The Tuberculosis Nurse
                  Her Function and Her Qualifications
     A Handbook for Practical Workers in the Tuberculosis Campaign


                                   By

                        Ellen N. La Motte, R.N.

    Graduate of Johns Hopkins Hospital; Former Nurse-in-Chief of the
         Tuberculosis Division, Health Department of Baltimore

                            Introduction by

                           Louis Hamman, M.D.

   Physician in Charge, Phipps Tuberculosis Dispensary, Johns Hopkins
                               University


                          G. P. Putnam’s Sons
                          New York and London
                       =The Knickerbocker Press=

                                  1915




                            COPYRIGHT, 1915
                                   BY
                           ELLEN N. LA MOTTE

                          _Second Impression_


                  =The Knickerbocker Press, New York=




                                   TO

                              MARY E. LENT

                               MY FRIEND




                              INTRODUCTION


To tuberculosis, more than to any other infectious disease, the parable
of the seed and the soil is strictly applicable. Without the tubercle
bacillus there can be no tuberculosis, but for tuberculosis to develop,
many factors of great complexity and as yet but little understood must
facilitate the implantation of the bacillus and augment its growth. It
is true that though we may emphasize the rôle of the bacillus, still we
cannot completely ignore those personal factors that contribute to make
the infection fruitful, and likewise though we focus our attention upon
individual resistance, still we cannot keep out of sight the invader
that is being resisted. The two viewpoints meet and run together, but
are sufficiently separate to lead to different methods in our efforts to
eradicate tuberculosis.

On the one hand are those who direct their efforts toward the
annihilation of the tubercle bacillus. We are sufficiently instructed
about the life history and habits of this organism to lay our plans upon
a firm, scientific basis—a basis so firm and at first sight so simple
and so plausible that over-enthusiasm led to predictions that have been
sadly disappointed. The principles are sound indeed, but in practice
their application has met with insuperable difficulties. These
obstructions have sharpened our wits to find new avenues that now
promise a more ready approach to the goal. To put the matter briefly,
the tuberculosis campaign of the past fifteen years has taught us two
important lessons: first, that the tuberculous cannot be isolated in
their homes; second, that they cannot be cured in or out of sanatoria. I
am shocked myself to read these bald statements, particularly the
second, and still I am convinced that they are true. Some patients can
be isolated in their homes, and many patients recover from tuberculosis
and remain well. Tuberculosis is very amenable to treatment and under
proper conditions the results of treatment are very gratifying. The
difficulty is that the proper conditions are in most instances wanting,
and when they are absent sanatorium recovery is almost invariably
followed, after a brief period, by relapse. The records of cases with
tubercle bacilli in the sputum establish this fact. Concerning the value
of statistics of cases without tubercle bacilli in the sputum I
entertain the gravest doubt. While I am heartily in favour of treating
such patients, the personal equation enters too largely into the
diagnosis to give the results convincing value as evidence of the
lasting benefits of treatment. Experience has taught me that the
educational value of sanatoria has been grossly exaggerated, and that
this value is of small account in a broad plan of prevention. Our
present knowledge, fortified by the costly experience of the past
fifteen years, forces us to believe that the most direct and effective
way of dealing with the tubercle bacillus is to isolate as many advanced
consumptives as is possible. The hospital, perhaps supplemented by
colonies, is the rational method of procedure. Other factors are of
importance; all other factors are, but this is the fundamental and
essential factor in the campaign.

On the other hand are those who direct their efforts towards cultivating
the soil. Reliable studies inform us that ninety per cent. of the human
race is tuberculosis infected, and that infection occurs at a very early
age, so that at twelve years few children have escaped it. Relatively a
small number of those infected subsequently become tuberculous, so that
something more than infection is necessary for tuberculosis to develop.
What this something is we do not know. Time, manner, frequency, and
intensity of infection play an important part. Apparently too there is a
wide personal variation in susceptibility. To just what this personal
factor is due we are not in a position to say, but certain general facts
known about the distribution of tuberculosis afford us a clue to its
interpretation. Tuberculosis, like most infectious diseases, thrives
under the conditions that poverty induces. Inadequate housing
facilities, insufficient food, filth, and sordid care are a few of
these. If, as all must admit, the tubercle bacillus is more or less
ubiquitous and few escape contact with it, then an important part of our
campaign of prevention will be the raising of personal resistance so
that when infection occurs it may be successfully overcome. Here is the
field for wide social activity. Everything that makes for higher
standards of living and for improved personal hygiene is a valuable arm
against tuberculosis. Housing laws, child-labour laws, the wage
question, municipal recreation centres, the liquor question, social
service in all its departments, vacation lodges, open-air schools,
factory inspection, and so on and so on, are all indirectly valuable
anti-tuberculosis agitation.

It is not my purpose to discuss the relative merits of the various
phases of the anti-tuberculosis campaign. The death-rate from
tuberculosis is falling steadily and rapidly, and it has fallen most
rapidly in just those centres where the campaign has been vigorously
pushed on a broad basis. Which phase of the work is responsible for the
decrease or deserves the greatest credit, it is impossible to conclude
from a study of available evidence. The same statistics are interpreted
by one, for instance Cornet, as evidence of the efficiency of sputum
prophylaxis; by another, for instance Hoffman, as evidence of the
influence of improved economic conditions; by yet another, for instance
Newsholme, as evidence of the value of hospitals for advanced cases; and
finally by many, for instance Fränkel, as evidence of the undisputed
value of all three factors. Which factor one emphasizes will depend
largely upon one’s training and the field of activity in which one is
engaged.

Being a physician and by training accustomed to view problems from a
medical standpoint, it is natural that I should emphasize the attacks
upon the bacillus. As I have said, it seems to me to be firmly
established that the most efficient, the most direct, and the cheapest
way to enforce isolation and prevent infection is by hospital
segregation of cases of advanced pulmonary tuberculosis. While early
diagnosis, sanatorium treatment, and education are valuable features of
the campaign, their value will be but slight if this one essential
feature is neglected. Indeed I am inclined to see the chief value of
economic improvement in the indirect influence this improvement
exercises upon the facility for infection. With economic advance the
æsthetic value of general and personal hygiene grows apace, and the
dictates of ordinary cleanliness offer a very strong barrier to
infection. Poverty itself does not produce tuberculosis, but the
conditions that poverty fosters do, and the advantages of better living
reside not so much in an improved personal fitness as in the eradication
of the conditions that facilitate infection. This view is in accord with
what we have learned of other infections. Plague has been notoriously a
scourge to the poor. To improve living conditions lessens plague, and
this general fact was known before we learned that cleanliness produced
results indirectly by eliminating rats. Malaria has always been
particularly prevalent amongst labourers living in unprotected huts. To
improve living conditions reduces malaria, but we gain the result more
surely and directly by an intelligent campaign against mosquitoes.
Unfortunately, we are not sufficiently instructed about tuberculosis to
pick out of the whole mass of ills that poverty entails those few
essential features that control infection. Perhaps some day we will, and
then we shall be able to manage the social campaign more efficiently and
economically. For instance, we are quite at sea to know what
prophylactic use to make of the firmly grounded fact that tuberculosis
infection establishes a strong resistance to reinfection. Upon an
analogous principle rests the conquest of smallpox by vaccination. No
doubt this immunity reaction has an important influence upon the
development of tuberculosis, but as yet we know too little about it to
control it and use it to advantage in our fight with the disease.

In the anti-tuberculosis campaign the nurse must look to medical science
for the plan and inspiration of her work. Her attitude in the
tuberculosis campaign must always conform to the medical attitude,
although she may and indeed has added valuable material for building up
this attitude. It is because this intimate relation exists that I have
briefly outlined the medical impression of the tuberculosis campaign. It
is quite natural that it should represent at the same time the nurse’s
attitude. My object was to point out the numerous factors concerned in
the anti-tuberculosis crusade, their interrelation, and the quite
natural and necessary specialization that must occur. The field of the
nurse and particularly the municipal nurse is circumscribed, but it is
large enough to engage all her energy and devotion. It is not necessary
nor even desirable that she should diffuse her interest and energy over
the adjoining fields.

For more than ten years Miss La Motte and I have been engaged in working
at the same problems, from the same broad though different personal
viewpoint. Our work has brought us into almost daily contact. I
acknowledge, with gratitude, the many valuable suggestions that I have
borrowed from her experience, and in reading her book I note with the
greatest satisfaction what I believe to be evidence of influence from
the experience I have gained. It is a pleasure to find that after years
of arduous work we agree at least upon what is the fundamental problem
of the tuberculosis campaign, namely—institutional care of the advanced
cases of pulmonary tuberculosis. I think it is right and proper that
Miss La Motte has made this fact the guiding principle of her book, and
that she has shown the relation of nursing activity to its furtherance,
and that she has held all other phases of tuberculosis work subservient
to it. To avoid misunderstanding it may be necessary to point out that
other features of the anti-tuberculosis campaign have been merely
touched upon or entirely ignored. This apparent slight is not offered, I
am sure, as a reflection upon the value of these features; they are
omitted simply to accentuate more boldly the dominant idea of the
nurse’s work.

Another noteworthy feature of the book is the purely personal and local
character of the experience presented. It details the problems that have
offered themselves here in Baltimore, how these problems have been met,
and how an effective nursing staff has been built up, first under
private and then under municipal control. What has been accomplished
abroad and in other localities in this country is not considered. In a
way this is a disadvantage, for the book loses somewhat in breadth and
erudition. However, I am convinced that what may be lost in this respect
is more than compensated for by the gain in force and conciseness. After
all, the fundamental problems are the same everywhere, and though local
conditions will necessitate adjustment of details, still I believe the
adjustment will be stimulated and facilitated more by a spirited account
of what has been done under specific conditions than by a colourless
review of the whole field of activity.

No doubt many will find personal views expressed with which they
disagree. This is unavoidable before such a frank and radical
presentation of the situation. One is impressed by the honesty and
enthusiasm of the book, but some may wish that certain of the
statements, and particularly some strictures, had been a little
mollified. The book will be interesting and helpful and, what is more
important, stimulating to all engaged in tuberculosis work. All the
better if some parts of it cause surprise and opposition,—we will then
review more critically our own attitude.

                                  LOUIS HAMMAN, M.D.,
              Physician-in-Charge, Phipps Tuberculosis
                      Dispensary, Johns Hopkins Hospital.




                                PREFACE


During eight successive years the writer has been engaged in special
tuberculosis work, first as field nurse of the Visiting Nurse
Association of Baltimore, later as organizer and director of the
Tuberculosis Division of the Baltimore Health Department. Entering the
field in the pioneer days of 1905, she has seen the work pass through
the struggling stages of private enterprise into the well organized,
almost automatic grooves of the city machinery. This continuity of
service has been an experience of unique value. During this period we
have walked into and backed out of many blind alleys or “No
Thoroughfares,” and have acquired wisdom through the loss of infinite
time, effort, and money. Although the material for the following pages
was gathered in Baltimore, and is therefore, strictly speaking, of a
local character, yet since practically all of the conditions indicated
or dealt with are common to all towns and cities, this need not limit
the application of the ideas and principles set forth.

It is also hoped that though the work of tuberculosis nursing is dealt
with chiefly as done under the auspices of a Visiting Nurse Association,
or as part of the work of a City Health Department, what is here
presented will be of value to nurses working under private associations,
and to private associations themselves. Therefore, in presenting this
book to the public—to nurses, physicians, social workers,
anti-tuberculosis associations, and all those engaged in public health
work—the writer has two objects in view. First, to offer a working model
by which any community can gain some idea as to how to organize and
conduct tuberculosis work; second, to offer conclusions, gained through
practical experience, as to the nurse’s part in the anti-tuberculosis
campaign.

The object of the anti-tuberculosis campaign is the eradication of
tuberculosis. Our experience has been to prove that the simplest and
most direct method of controlling this disease is through the
segregation—the voluntary segregation—of the distributor, and that to
remove the patient from an environment where he is dangerous to one
where he is harmless is the function of the public health nurse. This is
her chief and foremost duty, and all others are subsidiary to it.

The writer wishes to express her appreciation and deep indebtedness to
those friends and fellow-workers who have given her guidance and
assistance during these years of service. These are: Mary E. Lent,
Superintendent of the Visiting Nurse Association of Baltimore, and Susan
Edmond Coyle, “lay member” of that Association; Dr. Louis Hamman,
Physician-in-Charge of the Phipps Dispensary, Johns Hopkins Hospital;
Dr. Samuel Wolman, First Assistant to the Phipps Tuberculosis
Dispensary; Dr. Gordon Wilson, Physician-in-Charge of the Maryland
University Dispensary and of the Municipal Tuberculosis Hospital; Dr.
Martin F. Sloan, Superintendent of Eudowood Sanatorium; Dr. Victor F.
Cullen, Superintendent of the Maryland Tuberculosis Sanatorium; and my
Chief, Dr. Nathan R. Gorter, Health Commissioner of Baltimore.

                                                      ELLEN N. LA MOTTE.

 London, 4 June, 1914.




                                CONTENTS


                                CHAPTER I

                                                                    PAGE
 Statement of the Case—Beginning the Work—Reaching the
   Patients—Supervision of the Work—Necessity for Experienced
   Nurses                                                              1


                               CHAPTER II

 The Nurse’s Training—Health—Hours Off Duty—Afternoons
   Off—Character                                                      11


                               CHAPTER III

 Salary—Increase of Salary—Carfare—Transportation—Telephone—Vacation—
   Sick Leave—Uniforms—Badges                                         20


                               CHAPTER IV

 Object of Work—Districts—Hours on Duty—Number of Daily Visits—The
   Nurse’s Office—Lunch and the Noon Hour—Bags—Prophylactic
   Supplies—Cups, Fillers, and Napkins—Disinfectant—Waterproof
   Pockets—Books of Instruction—Stocking the Bag and Distributing
   Supplies—Nursing Supplies                                          33


                                CHAPTER V

 Records and Reports—The Patient’s Chart—The Card Index—Nurse’s
   Daily Report Sheet—Weekly and Monthly Reports—Examination of
   Charts—Taking the Patient’s History                                48


                               CHAPTER VI

 Finding Patients and Building up the Visiting List—Increasing the
   Visiting List—Social Workers—Dispensaries—Patients’ Families and
   Friends—Nurses’ Cases—Physicians                                   61


                               CHAPTER VII

 The General Practitioner and the Public Health—Responsibility of
   the Private Practitioner in Tuberculosis—Impossibility of
   Fulfilling this Obligation—Failure because of the Nature of
   Tuberculosis—Failure because of the Personal Equation              74


                              CHAPTER VIII

 The Nurse in Relation to the Physician—Municipal Control of
   Infectious Diseases—The Nurse’s Difficulties—A Waiting
   Game—Undiagnosed Cases—The Nurse’s Responsibility to the Ethical
   Practitioner Only                                                  87


                               CHAPTER IX

 Obtaining a Diagnosis—The General Dispensary—Sputum
   Examinations—Tuberculin Tests—Registration of Cases               105


                                CHAPTER X

 Prevention of Tuberculosis—Sources through which Calls are
   Received—Entering the Home—Telling the Truth to the
   Patient—Truth for the Family—Disposal of Sputum—Danger of
   Expired Air—Isolation of Dishes—Linen, Household and
   Personal—Disinfectant and Other Supplies—Phthisiphobia            117


                               CHAPTER XI

 Inspection of the House—The Patient’s Bedroom—Porches—Gardens and
   Tents—Flat Roofs—Clothing and Bedclothing—Artificial
   Heat—Rest—Fresh Air—Food—Cooking—The Bedridden Patient            136


