I fir*, Tuberculosis Jurse Her Functions and Her Qualifications WY 163 L235t 1915 54721250R NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE LIBRARY. *ut< (^ Cm Section - No. 113, \V. D.S. G. 0. No , A2A17J NLM052891959 DUE TWO WEEKS FROM LAST DATE 0cr 6 m JUL 13 1979 GPO 881473 ^ The Tuberculosis Nurse Her Function and Her Qualifications A Handbook for Practical Workers in the Tuber- culosis Campaign 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 Zbe Umlcfeerbocfter press 1915 '«..->. Copyright, 1915 BY ELLEN N. LA MOTTE Trawferred from the Libm, of C,nereM undw Seo. S9, Ube Iftnfcfcerbocfeer press, mew J9orfe MAR 16 1915 *() ©CI.A39714 5 '" Zo MARY E. LENT MY FRIEND INTRODUCTION 'T'O tuberculosis, more than to any other infec- tious 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 role of the bacillus, still we cannot completely ignore those personal factors that contribute to make the infection fruitful, and like- wise 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 eradi- cate 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 vi Introduction 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 cam- paign 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 con- ditions 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 Introduction vii 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 consump- tives as is possible. The hospital, perhaps sup- plemented 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 infec- tion occurs at a very early age, so that at twelve years few children have escaped it. Relatively a small number of those infected subsequently be- come tuberculous, so that something more than infection is necessary for tuberculosis to develop. viii Introduction 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 facili- ties, 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 tuber- culosis. Housing laws, child-labour laws, the wage question, municipal recreation centres, the liquor question, social service in all its departments, vaca- tion 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 Introduction ix merits of the various phases of the anti-tubercu- losis 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 ef- ficiency 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 Frankel, 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 X Introduction early diagnosis, sanatorium treatment, and educa- tion 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 aesthetic value of general and personal hygiene grows apace, and the dictates of ordinary cleanli- ness offer a very strong barrier to infection. Pov- erty itself does not produce tuberculosis, but the conditions that poverty fosters do, and the ad- vantages 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 sufficient- ly instructed about tuberculosis to pick out of the Introduction xi 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 advan- tage 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 tuber- culosis campaign must always conform to the medical attitude, although she may and indeed has added valuable material for building up this atti- tude. 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-tubercu- losis crusade, their interrelation, and the quite xii Introduction 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 prob- lems, from the same broad though different per- sonal viewpoint. Our work has brought us into almost daily contact. I acknowledge, with grati- tude, 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 experi- ence 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 tubercu- losis 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 Introduction xiii 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 experi- ence 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 concise- ness. 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. xiv Introduction No doubt many will find personal views ex- pressed with which they disagree. This is unavoidable before such a frank and radical presen- tation 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. XV xvi Preface It is also hoped that though the work of tuber- culosis 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 Preface xvii and deep indebtedness to those friends and fellow workers who have given her guidance and assist- ance during these years of service. These are: Mary E. Lent, Superintendent of the Visiting Nurse Association of Baltimore, and Susan Ed- mond 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 Statement of the Case—Beginning the Work- Reaching the Patients—Supervision of the Work—Necessity for Experienced Nurses . CHAPTER II The Nurse's Training—Health—Hours Off Duty—Afternoons Off—Character . CHAPTER III Salary—Increase of Salary—Carfare—Trans- portation — Telephone — Vacation — Sick Leave—Uniforms—Badges CHAPTER IV Object of Work—Districts—Hours on Duty- Number of Daily Visits—The Nurse's Office —Lunch and the Noon Hour—Bags—Pro- phylactic Supplies—Cups, Fillers, and Napkins—Disinfectant—Waterproof Pock- ets—Books of Instruction—Stocking the Bag and Distributing Supplies—Nursing Supplies...... xix XX Contents CHAPTER V Records and Reports—The Patient's Chart— The Card Index—Nurse's Daily Report Sheet—Weekly and Monthly Reports—Ex- amination 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' Fami- lies and Friends—Nurses' Cases—Physi- cians ....... 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—Mu- nicipal Control of Infectious Diseases—The Nurse's Difficulties—A Waiting Game— Undiagnosed Cases—The Nurse's Responsi- bility to the Ethical Practitioner Only. . 87 Contents xxi CHAPTER IX Obtaining a Diagnosis—The General Dispen- sary—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 Spu- tum—Danger of Expired Air—Isolation of Dishes—Linen, Household and Personal— Disinfectant and Other Supplies—Phthisi- phobia . . . . . . .117 CHAPTER XI Inspection of the House—The Patient's Bed- room—Porches—Gardens and Tents—Flat Roofs — Clothing and Bedclothing — Ar- tificial Heat—Rest—Fresh Air—Food— Cooking—The Bedridden Patient . . 136 CHAPTER XII Care of the Family—Examination of the Family —Taking Patients to Dispensaries—Chil- dren—Tuberculosis in Children—Open-Air Schools—The Danger of Sending Patients to the Country . . . . -154 xxii Contents 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 Pa- tients— Function of the Dispensary — The Physician's Service—The Physician's Qualifications—The Physician and the Pa- tient—Duties of the Nurse—Tuberculin Classes—The Nurse in Home and Dispen- sary—The Nurse as a Community Asset . 184 CHAPTER XV The Nurse in Relation to the Institution—Re- ports Made to the Institution—Procuring Patients for it—The Value of the Sanator- ium—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 Contents xxiii Care of the Advanced Case—Exceptions to Institutional Care—Compulsory Segre- gation .......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—Super- vision Outside the Home .... 252 CHAPTER XIX Municipal Control of Tuberculosis—The Danger of "Political" Control—"Politics" in Co- operating Divisions of the Health Depart- ment—Results in Baltimore—Tuberculo- sis and Poverty ..... 273 The Tuberculosis Nurse CHAPTER I Statement of the Case—Beginning the Work—Reaching the Patients—Supervision of the Work—Necessity for Experi- enced Nurses. Statement of the Case. Pulmonary tubercu- losis 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 cough- ing. 