity of such an institution. Considerable -education is required to calm them to a realization that the consumptive -sheltered and cared for is less dangerous than the consumptive at large -and unrecognized. When it comes to a special ward in connection with a -city hospital, we may again encounter great opposition, really from the -same reason, though the objections expressed are expense of such a ward, -the lack of nursing facilities, that the room is needed for acute -diseases, and so on. All of which is a grave commentary, from the people -who best understand it, upon the infectious nature of this disease. Yet -the medical profession tells us with apparent sincerity that “the -careful consumptive is not a menace.” If this be true, where can he be -more careful and less of a menace than in a place specially provided for -him? - -The truth of the matter is, there is not, nor can there be, a _careful -enough_ consumptive. The very nature of the disease precludes such a -possibility, however much we educate him, or however earnestly he -himself may try to co-operate to that end. And for the vast majority of -patients, from whom we can obtain but little or only spasmodic -co-operation, there is even less to be said. There is one simple method -of determining whether or not a patient is careful—it consists in asking -the question: Under these circumstances, would I, myself, feel safe? -Would I be satisfied as to the safety of my nearest and dearest friend? - -At the beginning of the year 1912, the nurses of the Tuberculosis -Division of Baltimore had on their visiting lists about 2800 patients. -Of these 2020 were positively diagnosed, and had been under supervision -for over three months. Undiagnosed cases, and positive ones who had been -under supervision less than three months were excluded. These 2020 cases -were then classified according to their willingness or ability to follow -instructions, the groups being: Fairly Careful, Careless, and Grossly -Careless. We purposely omitted a “Careful” class, since adequate -carefulness would imply a condition in which there was absolutely no -danger, a condition hardly possible with this disease. In Fairly Careful -we included all those patients who really tried to follow advice, doing -so to the best of their ability. Careless included those who tried -intermittently, or who were badly hampered by circumstances. Grossly -Careless speaks for itself. - -The results of this analysis are here given: - - Patients visited over three months 194 - - Fairly Careful 98, or 50.5% - Careless 75, or 38.65% - Grossly Careless 21, or 10.82% - - Patients visited over six months 346 - - Fairly Careful 171, or 49.43% - Careless 151, or 43.64% - Grossly Careless 24, or 6.84% - - Patients visited over one year 623 - - Fairly Careful 300, or 48.15% - Careless 267, or 42.85% - Grossly Careless 56, or 8.98% - - Patients visited over two years 857 - - Fairly Careful 443, or 51.69% - Careless 339, or 39.55% - Grossly Careless 75, or 8.75% - - Total Number of Patients 2020 - - Fairly Careful 1012, or - 50.09% - Careless 832, or 41.13% - Grossly Careless 176, or 8% - -It will be noticed that these percentages vary but slightly, or to a -negligible extent. Roughly speaking, about half the patients try to be -careful, and half do not try, or do not succeed if they attempt it. -Furthermore, it will be noticed that the time element has little to do -with making a patient careful. The natural supposition would be that a -patient visited for one or two years would show a marked increase of -carefulness over those who had been under supervision but a few months. -Yet there is virtually no difference between them, 50.5% of the -three-months class being careful, as against 51.69% of the two-years -class. These figures, we believe, show conclusively that long-continued -teaching does not necessarily lead to satisfactory results. They also -show that the patient left in his own home, even under constant -supervision, is unable to achieve a degree of technique which means -positive protection to those around him. There is but one conclusion to -be drawn from these facts—not that the nurse is useless, but that the -patient at large is dangerous. It proves the necessity for hospital -care. - -The hospital for a patient to die in appeals less to public sympathy -than as a place in which he may get well. But it is better economy. Care -of the open case, during his last and most infectious stages, is care -which strikes at the very root of the evil. Until this fact is realized -and full provision made for these cases, it will be a waste of time and -money to spend them on superficial or half-way measures. If our goal is -the elimination of tuberculosis, we should concentrate our efforts upon -radical and fundamental methods. - -At present, however, we can conceive of no community sufficiently -advanced or far-seeing to make adequate provision for these last-stage -cases. Therefore, the patients who make up the difference between the -number of those needing hospital care, and those receiving hospital -care, must be cared for in their homes by the nurse. Never for a moment -should home supervision be considered a satisfactory substitute for -hospital accommodation. The nurse’s efforts, no matter how thorough and -conscientious, can never entirely remove the danger. Her care often -lessens it to a marked degree, but never absolutely eliminates it. It is -at best a makeshift, a stopgap—better than nothing, often much better -than nothing, but never for a moment the proper alternative to removing -the patient from his home. No one knows better than the nurse herself -the inadequacy, the futility, of even the closest supervision. - -=Chief Duty of the Nurse.= For this reason, the chief, the absolutely -most important duty of the nurse is to induce the infectious patient to -go from his home into an institution. To accomplish this end, she must -bring every effort to bear upon the patient and his family, and appeal -to them from every conceivable angle. This is her one great duty—the -paramount reason for her existence. - -To accomplish this, is as difficult as it is important. A patient does -not willingly give up his home, however poor and humble it may be, while -his family often cling to him with an obstinacy open to no argument. As -a rule, the difficulty of removing him is in inverse ratio to his -intelligence, and to the danger to those surrounding him. - -=Responsibility of the Institution.= In overcoming this prejudice, a -great deal depends upon the character of the institution itself. It is -not enough to establish hospitals:—they must be attractive and -comfortable to such a degree that they become highly desirable to -prospective patients. They must be well run, well managed, the food must -be good, and the patients well treated. To obtain segregation, we must -have hospitals which offer great advantages over the home. - -=Home Care of the Advanced Case.= If there are no hospital facilities, -it then becomes the nurse’s duty to give nursing care to the bed-ridden -patient. This is also done when the hospital accommodations are limited, -and the patient must wait to be admitted. During this waiting period, -which may extend over weeks, he should be visited every day (or at least -as often as the work will permit), and given such care as he requires, -including bed-baths, care of the back, and so forth. The nurse must also -teach some older, responsible member of the family how to care for him -in the intervals between her visits. Sometimes, when a vacancy finally -occurs, the patient may be contented with home treatment and refuse to -enter the institution, or his family may refuse to let him go. The nurse -must do her utmost to persuade them. She must explain that in the -hospital he will receive constant, not intermittent care, and that her -work will only permit her to render nursing service to those who cannot -otherwise be provided for. Should he still refuse, she must continue her -visits of supervision, but must stop all nursing care. No premium -whatever should be placed on his remaining at home. This may seem like a -harsh and unfeeling policy, but it is the only course to pursue when we -take into consideration the fact that the institution is the proper -place for an infectious disease. If a patient has become accustomed to a -daily bath and other attentions, he will miss them; when he misses them -badly enough, he will consent to go where they may be had. This plan -does not mean that the nurse neglects the patient,—if he suffers, it is -through choice. An excellent alternative has been offered, and his -refusal to accept it should not entitle him to continue infecting his -family, assisted by the nurse to do it in comfort. - -=Exceptions to Institutional Care.= A few exceptions may be made in -advising institutional care. For example, if a family is in good -circumstances, with excellent home conditions, and the patient is -surrounded with every care and attention, it would hardly be necessary -to counsel his removal. On the contrary, with our present lack of -hospital facilities, to urge such a patient to leave his home might mean -taking a hospital bed from another who needed it infinitely more. Again, -if a tuberculous child is being cared for by his mother, or some one -equally unlikely to contract the disease, it might not be worth while to -remove him. An exception might also be made in the case of a childless -couple, advanced in years. The nurse must use her judgment and -common-sense in such cases, where the chances of infection are slight, -or non-existent. On the other hand, if there is ample hospital -accommodation, and cases like the above ask for admission, they should -always be taken in. - -The cases in which separation is imperative are those in which there is -great exposure, inability to control the home surroundings, extreme -poverty and neglect, or undue and prolonged strain upon other members of -the household. - -=Compulsory Segregation.= Not until our hospital facilities are so large -that we can accept every case which applies for admission, can we -consider forcing people to enter these institutions against their will. -It is illogical to consider compulsory segregation, while we cannot -accommodate all those who voluntarily ask for it. The patient who -refuses to go to an institution is probably no more dangerous than he -who clamours in vain for a bed. The docile, well intentioned, kindly -consumptive is doubtless as much a menace as the selfish, vicious, -avowedly careless one; in fact, the former may be more harmful, since -his kindly nature surrounds him with friends, whereas the latter forces -people to avoid him. - -As for the tramp, the homeless man who wanders from pillar to post, -sleeping in saloons and lodging-houses, he is far less of a menace than -people suppose. He comes into but casual relationship with his fellows, -and no one is in prolonged and intimate contact with him, as is the case -of the man in the home, the centre of the family circle. Until we can -accommodate the latter, we must let the former do as seems best to him. -If ten anxious people are clamouring for every hospital bed at our -disposal, why force it upon the reluctant one who refuses? When we can -handle the problem of voluntary segregation, it will be time to consider -compulsory measures. - - - - - CHAPTER XVII - - The Problem of Giving Relief—The Giver of Relief—Co-operation between - Agent and Nurse—General Rules for Nurses and Agents—Conditions of - Asking for Relief—Wrong Conditions of Relief-Giving—Incidental - Assistance—Withdrawal of Relief—Supplying Milk and Eggs. - - -=The Problem of Relief-Giving.