                               CHAPTER XII

 Care of the Family—Examination of the Family—Taking Patients to
   Dispensaries—Children—Tuberculosis in Children—Open-Air
   Schools—The Danger of Sending Patients to the Country             154


                              CHAPTER XIII

 Disinfection of Houses—Value of
   Fumigation—Formaldehyde—Housecleaning—Burning and
   Sterilizing—Boiling—Carpets, Rugs, and Mattings—Painting,
   Papering, and Whitewashing—Temporary Removals—Vacant
   Houses—Concessions—Compulsory Cleaning                            169


                               CHAPTER XIV

 The Tuberculosis
   Dispensary—Equipment—Medicines—Hours—Consideration for
   Patients—Function of the Dispensary—The Physician’s Service—The
   Physician’s Qualifications—The Physician and the Patient—Duties
   of the Nurse—Tuberculin Classes—The Nurse in Home and
   Dispensary—The Nurse as a Community Asset                         184


                               CHAPTER XV

 The Nurse in Relation to the Institution—Reports Made to the
   Institution—Procuring Patients for it—The Value of the
   Sanatorium—Sanatorium Outfit—Return from the Sanatorium—Work for
   the Arrested Case—Light Work—Outdoor Work                         203


                               CHAPTER XVI

 Hospitals for Advanced Cases—The Careful Consumptive—Chief Duty of
   the Nurse—Responsibility of the Institution—Home Care of the
   Advanced Case—Exceptions to Institutional Care—Compulsory
   Segregation                                                       218


                              CHAPTER XVII

 The Problem of Relief-Giving—The Relief-Giver—Co-operation between
   Agent and Nurse—General Rules for Nurses and Agents—Conditions
   of Asking for Relief—Wrong Conditions of
   Relief-Giving—Incidental Assistance—Withdrawal of Relief—Milk
   and Eggs                                                          230


                              CHAPTER XVIII

 Home Occupations of Consumptives—Sewing and Sweatshop
   Work—Food—Milk and Cream—Lunch Rooms and Eating-Houses—Laundry
   Work—Boarding and Lodging-Houses—Miscellaneous Occupations—The
   Consumptive Outside the Home—Cooks—Personal Contact in the
   Factory—Supervision Outside the Home                              252


                               CHAPTER XIX

 Municipal Control of Tuberculosis—The Danger of “Political”
   Control—“Politics” in Co-operating Divisions of the Health
   Department—Results in Baltimore—Tuberculosis and Poverty          273




                         The Tuberculosis Nurse




                               CHAPTER I

  Statement of the Case—Beginning the Work—Reaching the
      Patients—Supervision of the Work—Necessity for Experienced Nurses.


=Statement of the Case.= Pulmonary tuberculosis is a communicable
disease, transmitted from person to person by means of the tubercle
bacilli contained in the sputum of infected patients, or in the breath
expired during paroxysms of coughing. The bacilli thus liberated, find
their way into the system of another individual, either through the
respiratory or alimentary tract, or both. The enormous prevalence of
tuberculosis is due to the fact that its infectious nature was not
recognized until 1882 when Koch discovered the bacilli. Since that time
it has been classed as a transmissible disease, and during the past ten
years a vigorous effort has been made to eradicate it. This agitation is
popularly known as the anti-tuberculosis campaign, and associations for
the suppression of tuberculosis have sprung up in all parts of the
country. So far, no serum or vaccine has been found by which this
disease may be controlled, as was the case when smallpox and diphtheria
were checked. The sole way of overcoming it is to overcome the ignorance
concerning its nature, its transmissibility, and the means by which it
is spread.

At the beginning of the campaign it was believed that simple education
along these lines was all that was needed to obtain results. These
results were expected to follow as soon as the patient was informed of
the nature of his disease, and how to avoid spreading it, and as soon as
those in contact with him were given like information and taught how to
avoid infection. Ten years ago, in the optimism of the moment,
tuberculosis was freely proclaimed a “curable” disease; so that together
with the campaign of prevention went a campaign of teaching the patient
how to become a “cured,” or as we now call it, an arrested, case. The
mechanics of cure were equally simple—rest, fresh air, and food were all
that was needed, provided the disease was taken in the early stages. And
all that was necessary for “cure,” just as all that was necessary for
prevention, was to tell the patient what to do, and those about him what
to do, and the thing was done. This is the theory upon which the work
was founded, and in theory this is still a sound principle upon which to
continue it. Unfortunately, a series of unlooked for conditions
interposed themselves between this theory and our ability to put it into
practice. At the time when the crusade was begun these conditions were
not recognized, and it is only through long study of the situation, from
its social, economic, and legal as well as clinical aspects that we get
some idea of the difficulties and complexities of the task before us.

In the first place, tuberculosis is largely a disease of the poor—of
those on or below the poverty line. We must further realize that there
are two sorts of poor people—not only those financially handicapped and
so unable to control their environment, but those who are mentally and
morally poor, and lack intelligence, will power, and self-control. The
poor, from whatever cause, form a class whose environment is difficult
to alter. And we must further realize that these patients are surrounded
in their homes by people of their own kind—their families and
friends—who are also poor. It is this fact which makes the task so
difficult, and makes the prevention and cure of a preventable and
curable disease a matter of the utmost complexity.

People of this sort, however, constitute almost the entire
problem—otherwise the situation would be so simple that the word problem
would not apply.

This is why “cure” is not the solution of the matter. Too few people are
cured, in comparison to the numbers annually infected, to make any
impression on a disease of such wide prevalence. The sanatorium,
valuable as it may be for certain cases, is of little use to those who
relapse upon return to an environment they will not or cannot control.
This is also why mere instruction in preventive measures, unaccompanied
by effective isolation, is barren of results.

Experience has taught us the unsatisfactory nature of so-called cures,
and the futility of that prevention which allows the distributor of
tuberculosis to remain at large in the community and heedless of his
obligations. Hence we must look to segregation as the only reasonable
course to pursue. If segregation can be obtained in the home, well and
good. If not, then we must look to the institution to provide the proper
care. This segregation, most of it voluntary, some of it enforced, is
the only way to do preventive work on a scale large enough to count. To
this end, we need dispensaries where the disease may be recognized and
diagnosed, nurses to visit the patients in their homes, and hospitals
for advanced cases, the function of the nurse being to teach patients
and their families the necessity for segregating the former in
hospitals.

=Beginning the Work.= Let us suppose that a certain community, town or
country, suddenly becomes aware of tuberculosis in its midst, and in
consequence wishes to get rid of it. It is but a fraction of the
community which is enlightened enough for this, but from this nucleus
must come all that awakening of public sentiment needed to facilitate
the campaign. To estimate the number of tuberculous persons in any
locality, multiply the yearly tuberculosis death-rate by five or
ten—authorities differ as to the exact figures. The result will be the
approximate number of those afflicted. The public press will help in
disseminating this information, which is the basis from which we must
work. Since the beginning of the campaign, newspapers have been
wonderfully helpful allies in giving wide publicity to facts concerning
tuberculosis. As a result of this newly aroused interest, an
Anti-Tuberculosis Society may be created, and into its fold are gathered
all those willing to help in the work, each with his dollar. Lectures,
exhibits, open-air speaking, lantern-slide exhibitions, meetings in
churches and others held before various societies are given in various
parts of the town, and in this way information about tuberculosis is
spread far and wide.

There are two classes of the community, however, that must be
reached—those who have tuberculosis and those who have not. The people
who go to lectures and exhibits belong chiefly to the latter class.
Frequently, of course, the sick ones find their way in, in an endeavour
to learn something which may be helpful to them; unfortunately, they are
able to take away but little, and the little they do get they often
misapply. We recall the case of a man who went to a tuberculosis
exhibit, and learned that fresh air was good. As a result, he walked
several miles a day in order to get it, and nearly killed himself. He
had succeeded in learning one important fact—that fresh air was
valuable—but another, of equal importance, that exercise was harmful,
had escaped him.

To make the undertaking succeed, it is necessary to reach both the sick
and the well, since that strong, intelligent public opinion, which is
the motive force behind all new movements, must be aroused among the
sick as well as among the healthy. But as we have seen, the former are
not those who go largely to lectures, so they must be reached through
some other means. The most effective way of reaching them is through the
employment of a special nurse, who shall give eight hours a day, week in
and week out, to visiting in the homes where tuberculosis exists, and
giving instruction adapted to each individual case. By this means the
people most in need of assistance are reached without loss of time and
effort, and case after case is uncovered. This is shooting straight for
the bull’s-eye—namely, the infected home from which tuberculosis is
spread.

There may be laws on the statute books compelling doctors to notify the
local health authorities of their tuberculosis cases, but these laws are
not lived up to. Nor will the establishment of a hospital for advanced
cases bring these patients to light; neither will the sanatorium, nor
even the special tuberculosis dispensary. The surest and most effective
way of unearthing them is through the visiting nurse. Therefore the
nebulous plans of the newly formed anti-tuberculosis association may
well crystallize themselves into a decision to put such an effective
agent into the field.

=Supervision of Work.= After this decision has been made, the question
arises, by whom is the nurse to be directed? Is she to be placed under
the local health department, under a dispensary, under the charity
organization society, or under the visiting nurse association, if such
an organization exists in the town? If supported by a church or special
association of some sort, should not the governing board of such
organization direct her work? Or is she to be a free lance and manage
herself?

Unless taken over by the local health department (which in that case
becomes responsible for her salary and expenses incurred in the work),
the nurse should be affiliated with the Visiting Nurse Association,
rather than with any lay organization. Better results will be obtained
if her work is directed by a superintendent of nurses who is accustomed
to dealing with and judging nurses, and familiar with their duties along
technical lines. The credit of supporting the nurse would still rest
where it belonged—with the church, with the anti-tuberculosis
association, or whatever group of people might be responsible for her
maintenance,[1] but this arrangement would relieve the lay organization
of much responsibility, for no matter how good their intentions, such a
group cannot direct nursing work as well as this can be done by one
qualified for the purpose. Another advantage gained by placing the new
nurse with the Visiting Nurse Association is that it keeps together the
various branches of public health service, and the tuberculosis nurse
realizes more fully than she otherwise might, how completely her own
specialty is interlocked with and dependent upon other forms of social
activity.

Footnote 1:

  For five years the Maryland Tuberculosis Association supported five
  nurses, which it placed under the management of the Superintendent of
  the Visiting Nurse Association of Baltimore.

There is still another advantage in placing the new nurse with the
established organization, for then a nurse may be selected with regard
to her ability alone, leaving it to the Superintendent of Nurses to give
her the necessary careful training in social work, and the proper
supervision.

If there is no Visiting Nurse Association in the community, under whose
auspices the new special nurse may be placed, the lay organization will
have to do the best it can. In this event, it will be absolutely
necessary to select a nurse thoroughly trained in social work, and since
the number of women with this equipment falls far short of the demand, a
delay of some duration may take place. This delay is always borne with
great impatience by the newly formed group of people, anxious in their
enthusiasm to attack the tuberculosis problem at once. Yet policy would
counsel postponing the undertaking until a suitable person can be found,
for it is usually a fatal mistake to begin new work with an
inexperienced worker. Moreover, a situation which has existed for years
may be tolerated a few months longer without undue alarm as to
consequences.

If it is impossible to obtain a nurse fully trained in public health
work, the community may select a good nurse and send her for a few
months’ experience to some well recognized centre of public health work,
such as New York, Chicago, Boston, Baltimore, etc. The money thus spent
will prove a valuable investment to a community thus far-seeing, and an
ample return will be manifest in the efficiency of the nurse’s work.

A wrong start in choosing a nurse has driven many an enthusiastic
organization into deep waters, and caused trouble and misunderstanding
of a most grievous sort. In several instances, the local campaign
against tuberculosis has come to a disappointed end; in others, public
interest has been so antagonized and repelled that the movement received
a check from which it did not recover for several years.




                               CHAPTER II

  The Nurse’s Training—Health—Hours off Duty—Afternoons off—Character.


=Training.= One of the first qualifications of the nurse should be
proper training. She should be a graduate of a first-class general
hospital, which gives a three-years’ course. In States where
registration is established, she should be a registered nurse as well.
This means that she has passed the examinations set by the State Board
of Examiners for Nurses, and has attained at least the minimum degree of
efficiency prescribed by that body. Of course, it is well if she far
exceeds this minimum, but she must not fall below it in any case.

It is sometimes said that a woman trained in a sanatorium or special
tuberculosis hospital will make as good a tuberculosis nurse as one who
has been trained in all branches of nursing work. This claim is often
made by those sanatoriums which seek to find positions for their
ex-patients, to whom they have given a more or less sketchy training and
a diploma. Needless to say, if a community undertakes to support a
nurse, it should procure the best that can be found. There is no economy
in employing a half-trained woman. In social work the nurse occupies a
unique position in the patient’s household—she must be able not only to
gain but to retain the family’s confidence, and this cannot be done by a
half-educated woman, not sure of herself and unable to carry conviction
to her hearers.

=Health.= Next to thorough training, the health of the nurse is of
utmost importance. All nurses should be examined before they undertake
tuberculosis work. This should be done for two reasons: first, for the
obvious reason of protecting the nurse herself; secondly, for the
protection of the work. There is already sufficient prejudice against
tuberculosis work, and it is well not to increase it by having a nurse
break down soon after going on duty. In Baltimore, all applicants are
examined by a specialist before they are accepted. Note that this is
done by a specialist, and that the applicant is not permitted to go to
her own “family physician” who may or may not be able to make a proper
examination. The candidate is given a choice of several specialists, to
any one of whom she may go. The report of her physical condition, mailed
to the superintendent, determines her eligibility from the standpoint of
health. In this way, the responsibility is assumed by those most capable
of assuming it, and neither the health of the nurse nor the prestige of
the work is jeopardized.

After the preliminary examination, it is well for the nurse on duty to
be re-examined every six months. If suspicious symptoms present
themselves, this should be done oftener. Part of the superintendent’s
duties are to watch the health of her workers, and keep a sharp look-out
for suspicious symptoms—symptoms which the nurse herself may be unaware
of or afraid to acknowledge. Each nurse, however, should assume the
responsibility for her own health; she should remember that she is
dealing with a highly infectious disease, and that it behooves her to
keep in as good physical condition as possible. Nurses with a
predisposition to tuberculosis should not undertake this work.

The question often arises as to whether this visiting work is suitable
employment for arrested cases—for nurses who have had tuberculosis and
recovered. It is not suitable. It is far too hard and trying, for it
must be done day in and day out, at all seasons and in all weathers, and
involves severe physical strain. For that reason it is not proper
occupation for one whose health is in any way precarious. The danger of
relapse is too great. Nor should this work be done by those who are
afraid of tuberculosis. If fear of tuberculosis develops after a nurse
goes on duty, she should be released at once. Under such circumstances
she cannot do good work, while to persuade her to remain on duty,
contrary to her instincts, is a responsibility too grave for any one to
assume.

=Hours off Duty.= At this point we should like to speak of the nurse’s
hours off duty, though strictly speaking they are not within our scope.
As a rule, the hours on duty are eight—from 9 a.m. till 5 p.m., with an
hour in the middle of the day for lunch. This is a long day, and at the
end of it, any woman is in a condition of mental and physical fatigue.
The constant nervous strain occasioned by contending with the ignorance
and stubbornness which a nurse must encounter, is particularly wearing.