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- 2 The Tuberculosis Nurse 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 con- trolled, as was the case when smallpox and diph- theria 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 mechan- ics 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, Statement of the Case 3 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. Unfor- tunately, a series of unlooked for conditions inter- posed 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 handi- capped 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, 4 The Tuberculosis Nurse 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 tuber- culosis 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 recog- Beginning the Work 5 nized 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 dissemi- nating 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, 6 The Tuberculosis Nurse lantern-slide exhibitions, meetings in churches and others held before various societies are given in various parts of the town, and in this way in- formation about tuberculosis is spread far and wide. There are two classes of the community, how- ever, that must be reached'—those who have tuber- culosis 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 some- thing which may be helpful to them; unfortunate- ly, 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 Supervision of Work 7 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 em- ployment 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 com- pelling doctors to notify the local health authori- ties 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 sanitorium, 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 8 The Tuberculosis Nurse the local health department, under a dispensary, under the charity organization society, or under the visiting nurse association, if such an organiza- tion 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,x but this arrangement would relieve the lay organization of much responsibility, for no matter how good their intentions, such a group 1 For five years the Maryland Tuberculosis Association sup- ported five nurses, which it placed under the management of the Superintendent of the Visiting Nurse Association of Baltimore. Supervision of Work 9 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 depen- dent upon other forms of social activity. 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 prob- lem at once. Yet policy would counsel postponing io The Tuberculosis Nurse the undertaking until a suitable person can be found, for it is usually a fatal mistake to begin new work with an inexperienced worker. More- over, 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' ex- perience 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 move- ment received a check from which it did not re- cover 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 regis- tered 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 ii 12 The Tuberculosis Nurse 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 tu- berculosis 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 Health 13 her physical condition, mailed to the superin- tendent, determines her eligibility from the stand- point 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 them- selves, 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 sus- picious symptoms—symptoms which the nurse herself may be unaware of or afraid to acknow- ledge. Each nurse, however, should assume the responsibility for her own health; she should re- member 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 14 The Tuberculosis Nurse 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 stubborn- ness 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 insuf- ficient, 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 Afternoons Off 15 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 im- press 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 superin- tendent'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 fresh- ness. 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 satis- factory 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 16 The Tuberculosis Nurse nurse is enabled to rest before she becomes too tired. Sundays, of course, should always be free. Under no consideration should the nurse be sub- ject 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 train- ing, 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 pro- fession, 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 Character 17 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 ob- tain 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 ac- tivities bring her into close relations with physi- cians, 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 experi- enced she may be, or how well trained, if she cannot gain the confidence and friendship of her 18 The Tuberculosis Nurse 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 pa- tients. Through familiarity she loses the personal dignity which means so much to her authority. Authority is a term somewhat subtle in its defini- tion—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 as- sured 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 quali- ties of honesty, loyalty, and conscientiousness. Character 19 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 be- tween 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—Tele- phone—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 forth- coming. 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, dispen- saries, and physicians' services, but retrenchment takes place when it comes to the nurse. Her work seems to be the one point where economy prevails. 20 Increase of Salary 21 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 charac- ter 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 22 The Tuberculosis Nurse duty are largely spent merely in acquiring rudi- mentary knowledge concerning her work. As she learns to know her district, her patients, the doc- tors, 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 ex- hausting. 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 Increase of Salary 23 staff. One is the ambitious nurse, who comes for the experience and training, to fit herself for an execu- tive 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 experi- ence 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 24 The Tuberculosis Nurse down into a rut, and her daily task, though faith- fully 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 personel 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 Transportation 25 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 terri- tory. Unless there is proper provision for trans- portation, 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 un- hampered by any considerations as to if or how she can reach her patients. Telephone. In making up the budget of neces- 26 The Tuberculosis Nurse sary expenses, a reasonable sum should be set aside for telephone calls. The nurse has constant occasion to communicate with doctors, institu- tions, 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 suf- ficient 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 Sick-Leave 27 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 neverthe- less 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 under- take this arduous work. A fixed allowance for sick-leave, therefore, will tend to work automatic- ally, 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 28 The Tuberculosis Nurse 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 dis- advantages of such a dress are more than offset by the numerous reasons in its favour. Two objec- tions 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. Uniforms 29 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 accord- ingly. 