= Giving financial assistance or relief to -patients on or below the poverty line is a question which sooner or -later confronts the nurse who undertakes social work. Long hours, -overwork, and low wages produce a class of people who offer little or no -resistance to disease, and when tuberculosis once gets a foothold -amongst them, it is passed on from one devitalized individual to -another. This is why it is necessary to remove a disease-distributor -from among a group of highly susceptible individuals. For example: let -us take a family consisting of father, mother, and four children. The -father contracts tuberculosis and stops work—his income also stops. Even -at best, it was a pitifully inadequate income, and in consequence the -entire family is undernourished, anæmic, and generally run down. With -the income gone, their resistance is still further lowered, and their -chances of infection are correspondingly increased. The result is a -patient surrounded by a group of people able to offer but slight -opposition to this insidious disease. The environment, bad as it was -originally, grows worse. The family moves into smaller, fewer, cheaper -rooms, and food, heat, clothing are all reduced to a minimum. This -increasing poverty means diminished vitality, and heightened -susceptibility to the threatening danger. In attempting to relieve this -situation we are dealing not with a simple, but with a twofold -problem—poverty, plus an infectious disease. - -Because of its complex nature, the question of giving assistance is a -difficult and delicate matter. In our efforts to relieve distress and -want, we must be careful to do nothing which will result in spreading -tuberculosis. The paramount consideration is the prevention of -infection, and for this reason, relief should be made conditional upon -the removal or reduction of the danger. If we keep this idea firmly -before us, the problem will be much simplified. - -In Baltimore, from one third to one half of the families under -supervision are on or below the poverty line. This means that they are -registered on the books of some charitable association, and are, or at -times have been, dependent upon these organizations for food, rent, -fuel, clothing, or other assistance. In other words, the gap between the -income and the cost of living has needed to be bridged over by outside -aid. In a new community when the nurse’s first patients are the “poor -people” of the locality, she will find that nearly a hundred per cent. -of her cases are on the poverty line. This was our experience in -Baltimore, when the work was first organized, but now that it is well -established the percentage is much reduced. The nurses are now working -in homes where economic conditions are not acute, hence the number of -those receiving or rather of those needing relief (the terms are not -always synonymous) is less than a few years ago. Still, distressing -poverty is found in from one half to one third of the families, which -means that the problem of fighting tuberculosis is gravely complicated. - -=The Relief-Giver.= When people need financial assistance, the question -arises, by whom shall it be given? a point which provokes much -discussion. Many people think that the nurse should give this relief, -because of her intimate knowledge of the home conditions of the families -under her charge—a knowledge far more extensive than that gained in any -other way. Some think if she is socially trained, _i.e._, supplements -her hospital training by a course in a school of philanthropy, that she -can combine the duties of both nurse and charity organization agent, and -become in this way a most effective social worker. By this combination, -the family will be spared the infliction of two visitors, nurse and -agent, a desirable result, since the advice given by these two workers -is often flatly contradictory. Other people think that instead of having -a nurse, it would be better to have a graduate from a school of -philanthropy, with a training supplemented by a six months’ hospital -course. The superficial nature of this course is sufficient commentary -on its value. Moreover, more than one half of the patients with -tuberculosis do not come within the reach of a relief-giving agency. - -These two people, nurse and agent, are both specialists in their own -lines, and they are equally needed. They have had a different training -and are equally valuable in the field of social service. Even if it were -possible, we should not like to see these two offices combined in one -person—somewhere there would be a loss. It is difficult enough to get a -first-class tuberculosis nurse, and it is equally difficult to find a -first-class charity organization agent. How much more difficult to find -these combined in one person. There is full warrant for saying that -under no circumstances whatever should the nurse become a relief-giver, -or even remotely identified as such. In the foregoing pages we have -learned something of the extent and responsibility of her work, and if -she concentrates her attention upon bringing it to the highest degree of -efficiency, she will find time for nothing else. Moreover, if she -becomes known as one able to give material assistance, her value as a -public health nurse will decline. That she can give or withhold relief -will become known to her patients, who will follow or reject advice -according to what they receive from her. Her prestige as impartial, -disinterested adviser will at once diminish, and the force and authority -of her opinion be lost. Never, even by the gift of a five-cent piece, -should she jeopardize her unique position. The well-to-do patients will -scorn her services, and resent the implication of her visits, while the -others will follow advice when they are bribed, so to speak, and do as -they like when for any reason this bribe is withdrawn. And other -patients will be disobedient or resentful if they cannot obtain what -their neighbours have, or what they believe themselves entitled to. - -=Co-operation not Interference.= To concentrate on one’s specialty is -all we should ask of anyone. Any social agency which scatters instead of -concentrates, produces superficial work, which is open to well-deserved -criticism. As well expect a nurse to become a kindergarten teacher, -because she sees the need for kindergartens, or to become a playground -teacher or settlement worker, as to take upon herself the rôle of -charity-organization agent. _And the reverse of this is true._ We should -not expect a relief-giver to undertake a nurse’s duties. It is not the -combination of various effective qualities in one person, but the -co-operation of various effective persons or specialists, which counts -in social service. Furthermore, each set of workers should recognize its -own limitations. The line of demarcation should be sharply drawn between -the work of one agency and that of another. - -One sometimes encounters an intense zeal which causes one social worker -to try to do her own, and everyone else’s work as well; or even worse -than this, to neglect her own work in order to do that of another -person. All social workers should learn where to stop—where to transfer -the case to someone else better fitted to deal with another phase of it. -We sometimes hesitate to call in other agencies, because they do not -recognize their boundaries. Co-operation should be substituted for -rivalry and interference; when this is brought about, petty bickerings -and jealousies among the social agencies will cease. - -To become an effective co-operator, instead of a critical interferer, -the public health nurse must familiarize herself with all the agencies -in the wide field of social service. She should try to understand the -object and method of their work, and to know where her own work -interlocks with theirs. In a way, they are all interdependent, one upon -the other, and have the same object in view—to relieve distress and -raise the sum total of human happiness. Whether their work is effective -or superficial is not our concern. The nurse should understand what each -of them has to offer, and by picking here and there among them, secure -valuable assistance for the families under her charge. She can thus -reinforce her own efforts, and supplement her own work in behalf of -their well-being and security. - -Since nurses come in almost daily contact with the Charity Organization -Societies it should be part of their duties to attend the local district -meetings of these associations, for during the discussions which take -place, the nurses are able to give most helpful information concerning -their own cases, while in regard to other cases, not complicated by a -communicable disease, they learn much as to the methods and theory of -relief-giving. For this reason, these district meetings are useful to -both nurse and agent alike; the interchange of opinion enlarges the -outlook of both workers, and each gains an insight into the difficulties -of the other’s work. This interest and understanding promotes good -feeling, tolerance, and personal friendliness—the basis of successful -team work. - -=General Rules for Nurses and Agents.= In a small community in which -there is but one nurse and no Charity Organization Society or its -equivalent, it is well to form a Relief Committee, to whom the nurse may -refer such of her cases as need assistance. In cities where -relief-giving organizations are already established, a few general rules -should govern the relation between nurse and agent; the observance of -these will prevent much trouble and misunderstanding. Under no -circumstances should the nurse give material assistance—neither money, -food, clothing, nor anything of the sort. When these things are needed, -the agent should be asked for them, and no case is so acute but that it -may wait until this consultation takes place. In a city where there is -no emergency or night bureau, it may be necessary to make an occasional -exception to this rule, in which case the nurse may tide the patient -over till the following morning, when the agent may be conferred with. -Such instances will be so rare, however, that they are merely noted as -exceptions to the general rule—under no consideration whatever should -the nurse give any material relief. - -It sometimes happens that the nurse has been given a small sum to buy -food, clothing, or special articles for some of her patients. This fund -was perhaps intended for a specified case, or to be used at discretion. -It is wiser to give this money to the agent, with the request that it be -spent (if circumstances warrant) as the nurse suggests. This course may -involve additional trouble, a little extra work for both nurse and -agent, but it is necessary to be extremely punctilious in order to avoid -serious misunderstandings. - -When a nurse has been in the work a long time, and is dealing with -agents whom she knows and understands, a feeling of mutual trust and -dependence will arise. Under such circumstances, both may take far more -leeway than should be granted a new worker—but unfortunately this happy -and comfortable state is not always reached. The safest plan is that -each should follow her own line with utmost precision, being rigidly -careful not to overstep the boundaries between her own and another’s -duties. - -For example: a benevolent individual may give the nurse an overcoat, to -be used for any patient who needs it. The nurse knows a patient who is -expecting to enter a sanatorium in a few days. Her first inclination -would be to give him the coat and say nothing. Apparently it concerns no -one but herself and her patient. In adherence to the rules laid down, -however, she must first consult the agent before giving away the coat. -This consultation may reveal the fact that the family (new to the nurse) -is well known to the Federated Charities, and that but a short time ago -this patient was given an overcoat which he sold for drink. At this -time, be it said, he was not known to be tuberculous. Of course, this -constitutes no argument against giving him another chance, inasmuch as -he depends upon it to enter the sanatorium, but it gives the nurse a -side light on her patient’s character. She should make sure that he will -not play fast and loose again; also upon entering the sanatorium the -physician must be informed that the man is addicted to alcohol—a -tendency to be considered in his treatment. - -Tuberculosis, like poverty, is