The hours off duty are for recuperation from the day’s toil, and if this
recuperation is insufficient, it will manifest itself in various ways. A
tired nurse is of no use as a teacher—she cannot cope successfully with
the obstinate wills of her patients, nor with the trying demands of the
daily routine. Moreover, a physically tired person is one who offers
ready soil for the development of tuberculosis. These two facts must be
constantly borne in mind. Therefore we should like to impress upon all
nurses who undertake this work that they must take excellent care of
themselves. Rest, sleep, and food are the three essentials to good
health, and any scheme of life which reduces these below a certain level
is bound to lead to disaster.

No one condemns reasonable pleasures, and in no other work is relaxation
and recreation so much required, but one must be careful not to burn the
candle at both ends. It is no part of the superintendent’s duties to
regulate the life of her nurses outside of working hours, but when their
life off duty diminishes their working ability, she is then called upon
to interfere. Tuberculosis work is trying, serious, and difficult, and
demands a high degree of mental and physical strength and freshness. If
a nurse is not willing to give this, she should not undertake public
health work.

=Afternoons Off.= Each nurse should be given one afternoon a week off
duty. It is more satisfactory to give this half-day in the middle of the
week, on Wednesday or Thursday, rather than on Saturday, at the week’s
end. In this way, the rest period breaks the long stretch of days, and
the nurse is enabled to rest before she becomes too tired. Sundays, of
course, should always be free. Under no consideration should the nurse
be subject to night calls and it is well to have this fact understood at
the outset of the work. A nurse cannot be on duty night and day both,
and certain rules should be established, regarding her hours on duty,
and be rigidly adhered to.

=Character.= The questions of training and of health having been
satisfactorily answered, there remains a third great essential to be
considered—the question of personality. Social nursing differs from all
other branches of nursing, since in this specialty there is a wider
departure from the routine and mechanical duties which form so large a
part of nursing work. Those qualities which make a good institutional,
or a good private nurse, do not necessarily make a good social or public
health nurse. Something more is demanded.

Broadly speaking, apart from professional training, the more highly
educated and cultivated the woman, the better will she be qualified.
This, one may say, would apply to all branches of the profession, but we
believe these qualities are more necessary in the tuberculosis nurse
than in the operating-room nurse, for example. The latter does work
which demands mechanical quickness and coolness; the former requires a
personality capable of dealing with human beings in all stages of
refractoriness, over whom she has no authority, but from whom she is
expected to obtain results. As every one knows, it is far easier to deal
with things than with people.

The qualities of a teacher are requisite. No matter how well one may
know a subject, if one cannot present it clearly and impressively, small
progress will be made. Nor is it the patient alone that the nurse is
called upon to deal with. Her activities bring her into close relations
with physicians, social workers, politicians, boards of directors, and
“benevolent individuals” of all classes, whose interest and good-will it
is necessary to secure. She must be as well able to meet people of this
sort, as to teach the humblest patient in her district.

Since this is social work, the so-called social virtues are a
necessity—and these exclude a bad temper or a quarrelsome disposition.
It is as essential to work in harmony with other social workers as with
the patients themselves—the two relationships are interdependent.

Needless to say, a nurse who cannot get on with her patients is a
failure. No matter how experienced she may be, or how well trained, if
she cannot gain the confidence and friendship of her families she is
unfitted to deal with them. It frequently happens that for the first few
visits a family may be uncordial and suspicious, but within a short time
a well trained, sympathetic nurse should be able to change this attitude
into one of confidence and appreciation. A few, a very few families
remain unchangeable of course, but their number is so small that they
form a negligible quantity.

Neither should a nurse fraternize with her patients. Through familiarity
she loses the personal dignity which means so much to her authority.
Authority is a term somewhat subtle in its definition—it means that hint
of power, of sureness, of knowledge, which enables one to speak with a
confidence which transmits itself to others, and compels them to accept
one’s point of view. A strong personality easily conveys this sense of
authority, but it may also be conveyed by a personality less strong,
when the nurse is well assured of her facts and cannot be caught
tripping. It is the hall-mark of the successful teacher—this ability to
impress her points upon others, and to make them see that what she
proposes is right, reasonable, and advantageous.

It seems hardly necessary to speak of the qualities of honesty, loyalty,
and conscientiousness. When they are lacking, all or any one of them,
the nurse is useless. The nurse is alone in her district all day long,
from early morning till late in the afternoon, and she must be a woman
with a high sense of responsibility and worthy of her trust. Patience,
that despised virtue, is also an essential part of the nurse’s
equipment, for she must listen to long details of illness, and must be
willing to reiterate, over and over again, without show of annoyance,
the rules which have been needlessly and exasperatingly ignored. No one
knows better than the nurse the awful hiatus that exists between
preaching and practising—the glib promise and the broken pledge—but she
must never show her irritation. We have known many excellent nurses who
gave up this work because they could not stand discouragement of this
sort, and who had not vision enough to look into the future for results.

This standard of requirements may seem high, but it is not impossible.
In fact, it is the minimum from which successful work can be expected. A
superintendent who has a choice of nurses will of course approximate it
as nearly as possible, in choosing her staff. The higher and finer the
type of woman, the more valuable she will be—probably in no other field
do fine instincts and fine feeling tell so strongly.




                              CHAPTER III

  Salary—Increase of Salary—Carfare—Transportation—Telephone—Vacation—
      Sick-Leave—Uniforms—Badges.


=Salary.= A good nurse should command a good salary—she is worth it.
There is a tendency to underpay nurses even at the present day, because
of the tradition handed down from the Middle Ages, that nursing service
should be given largely as a matter of love or charity. A woman who
gives up her whole time to district nursing, doing highly specialized
work, should at the very least receive a living wage. Associations are
often asked to supply nurses at a salary of forty or fifty dollars a
month, and surprise and indignation have been expressed because such a
woman was not forthcoming. Salaries should be large enough to attract
and retain efficient women; a small salary does not attract desirable
applicants, as a rule, and this limits the field of selection. Large
sums are appropriated for hospitals, sanatoriums, dispensaries, and
physicians’ services, but retrenchment takes place when it comes to the
nurse. Her work seems to be the one point where economy prevails.

In Baltimore, the staff nurses are paid seventy-five dollars a month,
and this is the very least that any woman should receive. A small town
or country community would doubtless have to pay more than this,
especially if it looks to the city for an experienced nurse. The reason
is simple enough—other things being equal and the character of work the
same, one would hardly expect a nurse to prefer an unknown locality,
away from home and friends, unless some extra inducement were offered. A
nurse might be willing to organize work in a small city, at a low
salary, for the sake of the experience. In that case, it is the
experience which offers the inducement. This once gained, however, she
would shortly be in a position to demand more salary or seek a wider
field of service.

=Increase of Salary.= The question constantly arises whether or not it
is well to increase the salary of the staff nurse from year to year. If
she enters the work at seventy-five dollars a month for the first year,
is it well to increase this to eighty dollars a month for the second
year, eighty-five dollars the third, and so on till a definite maximum
has been reached? To this question there are two answers.

Undoubtedly a nurse becomes more valuable as her experience ripens. Her
first six months on duty are largely spent merely in acquiring
rudimentary knowledge concerning her work. As she learns to know her
district, her patients, the doctors, the institutions, the social
workers, her value to the community increases. Each succeeding year,
therefore, which increases her knowledge of social conditions, should
make her in so far more valuable. It would seem but just, under these
conditions, that her remuneration should be raised accordingly. But at
this point there enters a factor which we must recognize. To specialize
in tuberculosis work makes peculiar demands upon one’s strength. Quite
apart from the physical strain, which is always great, it demands the
expenditure of a vast amount of nervous force, required in the constant
combat with opposition. For this reason it is peculiarly wearing and
exhausting. Also, by its nature, it tends to become monotonous. These
two factors—one of which tends to wear out the individual, the other to
make her indifferent and stale—make us hesitate to say that the nurse’s
value keeps increasing year after year. It undoubtedly does increase up
to a certain point, but after that point has been reached, it tends to
diminish. Such being the case, the obligation of raising the salary is
debatable.

Two kinds of nurses are usually found on the staff. One is the ambitious
nurse, who comes for the experience and training, to fit herself for an
executive position elsewhere. To such a woman, the routine of field work
will not be desirable for long—not for more than a year or two, or until
she has gained enough experience to prepare herself for a wider field of
service. That point being reached, her executive ability will seek an
outlet in work where she herself may become the organizing and directing
force. To such a nurse, salary increase will offer no inducement, since
she will seek that increase through work which provides greater
opportunities and responsibilities.

There is another sort of nurse on the staff however, who has no such
ambition; no executive ability, no desire to occupy any other than a
subordinate position. This one will never venture into a position of
responsibility, such as her experience might warrant, but prefers
instead the easier path, choosing to be guided rather than to guide. She
prefers to work under direction, rather than to direct others. To such,
an increase in salary would seem but a just reward for faithful service.
But, as we have said before, the monotony of tuberculosis work tends to
produce stale workers. There is danger, after a time, that the first
alertness and energy may wear off, the nurse may settle down into a rut,
and her daily task, though faithfully performed, tends to become one of
mechanical routine.

One of the chief duties of the superintendent is to train new nurses,
and she should renew the personnel of her staff whenever the welfare of
the work demands a change. Sometimes, when a nurse shows flagging energy
and interest, sufficient stimulus may be given by removing her to
another district, where she will encounter new patients and new
problems, and so regain her old keenness and ability. When one once
becomes thoroughly tired of this work, however, it is unwise and futile
to attempt to continue it. Therefore, in the interest both of the nurse
and of her work, it does not seem wise to offer inducements for
prolonged service, unless the individual characteristics of any given
nurse make this wholly desirable.

=Carfare.= In addition to salary, a reasonable sum of money should be
allowed for carfare. This allowance should vary in accordance with the
territory to be covered, those nurses who visit in smaller areas
naturally having a smaller allowance for the purpose. While economy in
this matter is always necessary, it must be remembered that undue
economy in carfare is wasteful of something still more important,—the
nurse’s time and strength. If she is obliged to walk long distances
between cases, this will greatly reduce the number of visits she can
make in a day. Moreover, she will spend so much energy in mere walking
that she will become too tired for effective teaching. Only fresh,
energetic people can teach; those who are physically tired are apt
unconsciously to let the obstinate patient have his own way.

=Transportation.= In small towns and country districts the problem of
transportation is often a difficult one. There are either no street
cars, or their service is very restricted and inadequate. Under such
circumstances it will be necessary to provide the nurse with a horse and
runabout, especially if she is expected to cover a large territory.
Unless there is proper provision for transportation, it will be
impossible for her to visit the patients often enough to make any
impression,—her teaching will be laid on too thin to have much value.
And to depend upon haphazard, volunteer offers of transportation is
almost as bad as to expect her to make her rounds on foot. She should be
given proper facilities for going from case to case, and should be able
to plan a day’s work unhampered by any considerations as to if or how
she can reach her patients.

=Telephone.= In making up the budget of necessary expenses, a reasonable
sum should be set aside for telephone calls. The nurse has constant
occasion to communicate with doctors, institutions, social workers, and
so forth, and this item of expense should not come out of her own
pocket. A careful weekly account of all expenditures, including
telephone calls and carfare should be rendered by her.

=Vacation.= A vacation of at least one month should be given during the
year. Less than a month is not sufficient time in which to recover the
physical and nervous energy expended during the rest of the year. This
holiday should be taken all at one time, rather than split up into
shorter vacations, taken at intervals throughout the year. We all know
that a week or two is not sufficient time in which to restore a
thoroughly tired person; at the end of such a short period, one is just
beginning to feel rested, and there has been no margin left over for
amusement, which is a necessary part of all holidays.

Strong emphasis must be laid on the fact that if a nurse expects to
return to her work and continue it successfully for another year, she
should use this vacation as a means of fitting herself for another
year’s close contact with an infectious disease. She should return to
work thoroughly rested, with her resistance increased by rest and
recreation, not lowered by injudicious use of this time off duty.

=Sick-Leave.= While a nurse is supposed to be sufficiently well and
strong to go on duty every day, in all weathers and at all seasons of
the year, a reasonable allowance for illness should nevertheless be
made. Two weeks’ annual sick-leave is a good allowance. If a woman is
off duty for longer time than that, needless to say her work must suffer
and her patients must be neglected. If a nurse is constantly off duty
for small ailments, this shows that she is not strong enough to
undertake this arduous work. A fixed allowance for sick-leave,
therefore, will tend to work automatically, and will eliminate the
unfit, whose burden of work is otherwise added to that of the steady
working members of the staff.

In the case of acute illness, such as typhoid fever or appendicitis, it
would be perfectly possible to appoint a substitute until the nurse was
able to resume her duties. If no time has been taken off for sick-leave
during the year, the two weeks should be added to the time granted for
vacation. If exceeded during the year, the salary for every day thus
lost should be deducted from the monthly salary. This procedure may seem
harsh, but with a large staff it is necessary. It places a double
incentive on keeping well, and nurses who would otherwise have been
thoughtless and careless as to their health, will take excellent care of
themselves, in order not to lose one day of their coveted vacation.

In Baltimore, the municipality gives two weeks’ vacation, and two weeks’
sick-leave. If the sick-leave is unused, a reasonable vacation is the
result.

=Uniforms.= The question as to whether or not a nurse shall wear a
uniform is one which usually excites much discussion. The one or two
disadvantages of such a dress are more than offset by the numerous
reasons in its favour. Two objections are usually raised to wearing it:
by the nurse, because it makes her conspicuous; and by the patient,
because the uniform makes him a target for neighbourly gossip.

Let us consider the first objection, that made by the nurse. A nurse
does not feel conspicuous when on duty in her district. Her busy, daily
routine, taking her in and out of homes where she is needed, soon causes
her to forget her personal appearance. A self-conscious woman is hardly
the right sort for this work. The only rub comes when she is off duty
and going to and from her district, but this cannot be held to
constitute a serious objection.

As for the patient’s objection—he would be equally conspicuous if
regularly visited by any woman unknown to the neighbourhood, no matter
how attired. Prying eyes would recognize her as an alien, and the
neighbours would speculate accordingly. We have often heard of patients
who for fear of what the neighbours would say objected to being visited
by agents of the Charity Organization Society. Yet the agents of that
Organization wear no sort of uniform. The truth is, it is usually really
the visit itself which is objected to, rather than the costume of the
visitor—the costume merely serving as an excuse. On analysing the
objections of a group of patients who disliked the uniform, they were
found to be, without exception, patients who strongly resented every
suggestion made to them. Their one desire was to be let alone, to be as
careless as they chose.

On the other hand, the advantages of the uniform are many. In the first
place, all effective care given to a consumptive has to include nursing
as well as teaching. Now, one can “educate” in a woollen dress, but one
certainly cannot give bed-baths in anything but a cotton dress, which
can be plunged into a tub and washed. And whether she enters the home to
give a bed-bath, or whether she goes in merely to distribute
prophylactic supplies, the fact remains that a nurse spends some eight
hours a day in contact with an infectious disease. Good technique
demands that she be dressed in washable material.

In summer, a dress of washable material is not conspicuous. In winter,
it may be covered with a long coat. And if we admit that such a dress is
necessary, what objection can there be to making it of simple and
uniform design? A single nurse so arrayed looks neat and business-like;
a staff of nurses looks equally so. Moreover, uniformity of dress
suggests uniformity of method, standard, and character of work, and
hence inspires confidence. A staff of nurses, each one dressed according
to the hazard of her own fancy, would hardly create the same impression.