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 30 The Tuberculosis Nurse 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 confi- dence. A staff of nurses, each one dressed accord- ing 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 lodg- ing 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 Badges 3i 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, al- though 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 32 The Tuberculosis Nurse 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 super- vision 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 contradis- tinction to advanced, cases. No organization which expects to do effective work should deal with one class of patients alone, since the bound- ary lines between the different stages are con- stantly 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 inclu- sive lines, it will be necessary to place a second organization in the field, to care for those cases 3 33 34 The Tuberculosis Nurse 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 organiza- tion, while the advanced, bed-ridden, more in- fectious 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, duplica- tion of visits, endless transferring of cases back- wards 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 sus- Districts 35 picious 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 consump- tive in her district, and her constant endeavour should be to bring under supervision every case of tuberculosis that exists. She must visit all pa- tients 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, 36 The Tuberculosis Nurse and all social workers whose co-operation is neces- sary 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, es- pecially in summer. It is a mistake to work overtime, no matter how interested and enthusi- astic 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 recog- nize 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 Number of Daily Visits 37 new patients and bed-ridden patients always de- mand 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 com- pelled 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 unimpor- tant details. To judge if a district is being properly visited, the superintendent should know the dis- trict, and she should also know her nurse's capac- ity. 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 38 The Tuberculosis Nurse 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 vis- ited 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 in- frequent 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 con- dition 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 speci- fied hours, therefore, it will be possible to reach her, The Nurse's Office 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 Baltimore1 these branch offices are usually in the same building which houses a branch of the Federated Charities, the branch office of the Visit- ing Nurse Association, the Infant Welfare Asso- ciation, and other similar agencies. In this way, the various social workers learn to know each other, and to secure close co-operation and under- standing. The different agencies, however, each have their separate rooms or offices. The nurse's office should be simply but com- fortably furnished. It is used for several purposes —as a store room for supplies, and as a rest room, 1 Baltimore is divided into sixteen nursing districts, with eight branch offices or sub-stations, for the use of the sixteen nurses. 40 The Tuberculosis Nurse 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 cup- board 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 Bags 4i 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 neces- sary 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. 42 The Tuberculosis Nurse Thus, at the end of the day, when she is most tired, it is practically empty. Prophylactic Supplies. The prophylactic sup- plies used for the patients consist of tin sputum cups, cardboard fillers, paper napkins, water- proof pockets, disinfectant, and books of instruc- tion. 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, ac- cording 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 ad- vised 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 Disinfectant 43 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 sup- plies 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 wip- ing up floors, furniture, and so forth. It is of necessity too dilute to have much germici- dal 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 pa- tients that better results may be obtained by the lavish use of hot water, brown soap, and a scrub- bing 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 44 The Tuberculosis Nurse 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 no- thing 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 prepara- tion 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 in- tended 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 dis- tribution. The best of them are inadequate. Stocking the Bag and Distributing Supplies. Prophylactic Supplies 45 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 fam- ily, 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 46 The Tuberculosis Nurse other hand, the nurse must see that the supplies are used for the purpose intended—we have some- times 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 prophy- lactic supplies, the bag also contains a number of articles used in caring for bedridden 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, how- ever, 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 pro- gramme to keep these advanced cases at home Nursing Supplies 47 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 concern- ing 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 indi- vidual 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 em- ployed 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 pa- tients—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 sus- 48 The Patient's Chart 49 pects, or those for whom the diagnosis is not pos- itive, 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 his- tory, one demanding dozens of intimate details, is apt to alarm the patient excessively. To collect exhaustive statistics would be valuable for the 4 TUBERCULOSIS DIVISION HEALTH DEPARTMENT OF BALTIMORE DATE Patient...................................................... Birthplace...................................Ag^........... Address..........................._........................... Married.......Single........Widowed.......Color....... Reported by................................................... Occupation ...................Salary per week............ Doctor....................... ............................... Home Occupation.......................................... Condition....................................................... No. in Family................No. of Rooms............... Registered.................................................... Other Cases in Household.................................. Hospital Treatment............................................ Family History___......................................... Aid Recerred.................................................................................................................. Result................................................................................................................„.......... Ncof Visits..................... Time..................... Nurse........................................................ History—Sick Since...........................Able to Work..........................Part Time....................Unable to Work........................Confined to Bed................................................................................ (OTBB) Patient's Chart. Cardboard, five by eight inches TUBERCULOSIS DIVISION Name—-------------------AnnuF«« DATE WORK DONE DATE WORK DONE Reverse side of Patient's Chart, showing spaces for recording visits. The Second Chart Sheets are similar to this, but alike on both sides Cn 52 The Tuberculosis Nurse sociologist, but to do so at the expense of the patients' confidence and trust would be to defeat the object of the work itself. 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 re- corded 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 con- dition, 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 prop- erty 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 Card Index 53 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 dis- charged, 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 con- fidential. 