a chronic condition, and the delay -required for wholesome co-operation will seldom prove fatal. - -The agents, likewise, should be governed by one very simple rule, which -will obviate all misunderstandings and ill feeling. This rule should -be—no advice, suggestions, or interference in regard to medical -attention, nursing, or treatment. All this lies strictly within the -nurse’s province and should be left absolutely to her. For example: if -an agent enters a house and finds a consumptive, she should make no -suggestions as to changing doctors, going to this or that dispensary, or -to such and such an institution. If the case is already known to the -nurse, the agent may consult her, and find out what plans and -arrangements have been made and then aid in bringing them about. If the -case is unknown to the nurse, the agent should report it at once, -leaving the nurse to take all necessary steps as to diagnosis and -treatment. Grave results often follow the abuse of this one simple rule. -For example: an agent enters a patient’s home, and finds him in charge -of a certain doctor. Without knowing anything of the circumstances, she -may advise him to change doctors, go to a dispensary, or even to a -sanatorium. She does not know that the patient is in charge of a -physician with a large private practice, and that this is the first time -he has called upon the tuberculosis nurse. His co-operation and help in -the tuberculosis campaign depends upon the way this first case is -handled. His indignation at finding the nurse has played him false (for -it is apt to be the nurse who is credited with these objectionable -things) may be so great that months of explanation cannot wipe it out. -As we have said before, tuberculosis is like poverty—a chronic -complaint—and the delay needed for co-operation will not prove fatal. - -If nurses and agents will follow strictly this one simple rule—the -former to give no material assistance, the latter to offer no advice -concerning the patient’s treatment—the chief cause of friction between -these two sets of workers will be eliminated. - -=Conditions under which Relief is Asked.= The nurse who visits a family -every week or two is in a position to know when they have come to the -end of their resources and need relief. When this point is reached, she -should report the case to the agent of the Federated Charities. She must -always bear in mind that her chief work is the prevention of -tuberculosis; it is not necessarily the prolongation of human life, -although the two are sometimes coincident. Relief should be asked for if -it brings about the prevention of tuberculosis, but under no -circumstances if it means increased opportunities for scattering the -disease. Under the latter conditions, assistance should be withheld or -withdrawn as the case may be. - -For example: we have a family consisting of father, mother, and several -children. The income ceased when the father, the wage-earner, became too -ill to work. The family is in great need of fuel, rent, and groceries. -The giving of this assistance should be made conditional upon the -removal of the danger—that is, upon the patient’s going to an -institution where he will be better cared for than in the home. By -insisting upon this removal, the Federated Charities can play an -important part in the suppression of tuberculosis. - -Suppose there are no hospital facilities, and it is necessary to keep -the patient at home. In this case, the most susceptible members of the -household, namely, the children, should be removed. To place out -children is a difficult matter, since it is hard to get the parents’ -consent; this can be done, however, with time. - -If this turns out to be impossible, relief may be given on condition -that the strictest precautions are observed. This assistance may be -given as long as both patient and family follow rigidly all directions -given by the nurse; failure to do so should be a signal for the -withdrawal of all aid. To assist the patient who has no choice but to -remain at home, means to give relief under the least favourable -conditions, but it must answer when there are no hospital facilities. -When such facilities exist, no alternative should be permitted. When a -family reaches the point where outside interference—social -interference—is needed, we think it not unreasonable that this -assistance should be given upon terms which tend to promote, rather than -diminish the welfare of its members. - -=Wrong Conditions of Relief-Giving.= Relief is sometimes given in a way -that makes it defeat preventive work, and tends to create new sources of -infection. For example: we recall a case in which the father of a family -was in the last stages of consumption. His wife took in washing, and was -general drudge for the patient and five small children. This man refused -to go to a hospital, and also refused to use his sputum cup, or take any -other precautions. Most of his time was spent in bed, and beside him in -the bed were his two small children, whose presence gave him pleasure. -Neither doctor, nurse, nor agent could bring about a better state of -things, yet the family was desperately poor and in great need of help. -In consequence, assistance was given upon the patient’s own terms of -being allowed to carry out his right to infect his family. Groceries -were given in large amounts, and the patient himself was supplied with -abundant milk and eggs, which kept him alive for weeks beyond the point -where his own manner of living would have ended the matter. Soon after -his death, one of the children died of tubercular meningitis, while his -wife developed a pulmonary lesion. All the family are now public -charges. - -We recall another case: The family consisted of the patient, his wife, -and eight children. The patient was grossly careless, declining to -observe the slightest precautions, and flatly refused to enter a -hospital. After his death, his wife and five of the eight children were -found to have tuberculosis. During the last six months of his life, a -certain agency had poured in unceasing relief, thereby subsidizing a -centre of infection. - -Still a third case is that of a widow, with two small children. She -would not part from these children, and refused to go to a hospital, or -to let them go to the country. A separate bed was provided, so that for -part of the time at least the children might be away from her, but she -declined to let them occupy it. She kept them in bed with her. Neither -would she use a sputum cup nor follow advice in any way. All this time, -some benevolent old ladies kept her well supplied with groceries, milk, -eggs, coal, rent, and so forth, by means of which assistance she was -able to drag out a moribund existence for eight or ten months. Pitiful -as this case was, the utter selfishness and immorality of this sort of -“mother love” is something which should repel rather than attract the -sympathies of thinking people. - -These are perhaps extreme instances, yet in a lesser degree this is what -usually happens unless relief is made conditional upon removal of the -danger. Charitable associations should be careful not to act as -accessories in the spread of tuberculosis, and should not prolong -conditions under which this is practically inevitable. If centres of -infection are thus perpetuated, through sources over which the -associations in question have no control, nurse and agent, at least, -should not countenance such “benevolence.” - -=Incidental Assistance.= There are many occasions when the nurse should -ask for relief, and when this should be freely and generously given. -When a patient enters an institution, it may be necessary to pension his -family during his absence; assurance of their welfare will enable him to -leave with an easy mind. Unless such provision is made, we are -threatened with the alternative of seeing him sit at home, unable to -work, but engaged in the minor though highly dangerous occupation of -caring for the children while his wife goes out to service. - -Relief may also be of a temporary nature. While a patient waits for -admission to a hospital he may be too sick to remain alone at home. This -may mean that his wife, the breadwinner, is forced to give up work in -order to care for him. Assistance should be given during this waiting -period, after which time the wife will return to her employment and the -family affairs readjust themselves. - -Again, we may have a family in which the patient himself is the only one -who needs help, the income sufficing for all ordinary demands, but not -for the extraordinary demands of illness. While awaiting admission to an -institution, it may be necessary to give him extra food, extra clothing -or bed clothing, an overcoat, railway fare, or something of like nature, -either to make him comfortable, or to facilitate his removal when the -time comes. The patient must not be allowed to suffer during this -enforced wait, but this assistance must not be interpreted as -encouragement to remain at home. - -In the foregoing instances, relief has been conditional upon removal. We -must sometimes give assistance under other circumstances. If there are -no hospital facilities, or if he will not avail himself of them, we are -doing good preventive work if we give the patient an extra bed, since -this may result in his partial separation from the children or other -members of the household. Extra clothing may also be given under like -conditions. On the other hand, if we gave milk and eggs to the patient, -we should be supplying food which would maintain indefinitely a centre -of infection. (Good preventive work may be accomplished by ample feeding -of the other members of the household, thus increasing their resistance. -In this case we should be sure that this food is taken by the children, -or by those for whom it was intended, since otherwise it would be -wasted.) Let us put the matter very frankly: it is wrong to prolong a -patient’s life, unless at the same time we can make him harmless to -those about him. If the two are coincident, well and good. If not, then -the shorter the exposure, the better for all those who must submit to -it. We repeat what was said at the beginning of the chapter: the patient -on the poverty line is surrounded by a group of individuals whose -vitality is at a very low ebb. Our first duty is to protect these -individuals. - -=Withdrawal of Relief.= When relief is given with the understanding that -certain conditions be complied with, it should be withdrawn if this -compact be violated. The nurse is in a position to know of any breach of -faith, and should notify the agent accordingly. The objection is -sometimes raised that assistance given in this way is a bribe, or a -threat, or a means of coercion, and is therefore wrong. This rather -overstates the case. Let us say, rather, that under these circumstances -we have in our hands a powerful lever, by which mountains of ignorance -and prejudice may be removed. By the use of this lever, we can work -quickly and well for the best interests of the family and the community. -We constantly see families who are not on the poverty line, and over -whom we have no control, yet who are equally obstinate, ignorant, and -dangerous, and regret infinitely that we have no such lever as in the -case of patients who are below the poverty line. - -When asking for relief, the nurse must be sure that her patients will -take advantage of it, and that she is not sending the agent on -wild-goose chases. Patients have sometimes been supplied with cots, -window-tents, reclining chairs, and other similar and expensive -articles, which they subsequently declined to use. An indifferent, -careless patient, unwilling to co-operate in any way, is not one for -whom to demand such an outlay. - -=Milk and Eggs.