In itself, the uniform is a protection to its wearer. It enables her to
go freely and without molestation into all kinds of tenements and
lodging houses, into side alleys and back streets. The well-known dress
surrounds her with recognition, affection, and respect.

The uniform is also of value to the patients and to their friends. It
enables them to recognize the nurse as she passes, and to call upon her
as she goes by.

The uniform worn in Baltimore consists of a plain shirtwaist suit, worn
with white linen collar and black necktie. The dress is made of blue
denim, such as is used for overalls. Denim of this sort has two sides, a
light and a dark; the dress is made up with the light side out, as in
washing it seems to “do up” better than the darker side. Black sailor
hats are worn, and in winter long, dark coats protect the dresses. This
uniform is not necessarily the last word as to what a uniform should be,
but it is simple and inexpensive, and the nurses look well in it.

=Badges.= The staff of a municipal nursing force is usually provided
with badges to denote that they are connected with the Health
Department. These badges should never be worn conspicuously, although
they should be readily accessible. They are only occasionally needed,
however, as when entering some lodging or rooming houses, or houses of
prostitution, or other places where there may be marked opposition. To
show them when entering a private home would be bad policy. A nurse
usually enters a private house as a friend, but a public house she is
sometimes obliged to enter in her official capacity. In dealing with all
her patients, however, no matter where they are situated, the less show
made of officialdom the better. By the time her patient finds out that
she is connected with the Health Department, she should be already
firmly established as his friend, and then the discovery will have no
terrors. Indeed, at that stage, it very often enhances her value, and
patients often feel intense pride at being visited by the “city nurse.”




                               CHAPTER IV

  Object of Work—Districts—Hours on Duty—Number of Daily Visits—The
      Nurse’s Office—Lunch and the Noon Hour—Bags—Prophylactic
      Supplies—Cups, Fillers, and Napkins—Disinfectant—Waterproof
      Pockets—Books of Instruction—Stocking the Bag and Distributing
      Supplies—Nursing Supplies.


=Object of Work.= The object of tuberculosis nursing is the home
supervision of all persons suffering from pulmonary tuberculosis. This
supervision should include patients in all stages of the disease, and
not be limited to those who are in some particular stage, such as early,
in contradistinction to advanced, cases. No organization which expects
to do effective work should deal with one class of patients alone, since
the boundary lines between the different stages are constantly shifting;
the ambulatory case of to-day may be the bed-ridden case of to-morrow,
and _vice versa_, and any attempt to limit the nurse to one class or the
other would mean neglect of both. Unless the work is planned on such
inclusive lines, it will be necessary to place a second organization in
the field, to care for those cases which have been thrown out by the
first. Policy of this sort would mean a number of similar organizations,
duplicating and overlapping each other’s work at every turn. Thus, in
the same household, we should see the early, ambulatory patient
“advised” by the nurse of one organization, while the advanced,
bed-ridden, more infectious case is being bathed and cared for by the
nurse from another. Invidious comparisons would doubtless be made by the
family, with the decision in favour of “deeds, not words.” True, there
would be co-operation between these two societies,—which would mean, as
a rule, double work, duplication of visits, endless transferring of
cases backwards and forwards, and opening and closing of records. From
whatever point of view we consider it, this is a very poor plan of work,
and a wasteful method. The nurse should be in a position to follow the
fortunes of her patients for months and years. Any scheme which involves
transferring him to a stranger, from an old friend to a new, at the
moment when he slips from an early into a most infectious stage, is to
lose sight of him and of his family at a most critical time.

Adequate supervision means that the nurse must teach, nurse, and ferret
out patients, and her patients must include advanced, early, and
suspicious cases. The care should be of two kinds—instruction as to the
nature of tuberculosis, with general teaching along the lines of
prevention and prophylaxis; as well as actual nursing service, rendered
to advanced and bed-ridden cases. The Baltimore nurses take charge of
all tuberculous patients, in whatever stage, and we feel that this is
the most effective way to carry on the work.

=Districts.= A small town, of course, constitutes but one district in
itself. A larger town may be divided into two or three districts; a
city, into as many as may be necessary. The principles upon which the
work is conducted are the same in each case. The nurse is responsible
for every consumptive in her district, and her constant endeavour should
be to bring under supervision every case of tuberculosis that exists.
She must visit all patients referred to her—give them instruction,
prophylactic supplies, and nursing care; unearth suspicious cases and
send them to a physician for diagnosis; secure hospital or sanatorium
treatment for those who are eligible, and arrange all details connected
with their admission. To accomplish these duties, she must know the
physicians of her district, the dispensaries and institutions where she
may send her patients, the philanthropic or relief-giving agencies whose
aid is so often needed, and all social workers whose co-operation is
necessary for the furtherance of the work in hand.

=Hours on Duty.= Eight hours should constitute the working day, from
eight or nine in the morning, till four or five in the afternoon. With a
large staff, the day will probably not begin till 9 A.M., while a single
nurse, in a small community, may prefer to begin earlier and so finish
earlier, especially in summer. It is a mistake to work overtime, no
matter how interested and enthusiastic one may be. A peculiarity of
tuberculosis work is its unending character—there is always more to do
than can be crowded into the longest day, and even after working ten,
twelve, fourteen hours, one would always feel that some important thing
was being left undone. It is well to recognize this fact in the
beginning, although the temptation to make “just one more” visit is
often hard to resist. The nurse who habitually works overtime only wears
herself out the faster, and in the end her patients will suffer through
her loss of health and energy.

=Number of Daily Visits.= This is a variable factor, and depends in
great measure upon the size of the district, as well as the number of
patients it contains. The character of the service rendered also
determines the number of visits, as new patients and bed-ridden patients
always demand considerable time. If a nurse calls on ten patients in a
block, and finds none of them in, she naturally can make more visits
than when compelled to spend a long time in each house. As in everything
else, it is the quality that counts, rather than the quantity; the day
which shows few visits may have been spent more profitably than that on
which she scored a high total. There is no general rule as to a nurse’s
capacity, yet it is always well to suspect the value of a large total of
daily visits; if a nurse dashes in and out of a house, spending but a
few moments with her patients, she has probably done her work so
superficially that nothing has been accomplished.

On the other hand, some nurses pay far too few visits because they have
no head for planning their work, but linger, past all necessity, over
unimportant details. To judge if a district is being properly visited,
the superintendent should know the district, and she should also know
her nurse’s capacity. To estimate the value of the day’s work by the
number of visits alone, is like those societies who reckon their value
by the number of pieces of literature they distribute, totally
regardless as to whether any of it bears fruit.

Roughly speaking, each patient should be visited once a week; failing
this, once every ten days or two weeks. In a few exceptional instances,
this time between visits may be still further extended, but this should
happen only when the patient is doing extremely well, following all the
rules, and giving efficient and intelligent co-operation. There are not
many patients in this class—for the average, supervision to be adequate
must be frequent.

Very ill patients, however, must be seen two or three times a week—every
day would not be too often, did the work permit. Unfortunately, if the
visiting list is large, these sick patients can be visited only at the
expense of other cases better able to take care of themselves. For this
reason, the visits to ambulatory patients may become as infrequent as
once every three weeks. If the visiting list grows so large that these
infrequent visits are all that the nurse can give, then her instruction
is laid on so thin as to be nearly worthless, a condition of affairs
which calls for another nurse.

=The Nurse’s Office.= An office is a necessity for the nurse as a place
where she may keep her nursing and prophylactic supplies, and at which
she will report at certain hours of the day, say at 9 A.M., at lunch
time, and possibly again in the afternoon before going off duty. At
certain specified hours, therefore, it will be possible to reach her,
either in person or by telephone, and her office hours should be known
to doctors, social workers, patients, or to any who have need to call
upon her. In a small town or country district, there will of course be
only one office, but in a city it will be necessary to have several
branch offices, accessible to the nurses of the different districts.
These branch offices should be situated on the border lines of two or
three adjoining districts, so that one office may be used in common by
several nurses. In a city there is also the central office, from which
the superintendent directs the work, and where the staff nurses report
daily.

In Baltimore[2] these branch offices are usually in the same building
which houses a branch of the Federated Charities, the branch office of
the Visiting Nurse Association, the Infant Welfare Association, and
other similar agencies. In this way, the various social workers learn to
know each other, and to secure close co-operation and understanding. The
different agencies, however, each have their separate rooms or offices.

Footnote 2:

  Baltimore is divided into sixteen nursing districts, with eight branch
  offices or sub-stations, for the use of the sixteen nurses.

The nurse’s office should be simply but comfortably furnished. It is
used for several purposes—as a store room for supplies, and as a rest
room, where she takes her lunch and spends an hour off duty in the
middle of the day. The furniture should consist of a large writing
table, which may also be used for a dining table; chairs, a lounge or
couch, and a small gas stove or Bunsen burner for cooking simple meals.
If there is no available closet, there will have to be a commodious
cupboard for storing the prophylactic supplies. A large stock of these
must always be kept on hand, so that the nurse may refill her bag before
starting out again on her afternoon rounds. A telephone in the office,
or at least in the same building, is of course necessary.

=Lunch and the Noon Hour.= It is not within the province of a
superintendent to dictate to her nurses as to what they shall eat. The
association, be it private or municipal, furnishes the office and the
hour, but the nurse must provide her own lunch and select it according
to her fancy. A word, however, in regard to this lunch. It should be as
nourishing as possible, and should consist of such wholesome food as
eggs, milk, cocoa, and so forth. If a nurse substitutes a pint of milk
for a cup of tea or coffee, she is wise.

In addition to nourishing, wholesome food (in contradistinction to
unprofitable pie and buns from the neighbouring bakeshop), a short
period of relaxation on the lounge or couch is a wise way in which to
spend a portion of the noon hour. In dealing with tuberculosis, food and
rest are necessary to keep one strong and well, and no nurse can afford
to trifle with her health when engaged in this serious work. On no
account should the noon hour be cut short, no matter how little tired
she may be. Better work can be done if one is well fed and rested.

=Bags.= The association which employs the nurse should also provide her
with the bag for carrying the supplies. The kind of bag needed is a much
discussed question. It should be strong, even though this necessitates
its being heavy. There is no other way out of it—for unless the bag has
the first qualification, strength, the weight of the supplies will soon
wear it out. Very light bags are not practical.

The bags used in Baltimore are made somewhat like the ordinary Boston
bag, about fourteen inches long, and of good black leather. They weigh a
few more ounces than those used by other associations, but they last
longer. It must also be remembered that the bag used by the tuberculosis
nurse, no matter how heavy it is when she starts forth on her rounds,
grows lighter and lighter as she goes from house to house, leaving the
supplies. Thus, at the end of the day, when she is most tired, it is
practically empty.

=Prophylactic Supplies.= The prophylactic supplies used for the patients
consist of tin sputum cups, cardboard fillers, paper napkins, waterproof
pockets, disinfectant, and books of instruction. The first three are of
primary importance. The Health Department of a community usually
provides these supplies, even when the nursing work is carried on by a
private association. Thus, in Baltimore, where for six years the
tuberculosis work was done by the Visiting Nurse Association, an
arrangement was entered into between this Association and the State
Board of Health, according to which, the latter paid for and provided
the supplies which the nurses distributed. The only condition imposed
was that each case should be reported to the Health Department, and that
the Health Department should be constantly advised as to the number of
cases under supervision. If no such arrangement is possible, then the
private association supporting the nurse must be put to the additional
expense of buying the supplies.

It is impossible to make the patients themselves pay for them.
Naturally, they consider them a nuisance and a bother, and it is
difficult enough to persuade them to use them, even when given free. The
cost is not great, however.

       Tin sputum cups, (in lots of 5000)         7 cents apiece.
       Fillers, (in lots of 1,000,000)        $3.50 per thousand.
       Paper napkins, (in lots of 5,000,000)   $.55 per thousand.
       Disinfectant,                           10 cents a bottle.
       Waterproof pockets                         4 cents apiece.
       Books of instruction                  2 or 3 cents apiece.

=Disinfectant.= The most expensive of the supplies is the disinfectant,
which is also probably the least valuable. That used in Baltimore is a
special preparation, consisting largely of creolin; it is put up in pint
bottles by one of the large wholesale drug houses. For use, it is
diluted in water, a tablespoonful to a pint, and used in wiping up
floors, furniture, and so forth. It is of necessity too dilute to have
much germicidal action, and the patients place far too much reliance
upon its odor—which, to the ignorant mind, is of prime importance.
Although we use this disinfectant, we prefer to teach our patients that
better results may be obtained by the lavish use of hot water, brown
soap, and a scrubbing brush, and that thorough cleaning of this kind is
of more value than the most malodorous drug ever dispensed. Disinfectant
to be of real use must be strong and powerful, and it is dangerous to
distribute such powerful drugs promiscuously. Several of our patients
have tried to commit suicide by drinking even the weak preparation that
we gave them. On the whole, we believe that an anti-tuberculosis society
would lose nothing by omitting disinfectant from its list of
prophylactic supplies, and better results could be obtained by
substituting a thorough grounding as to the value of soap and water.

=Waterproof Pockets.= These are little calico bags, dipped in paraffin,
or some similar preparation which makes them fairly waterproof. These
are pinned inside the coat pocket, and the patient uses them as a
receptacle for his soiled napkins, when he is out on the street, or in
other places where he cannot carry his sputum cup. The napkins are
burned upon his return.

=Books of Instruction.= These little books are more or less valuable,
but are by no means intended to take the place of the verbal instruction
which it is the nurse’s duty to give. They serve merely to refresh the
memory after she has gone. They can be procured at small cost through
the various anti-tuberculosis organizations, and most Boards of Health
print them for their own distribution. The best of them are inadequate.

=Stocking the Bag and Distributing Supplies.= When the nurse starts
forth on her morning rounds, her bag should contain enough supplies for
the patients she proposes to call on. Each should be given enough to
last until her next arrival. It is sometimes possible to direct either
the patient himself, or some member of his family, to come to the office
and get a fresh stock whenever necessary. By putting this slight
responsibility on the family, it is made to realize how necessary are
these supplies, but it should not relieve the nurse of her obligation to
visit such a household, and keep it under as close observation as any
other case. If a nurse thus trains a certain number of patients to come
themselves for the supplies, she will be able to reserve the contents of
her satchel for those patients who cannot call for them, or who are too
indifferent to do so.

Supplies should always be given out freely, and the patient should not
feel that he is put under any obligation by accepting them. They are
intended for his personal use and convenience, and he should be made to
realize this. Otherwise, some patients may hesitate to accept all that
they really need. If a patient needs four or five fillers a day, he
should unquestionably have them—otherwise he may practise small
economies which will mean unnecessary exposure for his family. On the
other hand, the nurse must see that the supplies are used for the
purpose intended—we have sometimes known handkerchiefs used as a
decoration for kitchen shelves, simply because the nurse had given away
far more than was necessary.

=Nursing Supplies.= In addition to the prophylactic supplies, the bag
also contains a number of articles used in caring for bed-ridden or very
ill cases. Naturally, these articles are not given to the patients, but
are used from case to case, as necessity arises. They include a bottle
of alcohol, boracic ointment, talcum powder, gauze, adhesive strapping,
absorbent cotton, and a thermometer. The nurse should always carry an
apron, to be worn when doing any nursing work.