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. 54 The Tuberculosis Nurse The charts themselves, however, are distributed among the filing boxes of several nurses. If particu- lars 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 TUBERCULO8I8 DIVISION. N""» Color, Address_____ First Visit_ Condition__ Reported by. Card, three by five inches, used in Card Index would be necessary to search through all the filing boxes before finding the desired chart. 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 rcords, and of balancing from day to day the number of patients on the visiting list. This balance may be made .Last Visit. .Result- .Occupation. -M D.____________________Nurs Nurse's Daily Report Sheet 55 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 sub- traction. Needless to say, no one but the super- intendent or her secretary should have access to, or touch these files in any way. Nursed Daily Report Sheet. Beside the pa- tients' charts, the nurse must fill in a day sheet, or daily report of her work, to be handed to the super- intendent, 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. 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 56 The Tuberculosis Nurse heavy; it will show the number of new patients and ill patients, and how many bed-baths and TUBERCULOSIS DIVISION DAILY REPORT TO THE HEALTH OEPARTMENT OF BALTIMORE io NAME ADDRESS TIME WORK DONE 1 _L_ Vuit. trt intpMl kfkr fiinrif.tion ,_____T>utr ict No Nurse's Daily Report Sheet, seven by nine inches dressings were given; how much time was spent in calling on doctors, dispensaries, social workers, and so forth, and arranging houses for fumigation. DAY SHEET TUBERCULOSIS DIVISION. BALTIMORE HEALTH DEPARTMENT. District N DATS li a £ "8 S "8 1 I m 5 6 5| 1 5 a :s > > e 8. i 1 Day Sheet, used for summarizing the day's work. From this sheet the weekly and monthly reports are made out 57 58 The Tuberculosis Nurse 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. 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 Examination of Charts 59 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. MONTHLY REPORT OF THE TUBERCULOSIS DIVISION HEALTH DEPARTMENT Month of_____________ fa___ Nukse----_--,—------------ District No- Patients under Supervision..___ New Patients.........____.___ Died.......................... Discharged___._____....____... Balance..__________....--.____ Sent to Dispensaries___________ " Bay View.________...... " State Sanitorium..._____ " Eudowood...____...____ Sent to Jewish Home foi Consumptives.. Cases Registered_____.... Visits to Patients______.. Before Fumigation. " After of Co-operation.... Referred to Charitable Agencies—Relief... Diet____ 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 im- portant as the visiting itself. By carefully exam- ining the charts, the superintendent is able to call the nurse's attention to any lapses in them—■ incomplete histories, long intervals between visits, 60 The Tuberculosis Nurse 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 sup- erintendent 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 dis- trust or suspicion, but because she is the person re- sponsible 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 61 62 The Tuberculosis Nurse 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 com- munity, 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 re- port. This involves one great reason why the nurse should be thoroughly equipped in character and training; the colourless, uneducated, uncon- vincing 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. Increasing the Visiting List 63 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 fur- nish the nurse with the necessary names and addresses. That the response is not great should cause no discouragement. As we have said else- where, the tuberculosis death-rate, multiplied by five, will give a conservative estimate of the number of tuberculous individuals in a commun- ity. 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 reluc- tantly 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 be- comes so large and unwieldy that she cannot manage it, should be the ambition of every tu- berculosis nurse. At present, in every city in the country, there is so much undiscovered and un- reported tuberculosis, that the failure of the nurse to increase the visiting list is an indication of poor 64 The Tuberculosis Nurse 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 neces- sarily 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. Increasing the Visiting List 65 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 begiur under the Visiting Nurse Association, that or- ganization had a visiting list of some 1700 consump- tive patients, divided among five nurses. As five nurses represented the largest number the Asso- ciation 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 per- suaded to assume the tuberculosis work of the private association, and to incorporate it as part of the city machinery. If the need for this trans- fer 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 s 66 The Tuberculosis Nurse the five struggling nurses of the private association. Therefore, each community which undertakes tu- berculosis 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, con- tinually 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 Dispensaries 67 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 attend- ance 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 busi- ness to obtain the diagnosis. Dispensaries. If there is a hospital or dispen- sary (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 in- stitutions, however, is not enough. Every week or 68 The Tuberculosis Nurse 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 tele- phone. 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 commun- ity 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, how- ever, 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 diag- nosis was wonderful—her son had died of tuber- culosis, so she knew all the symptoms, and she did Nurse's Cases 69 not refer us to a single case, which, upon examina- tion, 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 dis- tributors 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 Balti- more, 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 particu- larly keen in questioning the parents of tubercu- 70 The Tuberculosis Nurse lous 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 pur- posely left until the last that which most people would have deemed the first and most important source of all, namely, the physicians of a commun- ity. 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 pro- fession, 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 mani- fested by laws in which the welfare of the com- Physicians 71 munity 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 particu- larly strong among physicians of an older genera- tion, hold-overs from a passing regime. To such as these the nurse is nothing less than an imperti- nence. 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 72 The Tuberculosis Nurse 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 profes- sion 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 Physicians 73 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 com- mon 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 phy- sicians 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 74 The Private Practitioner 75 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 indi- vidual 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 Tu- berculosis. In the pursuit of his calling, the private practitioner comes into contact with certain dis- eases 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 compell- ing 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 ser- vice 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. 