= Ten years ago, milk and eggs for consumptives was an -integral part of the tuberculosis campaign. In those early days, they -were considered as necessary as was fresh air itself. They were -prescribed as a matter of routine, and if the patient could not afford -to buy them, they were at once supplied by some charitable association. -We have come a long way since then. - -Attention has already been called to the fact that, in the past few -years, medical opinion has undergone a great change as to the value of -milk and eggs. This rich and highly concentrated food is considered far -less advantageous than was at first supposed. By reason of their fat -content (especially the case with eggs), they tend to cause indigestion, -always a serious complication in pulmonary tuberculosis. For this -reason, the old idea of living on enormous quantities of milk and eggs -has been largely abandoned. Some sanatoriums do not give them at -all—other food is substituted, equally nourishing but less apt to upset -the stomach. Yet the idea that they are necessary for consumptives dies -hard. - -In Baltimore, there is now no question of providing them. During the -past year, nearly five thousand consumptives passed under the -supervision of the Tuberculosis Division; we asked that milk and eggs be -given to only thirty-eight of this number. Of these thirty-eight cases, -thirteen were advanced, waiting admission to a hospital; two were early -cases, waiting admission to a sanatorium; nine were suspects, and extra -nourishment was needed in order to facilitate diagnosis; and fourteen -were chronic cases, to whom this diet was given as a valuable tonic. - -Quite apart from their value, the real reason that we have ceased to -give milk and eggs is because of our policy of removing the patient to -an institution. The furnishing of this diet, or of anything else which -tends to keep him at home, is something we do not endorse. We do not -wish to place any premium upon the home, or to offer any inducements to -remain in it. If our patient wants milk and eggs, we can send him where -they may be had. - -If there is no hospital for the tuberculous patient in a community which -is able to furnish one, the maintenance of the patient by charity as a -centre of infection, makes little difference, one way or the other. In -this case, the absence of a hospital means that the community is merely -sentimentalizing and pottering over the tuberculosis problem. - - - - - CHAPTER XVIII - - Home Occupations of Consumptives—Sewing and Sweatshop Work—Food—Milk - and Cream—Lunch Rooms and Eating-Houses—Laundry Work—Boarding- and - Lodging-Houses—Miscellaneous Occupations—Summary—The Consumptive - Outside the Home—Cooks—Personal Contact in the Factory—Supervision - Outside the Home. - - -=Home Occupations of Consumptives.= Up to this point we have considered -the patient solely in relation to his own family, or to those with whom -he comes in immediate, constant contact. The people surrounding him are -in their turn infected, transmitting the disease to others who in like -manner are intimately exposed. Roughly speaking, all of this infection -takes place within the four walls of the home. The home, therefore, is -the centre of infection,—the focus from which tuberculosis radiates into -the community. The further one is removed from this focus, the less the -danger. - -There are certain ways, however, in which danger from the home threatens -people who live outside, people in no wise connected with the patient, -and unaware of his existence. This occurs when the patient leaves his -home to seek employment in the community, or when he makes or handles -certain articles which go forth into the community as carriers of -bacilli. Infections of this sort may be termed accidental. They are -infrequent as compared to house infections, but infrequent as they are, -they should be prevented. - -In Baltimore, nearly fifty per cent. of the patients under supervision -are able to work. They seek a livelihood in office, factory, shop, -hotel, and private home. We also find that nineteen per cent. of the -families under supervision carry on some sort of gainful occupation -within the confines of their own homes. As a rule, the patients who -conduct these little home industries or occupations are more advanced -cases than those able to find employment in shops and factories. In some -instances, this home industry was carried on before the patient became -ill; in others, by far the greater number, it is the direct result of an -illness which has modified his earning power and compelled him to eke -out a scanty income by this means. In many cases the actual work is not -done by the patient himself but by some other member of the household. -Sometimes these industries are not dangerous to other people, or the -risk is so slight as to be negligible. At other times, the menace is -grave. Each case must be considered upon its individual merits—one must -not generalize and condemn in wholesale fashion. - -=Sewing and Sweatshop Work.= A number of our patients are dressmakers, -or do factory sewing at home. Much has been written about the danger of -clothing made under such conditions, either by the patient himself or by -other members of his family. This output is not as dangerous as many -people suppose, although such an admission would deprive the campaign of -much picturesque photography. Much of this clothing is of washable -material, such as cotton shirts, blouses, overalls, and the like, -therefore any germs they might carry would be removed in the first -washing. The danger has also been exaggerated in the case of woollen -materials, such as coats, trousers, etc. Any organisms contained in -these articles would soon die, or their virulence become so attenuated -that little harm would result. This also applies to artificial flowers. -It is not the occasional dose of bacilli, conveyed in this or any other -manner, but the large and repeated implantations which do the damage. - -Infected clothing doubtless plays considerable part in the spread of the -acute contagious diseases, such as measles, diphtheria, and scarlet -fever, but in tuberculosis the risk is so slight that it may almost be -called non-existent. Under such conditions, the danger is not to the -wearers, or probable buyers, but to workers who make this clothing while -in contact with the consumptive himself. - -=Food.= There are other home occupations about whose danger to the -public there can be little doubt. Many patients keep small grocery -stores, confectionery shops, and lunch rooms, and prepare and handle -foodstuffs of all kinds. Again we must discriminate. The consumptive who -sells tinned foods (which he does not handle), or meat, fish, or -vegetables which are cooked before they are eaten, is not necessarily -spreading disease among his customers. On the other hand, he who sells -and handles milk, cream, ice-cream, bread, cake, candy, and so forth, is -a decided danger to all who buy his wares. The alimentary tract is one -of the main portals of entry for the tubercle bacilli, and every -precaution must be taken to prevent the contamination of food. The -patrons of these little shops are the people of the neighbourhood, who -are regular customers, and their health is endangered not by occasional -but by repeated doses of germ-laden food. - -=Milk and Cream.= There is an ordinance in Baltimore forbidding the sale -of milk and cream in a house where there is an infectious disease; this -includes tuberculosis. In order to sell milk, it is first necessary to -obtain a permit from the Health Department, but this permit may be -revoked whenever occasion demands. If the nurse finds that one of her -patients is selling milk (as is often done in connection with a small -grocery business), she reports this fact to the Health Department. It -may be that the patient himself never comes near the shop, and is out at -work or away all day. This sometimes happens, but not often. Usually he -waits upon the customers himself, selling milk in penny amounts, with a -dirty finger inside the measuring cup. Or he may be too ill to attend -the shop, but sits or lies in an adjoining room, so that his wife may -wait upon him and upon the customers alternately. Under such conditions, -the danger may be almost as great as if he himself handled the milk, -since she does not take time for proper cleanliness. - -To revoke a permit usually occasions considerable hardship, and the -reduction of an already pitiful income. Yet summary measures must be -taken unless the milk is sold without risk to the purchasers. The -patient should be removed to a hospital, and the family must choose -between letting him go and giving up the permit. When there are no -hospital facilities and the permit must be withdrawn, leaving the family -under financial stress, the nurse should ask assistance of the Federated -Charities. This assistance, however, should never be offered as an -alternative to removing the patient to a hospital. - -There are other foods besides milk and cream liable to contamination, -the sale of which is not controlled in any way. Thus as we have seen, -while a consumptive may be prohibited from selling milk, he may sell -ice-cream without let or hindrance. And furthermore, an ice-cream cone -or “snow-ball,” handled by dirty, germ-laden fingers, is most often sold -to the most susceptible of all customers—the child. - -=Lunch Rooms and Eating-Houses.= Many patients earn their living by -keeping eating-houses, oyster-parlours, ice-cream saloons, and so forth. -There is danger to the customer whenever the cooking and serving of food -are done by a consumptive, or by those in contact with a consumptive. A -community to be well protected should enact comprehensive legislation -controlling every aspect of the food supply, and special emphasis should -be laid upon the handling of food by those with a transmissible disease. - -=Laundry Work.= Another home occupation is laundry work—unskilled labour -requiring no capital and largely resorted to, especially among negroes. -This is heavy work, hence not always done by the patient, but often by -some other member of the household. Whether the patient irons the clean -clothes or sits coughing in the same room where this is done (we have -often seen newly ironed clothes spread upon the bed of a last-stage -case), the result is much the same. Under such circumstances clothes -become contaminated. Since this sort of laundry work is usually done for -regular customers, they week after week wear clothing that has come from -an infected house. It is dangerous to sleep constantly on pillow cases -that have been coughed on by a consumptive, and to use towels and -napkins that have been subjected to a like infection. - -Since there are no laws to govern conditions of this sort, the question -arises, what is the nurse to do in such a case? Must she look on and say -nothing, or must she warn those for whom this laundry work is being -done? It would be futile to argue with the patient’s family—they would -refuse to recognize the danger to others, seeing instead the financial -loss from giving up the work. The nurse must first try to remove the -patient to a hospital, thus doing away entirely with the danger. Failing -in this (through lack of hospital facilities), the family may be willing -to give up the work on condition that an income be substituted by some -charitable agency. Simple as the latter course may seem, so many -obstacles to procuring this aid will arise, that it offers no practical -solution of the matter. If the home surroundings cannot be altered and -the danger reduced, then the patrons or customers should be told of the -conditions under which their laundry work is done. It is not always -possible, however, to locate these customers, since the patient is very -wary of giving information upon this subject. Whenever possible, -nevertheless, they should be told; if they prefer to continue the risk, -they are at least not in ignorance of it. - -It is deeply regrettable that exposure to infection by tuberculosis is -still an optional matter, and that the necessary curtailment of -individual liberty has not yet been made in regard to all opportunities -for it. In the case of impure milk, for instance, the law at least makes -an effort to curb the preference which any individual may entertain for -it. - -=Boarding and Lodging Houses.