The most common dressing is that of bedsores; many patients with
pleurisy have to be strapped; others have drainage tubes, which must be
taken out and cleaned. These extensive dressings are not those which the
nurse should properly be required to attend to, since a patient ill
enough to require an extensive dressing, is a patient who should be sent
to a hospital. Hospital accommodation, however, is unfortunately very
limited, and the nurse is often obliged to do these dressings while
waiting for a vacancy to occur. It is no part of the programme to keep
these advanced cases at home rather than in an institution; on the
contrary, the nurse must make every effort to get them away—but until
this can be accomplished, it is her duty to care for them at home.




                               CHAPTER V

  Records and Reports—The Patient’s Chart—Closing the Chart—The Card
      Index—Nurse’s Daily Report Sheet—Weekly and Monthly
      Reports—Examination of Charts.


=Records and Reports.= Every association, whether it be private or
municipal, supporting one nurse or fifty, should keep careful records
concerning its patients, and concerning its nurses’ work. These two sets
of records should dovetail and form a cross file; by looking at the
patient’s chart, one should be able to note the condition of each
individual case, and how often and on what dates he was visited. By
looking at the nurse’s record, one should be able to know exactly how
she had employed every moment of her day, and to see the number of
patients she had visited during the course of it. The patients’ charts
account for the patients—the nurse’s daily report accounts for her work
among them.

=The Patient’s Chart.= Each patient should have a chart made out for him
at the moment when he is taken on the visiting list. This also applies
to suspects, or those for whom the diagnosis is not positive, but whom
the nurse is required to visit and care for. This also applies to those
moribund patients, who may live but a few hours after being reported,
and who die before a second visit can be made. Whether he has been on
the list a year or an hour, it is necessary to account for every patient
who passes under supervision, and to record the result in each case.
Unless this is done, accurately and promptly, it will be impossible to
estimate the amount of work, and its value to the community.

The patient’s chart should contain name, sex, age, colour, address,
occupation, social status (married, single, or widowed), and a brief
history concerning the onset and progress of his disease. These charts
may be as simple or as elaborate as one desires. Herewith is submitted a
specimen chart, such as are used in Baltimore; they are not perfect, nor
the acme of all that is or might be desirable in a record of this kind,
but they have proved simple and fairly satisfactory. There is much left
out which with advantage might have been added, but in this connection
it is well to remember that an elaborate and exhaustive history, one
demanding dozens of intimate details, is apt to alarm the patient
excessively. To collect exhaustive statistics would be valuable for the
sociologist, but to do so at the expense of the patients’ confidence and
trust would be to defeat the object of the work itself.

[Illustration: Patient’s Chart. Cardboard, five by eight inches]

[Illustration: Reverse side of Patient’s Chart, showing spaces for
recording visits. The Second Chart Sheets are similar to this, but alike
on both sides]

The reverse side of this chart contains spaces in which each visit may
be recorded. Sometimes these charts are kept up for months and years,
and it is therefore necessary to have what are called second
sheets—alike on both sides, and resembling the reverse side of the first
sheet, which contains the patient’s history. These sheets are fastened
together, and the chart of a chronic case may thus record hundreds of
visits. Each nurse is responsible for keeping up the charts of all
patients under her supervision. The notes should be carefully recorded
at the end of each day’s work, for it is bad policy to let this charting
accumulate for even two or three days. The entries should be brief and
concise, and should describe the patient’s condition, or the work done
for him.

Each nurse should have a filing box or drawer in which to keep these
charts; they should be arranged in alphabetical order, and kept at the
central office, where the superintendent may have ready access to them.
These charts are the property of the association, and under no
circumstances are to be removed from the central office. The nurse may
make her entries upon them either at the end of the day’s work, or
before she goes on duty the next morning.

=Closing the Chart.= Patients are removed from the visiting list when
they die, or when they are discharged. They are discharged only for one
of three reasons—either they leave the city, or they move and their
address is lost, or they prove not to be tuberculous. When a patient
dies or is discharged, a suitable entry is made on his chart, which is
then turned in to the superintendent of nurses, or to whomever is
responsible for the records. If there is only one nurse, it is of course
her duty to file these closed histories. These records should be rich
mines of sociological information, and should contain valuable material
for those who have access to them, such as municipal authorities,
physicians, and social workers. Except for the access allowed to these,
the files should be confidential.

=The Card Index.= All offices should contain a card index, giving the
name and address of each patient under supervision. Change of address
should always be noted, since it is only by means of this card index
that the particular chart desired can be referred to. For example: the
card index contains the names of some 3000 cases, all under supervision,
and each one having its own chart. The charts themselves, however, are
distributed among the filing boxes of several nurses. If particulars are
wanted concerning John Doe, it would be necessary to turn first to the
card index, find his address and the district in which he lives, and
then turn to the filing box of that district and take out the chart. If
it were not for the card index, it would be necessary to search through
all the filing boxes before finding the desired chart.

[Illustration: Card, three by five inches, used in Card Index]

As the discharged charts are handed in, the corresponding card in the
index is withdrawn and filed away in a drawer containing either the dead
or the discharged cases according to circumstances. This is a very
simple way of keeping records, and of balancing from day to day the
number of patients on the visiting list. This balance may be made every
week or every month, as desired, for it is a simple method and reduces
to a minimum the opportunities for mistakes in addition and subtraction.
Needless to say, no one but the superintendent or her secretary should
have access to, or touch these files in any way.

=Nurse’s Daily Report Sheet.= Beside the patients’ charts, the nurse
must fill in a day sheet, or daily report of her work, to be handed to
the superintendent, or to whomever she is responsible. This sheet
accounts for her time and occupation all through the day. Beginning with
the time she goes on duty in the morning, she will record each visit to
each patient, the service rendered, and the time spent on him. She will
also record the time she reached her office for lunch, and the time she
left it for her afternoon rounds, also the hour at which she went off
duty for the day. A record of this kind means additional clerical work,
but how else is the nurse to account for her day? And be it noted, it is
always a satisfaction to the nurse to place on record the summary of her
day’s work.

[Illustration: Nurse’s Daily Report Sheet, seven by nine inches]

This daily report sheet is of great value to the superintendent: without
it, there is no way in which she can estimate either the quality or the
quantity of each nurse’s work. A glance at the report will show whether
the day has been light or heavy; it will show the number of new patients
and ill patients, and how many bed-baths and dressings were given; how
much time was spent in calling on doctors, dispensaries, social workers,
and so forth, and arranging houses for fumigation. In short, a record of
this kind shows the day’s work at a glance, and is the only way in which
it can be satisfactorily accounted for, and if necessary verified.

[Illustration: Day Sheet, used for summarizing the day’s work. From this
sheet the weekly and monthly reports are made out]

True, this information may be obtained by going over the charts one by
one, and verifying the records made upon them. But this is a clumsy and
laborious way of doing it. If a nurse has two hundred charts in her box,
and pays fifteen visits a day, it would be necessary to search through
the whole boxful of charts in order to find the fifteen cases visited. A
day sheet therefore, is not only a simple and practical way of recording
a day’s work, but it is a protection both to the nurse and the work
itself.

=Weekly and Monthly Reports.= From her daily report sheet, the nurse
should make up a weekly or monthly report, to be turned in at specified
intervals. This weekly or monthly balance sheet should be presented to
the superintendent, or to the officers of the association to whom the
nurse is responsible. Herewith is given a sample of the monthly report
cards used in Baltimore, but again attention is called to the fact that
these are not the last word in desirability. In using them as models,
they would of course be altered to meet local needs or conditions, and
enlarged or changed to suit other requirements. These monthly reports
should be carefully filed away; they are needed for the construction of
the annual report, and it may be necessary to refer to them on other
occasions.

[Illustration: Card, four by six inches, used for summarizing the weekly
and monthly reports]

=Examination of Charts.= One of the duties of the superintendent is to
examine the patients’ charts from time to time, to see how well the
nurses do the clerical work, which is quite as important as the visiting
itself. By carefully examining the charts, the superintendent is able to
call the nurse’s attention to any lapses in them—incomplete histories,
long intervals between visits, and so forth. If, for any reason, the
nurse allows considerable time to elapse between her visits to a
patient, the reasons for this should be fully noted on his chart. For
example: some one wants to know when Mrs. Jones was last visited. On
looking at the chart, we find the last visit was made on June first—and
it is now August first. A two-months’ gap between visits looks like
careless and inattentive work. The nurse, being questioned, however, is
able to give a satisfactory explanation—Mrs. Jones had gone to pick
berries, leaving the city the first of June, and not due to return till
the first of September. This important fact, however, should have been
noted on the chart, since it is almost as careless not to have made this
entry, as it would have been to neglect the patient for so long a time.
If a chart is to have any value, it should tell its own story, briefly
and clearly.

These charts, therefore, should be examined every two or three weeks. It
is the duty of the superintendent to go over these records, just as it
is her duty to make rounds from time to time among the patients, and
visit them in their homes. This is done by the superintendent, not in a
spirit of distrust or suspicion, but because she is the person
responsible for the work, and it is her duty to oversee it, and bring it
to its highest degree of efficiency.




                               CHAPTER VI

  Finding Patients and Building up the Visiting List—Increasing the
      Visiting List—Social Workers—Dispensaries—Patients’ Family and
      Friends—Nurses’ Cases—Physicians.


=Finding Patients and Building up the Visiting List.= The first thing
for a nurse to do when she begins her work in a new community is to find
the patients she is to instruct and care for. And the question naturally
arises; how are these patients to be discovered?

The campaign of propaganda concerning the need of tuberculosis work has
aroused the interest of people of all classes. The funds to support the
nurse are evidence of this. But the people who pay the bills are not
those who can produce the patients. To get in touch with the patients,
it is necessary to approach people of another class, those whose work
brings them in contact with the very poor. For, as a rule, in beginning
tuberculosis work, it is only patients of the poorest class who find
their way to the nurse’s visiting list. Later, as the work becomes more
firmly established, and better known and understood, her visiting list
will include not only the poor, but those in well-to-do and comfortable
circumstances.

The Board of Managers of the new association may interest themselves in
finding the patients, but in the end it is the nurse herself upon whom
this responsibility rests. Upon her initiative and ability depends the
success of the work. Her first step, therefore, should be to call upon
all those who can in any way be of service, and who can direct her to
the patients she is anxious to reach. She should call upon the
physicians of the community, the dispensaries and hospitals (if there
are any), social workers, such as the agents of charitable associations;
priests, clergymen, and all those who come into contact with the
suffering and the destitute. Her visits should be made in person, since
a personal interview makes a stronger appeal to the memory of the busy
man than the most convincing letter or the most eloquent report. This
involves one great reason why the nurse should be thoroughly equipped in
character and training; the colourless, uneducated, unconvincing woman
carries with her no conviction, and inspires no confidence either in
herself, or in what she proposes to do. A physician may well hesitate
about turning over his patients to a woman who is unable to put her case
before him.

It may be that considerable time will thus have to be spent in calling
upon all those likely to know of tuberculous patients, and therefore
able to furnish the nurse with the necessary names and addresses. That
the response is not great should cause no discouragement. As we have
said elsewhere, the tuberculosis death-rate, multiplied by five, will
give a conservative estimate of the number of tuberculous individuals in
a community. It is the nurse’s duty to unearth them. They exist—she must
find them, and the greater the obstacles, the greater the incentive to
overcome them. The total result of a two or three weeks’ campaign may be
a mere handful of cases reluctantly handed over by a few physicians, and
a few undiagnosed suspects, reported by an earnest priest. In this way
the visiting list is begun.

=Increasing the Visiting List.= To increase the visiting list—that is,
to bring under her care an increasingly larger proportion of the total
number of tuberculous patients, even though the list becomes so large
and unwieldy that she cannot manage it, should be the ambition of every
tuberculosis nurse. At present, in every city in the country, there is
so much undiscovered and unreported tuberculosis, that the failure of
the nurse to increase the visiting list is an indication of poor work,
not an indication that a full round-up has been made of all those
suffering from this disease. This is especially true in a new community;
a small or stationary visiting list is a sure sign, not necessarily of
lazy or unconscientious work, but at least that the undertaking is being
managed by someone who does not know how.

To illustrate this: A nurse is sent to a certain house, to see a
specified patient. She does her work well—gives him a bed-bath, shows
the family what to do, and makes considerable impression along lines of
general hygiene. As far as it goes, her work is satisfactory and good.
Another nurse, however, sent into this same house, would not only do all
these things equally well, but, in addition, she would discover that the
patient’s wife was coughing and probably infected, while his old mother,
retired in the chimney-corner, was in even worse plight than the patient
himself. These suspects, therefore, she sends to the dispensary, where
her suspicions are confirmed by the doctor’s findings. Thus, if a
community possesses a nurse of the first type, it may rejoice to find
the amount of tuberculosis so small. If, on the other hand, it has a
woman of the second type, it will become alarmed and anxious at the
increasing number of patients who need care and control.

Nothing should diminish the enthusiasm for gaining new patients. The
mere fact that a nurse has more than she can manage should never deter
her from continually trying to find more. More patients, more patients,
and even then, more patients, should be her constant aim—and then the
chances are that she has not found all that exist. In Baltimore, when
pioneer work was begun under the Visiting Nurse Association, that
organization had a visiting list of some 1700 consumptive patients,
divided among five nurses. As five nurses represented the largest number
the Association could support, and as 1700 patients was only about
one-fourth of those who needed care and attention, some other method of
caring for the latter had to be devised. It was at this critical moment
that the Health Department was persuaded to assume the tuberculosis work
of the private association, and to incorporate it as part of the city
machinery. If the need for this transfer had never been proved, it is
hardly possible that the change would have been made. If the first
nurses had confined their visits to the patients they could reasonably
manage, and had refused to accept others, it would have been impossible
to prove how great the number of infectious patients was, and how
inadequate the care given them by the five struggling nurses of the
private association. Therefore, each community which undertakes
tuberculosis work should endeavour to unearth all the cases that exist,
if for no other reason than to show the size of the problem, and the
necessity of adequate measures for handling it. New patients, positive
and suspicious, should be sought for from every possible source. This is
better policy than to confine the work to the conscientious care of a
handful of manageable cases.

=Social Workers.= The agents of the Charity Organization Society, or
similar associations, continually come across cases of tuberculosis. The
new nurse should canvass all these agencies, and ask that all cases of
this kind be referred to her. If a case is not positively diagnosed,
that should be no drawback to reporting it; while the agents of these
associations are laymen and therefore not able to make diagnoses,
laymen, nevertheless, are able to make very shrewd guesses. It is the
nurse’s duty to take charge of these doubtful cases, and get them
examined and diagnosed by the proper agencies. The mere fact that a
patient presents suggestive symptoms makes it all the more urgent that
he be examined as soon as possible, and lack of positive diagnosis
should be no reason for the agent to withhold, or for the nurse to
refuse to take charge of, such a case. To visit a suspect does not
necessarily classify him as a consumptive, while not to visit him might
be to deprive him of assistance at a most critical time.

In finding cases, extensive co-operation should be invited; almost every
one whose work brings him into contact with numbers of people, knows one
or two among them who are tuberculous. Thus settlement workers, school
teachers, school attendance officers, juvenile court officers,
clergymen, Salvation Army workers, and so forth, are all people whose
aid and interest should be solicited. It makes no difference whether or
not the case is positively diagnosed—any sick person, with the symptoms
of a consumptive, is a person whose case should be looked into. It is
the nurse’s business to obtain the diagnosis.