76 The Tuberculosis Nurse 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 regula- tions 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 depart- ment, since in dealing with a transmissible disease it is necessary to learn its distribution and preva- lence. 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 The Private Practitioner 77 free of charge by the Health Department, so that the physician is under no expense in distributing them. Third, all houses vacated by a consump- tive, either through death or removal, must be reported to the Health Department for fumiga- tion. If these regulations could have been thor- oughly 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 super- vision and control which these regulations were designed to secure. The private practitioner, en- dowed with special education, special opportunity, and special authority, has not used these endow- ments, 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 pur- pose? 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 in- struct and keep careful watch over their con- sumptive patients, had been able to do this, why 78 The Tuberculosis Nurse 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 differ- ence 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 super- vise 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 Private Practitioner's Failure 79 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 ex- amination. During a hiatus of this kind, how can we possibly hold the doctor responsible for the tuberculous patient? How can we hold him res- ponsible for the conduct, training, and surroundings 80 The Tuberculosis Nurse 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 whatso- ever, 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 Private Practitioner's Failure 81 change their doctors. Unlike people in more fortunate circumstances, they have no one phy- sician 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 tu- berculosis. 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 6 82 The Tuberculosis Nurse 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 explana- tion. 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 commercial- ism, 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 Failure through Personal Equation 83 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 tubercu- losis, or the use of the prophylactic supplies. He does not realize that that which is obvious to him is frequently unintelligible to those less enlight- ened. We have often found patients possessing bundles of prophylactic supplies, given conscien- tiously 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 84 The Tuberculosis Nurse 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 con- tribute much towards the anti-tuberculosis cam- paign. 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 practi- tioner, who, while competent enough, feels himself under no obligation to protect the community from an infectious disease. There is sometimes Failure through Personal Equation 85 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 fol- lowed 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 in- tent on earning a living, too indifferent, or too poorly educated to assume effective supervision 86 The Tuberculosis Nurse 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-tu- berculosis campaign, is to do what he can to hasten the advent of full municipal control. 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 pro- fession 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 per- sonal 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 never- theless 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 87 88 The Tuberculosis Nurse 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 Nurse's Relation to the Physician 89 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 Depart- ment, 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 ad- vanced 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 author- ity 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 Depart- 90 The Tuberculosis Nurse ment. 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 house- hold. 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 Municipal Control of Disease 91 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. Further- more, the private practitioner will no more resent this, nor consider it interference with his private business, than he resents municipal care of small- pox 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, how- ever, 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 today. The infectious nature of tuberculosis has become known com- paratively recently, hence we find ourselves con- fronted with a delicate and difficult situation, as must always be the case when public opinion is evolving. Today 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 92 The Tuberculosis Nurse 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 dis- pensary diagnosis was all nonsense. The dis- pensary 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 physi- cian'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's Difficulties 93 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 dis- pensary physician, and her grief, remorse, and opinions were given wide circulation in the neigh- bourhood. At no time during his illness had in- struction 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 con- tact. The sacrifice of this boy to the ignorance, obstinacy, jealousy, or stupidity of the local phy- sician proved a striking object lesson to the neigh- 94 The Tuberculosis Nurse bourhood. 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 Depart- ment, where it was proved positive. So far, all was clear going. The patient was given her prophylac- tic 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 doc- tor," who declared she had nothing but a passing The Nurse's Difficulties 95 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 con- tinue 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 96 The Tuberculosis Nurse 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 wait- ing for that slow change in public sentiment which shall give one the right to interfere. Thus, a phy- sician 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 appar- ently 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 Depart- ment went to the house to arrange for the fumiga- tion. The front door was opened by a young girl obviously tuberculous—the nurse was struck with A Waiting Policy 97 her appearance; further search revealed still an- other member of the household who presented suggestive symptoms. In their distress, the fam- ily 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 pre- sented 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 today, 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 dis- missal and turn away, or is she to continue her 7 98 The Tuberculosis Nurse 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 un- questionable 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 encoun- ters 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 instiga- tion, which is able to turn her out. Thus, when Undiagnosed Cases 99 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 permis- sion 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 en- courage 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 ioo The Tuberculosis Nurse 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 criti- cism 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 today, 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 hemorchage—she must be particu- larly 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 re- ferred 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 Undiagnosed Cases 101 supplies, taking care, however, never to use the word "tuberculosis" in connection with them. She simply offers them as a convenience for a dis- tressing 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 bron- chitis; as nurses, we cannot make diagnoses, therefore we have no right to question the phy- sician's findings. But it is impossible for an in- telligent 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 dis- trust. 