= There are other home occupations in which -the menace is of a personal nature, and does not come through -contaminated articles. Many patients take in boarders—an occupation -which frequently entails considerable overcrowding of the home. This -brings healthy individuals directly within the danger zone, and subjects -them to the same risks incurred by the family itself. Other patients -take in lodgers; here the risk is less, because meals are not included. -In either case, there is great personal exposure, with equally great -opportunities of infection. - -=Summary.= To sum up: Among 3107 patients under supervision, we find -608, or 19 per cent., carrying on some sort of gainful industry within -the confines of their own homes. The resultant danger is of two kinds: -from personal contact with the patient, and the remoter possibility of -infection through articles which he makes or handles. The most serious -risk is that incurred in boarding- and lodging-houses, where the inmates -are subjected to a high degree of personal exposure. In other -occupations there may be some personal risk, but it is slight and -transitory, and therefore insignificant. In considering contaminated -articles, we find there also two classes: those dangerous to a high -degree, and those but slightly so, if indeed they may be called -dangerous at all. Among the former, the most harmful are the -contaminated foodstuffs, in which the risk is almost as great as through -personal contact. Next comes laundry work, where the risk is in the -repetition of infection, as in the use of household linen. Then comes -the output of clothing, cotton and woollen, where also the risk is -slight. In the case of other articles handled by the consumptive the -risk involved is so insignificant as not to be worth mentioning. - -The following table shows the nature of these various Home Occupations, -ranged in order of their risk to the community: - - Personal: Boarders 104 - Lodgers 18 122 - ——— - - Food: Bakeries 4 - Confectioneries 4 - Cook shops 6 - Groceries 73 - Oyster-parlours 1 - Saloons 13 101 - ——— - - Clothing: Laundry work 222 - - Sewing 109 - Millinery 1 - Tailor shop 4 114 - ——— - Miscellaneous: Barbers 8 - Basket-maker 1 - Cigar store 2 - Cleaning and Dyeing 1 - Drygoods 10 - Second-hand shop 1 - Shoemaker 21 - Umbrella-mender 1 - Wall-paper shop 1 46 - ——— - - Total, 605 - -=The Consumptive Outside the Home.= We must now consider the patient who -is employed outside the home. As we have said before, nearly fifty per -cent. of our patients are able to work. The danger to the public is of -two kinds, that arising through personal contact, and through certain -articles which the consumptive may make or handle. In the latter case, -just as we find it among the home occupations, the risk to the community -depends upon the articles themselves. Whatever affects food, is far more -dangerous than the contamination of articles not taken into the -alimentary tract. - -To prevent the possibility of food infection, we should enact and -enforce laws forbidding the employment of consumptives in any factory, -shop, or establishment of any kind in which food is either prepared or -sold. This would include candy factories, bakeries, cake, biscuit, and -cracker factories, canning and preserving establishments, as well as -dairies, restaurants, lunch rooms, sodawater stands, candy shops, and -the like. We must never forget that the home is the chief centre of -danger, the place responsible for the vast majority of infections, and -that every infection which occurs outside the home is accidental, so to -speak. Yet accidental infections, while relatively few in number, are -still plentiful enough to make it necessary to safeguard the community -in every way. An effective tuberculosis campaign demands the stoppage of -all leaks. - -For example: on our visiting list was a girl employed in a biscuit -factory, packing cakes. She was an advanced case, and every now and then -had a hemorrhage which compelled her to stop work, though sometimes only -for a few hours. Between hemorrhages, she worked steadily. The cakes -packed under these conditions doubtless carried a full quota of germs. -We tried to induce her to go to a hospital, but she declined. The -manager was appealed to but he wanted to keep her—she was a quick -worker; besides, he did not have to eat the cakes—so he refused to add -his influence to ours to get the patient to an institution. The public -should be protected by law from the possibility of such infection. - -The saving phase of the situation is this: while the patient who keeps a -bakeshop and sells his wares day after day to practically the same -customers, fulfils the condition that repeated implantations are -necessary to contract the disease; on the other hand, the cakes -distributed by a factory cover a wider range of territory—thus, while -many more people get doses of germs, the doses themselves are probably -too small to be harmful. This also may be said for other kinds of -foodstuffs, handled in factories by tuberculous persons; these articles -are distributed so widely that no individual consumer is really -endangered. In this way, the risk is minimized. But still we must -remember that every factory in the country has its tuberculous -employees, with their output of bacilli to be reckoned with. The -consumer is thus threatened on every side. No wise community should -tolerate such chances of infection. - -=Cooks.= There is considerably more danger from the tuberculous cook -employed in a private family. Under such conditions the household is -steadily infected day by day, not through personal contact, but by -small, repeated doses of bacilli received into the alimentary tract. - -If typhoid fever permitted a patient to work—if it were a chronic -instead of an acute disease—we should consider it a highly dangerous -expedient to permit such a patient to handle food in any way, and we -should be exceedingly wary of restaurants which employed typhoids as -cooks or waiters. This argument applies with equal force to -tuberculosis. In typhoid, there is but one portal of entry—the digestive -tract. In tuberculosis there are two—the respiratory as well as the -alimentary—and they are equally important. - -=Personal Contact in the Factory.= While the patient in the factory is a -menace, he is less dangerous than the patient in his home. A man well -enough to work is seldom in the most advanced and infectious stages of -tuberculosis. Moreover, his fellow-workers, unlike the members of his -household, are not in constant but rather in casual and intermittent -contact with him. These two conditions tend to diminish the risk to his -associates; still, it always exists. The consumptive does not seek -employment from a malicious desire to spread tuberculosis—he seeks it -because of economic conditions compelling him to work until he falls in -harness. We must recognize this driving necessity, but at the same time -we must protect the workers who perforce surround him. They too are -impelled by the same need, and their rights equal his. - -When a patient is visited at home, he and his family are often -stimulated to a high degree of carefulness. The patient uses a sputum -cup for his own convenience, and the family insist upon this for their -own interest and safety. The result is a lessening of danger, and an -improvement upon a neglected and uninstructed case. In the factory, -these conditions are reversed. His cup is no longer a convenience, and -he dreads being conspicuous through its use. Moreover, since his illness -is unknown to his fellow-workers, there is no one to insist upon -precautions of any kind. The result is that we maintain in the factory -conditions which we seek to abolish in the home. We give one set of -people information whereby to protect themselves, and we withhold this -information from another group of people who need it almost as much, -which is illogical and stupid and costly. Enormous sacrifices have been -made to this policy of silence, and it is time for these sacrifices to -cease. - -Those in contact with a consumptive, whether this contact takes place in -the home or in the factory, are entitled to know the nature of his -disease. It is not the degree of consanguinity, but the degree of -contact which should determine this knowledge. We cannot trust the -patient to protect others—it is a trust too often violated. We must -surround him in the shop with a public opinion even more potent than -that which he finds at home. His fellow-workers will be less tolerant of -breaches of technique, will make less excuse for whims and temper, than -does the tired family. We knew of one patient who insisted on spitting -on the floor—at home; when his wife remonstrated, he knocked her down. -In the shop, such conduct would cost him his place, and rightly. - -=Supervision Outside the Home.= Whenever the infectious case is at large -in the community, his whereabouts should be known to those most exposed -to the danger. This applies alike to employer and employee. The head of -the department in which the consumptive is at work should see that those -in contact with him know of his condition. The patient should be -compelled to use his sputum cup when he expectorates. Knowledge of the -patient’s condition does not necessarily mean that he should be -dismissed—it should merely mean that he will be held up to the required -standard of carefulness. For example: the Baltimore Health Department -received a letter from a certain firm in the city, stating that many -cases of tuberculosis had developed among the employees on a certain -floor in their factory—and on this one floor alone. This led them to -suspect that a consumptive might be among these workers, distributing -the disease. A list of all the employees was submitted. Investigation -promptly showed that on this particular floor was a chronic case of -tuberculosis of long standing, a man who had been under supervision at -home for several years. In his home, this patient was exceedingly clean -and punctilious in the use of the sputum cup; at his work, however, he -was absolutely the reverse. On receipt of this information, the employer -had a sound talk with this man, which resulted in the use of the sputum -cup and all other precautions. The patient did not lose his place, but -he was no longer permitted to jeopardize the health of his -fellow-workers. - -Patients with chronic tuberculosis are also found in domestic service, -and go in and out of private homes, carrying infection with them. This -danger is especially great in the South, where there is a large negro -population, and we constantly find consumptives employed as cooks, -housemaids, nursemaids, and butlers, as the case may be. For the most -part, the employers are entirely ignorant as to their condition. In -these cases, just as in the factory, office, department store, and so -forth, the employer should be notified of the presence of tuberculosis. - -To give this information should be the duty of the Health Department. -The municipal nurses are aware of the facts, and they also know when a -patient changes his occupation, or place of employment. But to give this -information without following it up, would not be enough. To notify an -employer of the presence of a tuberculous worker, would not necessarily -mean that any action resulted. A poor workman might be summarily -dismissed, and a good one retained, without those in his vicinity being -enlightened as to the nature of his disease. To make this information of -value, it would be necessary to supervise the patient in the factory, -just as he is supervised in the home. This double supervision would -demand a greatly increased staff of nurses, since factory visiting -should not be done through curtailment of the nurse’s other duties. We -must once more emphasize the fact that the home is the fountainhead of -tuberculosis, and that every infection which occurs outside the home -circle (or its equivalent) is practically an accidental infection. But, -as we have already said, a comprehensive plan for checking tuberculosis -must include the stoppage of all leaks, and the unknown, unsupervised -consumptive, at large in the community, is a leak which should be -recognized by common-sense. - -Yet certain conditions must be complied with before we can extend this -municipal supervision. Outside-the-home supervision will create an -enormous amount of phthisiphobia. Consumptives are now tolerated because -their presence is either unknown or but dimly guessed at; when this -ignorance is dispelled—as it must be if the nurse visits them at their -places of employment, and their presence and numbers are made known, a -great wave of fear will spread over the community. Such a result is -inevitable when for the first time the public realizes, suddenly and -concretely, the extent to which it is threatened. Tuberculous workers -will be discharged by hundreds, and there will be widespread suffering -in consequence. - -On the other hand, however, thousands of non-tuberculous workers will be -relieved of a great danger. Our factories already produce workers so -worn out and devitalized as to fall ready victims to any disease that -presents itself. Would not these same factories be somewhat less -dangerous if swept clear of consumptive employees?