=Dispensaries.= If there is a hospital or dispensary (not necessarily a
tuberculosis dispensary), the nurse should visit these institutions and
ask to have all positive and suspicious cases referred to her. Since the
patients who come to these places are usually those of the poorer
classes, the doctors will not be likely to object to giving their names
to the nurse. Indeed, they may be glad to accept the assistance she
offers. One visit to these institutions, however, is not enough. Every
week or two the nurse must present herself and renew her request for
patients—she must not trust to the busy physician to report them by
letter or telephone. Even when tuberculosis work is conducted on a large
scale, as in Baltimore, it is always part of the nurse’s duty to visit
these institutions regularly, to remind the doctors of their existence
and of their unquenchable desire for more patients.

=Patients’ Families and Friends.= After the nurse is well established,
and her position in the community recognized and assured, she will find
that a certain number of new cases are referred to her through the
families and friends of those already on her visiting list. This is a
high tribute, and should be valued accordingly. She should not rely
entirely upon this voluntary assistance, however, but from time to time
should question her patients, and find out whether they have any friends
who are ill, who would like to be visited. Surprising revelations often
follow. There was in Baltimore one old coloured woman who took special
pride in discovering patients, and who made an indefatigable agent in
hunting up cases in the neighbourhood. The accuracy of her diagnosis was
wonderful—her son had died of tuberculosis, so she knew all the
symptoms, and she did not refer us to a single case, which, upon
examination, failed to be tuberculous. We must remember that while in
its early stages tuberculosis is difficult to detect, when it is so
advanced that a layman can recognize it, in nine times out of ten he is
right. And as these advanced cases are the chief distributors of the
disease, the alert nurse should be keen to learn of these patients
through any source that presents itself. Of course many calls from such
sources send one on mere wild-goose chases, but it is better to go on a
dozen fruitless errands, than to overlook one real case of tuberculosis.

=Nurse’s Cases.= A large proportion of her cases will be unearthed by
the nurse herself. In Baltimore, the nurses themselves discover nearly
thirty-three per cent. of the cases under supervision. Thus, on being
sent to see a certain patient, before her visit is over the nurse may
discover one or two others of the family whose condition is such as to
call for immediate examination. The nurse should look with suspicion
upon every member of a household which has been exposed to tuberculosis.
The prolonged and intimate contact which is necessary for the
transmission of this disease has unfortunately, in most families,
existed for months before her arrival. The nurse should be particularly
keen in questioning the parents of tuberculous children since it is from
the parents that most children contract this disease.

=Physicians.= In considering the various sources from which patients are
recruited, we have purposely left until the last that which most people
would have deemed the first and most important source of all, namely,
the physicians of a community. While the medical profession has blazed
the way, and has indicated the paths along which the work must be
carried on, it is unfortunately only the greater men in the profession
who have done this. The others, through ignorance, through indifference,
or through that spirit which according to Dr. Cabot makes medicine “the
greatest profession, the meanest of trades,” have succeeded in placing
effective if temporary barriers in the path of the anti-tuberculosis
worker. The rigid adherence to the old Hippocratic oath, by which the
physician was sworn to keep inviolate the confidence of his patient, and
to place foremost the welfare of the individual, has for the most part
been very nobly lived up to. This oath, however, antedates our knowledge
concerning infectious and communicable disease. With the knowledge as to
the nature of transmissible diseases, there has come a change in medical
ethics, a change manifested by laws in which the welfare of the
community is placed above that of the individual. We see this reflected
in the regulations governing diphtheria, smallpox, scarlet fever, and so
forth—diseases which are distinctly the concern of the community, as
well as of the patient himself. But with tuberculosis, which has but
recently become recognized as a communicable disease, we find a halting
reluctance to consider anything but the rights of the individual. This
feeling is particularly strong among physicians of an older generation,
hold-overs from a passing régime. To such as these the nurse is nothing
less than an impertinence. Even if physicians of this sort are unable to
see their patients oftener than once or twice a year, or know them to be
in need of supplies which the nurse will gladly furnish, they refuse to
call upon her, and consider her advent as intolerable.

Again, there are physicians who do not object to the nurse on this
score, but who resent her as a subtle menace to their practice. They
feel that if a layman is able to preach rest, fresh air, and food, and
distribute prophylactic supplies, that the ground will be cut out from
under them, and that they will lose a chronic and fairly lucrative class
of patients. As a matter of fact, the physician who preaches this simple
doctrine has nothing to fear from the tuberculosis nurse—if her words
echo his they only add force.

There are other physicians, however, who have received an inferior
medical education; they are neither sure of themselves, nor able to
diagnose tuberculosis until it is in an advanced state. These object to
the nurse on the ground, implied rather than expressed, that she is
supervising and criticizing their work, and this self-consciousness
often takes the form of a violent antagonism. It is always the badly
trained physician who fears the well-trained nurse.

Furthermore, there are certain practitioners who frankly exploit their
patients. They may be competent enough but they are in medicine to make
a living, and are often brutally unethical as to how this is done. If
through self-interest it seem best to them to withhold from the patient
the nature of his disease, they do not hesitate to do so, regardless of
the danger to which others may be exposed. By a strange paradox, the
same profession which gives us the noblest, the most unselfish workers
in the interests of public health, also gives us its most implacable
enemies.

However, the new nurse must call upon all the physicians of the
community, and endeavour to obtain their assistance and support. But,
for the reasons mentioned, she must not be discouraged if she is not
always cordially received by them. There will always be among them many
who are enlightened and progressive, and who will assist generously in
the anti-tuberculosis campaign. If a community can boast of only one or
two such men, even, success is assured. And later on, as the nurse
progresses quietly in her work, she will come into contact with other
doctors, who promise her aid, but ignore their promises because they
think she is trying to steal away their patients. As it gradually dawns
on them that this is not the case, their opposition will wear off. To
conquer this prejudice as soon as possible is part of the nurse’s work.

Furthermore, the community itself should not be daunted if the
physicians as a body do not endorse the prospect of a tuberculosis
nurse. This prejudice against public health nursing is the common
experience in all cities where visiting work has been established, but
it gradually wears off as the nurse is able to demonstrate her value.
Little by little the doctors are won over, as they begin to realize that
she is not a rival but an assistant. In Baltimore, our experience has
been that those physicians who were at first our worst opponents have
now become our staunchest and warmest friends.




                              CHAPTER VII

  The General Practitioner and the Public Health—Responsibility of
      the Private Practitioner in Tuberculosis—Impossibility of
      Fulfilling this Obligation—Failure because of the Nature of
      Tuberculosis—Failure through the Personal Equation.


=The General Practitioner and the Public Health.= Roughly speaking, we
may say that the medical profession is divided into three or four
branches—private practice, hospital or laboratory work, and public
health service. A man who takes up one of these branches is not
necessarily interested in or equipped for another. While all physicians
are supposed to have approximately the same medical education, and
therefore to be interested in those measures which tend to raise and
improve the standard of public health, it is only those who are most
keenly interested in this work who have made it a special study. For it
must be remembered that public health work is as much a specialty and
calls for as much training and ability along certain lines as laboratory
work, or the administration of an institution. This being so, a man who
goes in for it does so because he is more interested in it than in
private practice, or in research work. And the converse of this is also
true. The selection of one field rather than another is a matter of
individual taste or inclination. Yet curiously enough, the State does
not take note of this fact. It places certain obligations upon all
members of the medical profession, and expects them all to live up to
the responsibilities thus arbitrarily imposed.

=Responsibility of the Private Practitioner in Tuberculosis.= In the
pursuit of his calling, the private practitioner comes into contact with
certain diseases which by their nature are a matter of public as well as
private concern. In so far, therefore, he is expected to interest
himself in the general welfare of the community, but there is no way of
compelling him to do this. The State grants him a licence to practice
medicine, and in exchange for this licence or permission, he is expected
to serve the State more or less gratuitously. At best, it is volunteer
service, and therefore intermittent and unsatisfactory. That the State
expects this service is shown by laws referring to transmissible
diseases, the notification of births and deaths, and other matters which
in one sense belong to his private business, but which in another sense
are part of his public responsibility.

Physicians who have no taste for research work are not forced to
undertake it, nor are they coerced into any other line of service. Yet
the State obliges those who are least inclined, as well as the others,
to assume a graver responsibility; care of the public health. It takes
no account of the many reasons which may prevent their doing this, or
prevent their willingness to assume any part of this responsibility. It
is thrust upon them just the same, but the expected results are not
forthcoming. The State, therefore, is in the position of making an
unfair demand upon the private practitioner, and at the same time
relying upon an unfulfilled requirement for the security of the public
health. In regard to tuberculosis, there are certain regulations which
all physicians are supposed to comply with, no matter how little
interested they may be in public welfare, or how unwilling to consider
any other than their personal interests. These laws require, first, that
all cases of tuberculosis be registered with the local or state health
department, since in dealing with a transmissible disease it is
necessary to learn its distribution and prevalence. Second, the
physician in charge of a tuberculous patient must give this patient full
prophylactic supplies, and teach him how to use and dispose of them.
These supplies are furnished free of charge by the Health Department, so
that the physician is under no expense in distributing them. Third, all
houses vacated by a consumptive, either through death or removal, must
be reported to the Health Department for fumigation. If these
regulations could have been thoroughly complied with, they would
doubtless have insured a system of complete and satisfactory supervision
of tuberculosis. As it is, most of our large cities have found it
necessary to place special workers in the field, to give exactly the
same supervision and control which these regulations were designed to
secure. The private practitioner, endowed with special education,
special opportunity, and special authority, has not used these
endowments, or else has used them to so slight an extent that the
community has received no benefit.

If the physicians of a community have been able to diagnose
tuberculosis, and have been required by law to report it, why has it
become necessary to establish municipal dispensaries for this purpose?
Can the dispensary physician make a better diagnosis? Or is he more
willing to fill in a blank and report the case?

And if the physicians, required by law to instruct and keep careful
watch over their consumptive patients, had been able to do this, why has
it become necessary to place tuberculosis nurses in the field, designed
to give just such service? Is the special nurse better fitted to explain
the nature and danger of the disease? Is she a more efficient
distributor of prophylactic supplies? To all these questions there
should be but one answer—there is, or should be, no difference between
the two. The private practitioner should be as well able to make a sure
diagnosis as the municipal physician. He should be as ready to report
the case. The private practitioner should be as capable a teacher, as
careful a distributor of supplies, as alive to the danger of
tuberculosis as the municipal nurse. The only difference between these
two groups of people is that one acts and the other does not—or acts in
such intermittent and irregular manner as to be productive of no
results. And it is because of this lack of action on the part of the
physicians in private practice, their failure to recognize, report,
teach, and continually supervise consumptive patients, that our cities
are placing the care of tuberculosis under municipal control. The care
of tuberculosis is gradually being withdrawn from the man in private
practice, and placed in the hands of specialists, who devote their
entire time to the welfare of the community. And although now as always
the latter solicit the support of the private physician, if he withholds
his co-operation they can do without him, and reach their goal through
other means.

=Impossibility of Fulfilling this Obligation.= We may ask why the
private practitioner is being supplanted by municipal control.
Undoubtedly he once held the key of the tuberculosis situation, as he
holds it of many other problems involving the public health. He is being
supplanted for two reasons: because of the peculiar nature of
tuberculosis, and because of the failure of the medical profession to
act as a united whole.

=Failure because of the Nature of Tuberculosis.= Let us first consider
the nature of the disease. Tuberculosis is a prolonged, chronic disease,
which may be drawn out over a period of months or years. The patient has
many ups and downs, being sometimes so ill that he places himself under
the care of a physician, sometimes so much better that he does not see a
doctor for months. We have known patients who have not been to a
physician for years, yet during that time they were infectious cases, as
proved by sputum examination. During a hiatus of this kind, how can we
possibly hold the doctor responsible for the tuberculous patient? How
can we hold him responsible for the conduct, training, and surroundings
of a case he never sees? Undoubtedly a very large number of patients
pass completely from under the observation of their physicians, and are
utterly lost to them. With the best intentions in the world, the private
practitioner cannot follow and supervise a disease of this character,
not acute, but chronic and ambulatory in nature. If he attempted this,
it would leave him little time for anything else.

Nor can we assume that the patient who closes his account with one
doctor necessarily places himself in the hands of another. He frequently
drifts along without any medical advice whatsoever, and only seeks it
again when his symptoms become alarming. These facts alone, exclusive of
all other considerations, show the necessity for centralized control of
these ambulatory patients.

Tuberculosis is largely a disease of the poor, as we have remarked
before. A poor consumptive must consider the spending of every dollar,
and the doctor’s fee is a matter of grave importance. For this reason,
the patient will pay just as few visits to the physician as he possibly
can. A doctor who sees a case only once or twice may well hesitate to
pronounce it tuberculosis, and may wish to keep the patient under
observation for a time, but the poverty of the patient prevents this.

Again, patients of the poorer classes continually change their doctors.
Unlike people in more fortunate circumstances, they have no one
physician to whom they always turn when in trouble. To such as these,
the “family doctor” is unknown. Their fickle interest is attracted by
the newest shingle, and they pay a visit or two to its owner and they
depart. We knew one patient who visited five different doctors within
the week. Small wonder that the doctor forgets these patients—mere
transients—and that, even if he has time to diagnose them, he does not
consider himself their physician, or responsible for them in any way. It
is for just such cases, however—those patients who come into fleeting
and haphazard relation with their physician, that municipal control is
required. It is no reflection upon the private practitioner that he has
failed to make headway against tuberculosis. It simply proves that
people with this disease must be watched and cared for by those who are
able to devote their entire time to it.

So much for the disease itself, and for the sociological and
psychological conditions which complicate it, and make it a matter which
cannot be handled successfully by the man in private practice. For no
matter how conscientious he may be, or how willing to assume the full
responsibility imposed by the State, he cannot do this when the patients
refuse him the opportunity. He cannot follow them up at the expense of
his private obligations. While the State expects service from those whom
it licenses to practise, it does not expect the impossible.

=Failure through the Personal Equation.= We must now consider the second
reason for removing tuberculosis from private into public control. For
while the nature of the disease itself explains in large measure why it
cannot be dealt with by the private practitioner, that is not the entire
explanation. And here we must put the blame where it belongs—at the door
of the physician himself.

When we think of the medical profession, we unconsciously think of its
finest members—not only of the leaders in thought and achievement, but
the numbers of highly educated, advanced, efficient, and conscientious
men who form so large a part of it. In thinking of these, however, we
are apt to overlook men of another sort, who are less well equipped, or
who are imbued with commercialism, yet who are none the less members of
this great profession. Yet even the least of these is armed, and has the
sanction of the State in bearing these arms, which may be used either
against a common enemy, or in a guerilla warfare in behalf of his own
interests. The wide diversity among its individual members is the reason
why the medical profession has been unable to act as a united whole in
the warfare against tuberculosis.

In the first place, all physicians, no matter how well they may be
trained, are not necessarily good teachers. No matter how keenly aware
of the danger of tuberculosis, they are often unable to impress it upon
their patients. Again, the busy physician has usually too little time to
be a careful teacher. When conscious of a crowded waiting-room, or of
the urgency of his next call, he is unable to give any but the most
superficial and hurried instructions about the nature of tuberculosis,
or the use of the prophylactic supplies. He does not realize that that
which is obvious to him is frequently unintelligible to those less
enlightened. We have often found patients possessing bundles of
prophylactic supplies, given conscientiously enough, but without
sufficient instruction to enable them to fold the fillers or to dispose
of them afterwards. We recall one such case, where the doctor had given
his patient a package of supplies, but had hurried off without opening
the bundle or explaining its contents. A week later, we found the
package still unopened. The patient, however, had torn a small hole in
the wrapper, through which opening he had seen enough to convince
himself that the strange objects within were no concern of his. We do
not mean to say that no physicians are good teachers, but we do say that
even where they are, and are moreover highly conscientious men, that
they frequently give inadequate instruction to the patients under their
charge, because they are too busy.