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 success- 102 The Tuberculosis Nurse ful 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 tubercu- losis 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 The Nurse's Responsibility 103 nature of tuberculosis makes this situation possi- ble, 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 de- sign, and fails to give proper instruction as to its infectiousness, then we must look for nothing but opposition and antagonism. We must hear ob- jections as to the nurse's interference, to her uni- form, 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 104 The Tuberculosis Nurse 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 ad- vanced 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 regime. 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 Ex- aminations—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 commun- ity 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 105 106 The Tuberculosis Nurse 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 doc- tor—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 imper- fect the equipment, it is necessary to establish as soon as possible a special place where these patients The General Dispensary 107 may be freely examined without any sense of intrusion or of incurred obligation. The General Dispensary. In many cities, gen- eral 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 dis- pensaries are usually crowded, and the physicians in charge are unable to give sufficient time to the protracted, careful examination which the con- sumptive 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 examina- tion. It may require repeated examinations to find the bacilli, or before their continued absence may be considered evidence that the patient is not 108 The Tuberculosis Nurse 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 Sputum Examinations 109 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 no The Tuberculosis Nurse 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 treat- ment 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 inocu- lating 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 there- fore a reaction has no significance. In the case of children, however, a positive skin test has some Registration of Cases in value. Children are not as a matter of course sup- posed 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 impor- tance. 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 conjunc- tiva becomes slightly red and inflamed, which condition persists for a day or two and then dis- appears. 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 dis- ii2 The Tuberculosis Nurse eases, 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 tu- berculous 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 atten- tion to the fact that certain patients are under her Registration of Cases 113 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 excel- lent 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 phy- sicians 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 munici- pal 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 8 ii4 The Tuberculosis Nurse of over three hundred per cent.—shows the stimu- lating effects of a staff of active public-health nurses. How necessary it is to have the diagnosis re- corded 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 com- plaints concerning him. These complaints came from pupils, who declared they were afraid to go to the classes, because the patient coughed so vio- lently 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 Registration of Cases 115 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 hur- ried search of the files brought forth the original registration card, sent in by the physician who had first diagnosed the case, and transferced 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 n6 The Tuberculosis Nurse 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 oc- currences 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, House- hold 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, how- ever, 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 117 118 The Tuberculosis Nurse 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 pro- tection 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. The Prevention of Tuberculosis 119 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 hope- less prognosis. Both patients are equally intract- able; 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. 120 The Tuberculosis Nurse 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 sadden- ing 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 tomorrow 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 Calls 121 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 men- tioned, 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 122 The Tuberculosis Nurse 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 reluct- ance. 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 thresh- old, the victory is won. Taking the Patient's History. The facts con- cerning the patient must be gathered in his home, and they are of two kinds, those concerning his physical and those concerning his social condition. Taking the Patient's History 123 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 insur- ance, 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 124 The Tuberculosis Nurse 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 dispen- sary, 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 commen- tary on the method of handling him. Telling the Truth to the Patient. The most difficult of the nurse's duties, and the saddest, is Telling the Truth to the Patient 125 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 126 The Tuberculosis Nurse 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 re- newed. 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 be- tween 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 him- self. His improvement depends upon his thor- ough understanding of his illness, and upon his ability or willingness to co-operate as to treatment. According to Dr. Minor,1 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. In making the best of things, the nurse must never over-encourage the patient. A half- starved, overworked person, suddenly put on a 1 Dr. Charles L. Minor, Asheville, North Carolina. Truth for the Family 127 regime 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 state- ments as to what may be accomplished. The over- confident patient mistakes temporary improvement for permanent cure. Tuberculosis is like a con- cealed 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 cir- cumstances 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. 128 The Tuberculosis Nurse 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 rudimen- tary altruism. Disposal of Sputum. The nurse has by this time prepared the way for the prophylactic sup- plies, 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 advan- tages—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 Disposal of Sputum 129 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 9 130 The Tuberculosis Nurse 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 Isolation of Dishes 131 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—liber- ation 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 aesthetic 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 house- hold. 