[9] - -Footnote 9: - - However bad certain factory conditions may be, these of themselves - cannot produce tuberculosis any more than they can produce scarlet - fever or diphtheria. The disease itself must be brought into the - factory by a carrier—someone who is himself infected. - -Outside-the-home supervision is the next logical step in the -anti-tuberculosis campaign. But valuable as this would be, from the -point of view of the general health, it cannot be done until the -community is prepared to care for all who would undoubtedly suffer as a -result. Some patients, of course, would not lose their situations, but -the majority would be turned adrift without a moment’s hesitation. These -the community must take charge of. Therefore, before we can supervise -tuberculosis beyond the boundaries of the home, we must have ample -hospital facilities. Hospital accommodation must be so extensive, so -complete, and so excellent that institutional care can be given to all -who need it. - -In this way, the community will be relieved automatically of a vast -amount of danger. Patients will either seek institutional care, or, if -they continue at work, will do so under conditions which do not -jeopardize other people. For the reaction from the first intense -phthisiphobia will be a demand for carefulness on the part of the -consumptive, and sane toleration of him. - -The one objection to this policy of supervision and publicity is the -seeming interference with the personal liberty of the individual, but to -curtail the liberty of the patient to transmit a communicable disease, -is to increase the liberty of hundreds to escape it. There should be no -question as to which has the superior claim. - - - - - CHAPTER XIX - - Municipal Control—The Danger of “Political” Control—“Politics” in the - Co-operating Divisions—Results in Baltimore—Tuberculosis and - Poverty. - - -=Municipal Control.= Tuberculosis is a communicable disease in which the -patient himself must be relied upon to protect the community. We depend -upon him for whatever protection he chooses to give, and whether this is -much or little is determined by his circumstances, temperament, and -environment. Whenever his ability or good-will breaks down, we are at -his mercy. We may try to overcome his ignorance by education; to -substitute ethical for unethical standards, and in a more or less -unsatisfactory way to reconstruct his immediate surroundings. But the -success of these efforts depends, in the last analysis, upon the patient -himself. The public is exposed to a communicable disease, the control of -which lies with the transmitter. - -For this reason, a disease which may be contracted by a neighbour -becomes as much his affair as it is that of the patient or possessor. -Should the interests of the two conflict, it is obvious that we must -have some impartial arbiter to decide between them. At such a point—the -right of one person to transmit, of another to acquire an infectious -disease—the matter becomes one of public as well as private concern. The -arbiter between these two interests should be the Health Department of a -community, and the control of all infectious diseases should be placed -completely under the municipality. - -In the first chapters of this book, we considered the special nurse as -supported by a group of private individuals, in connection with some -privately maintained association. Social experiments frequently begin in -this way; when their value is proved, it should be the aim of the -promoters to transfer this special work to the department of the -municipality in which it belongs. Upon looking over the various -municipal departments, we realize that much of what is now freely -recognized to be municipal work, was originally carried on through -private enterprise and initiative. This is the case with school nursing, -playground work, juvenile court and probation work; which in many cities -has passed through the stage of private enterprise and become firmly -incorporated into the city machinery. In all public health nursing, the -aim of the founders should be, first to prove its worth to the -community, and then make the community (municipality) assume full charge -of it as soon as possible. It is particularly necessary to transfer -tuberculosis work from private to municipal control. - -=The Danger of “Political” Control.= The question of doing this, -however, is often a matter of great concern to the founders. They are -usually deeply interested in the work, and have maintained it upon a -basis of efficiency, in spite of many obstacles. They fear, and often -rightly, that to transfer it to the municipality will be to transfer it -from the basis of efficiency in its own line, to the basis of politics, -and they dread that sinister condition known as “political control.” And -yet the administration of public affairs is not necessarily “political” -in the bad sense of the term. On the contrary, municipal control may, -and in many cities does mean, that work is conducted with the force, -authority, and financial backing of a great department, such as the -Health Department. Under such conditions, it can attain a far greater -degree of efficiency than could ever have been reached through private -administration. Under municipal control, it is possible to have a large -staff of nurses and pay them good salaries—which latter always means a -wide choice of applicants. It is also possible to establish many and -well equipped dispensaries, in charge of salaried, qualified physicians. -Money will be forthcoming for all necessary expenses connected with the -development and extension of the work—in short, the financial handicap -will be removed, and the work can go forward with increased facilities, -enlarged opportunities, and heightened dignity and authority. - -On the other hand, if the administration of the Health Department is “in -politics,” the reverse of this will take place. Unfortunately, in many -American cities, the business of “politics” is the business of providing -people with jobs at the taxpayers’ expense, regardless of the fitness of -the applicant. Many of our cities are managed in this way. Moreover, in -the same city, this corruptness may affect certain departments only, -some being negligently and dishonestly conducted, others cleanly and -efficiently. Or we may find both conditions existing in a single -department, some of whose branches or divisions may be well conducted -and on a high level, while other divisions may be grossly mismanaged and -worthless. If a Health Department is hampered by politics, either as a -whole or in certain mismanaged branches or divisions, it is useless to -expect results. Placed under such a handicap, tuberculosis work would -fail. Not only would the taxpayers’ money be wasted, but the community -would suffer through a false sense of security, gained through its faith -in, or rather its ignorance concerning, a badly conducted department. To -trifle with the health of a community is a criminal act, and a Health -Department which is “in politics” is the most immoral of all corrupt -city departments. - -Evil results of a Health Department being “in politics” may be of -several sorts. For example: the Superintendent of Nurses may be an -inexperienced, incapable woman, appointed by a ward politician to clear -off political debts. A ward politician is hardly one whose judgment—in -nursing matters at least—should be relied upon. - -On the other hand, the Superintendent herself may be capable and -efficient, but she may not be permitted to select the members of her -staff. Instead of being able to choose them herself, according to their -fitness and ability, she must accept any unqualified woman whom the ward -boss may appoint. A staff of incompetent nurses, appointed without -regard to character or education, is not a force from which to expect -results. Moreover, nurses chosen in this manner feel that they are -“protected” and can do as they like, subject to neither restraint nor -discipline. This means that their work cannot be controlled, corrected, -or directed in any way. Dismissal can be made only for the most flagrant -offences—not for any such trifle as incompetence, laziness, or -stupidity. When the Superintendent’s hands are thus tied—when she cannot -select her nurses, cannot control them, and cannot dismiss the worthless -as well as the unscrupulous, the result is a low grade of work. No able -and self-respecting woman could hold the position of superintendent -under such circumstances, thereby making herself responsible for work -which she cannot control. - -The acceptance of registered nurses only, and the requirement of Civil -Service Examination in addition, would do much to raise the level of -efficiency. These requirements, however, valuable as they are, would by -no means ensure the suitability of the applicant, or guarantee the -selection of nurses best adapted to public health work. Over and above -this, the Superintendent should have free choice in selecting her -workers, not only from the point of view of education, but also that of -personal worth. - -=“Politics” in the Co-operating Divisions.= Sometimes the Tuberculosis -Division itself may not be on a political basis, but the various other -divisions of the Health Department may be conducted in such a manner as -to nullify much of the nurses’ work. For example: much depends upon the -co-operation of the Fumigation Division. If the men employed to fumigate -houses do their work badly or improperly—if they are too lazy to stop -chinks and crevices, thus permitting the disinfectant to leak out; if -too ignorant to properly measure the rooms, and unable to calculate the -necessary amount of formaldehyde, this work will be valueless. Worse -still if they are the kind that can be “bought off” and so shirk work -entirely. - -Or the trouble may be with the Sterilization Division, where the duty of -the employees is to carry mattresses, etc., from the patient’s home to -the city sterilizer. When there is no law compelling this sterilization, -and it is an optional matter with the householder, if done, its doing is -altogether the result of the nurse’s teaching and advice. If the waggon -drivers are lazy and do not wish to carry the heavy mattresses, they can -shirk work by means of false excuses often difficult to detect. For -example: they can report that when a certain mattress was called for, -the family had changed their minds about having it sterilized and -refused to have it done. Upon investigation, we find that this refusal -was at the instigation of the waggon driver himself—he had assured the -family that sterilization was an unnecessary and stupid proceeding. To -ignorant minds, one Health Department employee is as good as another, -and when the advice is conflicting, they choose that which best pleases -them. - -Again, the fumigators or drivers may report that they cannot get into a -certain house; the key could not be found; there was no one to admit -them, or give them the articles to be removed. In innumerable ways they -may compel the nurse to return again and again to the same house, to -make arrangements which they try to frustrate by every conceivable -device. - -If, therefore, the employees of the various co-operating divisions are -mere jobholders—if they are neither honest nor intelligent, nor -interested in anything but pay-day—it is a heartbreaking task for the -honest and efficient division to work with them. All of these activities -interlock, and must work together to gain a common goal. If all are -operated at their highest level, working in close and intelligent -accord, then indeed we may expect results. But if the reverse is the -case—if the co-operating divisions are a drag and a hindrance—then the -task is overwhelming. The weak are corrupted and the strong discouraged. - -Those responsible for placing tuberculosis work under the city’s -administration—where it rightfully and logically belongs—should continue -their interest still further. It is not enough to transfer it from -pioneer, private control, and then drop the responsibility. - -If a Health Department is clear of politics, and all its divisions work -together harmoniously, magnificent results may be obtained. Power, -prestige, and efficiency is a combination which results in forceful -work. - -=Results in Baltimore.