There is another class of practitioners, who, while willing enough, are
nevertheless unable to contribute much towards the anti-tuberculosis
campaign. These are the men whose education is limited, who are unable
to recognize tuberculosis until it is advanced, and even then hesitate
to commit themselves. The patient under these circumstances has ample
opportunity to infect others, to say nothing of losing his own life into
the bargain. No amount of conscientiousness, of integrity, and of honest
intention can compensate for lack of skill. Indeed, many men of this
sort come perilously near the border-line of quackery. Yet the State has
granted them a licence, though thereby it entrusts them with obligations
which they cannot fulfil.

We have spoken before of the unethical practitioner, who, while
competent enough, feels himself under no obligation to protect the
community from an infectious disease. There is sometimes a reason for
this indifference, this failure to tell the patient he has tuberculosis,
and to inform those who surround him of their danger. This reason is
because many a patient is afraid to know the truth about his condition.
If the physician tells him he has tuberculosis, he at once changes his
doctor and seeks another who will give a more comforting diagnosis.
Thus, the struggling physician, to whom this may mean the loss of
livelihood and prestige, is forced to a decision between self-interest
and the interest of a community which he learns to despise, because it
has forced him to dishonesty. We grow cynical about the welfare of those
who force us to trim our ideals.

We have tried thus briefly to review the main reasons why tuberculosis
is emphatically a disease which should be removed from private practice
and placed under municipal control. On the one hand, this is necessary
because of the nature of the disease, since ambulatory patients cannot
be followed except by those able to devote their whole time to it. On
the other hand, it is necessary because of the wide diversity within the
ranks of the medical profession. The greater number of private
practitioners are either too busy, too intent on earning a living, too
indifferent, or too poorly educated to assume effective supervision of
an infectious disease which requires masterful handling. And since they
themselves have not been able to deal with this great issue, they should
not object to placing it in the hands of those qualified to do so. The
greatest contribution that the private physician can make to the
anti-tuberculosis campaign, is to do what he can to hasten the advent of
full municipal controls.




                              CHAPTER VIII

  The Nurse in Relation to the Physician—Municipal Control of Infectious
      Diseases—The Nurse’s Difficulties—A Waiting Policy—Undiagnosed
      Cases—The Nurse’s Responsibility to the Conscientious Physician
      Only.


=The Nurse in Relation to the Physician.= In the foregoing chapter, we
have seen that the task of preserving and improving the public health is
one which rests, theoretically, on the medical profession as a whole. As
a matter of fact, however, this task is assumed only by certain members
of the profession. We have pointed out the reasons for this—that
physicians vary greatly as to personal character, ability, and ideals.
In the field of public health, the nurse finds herself in contact with
physicians of all classes. Some are able, high-minded, and skilful, and
whether working as public officials or private practitioners, have
nevertheless the same end; improvement of the public health. Others have
standards quite the reverse. This brings us to the question: When the
nurse’s duties bring her in contact with men of the latter class, how is
she to meet the situation? In what relation does she stand to these men?
What shall be her attitude to them, as regards her work? They are not
numerous fortunately, but there are enough to constitute a serious
problem, and one which sooner or later the nurse must face. This
question will also have to be faced by those who are responsible for the
nurse, and for her work.

In our opinion, the answer is simple enough—or, rather it will be,
twenty years hence. For at present, public opinion is in a transition
state and needs moulding. The nurse should work under the direction of,
and in co-operation with, all those physicians who, whether as public
officials or private practitioners, are working for a higher standard of
public welfare. To all such, without discrimination, the public health
nurse is the faithful, efficient, and tireless ally. But to all those
other physicians who have no such aims or desires, the nurse stands in
but remote and casual relation. The old teaching that she is the
handmaiden of the doctor is gone. Both are now co-workers in the field
of public health. The nurse still carries out the doctor’s orders, but
there is this difference—she discriminates as to doctors. As a public
servant, she obeys the orders of the municipal authorities, or of the
private practitioner when the object of both is the same, that is, the
welfare of the community. But she is not responsible to those physicians
who try to defeat this object.

For this reason, the nurse can do more effective work if she is
connected with the Health Department, since it is the Health Department
of a city which must formulate standards of efficiency, and clothe its
employees with authority to carry them out. The authority of the Health
Department physicians should be superior to that of any private
physician, should there be any conflict of opinion between them.

If the nurse cannot be established in connexion with the local Health
Department, she will yet be responsible to a group of public-spirited
citizens, which group will undoubtedly include many advanced and
enlightened physicians. This group of people will represent advanced
public opinion on the subject of tuberculosis, and the authority which
the nurse gets from them will be of almost equal value to that which she
would get from the municipality. Municipal authority, or the authority
of enlightened public opinion, is a dangerous thing to oppose.

=Municipal Control of Infectious Diseases.= In the case of smallpox,
diphtheria, or scarlet fever, the private practitioner attends the
patient under the immediate supervision of the Health Department. Thus,
in diphtheria and scarlet fever, he notifies the Department of each case
that comes under his notice. A municipal physician is at once sent to
take cultures from the patient’s throat, as well as from all the other
members of the household. He placards the house, and instructs the
family in such preventive measures as shall insure their safety and that
of the community. The patient is then left in the charge of the original
physician, who notifies the Health Department when, in his opinion, the
infection is over. His opinion, however, is verified by the municipal
physician, who takes another series of throat cultures, and ascertains,
quite independently, whether or no the danger is past. If it is, he
orders the placard taken down, and arranges for the fumigation of the
house.

In the case of smallpox much more drastic measures are observed. The
patient is summarily removed to quarantine, and all those who have come
in contact with him are vaccinated and kept under observation for a
definite period. In this way the strong hand of authority protects the
community from infection—the private physician has been merely the means
of calling attention to the danger. The time will come, indeed it is
rapidly approaching, when enlightened public opinion will demand this
same care in the matter of tuberculosis. By reason of the chronic nature
of the disease, the care given must include long-continued supervision,
extending if need be, over months and years. This supervision will be
given by municipal physicians and nurses. Furthermore, the private
practitioner will no more resent this, nor consider it interference with
his private business, than he resents municipal care of smallpox or
scarlet fever. The readjustment of the point of view is necessarily
slow, but it is coming, none the less. Those of us on the firing line,
however, who daily witness the loss and sacrifice due to this slow
readjustment, cannot but wish for revolution instead of evolution in
medical ethics.

In this chapter, however, we must deal with the situation as it exists
to-day. The infectious nature of tuberculosis has become known
comparatively recently, hence we find ourselves confronted with a
delicate and difficult situation, as must always be the case when public
opinion is evolving. To-day if a private physician forbids a nurse to
visit his patient (and for nurse, read also Health Department), the
present status of public opinion will usually uphold him in his
decision. It is for us, therefore, to find out the reasons which prompt
him to this decision, and to lay them frankly before the public, and let
the public pass judgment. In no other way can opinion be altered, or can
we gain for tuberculosis the same supervision and control that we have
obtained for the other infectious diseases.

=The Nurse’s Difficulties.= Let us take a few examples of the
difficulties the nurse meets. A boy of fifteen had been diagnosed by the
Phipps Dispensary as a moderately advanced case, and the nurse was asked
to follow him up. On her first visit, the patient’s mother refused to
let the nurse enter, saying that her son had since called in a private
physician, who assured him that the dispensary diagnosis was all
nonsense. The dispensary man had counselled rest; the newcomer told the
mother to buy her son a bicycle and let him take all the exercise he
could. This treatment was followed out, and, still acting on the
physician’s advice, the nurse was refused admission to the house. The
mother was friendly enough when they met on the street, and she even
permitted the nurse to stop and inquire for her son, always cheerfully
replying that he was doing well. Useless as they were, the nurse
continued these visits, since she was anxious to see the outcome of the
case. Finally, one day six months later, the mother threw open the door,
and in deep distress, begged the nurse to come in. “Do what you can for
my boy,” she pleaded, and led the way to an upper bedroom, where the
young fellow was lying in a moribund condition. A few days later he
died. The mother bitterly accused herself for her folly in refusing the
disinterested advice of the dispensary physician, and her grief,
remorse, and opinions were given wide circulation in the neighbourhood.
At no time during his illness had instruction been given as to the
nature and danger of the disease, and not until a week before death did
the attending physician admit that something was seriously wrong. In
consequence of this wrong diagnosis, the boy lost his life, and the
physician’s reputation was damaged. Apparently he had not taken into
sufficient consideration the risk of contradicting a diagnosis that came
from such an expert source.

In this particular case, it was impossible for the nurse to force her
way in, or to do anything except await developments. As it happened,
there was no one in the family likely to become infected, since the
patient had no brothers or sisters, no one except his mother with whom
he came in contact. The sacrifice of this boy to the ignorance,
obstinacy, jealousy, or stupidity of the local physician proved a
striking object lesson to the neighbourhood. The bereaved and indignant
mother was a factor in forming public opinion in this particular
vicinity.

Another case is that of a woman who had in her employ a favourite
coloured servant, whom she suspected to be tuberculous. Accordingly, she
sent for the nurse, asking her to take all necessary steps towards
getting the case diagnosed. As the patient was too ill to go to a
dispensary and could not afford a doctor, the nurse brought a specimen
of sputum to the laboratory of the Health Department, where it was
proved positive. So far, all was clear going. The patient was given her
prophylactic supplies, put to bed in a clean, airy room, and the nurse
called daily to give her a bath and such attention as she required. This
should have been a hospital case, but at that time the hospital was
crowded and there was no available bed. One day, when the nurse called
as usual, she found the patient suddenly become very impudent. She was
lying in a room with all windows closed, and a coal oil stove in full
blast; no supplies were in sight and the patient was expectorating at
random over the floor. This change had occurred because the patient had
taken some of the money given by her employer, and had called in a
“private doctor,” who declared she had nothing but a passing cold. He
also told her the supplies were nonsense, and that he could cure her in
two or three weeks. Furthermore, this physician himself came down to the
Health Department, and forbade the nurse to continue her visits, and all
“interference” with his case. A few days later, the employer also came
to the Health Department, in considerable heat, and wished to know why
the nurse was neglecting her duty. The explanation was satisfactory, and
a visit to her servant amply corroborated the statements that had been
made. This woman had been paying her servant full wages while off duty,
as well as providing her with many little luxuries and necessities. She
was therefore in a position to dictate the terms upon which she would
continue this assistance, and these terms did not include visits from a
physician of the calibre of the man now in attendance. In every case,
however, it is not so easy to obtain the whip-hand of the situation.

In these two instances, there was little danger of spreading the
infection, since neither patient was in close contact with children, or
other persons likely to contract the disease. The young boy suffered an
early death, while the coloured woman suffered personal inconvenience
and discomfort, due to lack of nursing, care, and attention. In neither
case, however, was there danger to other people. Whenever other people
are involved, it is less easy to stand by and do nothing, while waiting
for that slow change in public sentiment which shall give one the right
to interfere. Thus, a physician diagnosed a case as tuberculous, and
asked the nurse to take charge of the patient, telling her that he had
carefully examined all the other members of the family, and found them
in apparently good condition. He added, however, that he had been
dismissed as soon as he had told the family the disease from which the
patient was suffering. For this reason, he feared the nurse would find
difficulty in entering the home. His fears were only too well grounded.
The family had straightway called in another doctor, who calmed their
anxiety by denying the previous diagnosis. He also advised them to turn
away the nurse, which they did.

The patient lived some eight months after this, during which time she
was given no supplies, no instructions of any sort, and the family were
kept in ignorance of the nature of her illness. When she died, the nurse
as agent of the Health Department went to the house to arrange for the
fumigation. The front door was opened by a young girl obviously
tuberculous—the nurse was struck with her appearance; further search
revealed still another member of the household who presented suggestive
symptoms. In their distress, the family turned to the nurse and asked
for advice and assistance, and she at once referred them to the
physician who had diagnosed the original patient, eight months ago. The
family obediently presented themselves to him, and he found that three
more members had become infected. Since they were all in the early
stages, it is probable that they had become infected during the last few
months of the patient’s life—during which time not one precautionary
measure had been observed. The day will surely come when the possibility
of treating tuberculosis lightly, at the option of the attending
physician, will not be allowed. Public sentiment will finally insist
upon full municipal control, which will do away with such malpractice
and sacrifice of human life.

=A Waiting Policy.= As matters stand to-day, we can do nothing but
accept the situation as we find it, and do the best that circumstances
will permit. Which brings us to the question of the hour—What is to be
done if the physician refuses to let the nurse visit his patient? Is she
to accept his dismissal and turn away, or is she to continue her visits
in spite of his objections, on the ground that the patient is hers as
well as his?

If the case is a positive one, diagnosed on unquestionable authority,
and if the nurse has been sent by a dispensary, the Federated Charities,
or through some other disinterested source, she should be readily able
to gain admission. Having gained this, she should be able to hold her
own against all comers. As a rule, it is the opposition she encounters
before, rather than after her first visit, which determines her ability
to do her work in the home. Once in the home, however, it should make
little difference whether or not the patient changes doctors. If he
does, she should continue her visits as usual—her knowledge of his
condition makes it advisable to hang on to the family at all costs. If
this change brings a friendly doctor, he will not object to the nurse.
If it brings a prejudiced one, she should do nothing to excite his
hostility. Thus, if the new doctor denies the presence of tuberculosis,
it may become necessary for her to seem to assent to this opinion—for a
time she may have to visit merely in the capacity of a friend, offering
no advice, and distributing no supplies. She must be careful not to
antagonize the family, for after all, it is the family, at the doctor’s
instigation, which is able to turn her out. Thus, when they triumphantly
tell her that the patient no longer has consumption, she should not
contradict them. Time will do it for her. She may express pleasure at
the happy change, and ask for permission to stop in now and then, in
passing, in the capacity of an old acquaintance. This request will
seldom be denied, and at all costs she must keep in touch with the
family which now, more than ever, needs her supervision and aid. She
must stand by, ready to give this as soon as it is wanted. During this
time it will be very hard to wait, to see the patient relax all
vigilance, and to see the family recklessly exposed. But this waiting
policy will pay in the end. As we have said elsewhere, the consumptive
changes doctors more often than any other class of patients, and the
nurse must realize this, and be ready to follow him through the
vicissitudes which these changes involve. She must avoid all criticism
when the family is fallen upon evil times, and be ready to uphold and
encourage them when they are fallen upon good times.