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 132 The Tuberculosis Nurse 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 fami- lies, 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 house- hold 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 Disinfectant and Other Supplies 133 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 over- come 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 appear- ance 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 134 The Tuberculosis Nurse 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 imagin- able 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 hard- ship in individual cases. As far as the community is concerned, fear of tuberculosis is a good, whole- some sentiment, and infinitely preferable to ignor- ance 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, in- stead of very transitory and fleeting. Tubercu- losis is so slow and insidious in its onset,—there is nothing spectacular, by which we can demon- Phthisiphobia 135 Strate 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 preven- tive measures which at first so strongly appeal to them, and which in the beginning they apply with boundless enthusiasm, we should have compara- tively 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 relaxa- tion 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 rearrange- ment, several factors must be considered: the stage of the disease, number in family, financial condition, home surroundings and the institu- tional 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 136 The Patient's Bedroom 137 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 approxi- mation, 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 ar- ranged, 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 open- ing, 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 138 The Tuberculosis Nurse 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 with- stand the temptation to sell or give away service- able 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 objec- The Patient's Bedroom 139 tion 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 un- wise 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 pro- longed, intimate contact with a consumptive must not be allowed to reduce their vitality in any way. 140 The Tuberculosis Nurse 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 occa- sions, 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 un- savoury 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 Gardens and Tents 141 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 valu- able 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 pur- poses, 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 142 The Tuberculosis Nurse chair or lounge. But excellent as they appear theoretically, the extremes of our climate, exces- sive heat and cold, often make them unpractical for the consumptive's use. Under such circum- stances, these little back yards often become any- thing 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 dis- tricts. These sometimes offer excellent condi- tions 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, Rest H3 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 cough- ing 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 improve- ment 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 144 The Tuberculosis Nurse 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 up- stairs to their bedrooms, and lie at full length on the bed placed next to the open window. By thus emphasizing the importance of rest—synony- mous 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 ambula- tory consumptive. Fresh Air 145 Whenever possible, the patient should be in- duced 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 him- self 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 essen- tial in the treatment of tuberculosis, and every patient should be taught to spend as many hours as possible out-of-doors. The nurse must ex- plain in words of one syllable why this is nec- essary—that clean, pure air contains life-giving oxygen, and that to breathe it entails little ex- ertion 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 10 146 The Tuberculosis Nurse 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 con- sideration 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 be- cause it is shaky, or because it may only be reached by passing through another person's room. In- vestigation 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 neigh- bours may say. It should be pointed out that his Food i47 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 bev 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 demon- strate how the thing is done. The consumptive is sick 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 pa- tients, 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; Visit- ing Nurse Association, 8, 39,42,65,201,202 Bed, for advanced cases, 145; placing of, 144 Bedclothing, 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, 178-179 288 Index Cases, tuberculosis, see Ad- vanced, 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; in- fection of, 95, ill, 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 compul- sory, 182-183; see Disinfec- tion Clothing for tuberculous pa- tients, 142-143, 211-212 Cooking, supervision of, and instruction in, by nurse, 149- 151 Cooks, infection from, see under Infection Co-operation, between institu- tions and nurse, 203, 205- 208; of newspapers in tuber- culosis work, 5; of organiza- tions 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 physi- cians, 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 clean- ing, 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; tu- berculosis, consideration for patients at, 189-190; equip- ment of, 186-188; establish- ment 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; tak- ing patients to, 159; see also Baltimore, Diagnosis, Nurse Districts, 35-36, 39 note Duplication of work, 33-34 E Education unsuccessful as pre- ventive measure, 2-3 Examination of patients, nurses, etc., see Diagnosis, Dispensary, Families, Health Department, Nurse, Patients, Physician, Sputum Index 289 Expenses of nurse, 24-26 Eye test, 111 F Factories, spreading of tuber- culosis in, 266-267, 271 note; supervision of patients in, 267; see also Patients, oc- cupations of Families of patients, co-opera- tion with nurse, 127, 174; examination of, 157-158; hygiene of, 155; infection of, 68-69, 97; relations with nurse, 152; recreations of, I55"I56; 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 Balti- more, Disinfection H Hamman, Doctor Louis, quoted, in Health Department, badges, 31-32; co-operation with in- stitutions, 205-207; dispen- saries, 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 dis- charged 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 pa- tients _ at, 225-227; condi- tions in patients', 139, 148, 160, 163; entering patients', 31, 118, 122; see Infection Hospitals, for advanced cases, 207-208, 218-219; impor- tance of, in tuberculosis, 223, 271,286; opposition to build- ing of tuberculosis hospitals, 219-221; sending patients to, 207-208; special wards for tuberculosis, 218-219 Houses, inspection of, by nurse, I36-i37; 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, Ba- cilli, 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 in- fection, 264; for registration and reporting of tuberculosis cases, 7, 111-112; State, in regard to tuberculosis, 76, 77 290 Index "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; Tu- berculosis Association, 8 note Milk, infection through, 255 Milk and eggs, see Diet Minor, Doctor Charles L., quoted, 126 Municipal control of tuber- culosis work, 77-86, 89-91, 274-275; see also Baltimore N Napkins, paper, use of, 130- 131 . , Newspapers as agents in tuber- culosis work, 5 Nurse, the tuberculosis, "as- set to community," 199; access to cases, 121-122; calls, 