= Results have been achieved in Baltimore by -reason of a well-managed Health Department, acting in close co-operation -with the institutions of both city and state. The tuberculosis machinery -consists of a staff of seventeen special nurses; three special -dispensaries with a physician in charge; a laboratory for sputum -examinations; a fumigation corps and a steam sterilizer. With this -force, we work in connection with three other tuberculosis dispensaries, -and six institutions for the care of early and advanced cases. Some of -these institutions are maintained by state appropriations, others by -both public and private funds. The co-operation between these -institutions and the Health Department is absolute; if the control was -all through one, instead of a dozen different centres, it could not be -more complete or harmonious. Failure in any one direction is felt down -the line, consequently each is stimulated to its best effort. Thus, the -nurse knows that if she fails to persuade her patient to enter the -hospital, the hospital is useless, or that if the bad food of the -hospital drives the patient back again to his home, the nurse’s work -goes for nothing. Each reacts upon the other, and as all are working for -the same end, there is constant incentive to become a strong, rather -than a weak link in the chain. The results obtained cannot be measured -in terms of individuals—we cannot point to so many patients improved, so -many working, and so forth. Individual welfare is too shifting and too -questionable a standard by which to judge. The only absolute standard is -that afforded by the death-rate. A declining death-rate means also a -decreasing morbidity—fewer people die of tuberculosis and fewer are -infected. While our tuberculosis death-rate is still enormously high, it -is nevertheless falling year by year. Thus we see: - - Deaths - from - Pulmonary - Tuberculosis: - - 1909 1400 - 1910 1234 - 1911 1165 - 1912 1189 - 1913 1129 - -There is nothing spectacular about this. It is heartbreakingly -slow—needlessly, uselessly slow work. Yet it is progressing in the right -direction. - -=Tuberculosis and Poverty.= Throughout the foregoing pages we have -considered the direct method of dealing with tuberculosis—the removal or -segregation of the distributor. But there is also an indirect method of -dealing with tuberculosis, namely the abolishment of poverty. -Tuberculosis recruits full fifty per cent. of its ranks from people of a -certain social level—the very poor. This class is composed of people -habitually overworked, underpaid, and subject to all the deteriorating -influences of unsanitary and vicious environment, and to the ignorance -and degradation which follow in the wake of extreme distress. The root -cause of these conditions is our present unjust economic system, which -produces an excess of luxury and frivolity on the one hand, and on the -other an army of people who must forego the barest necessities of life. -One class is maintained at the expense of the other. Every movement -which seeks to abolish this injustice, and to substitute a fairer and -more equable system, is a movement which at the same time tends to raise -the standard of public health. Any legislation, social or revolutionary, -which makes for the improvement of industrial conditions, raises the -level of public health through raising the welfare (_i.e._, resistance) -of the individual. Therefore, sweeping readjustment of social and -economic conditions would automatically eliminate an enormous amount of -disease, by reducing the number of highly susceptible individuals. To -increase the number of people with high resistance—or to decrease the -number of people with low resistance, whichever way one chooses to put -it—would probably diminish the amount of tuberculosis by about one half. - -This indirect method—the readjustment of social conditions and the -abolishment of poverty—valuable as it would be, would still leave the -problem unsolved. Even diminished by one half, the amount of -tuberculosis would still be formidable, and we should have to attack it -as vigorously as ever, if not to the same extent. The disease would -still exist, just as it now exists in well-to-do families in small -towns, in rural districts, and in other circumstances attributable to -neither poverty nor bad industrial conditions. - -A thousand years ago, industrial conditions were as distressing as those -which exist to-day—yet in those days the poor staggered under the -additional burden of leprosy. A hundred and fifty years ago poverty was -complicated by smallpox, the scourge of Europe. The rigid segregation of -lepers in the Middle Ages relieved the situation of leprosy, while the -discovery of vaccine has practically eliminated smallpox. The submerged -classes, while their economic condition remained unchanged, were at -least relieved of the added weight of these two great diseases. So in -our present fight against tuberculosis. An aggressive campaign against -this disease will not necessarily improve industrial conditions, but -those who suffer most from these conditions will be relieved of one more -handicap. - -In our present warfare against tuberculosis we are not impelled by the -blind fear that made society in the Middle Ages demand segregation, and -refuse to tolerate an infectious disease at large in the community. Nor -has any vaccine or similar agent been discovered by which the disease -may be wiped out. Instead, we must depend upon a campaign of -education—wholesale, widespread education, conducted amongst all classes -of society. We know the path to be travelled, and the machinery by which -we may gain our ends. If at any time we become impatient with our slow -rate of progress, we can accelerate our speed by the extension and -multiplication of the three fundamental agencies in the -anti-tuberculosis campaign—the Hospital, the Dispensary, and the Public -Health Nurse. - - - - - INDEX - - - A - - Advanced cases, 46–47, 119, 145, 223, 224–227; - see _Patients_ and _Segregation_ - - Air, fresh, 145–147 - - Alcohol, 151 - - Ambulatory cases, 33, 34, 38, 79–80; - see _Patients_ - - Anti-tuberculosis campaign, 1–3; - fundamental agencies in, 286 - - Anti-tuberculosis Society, 5–6 - - Arrested cases, 2; - nursing as work for, 13–14; - see _Patients_ - - - B - - Bacilli, tubercle, articles infected by, 253; - distribution of, 169, 262–266; - presence or absence in sputum, 107–108, 111; - tenacity of, 170 - - Badges, 31 - - Bag, nurse’s, 41; - supplies carried in, 42–46, 108 - - Baltimore, branch offices for tuberculosis nurses, 39; - co-operation of nurses with institutions, 202, 204–205, 281–282; - dispensaries, 92, 151, 186–187, 192, 198–199, 201–202; - examination of nurses, 12; - forms used for charts, etc., 50–59; - Health Department, 42, 157, 170–171, 174, 176, 183–192, 204, 206, - 250, 256, 267–268, 279–282; - milk and eggs for patients, 250; - nurse’s bag, 41; - nurses’ districts, 39 _note_; - occupations of patients, 253, 261–263; - ordinance in regard to selling milk, 255–256; - organization of tuberculosis work, 200–202; - poverty, 231–232; - registration of cases, 112; - salary of tuberculosis nurse, 21; - sick-leave, 28; - supplies for patient, 42; - Tuberculosis Division, 171, 183, 201–202, 250; - uniforms, 30–31; - vacations, 28; - Visiting Nurse Association, 8, 39, 42, 65, 201, 202 - - Bed, for advanced cases, 145; - placing of, 144 - - Bed clothing, 144 - - Bedding, disinfection of, 175, 176 - - Bedroom, patient’s, 137–140 - - Board of examiners for nurses, 11 - - Board of Health of Maryland, 42; - furnishes formaldehyde, 173 - - Books of instruction, 44 - - - C - - Cabot, Doctor, quoted, 70 - - Calls, night, 16; - sources from which received, 121 - - Calmette test, 111 - - Card index, 53–54 - - “Careful consumptive,” the, 220–223 - - Carpets, infected, 178–179 - - Cases, tuberculosis, see _Advanced_, _Ambulatory_, _Arrested_, and - _Discharged cases_; and _Patients_ - - Cases, undiagnosed, 63, 99–101 - - Charity Organization Society (or Federated Charities), 39, 66, 98, 108, - 109, 176, 210, 236–237, 239, 241, 242, 245; - rules for agents of, 237–241 - - Charts, patients’, 49–54, 58–60 - - Children, care of tuberculous, 163; - diagnosing, 161–162; - infection of, 95, 111, 151–152, 159–164; - open-air schools for, 163–165; - sending to school, 162–163; - pre-tuberculous, 163 - - Classes, tuberculin, 196–197 - - Cleaning should be compulsory, 182–183; - see _Disinfection_ - - Clothing for tuberculous patients, 142–143, 211–212 - - Cooking, supervision of, and instruction in, by nurse, 149–151 - - Cooks, infection from, see under _Infection_ - - Co-operation, between institutions and nurse, 203, 205–208; - of newspapers in tuberculosis work, 5; - of organizations for social work and nurse, 35–36, 143, 156–157, - 176–177, 182, 210; - wrong methods of, 33–34; - see also _Charity Organization Society_ and _Social Workers_ - - Country, the, for tuberculous patients, 165–168 - - Cullen, Doctor Victor F., quoted, 108 - - Cure of tuberculosis, 4, 125–127, 208–209 - - - D - - Daily reports, 55–57 - - Day sheet, 57 - - Death of patient, 49, 119, 120; - reporting, 53, 171 - - Diagnoses, erroneous, 92–97, 101; - lack of, 63; - “lay,” 68–69, 100; - necessity for formal, 115–116; - obtaining, 105–107, 184–185; - from sputum, 107–109; - value of recording, 114–115; - volunteered by physicians, 106 - - Diet of patients, 147–150, 249–251 - - Discharged cases, 204–205, 207, 209; - see also _Arrested cases_ - - Disinfectants, 43–44, 133, 173 _note_ - - Disinfection, by boiling, 131–132, 177, 178; - by burning, 175, 178, 179, 183; - by cleaning, 138, 172; - by fumigation, 170–173, 176, 179, 180, 181, 182, 183; - by painting and papering, 179; - by steam sterilization, 175–177; - effects of, on materials, 176 _note_ - - Dispensaries, general, 107; - tuberculosis, consideration for patients at, 189–190; - equipment of, 186–188; - establishment of, 105, 185; - hours, 188–189, 196; - importance of, 286; - necessity for, 105, 184–185; - nurses’ work in, 194–195, 197–199; - obtaining patients from, 67–68; - physicians’ work in, 191–194; - reports made to, by nurse, 202; - taking patients to, 159; - see also _Baltimore_, _Diagnosis_, _Nurse_ - - Districts, 35–36, 39 _note_ - - Duplication of work, 33–34 - - - E - - Education unsuccessful as preventive measure, 2–3 - - Examination of patients, nurses, etc., see _Diagnosis_, _Dispensary_, - _Families_, _Health Department_, _Nurse_, _Patients_, _Physician_, - _Sputum_ - - Expenses