121-122; character, 16-19; co-operation with physician, 88, 103, 109; discovering cases, 67; dis- pensary work, 194-199; dis- trict, 35-36; duties of, 46, 48-49, 52, 53-56, 58-59, 62- 70, ioo-ioi, 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; giv- ing relief, 232-233, 237, 241- 242, 245-248, health, 12-15; hours on duty, 14, 36; in- struction of patients and families, 127-131, 133-148, 155-156, 172, 174, 178, 183: lunches, 40-41; noon hour, 40-41; office, 38-40; physi- cal examinations, 12-13; re- lations with patients and families, 18, 123, 133, 152- 153, 181-182; relations with physicians, 71-73, 87-89, 92- 94, 99-I°4, I23! responsi- bility 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-opera- tion, Diagnosis, Diet, Dis- infection, Dispensaries, Fam- ilies, Health Department, Home, Registration, Reports, Visiting Nurse Association 0 Occupations of patients, see under Infection Office of tuberculosis nurse, 38-40 Open-air, schools, 163; treat- ment, 140-143 Organizations, see under Char- ily Organization Society, and Co-operation Outdoor work for tuberculosis patients, 216 P Patients, bedridden, 151-152; carelessness of, 97, 214-222, 266- 268; changing physi- cians, 80-81, 92-96, 98-100; charts, 48-53; co-operation with nurse, 248-249; dis- charged, 204 -207, 212- 215; employment of, 262; Ind( Patients—Continued examination of, 158, 190; histories, 123-124; home occupations, 261-262; iso- lation of, in homes, 151- 152; limitation of, 33, 200; objection of, to institutions, 210-211; outdoor treatment, 144; rest for, 143-144; send- ing to country, 165-168; su- pervision outside the home, 267-272; supplies for, 42-43, 45; telling the truth to, 124- 127; see also Advanced, Am- bulatory, and Arrested cases, Baltimore, Children, Diet, Dispensaries, Families, Health Department, Home, Infection, Instruction, Nurse, Segregation, Relief Phipps Dispensary, see Dis- pensaries under Baltimore Phthisiphobia, 14, 134-135, 270-272 Physicians, incompetent, 93- 97, 101-104; municipal, 90; standards of, 83; report- ing 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 tubercu- losis, 3-4, 61, 80-81, 230- 232, 265, 283-285 Prevention of tuberculosis, 4, 120, 155-156, 159-161, 247- 248; see also under Disinfec- tion, 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; ob- 29I tained 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, 2 1 8-2 2 o, 223-229 Sick leave, 26-28 Skin test, no 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 un- der Infection and Instruction Sterilization, see under Disin- fection Superintendent of nurses, 13, 15, 24, 59-60, 116 1 Supplies, nursing, 46; pro- phylactic, 42-45, 76-77, 133 T Tests, tuberculin, no-in 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 292 Index Tuberculosis Division, see un- der Baltimore, Health Depart- ment 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 tuberculo- sis patients, 218-220 Windows in patient's room, 137, 144 • Work done by tuberculous patients: "light work," 215; outdoor, 216, see also un- der Infection and Patients Jt Selection from the Catalogue of G. P. PUTNAM'S SONS Complete Catalogue sent on application 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°. 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 indis- pensable to the students of her great profession. Jill Booksellers 3-4-6 VJ. 1. rUlUUUl » tSUIlS 24 Bedford i W. 45th St. Strand AText-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°. net, $1.50 " The work is interesting, valuable, and wor- thy a position in any library."—TV. Y. Medical Record. "It is written very concisely, and little can be found in it to criticize unfavorably, except the in- evitable 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 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°. 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 edi- tion has been entirely reset, revised, andenlarged, and contains over 50 per cent, more material than the previous editions. An important fea- ture 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 cer- tain cases. Detailed instructions have been given, thus bringing the book in line with the latest developments in practical nursing. G. P. Putnam's Sons New York London A History of Nursing Vols. I. and II. The Evolution of the Methods of Care for the Sick from the Earliest Times to the Foundation of the First English and American Training School for Nurses. By LAVTNIA L. DOCK, R.N. and M. ADELAIDE NUTTING, R.N. 6Vo. 2 vols. With 80 Illustrations. $5.00 mi By mail, $5,50 Vols. m. and IV. The Story of Modern Nursing Presenting an Account of the Development, in Various Countries of the Science of Trained Nursing, with Special Reference to the Work of the Past Thirty Years. By LAVINIA L. DOCK, R.N. 8vo. 2 vols. With 75 Illustrations, 55.00 net By mail, $5.50 Beginning with the earliest available records of sanitary codes which were built up into health religions, and coming down through the ages wherever the care and rescue of the sick can be traced, through the pagan civilizations, the earfy Christian works of mercy, the long and glorious history of the religious nursing orders, military nursing orders of the crusades, the secular communities of the later Middle Ages, and the revival of the Deaconess order which cul- minated in the modern revival under Miss Nightingale, this history is the most serious attempt yet made to collect the scattered records of the care of the sick and bring them all into one unified and sym- pathetic presentation. _ The story is not told ina dry, technical fashion, but presents its pictures from the standpoint of general human interest in a subject which has always appealed to the sympathies of men. The history is amply illustrated, and contains a copious bibliog- raphy of nursing and hospital history. G. P. Putnam's Sons New York London 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 Nurs- ing and Dietetics in the Presbyterian Hospital School of Nursing. Crown 8°. 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 physi- ology hitherto provided fornurses. The book is very fully illustrated and con- tains a number of questions for each chapter; also an extensive glossary, which includes a detailed explanation of all the chemical and physical terms used. G. P. Putnam's Sons New York London " An exceedingly useful and practical book lor Nurses " A Quiz Book of Nursing for Teachers and Students By Amy Elizabeth Pope Joint-Author of "Practical Nursing" and "Essentials of Dietetics" and Thirza A. Pope Together with Chapters on Visiting Nursing By Margaret A. Bewley, R. N. Graduate of ^ Presbyterian School of Nursing, and_ of the Sloane Maternity Hospital, New York City • Instructor in Visiting and District Nursing in Presbyterian Hospital, New York City. Hospital Planning, Construction, and Equipment By Bertrand E. Taylor, A. A. I. A. and Hospital Book-keeping and Statistics By Frederic B. Morlok Chief Clerk in the Presbyterian Hospital, New York City. Crown 8°. Illustrated. Uniform with " Practical Nursing." $1.75 net This book aims to be useful, in the most practical way, to nurses who teach, and to those who are studying under them. It is, in large part, a quiz book, offering in the form of terse ques- tion and answer essential information on x wide range of subjects —the information that is essential from the nurse's standpoint. Those who teach will find these questions of assistance when the time they have to devote to preparation for their class work is limited; and those who are taking courses will find the book a great help ; especially when studying for examinations. Q. P, PUTNAM'S SONS New York London » w APR 3 WIS ;t«cr;sru:ir ■! ■ii-x'SfVirigyi^j ■ :-:i::--:t jpfr:d '.'iEiniTiHlS WY 163 L235t 1915 54721250R NLfl 05261115 1 NATIONAL LIBRARY OF MEDICINE ....fHrajii:!;:: ■'"•;.".rOvs-r.'- •' h-i'-iii:;:--! r '•: : ::::!tJil^!:-!!: pmm mm iUf.tii .'. ... in j'.iasiai'.u.'■::■ iiSPP .pi; NLM052891959