of nurse, 24–26 - - Eye test, 111 - - - F - - Factories, spreading of tuberculosis in, 266–267, 271 _note_; - supervision of patients in, 267; - see also _Patients, occupations of_ - - Families of patients, co-operation with nurse, 127, 174; - examination of, 157–158; - hygiene of, 155; - infection of, 68–69, 97; - relations with nurse, 152; - recreations of, 155–156; - respect for customs of, 181–182; - see also under _Children_ and _Nurse_ - - Food, importance to patient of proper, 147–150; - see also under _Diet_, _Infection_, _Nurse, instruction by_ - - Formaldehyde, formula for, 173–174 _note_ - - Forms, see _Charts_, _Records_, _Reports_ - - Fumigation, see under _Baltimore_, _Disinfection_ - - - H - - Hamman, Doctor Louis, quoted, 111 - - Health Department, badges, 31–32; - co-operation with institutions, 205–207; - dispensaries, 185; - examination of sputum by, 187; - laws in regard to tuberculosis, 76–77, 112; - notifying employers of tuberculosis patients, 269; - physicians of, 89; - politics in, 275–278; - registration of cases with, 112, of deaths, 171; - reports from institutions to, 206; - supervision of discharged patients through, 207; - supplies provided by, 42; - visiting physicians needed by, 184–185; - see also under _Baltimore_, _Disinfection_ - - Heat, artificial, in outdoor treatment, 143, 147 - - Histories, see under _Patients_ - - Home, “breaking up the,” 161; - care of advanced patients at, 225–227; - conditions in patients’, 139, 148, 160, 163; - entering patients’, 31, 118, 122; - see _Infection_ - - Hospitals, for advanced cases, 207–208, 218–219; - importance of, in tuberculosis, 223, 271, 286; - opposition to building of tuberculosis hospitals, 219–221; - sending patients to, 207–208; - special wards for tuberculosis, 218–219 - - Houses, inspection of, by nurse, 136–137; - vacant, watched by nurse, 181 - - - I - - Infection, of children, 159–160; - sources of, 140, 159–160, 165–168, 252, 255–268; - see also under _Advanced cases_, _Ambulatory cases_, _Bacilli_, - _Children_, _Factories_, _Families_, _Patients_ - - Institutions, see _Hospitals_ and _Sanatoria_ - - Instruction, books of, 44; - of patients and families, 127–133, 142–148; - see also under _Nurse_ - - - L - - Landlord, irresponsibility of, 180–181 - - Laws, for proper disinfection, 183; - for protection from infection, 264; - for registration and reporting of tuberculosis cases, 7, 111–112; - State, in regard to tuberculosis, 76, 77 - - “Light work” for tuberculosis patients, 215–216 - - Lyman, Doctor David R., quoted, 213 - - - M - - Maryland, State Board of Health, quoted, 213; - neglect of law for registration of tuberculosis cases, 113; - Tuberculosis Association, 8 _note_ - - Milk, infection through, 255 - - Milk and eggs, see _Diet_ - - Minor, Doctor Charles L., quoted, 126 - - Municipal control of tuberculosis work, 77–86, 89–91, 274–275; - see also _Baltimore_ - - - N - - Napkins, paper, use of, 130–131 - - Newspapers as agents in tuberculosis work, 5 - - Nurse, the tuberculosis, “asset to community,” 199; - access to cases, 121–122; - calls, 121–122; - character, 16–19; - co-operation with physician, 88, 103, 109; - discovering cases, 67; - dispensary work, 194–199; - district, 35–36; - duties of, 46, 48–49, 52, 53–56, 58–59, 62–70, 100–101, 105, 106, - 108–109, 122, 128–137, 149–153, 154–157, 169–170, 181–183, - 204–205, 207–208, 211–212, 213, 216–217, 224, 258–259; - establishment of, 7–10, 89; - expenses, 24–26; - function, 117–118, 224, 247–248; - giving relief, 232–233, 237, 241–242, 245–248; - health, 12–15; - hours on duty, 14, 36; - instruction of patients and families, 127–131, 133–148, 155–156, 172, - 174, 178, 183; - lunches, 40–41; - noon hour, 40–41; - office, 38–40; - physical examinations, 12–13; - relations with patients and families, 18, 123, 133, 152–153, 181–182; - relations with physicians, 71–73, 87–89, 92–94, 99–104, 123; - responsibility to community, to patient and family, 118; - to organization, 89; - salary, 20–23; - sick-leave, 27–28; - social worker as nurse, 233–234; - time off, 14–16; - training of, 10–12, 62; - uniforms, 28–31; - vacation, 26–27; - visits, 36–38; - visiting list, 63–70; - see also under _Baltimore_, _Charts_, _Children_, _Co-operation_, - _Diagnosis_, _Diet_, _Disinfection_, _Dispensaries_, _Families_, - _Health Department_, _Home_, _Registration_, _Reports_, _Visiting - Nurse Association_ - - - O - - Occupations of patients, see under _Infection_ - - Office of tuberculosis nurse, 38–40 - - Open-air, schools, 163; - treatment, 140–143 - - Organizations, see under _Charity Organization Society_, and - _Co-operation_ - - Outdoor work for tuberculosis patients, 216 - - - P - - Patients, bed-ridden, 151–152; - carelessness of, 97, 214–222, 266–268; - changing physicians, 80–81, 92–96, 98–100; - charts, 48–53; - co-operation with nurse, 248–249; - discharged, 204–207, 212–215; - employment of, 262; - examination of, 158, 190; - histories, 123–124; - home occupations, 261–262; - isolation of, in homes, 151–152; - limitation of, 33, 200; - objection of, to institutions, 210–211; - outdoor treatment, 144; - rest for, 143–144; - sending to country, 165–168; - supervision outside the home, 267–272; - supplies for, 42–43, 45; - telling the truth to, 124–127; - see also _Advanced_, _Ambulatory_, and _Arrested cases_, _Baltimore_, - _Children_, _Diet_, _Dispensaries_, _Families_, _Health - Department_, _Home_, _Injection_, _Instruction_, _Nurse_, - _Segregation_, _Relief_ - - Phipps Dispensary, see _Dispensaries_ under _Baltimore_ - - Phthisiphobia, 14, 134–135, 270–272 - - Physicians, incompetent, 93–97, 101–104; - municipal, 90; - standards of, 83; - reporting tuberculosis cases, 113; - State requirements of, 75–76; - “unethical practitioner,” the, 72, 84, 85; - see also under _Diagnosis_, _Dispensaries_, _Nurse_, _Patients_ - - Pockets, waterproof, 44 - - Poverty, relation to tuberculosis, 3–4, 61, 80–81, 230–232, 265, - 283–285 - - Prevention of tuberculosis, 4, 120, 155–156, 159–161, 247–248; - see also under _Disinfection_, _Nurse_, etc. - - - R - - Records and reports, 48–58 - - Registration of cases, cards for, 116; - laws for, 76, 111–113; - value of, 114–115 - - Relief, conditional, 231; - not to be given by nurse, 234; - obtained by nurse, 143, 210, 245–246, 257; - proper use of, 248–249; - rules for agents and nurses, 237–241; - withdrawal of, 248; - see also _Nurse_, _Co-operation_, _Patient_ - - Reporting cases to the Health Department, 7, 56–59, 171, 205–207 - - - S - - Salary of tuberculosis nurse, 20–22, 24 - - Sanatorium, outfit for, 211–212; - value of, 208–209, 213 - - Segregation, 4–5, 218–220, 223–229 - - Sick leave, 26–28 - - Skin test, 110 - - Social agents and workers, 35–36, 62, 66–67, 165, 234–239 - - Sputum, cups, 42–43; - disposal of, 128–130; - examination of, 9, 40, 107–108; - see also under _Infection_ and _Instruction_ - - Sterilization, see under _Disinfection_ - - Superintendent of nurses, 13, 15, 24, 59–60, 116 - - Supplies, nursing, 46; - prophylactic, 42–45, 76–77, 133 - - - T - - Tests, tuberculin, 110–111 - - Tuberculin classes, 196–197 - - Tuberculosis, abolition of, 223, 283–284; - arrest of, 125–126; - campaign against, 1–6, 285–286; - character of, 79; - cure, 2–4, 125, 208–209; - deaths from, 283; - difficulties in dealing with, 79–82, 85–86; - municipal control of, 85–86; - number of cases in given community, estimate of, 63; - see also _Bacilli_, _Infection_, _Prevention_, _Poverty_ - - Tuberculosis Division, see under _Baltimore, Health Department of_ - - - U - - Uniforms, 28–29 - - - V - - Vacations for tuberculosis nurses, 26 - - Visiting list, 63–66 - - Visiting Nurse Association, 8, 9; - see also under _Baltimore_ and _Co-operation_ - - Visits by tuberculosis nurse, 36–38 - - - W - - Wards, special, for tuberculosis patients, 218–220 - - Windows in patient’s room, 137, 144 - - Work done by tuberculous patients: “light work,” 215; - outdoor, 216, - see also under _Infection_ and _Patients_ - ------------------------------------------------------------------------- - - - - - A - - Medical Dictionary - - for Nurses - - - Giving the Definition, Pronunciation, and Derivation of the principal - terms used in medicine, together with supplementary tables of weights, - measures, chemical symbols, etc. arranged with special reference to use - by the nursing profession - - By Amy E. Pope - - Formerly Instructor in the Presbyterian Hospital School of Nursing - Author of “Anatomy and Physiology for Nurses,” etc. - - _12^o. Illustrated. 288 pages. $1.00_ - - _In full flexible Morocco, Thumb Index. $1.60_ - -No one could be better fitted to produce this book, filling a long-felt -want, than Miss Pope, because of her large practical experience as a -nurse, instructor, and author. Without question this volume must quickly -be recognized as indispensable to the students of her great profession. - - _All Booksellers_ - - NEW YORK LONDON - 2–4–6 =G. P. Putnam’s Sons= 24 Bedford St. - W. 45th St. Strand - - - - - Text-Book - - of - - Anatomy and Physiology - - For Nurses - - - by - Amy E. Pope - - Author, with Anna Caroline Maxwell, of “Practical Nursing,” and Former - Instructor in Practical Nursing and Dietetics in the Presbyterian - Hospital School of Nursing. - - _Crown 8^o. With 135 Illustrations, many in color - $1.75 net. Postage extra_ - -The object of this work is to provide a text-book containing more -physiology than the books on anatomy and physiology hitherto provided -for nurses. The book is very fully illustrated and contains a number of -questions for each chapter; also an extensive glossary, which includes a -detailed explanation of all the chemical and physical terms used. - - - - - Practical Nursing - - A Text-Book for Nurses - - By Anna Caroline Maxwell - - Superintendent of the Presbyterian Hospital School of Nursing - - and - - Amy Elizabeth Pope - - Formerly Instructor in the Presbyterian Hospital School of Nursing; - Instructor in School of Nursing, St. Luke’s Hospital, San - Francisco, Cal. - - _Third Edition, Revised. Crown 8^o. About 900 pages. With 91 - Illustrations. $2.00. - Postage extra_ - -Over 50,000 copies of _Practical Nursing_ had been sold up to January -1st, 1914. This new edition has been entirely reset, revised, and -enlarged, and contains over 50 per cent. more material than the previous -editions. An important feature of the new edition is, that the authors -have not confined themselves to one method of treatment where experience -has shown that other methods may be more effective in certain cases. -Detailed instructions have been given, thus bringing the book in line -with the latest developments in practical nursing. - - - - - A Text-Book of Materia Medica for Nurses - - - Compiled by - - Lavinia L. Dock - - Graduate of Bellevue Training School for Nurses, Secretary of the - American Federation of Nurses and of the International Council of - Nurses, etc. - - _Fourth edition, revised and enlarged. 12^o. net, $1.50_ - -“The work is interesting, valuable, and worthy of a position in any -library.”—_N. Y. Medical Record._ - -“It is written very concisely, and little can be found in it to -criticize unfavorably, except the inevitable danger that the student -will imagine after reading it that the whole subject has been mastered. -The subject of therapeutics has been omitted as not a part of a nurse’s -study, and this omission is highly to be commended. It will prove a -valuable book for the purpose for which it is intended.”—_N. Y. Medical -Journal._ - - * * * * * - - G. P. Putnam’s Sons - New York London - ------------------------------------------------------------------------- - - - - - TRANSCRIBER’S NOTES - - - 1. P. 173, the portions listed in “Potassium permanganate, oz. 111.; - liquid formaldehyde, pint 1.” are unlikely to be correct. Did not - alter the passage. - 2. Silently corrected obvious typographical errors and variations in - spelling. - 3. Retained archaic, non-standard, and uncertain spellings as printed. - 4. Re-indexed footnotes using numbers. - 5. 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