=Undiagnosed Cases.= In the matter of suspected or undiagnosed cases,
there is greater difficulty. In these cases the nurse has nothing to go
on but her own keen observation of symptoms, therefore the physician in
charge may make it very difficult for her to continue her visits. He can
withhold his diagnosis, ignorantly or wilfully, and there is nothing to
do but to accept this state of affairs. As before, the nurse must
quietly hold on to the case, saying nothing that can possibly imply
criticism or involve her in difficulty with the doctor. Time must be
trusted to clear the situation—either the patient will get better, or he
will get so much worse that a diagnosis may be forthcoming. Or else he
may change doctors. When a nurse is visiting a case in charge of one
doctor, she must be exceedingly careful never to advise another or to
suggest a dispensary. All this involves infinite waste of time and loss
of life, but as matters stand to-day, there is no other course to
pursue. When a nurse is visiting a case of this kind—it may be one who
presents every symptom of tuberculosis, including even hemorrhage—she
must be particularly careful. She may call up the doctor, tell him that
she has been called to his case through such and such an agency (these
cases are usually referred by a layman) and ask if there are any orders
he would like carried out. She may also ask him to tell her the nature
of the disease. If he refuses, it is then a question of further
“watchful waiting.” If the patient is expectorating a great deal, she
may provide him with a sputum cup and other supplies, taking care,
however, never to use the word “tuberculosis” in connection with them.
She simply offers them as a convenience for a distressing symptom. We
have known patients of this kind who died after being ill for months,
most of the time being spent in bed. Meanwhile, they had extreme
emaciation, night sweats, fever, cough, profuse expectoration, even
hemoptysis, yet the death certificate read “bronchitis.” It is true,
that these patients may really have died of bronchitis; as nurses, we
cannot make diagnoses, therefore we have no right to question the
physician’s findings. But it is impossible for an intelligent nurse to
look on at a case of this kind without wishing it were possible to
obtain a second opinion. As public health nurses we cannot but object
that the last word on so serious a disease should be said by men whose
diagnoses we distrust. That the health of the community should be
endangered by even a few physicians of this sort,—either ignorant, or
dishonest, or both,—is grave commentary upon the medical ethics of the
day. It is a severe criticism on that “professional courtesy” which
forbids intervention, even by the health authorities, with a physician
who drives his trade at the community’s expense. The war against
tuberculosis cannot be fought to a successful finish until the public
refuses to countenance ethics of this sort.

=The Nurse’s Responsibility to the Conscientious Physician Only.= In all
tuberculosis work, the nurse is singularly independent. When the patient
is in charge of the dispensary physician, or is in charge of a doctor in
sympathy with the tuberculosis movement, she may be said to be acting
under their orders. Or rather, there are no special orders, except in
individual instances, for the routine prescribed is always practically
the same. When a doctor reports a case, with the laconic statement,
“John Smith, such and such an address, usual thing,” he has fully stated
the situation. The doctor knows what should be done, and the nurse knows
what to do, and further words are unnecessary. Therefore, when for any
reason the patient gives up his doctor, the nurse can still continue to
supervise and direct. Months may pass before the patient revisits a
physician, and during these months the nurse is the only person in touch
with him. She also knows how to advise and direct those who are in
contact with him. When he finally calls upon a doctor again, her visits
still continue without a break—there should be nothing in her teaching
that is at variance with that of the newly arrived physician. The
chronic nature of tuberculosis makes this situation possible, and also
makes for the extremely independent position of the nurse.

Whenever the physician is in the vanguard of the anti-tuberculosis
movement, he will recognize the nurse as an ally, not a rival. He will
know that she will make no attempt to supplant him with the patient,
since the chances are that she has been caring for the patient for
months before he, the doctor, has been called in. He will regard her,
therefore, as a highly efficient ally, who will relieve him of tiresome,
time-consuming details connected with the case. She will take charge of
routine matters that he has no time for, and thus set him free for
larger and more important tasks.

If, on the contrary, the physician is one who exploits his patients, who
keeps the nature of the disease hidden, whether through ignorance or
design, and fails to give proper instruction as to its infectiousness,
then we must look for nothing but opposition and antagonism. We must
hear objections as to the nurse’s interference, to her uniform, to her
tactlessness, to her scaring the patient to death—and we must consider
the motives which underlie them. This brings us once more to the
question—under these circumstances, what is the nurse to do? Is she to
discontinue her visits, or is the value of her instruction to be
nullified by contradictory advice? Is a physician, who has consideration
for neither the patient nor the community to be allowed to jeopardize
both?

To men of this stamp, the tuberculosis nurse owes nothing. Her business
is to do her duty, even when it brings her to cross-purposes with them.
She has been taught her work by the most advanced and progressive
members of the medical profession, and in the homes of patients she is
but carrying out the orders of these abler men. That they themselves may
have no direct connection with the patient does not alter the situation.
She is their agent, not the agent of the hold-overs from a passing
régime. Therefore, we look to the former to establish their agent, the
public health nurse, in a position of unassailable dignity and
authority.




                               CHAPTER IX

  Obtaining a Diagnosis—The General Dispensary—Sputum
      Examinations—Tuberculin Tests—Registration of Cases.


=Obtaining a Diagnosis.= As we all know, it is not the business of the
nurse to make diagnoses, but it is emphatically her business to select
cases which should be diagnosed, and to send them where this may be
done. Therefore, if a community supports a tuberculosis nurse it will
also find it necessary to establish a place where she may send her
patients for examination—a special dispensary for the recognition of
pulmonary tuberculosis. If there is no such dispensary, in charge of a
capable physician, she may find it exceedingly difficult to obtain a
diagnosis for her patients, without which her hands are tied. She cannot
preach fresh air and prophylaxis to a person who has nothing but a
“heavy cold,” no matter how serious may be the symptoms in connection
with it. If the physician in charge of such a case is unable or
unwilling to make a diagnosis, it is necessary to have some court of
appeal to which the patient may be sent the moment he gives up his
doctor or his doctor gives him up. As we have said before, the nurse
must never influence a patient to change his doctor—on the contrary, she
must be exceedingly punctilious in this regard—but when the patient is
fickle and inconstant in his allegiance, she must take advantage of the
opportunities offered to send him where he may be skilfully examined.
The question of the special dispensary will be treated more fully in
another chapter—here it is simply our purpose to show the need of such a
place.

In a community which is beginning tuberculosis work, there are usually a
few physicians who will generously volunteer their services in examining
suspected cases. The nurse, however, will feel some hesitation in
accepting these kindly offers, since to take full advantage of them
would be to swamp these physicians with a class of patients which would
leave them but little time for their private practice. These offers,
however, may well be utilized in the formation of a special dispensary,
since the same men would doubtless be equally willing to examine
patients at some central locality. No matter how humble the quarters,
how imperfect the equipment, it is necessary to establish as soon as
possible a special place where these patients may be freely examined
without any sense of intrusion or of incurred obligation.

=The General Dispensary.= In many cities, general dispensaries exist for
the treatment of minor medical and surgical diseases. It is possible to
send tuberculous patients to these dispensaries, and to get them
examined and diagnosed, but as a rule this is not satisfactory. These
general dispensaries are usually crowded, and the physicians in charge
are unable to give sufficient time to the protracted, careful
examination which the consumptive requires. However, failing a special
dispensary, the nurse must take advantage of these general clinics and
accept all the help they are able to give.

=Sputum Examinations.= In many States, the local or State Departments of
Health maintain laboratories for the examination of sputum. The nurse as
well as the doctor should be allowed the privilege of sending specimens
for examination. If the findings are positive, the result is a diagnosis
from which there can be no appeal. The difficulty with this means of
diagnosis, however, is that many specimens are negative upon first
examination. It may require repeated examinations to find the bacilli,
or before their continued absence may be considered evidence that the
patient is not tuberculous. Dr. Victor F. Cullen, Superintendent of the
Maryland Tuberculosis Sanatorium, writes:

“We had one case that was examined sixty-seven times before tubercle
bacilli were found, and this was a far advanced case, with both lungs
involved from top to bottom, and cavities in each lung.

“We have at the present time (September 14, 1914) a patient in the
Sanatorium, with both lungs diffusely involved, with a huge cavity in
her left lung, expectoration about two boxes daily, whose sputum was
examined twenty-four times, with only three positive findings.

“These advanced cases with a lot of bronchial secretion are usually the
ones in which it is difficult to find tubercle bacilli in one or two
examinations.”

The nurse, therefore, should send in specimens frequently, every week or
so, and should never be satisfied with a negative report. As we have
said before, finding the bacilli is proof positive that the patient has
tuberculosis, but not finding them is no proof to the contrary.
Countless lives have been sacrificed by considering a negative return as
evidence that the patient was not tuberculous.

The nurse should carry in her satchel specimen bottles for collecting
sputum. These bottles are provided by the Health Department. If the
nurse has been called to a patient by the Federated Charities, or
through some similar source, or if the patient is one whom she herself
has discovered, she may send the specimen to the laboratory on her own
initiative. But if the patient is already under the care of a physician
who has not made a diagnosis, the nurse may call upon him and ask if she
may take such a specimen to be examined. This courtesy will doubtless
ensure better co-operation and understanding, but if the physician
refuses, the nurse is then in an awkward position. In a short time she
will learn the various physicians of her district, those whom she may
call upon, and those whom she may not, and she will learn to exercise
considerable discretion concerning them.

Valuable as these sputum examinations may be in the case of a positive
finding, they should never take the place of a careful physical
examination. It is only when this examination is not to be had, when the
diagnosis can be obtained in no other way, that the nurse will be
obliged to rely upon sputum examinations alone in dealing with her
patients. A positive sputum should confirm the diagnosis made by
physical examination—it is not, or should not be, the only means of
obtaining this diagnosis. Therefore, the fact that a Health Department
is equipped to make sputum examinations should never for a moment
supplant the dispensary, in charge of a specialist or expert. A
specialist is able by auscultation, percussion, and an ear finely
trained to detect changes in the breath sounds, and to recognize
tuberculosis weeks before the diagnosis is confirmed by sputum findings.
In this way it is possible to place a patient under treatment long in
advance of the time when the average physician would have recognized the
disease—an advantage to the patient and to the community as well.

=Tuberculin Tests.= There are two tuberculin tests commonly used, which
enable the specialist to diagnose doubtful cases. These are the eye and
the skin test. Strictly speaking, the public health nurse has nothing to
do with these tests, since they are entirely within the realm of the
physician, but she should at least understand their significance. The
Von Pirquet, or Skin Test, consists of inoculating the forearm with a
drop of tuberculin of a certain strength. A positive reaction is
manifest by a slight redness appearing within twenty-four hours and this
may persist for a day or two, after which it disappears. This test has
no value in the case of adults, since all adults are supposed to possess
some slight tuberculous focus, and therefore a reaction has no
significance. In the case of children, however, a positive skin test has
some value. Children are not as a matter of course supposed to possess
tubercular foci, and a positive reaction would therefore indicate that
they have become infected. A reaction, however, gives no indication as
to the location of the focus—it only proves its existence.

The Calmette, or Eye Test, has more importance. A drop of tuberculin is
placed inside the lower eyelid of one eye, and if a reaction occurs, it
does so within twenty-four hours. The conjunctiva becomes slightly red
and inflamed, which condition persists for a day or two and then
disappears. In adults as well as children, this is a positive indication
of tuberculosis—not necessarily of a mere latent focus, but of a
possible lesion which must be watched and guarded against. It gives no
indication, however, of the location of the lesion.

These tests are useful to specialists in helping them to highly refined
diagnoses. Dr. Hamman, however, questions the validity of these
extremely early diagnoses, unless they are confirmed by sputum findings.
If the bacilli are not found the diagnosis rests entirely with the
examiner, and is therefore dependent upon the personal equation.

=Registration of Cases.= Most States have laws which require the
notification of infectious diseases, including tuberculosis. This means
that all physicians are required to report their cases of tuberculosis
to the Health Department, filling in a card, more or less complex, in
which is set forth the patient’s name, age, address, occupation, and the
duration and stage of the disease. In Baltimore, the nurses also are
allowed to register their tuberculous patients in this way, with the
city as well as the State Health Department. The card used is the same
as that used by the physicians, but with this difference—since a nurse
is unable to make a diagnosis herself, she is required to place in the
corner of the card the name and address of the physician or dispensary
responsible for the diagnosis. In this way the authorities are enabled
to know how many patients are under the nurses’ supervision, and the
sources of the diagnosis.

Many of these registration cards are duplicates, the case having already
been registered by the attending physician, or the dispensary. If they
are not duplicates, it is necessary to have the official registration in
the handwriting of the physician himself—it is often needed when trouble
arises over the fumigation of houses, and so forth. There is nothing
official or authoritative about the nurse’s registration cards—these
merely call attention to the fact that certain patients are under her
supervision, attended by such and such a doctor. In most cases, the
diagnosis given is a verbal one. Should any difficulty arise, this
verbal diagnosis would not be valid, although it furnishes an excellent
basis from which to instruct the patient and his family. Therefore the
nurse’s registration card, if it is not a duplicate, serves to call
attention to the fact that a certain physician is in charge of a case
which he has not reported. The Health Department at once writes and asks
him to report, and in this way the diagnosis is officially recorded.

In Maryland, the law calling for the registration of tuberculosis had
been on the statute books some years, but was generally disregarded. The
physicians failed to report their cases, and it was therefore impossible
to estimate the amount or distribution of tuberculosis. To do this was
the object of the law. How generally this regulation had been ignored
may be judged from the fact that in 1909, the year before the Baltimore
municipal nurses went on duty, the number of cases of tuberculosis
registered by physicians was only 919, while the deaths from
tuberculosis for that same year were 1400. In 1910, the first year that
the nurses were on duty, the cases registered jumped up to 3202, while
the deaths fell to 1234. This sudden increase in the registrations—an
increase of over three hundred per cent.—shows the stimulating effects
of a staff of active public health nurses.

How necessary it is to have the diagnosis recorded in the physician’s
own handwriting may be judged by the following incident. There was a
coloured man on our list, referred to us by a private physician. This
patient was a model in a school of painting and drawing, and after a
time the Health Department was flooded with complaints concerning him.
These complaints came from pupils, who declared they were afraid to go
to the classes, because the patient coughed so violently and spat so
profusely. The students did not know he was tuberculous, but they
suspected it, and therefore asked us to look into the matter. Finding
that the man was one of our patients, we at once wrote to the directors
of this school, telling them of this, and of the complaints that had
been made against him. We further suggested that if he continued to pose
as a model he should use the prophylactic supplies that the nurse had
given him, and which he used faithfully enough in his own home. The
Directors, however, would not take our word for this; they sent the
patient to another physician, not the one who had originally examined
him. To this man, the darkey protested that he had never seen a doctor
in his life. The second physician declared that the patient did not have
tuberculosis, wrote a note berating us for our interference, and called
upon us for proof. A hurried search of the files brought forth the
original registration card, sent in by the physician who had first
diagnosed the case, and transferred it to the nurses of the Health
Department. This fact at once threw a different light upon the matter,
and we were able to uphold our contention. The first physician, however,
had completely forgotten this patient, and had it not been for his
registration card, on file at the office, we should have been in a very
disagreeable position.

Since there is nothing authoritative about the nurse’s registration
card, she must be exceedingly careful never to register a case unless it
has been properly diagnosed. This information should be obtained from
the physician himself, whether in writing, verbally, or over the
telephone. She should never accept a third person’s word for the
diagnosis, no matter how accurate it may seem. For example, if a
patient’s mother tells the nurse that the doctor has just been in, and
said her son had tuberculosis, the nurse must not accept this statement
as sufficient. She must call upon the physician and ask him herself.
Again, suppose the nurse has sent a patient to the dispensary, and,
meeting him on the street an hour later, she learns that the doctor’s
verdict was consumption. She must not take the patient’s word for this,
obvious as its truthfulness may seem. It is necessary to be thus
punctilious, to prevent unpleasant occurrences from taking place. The
diagnosis of tuberculosis is too serious a matter to be accepted through
any such irresponsible medium as the patient or his family.

To fill in the registration cards is the nurse’s work. To supervise
these cards, and note their correctness and accuracy, should be the work
of the superintendent of nurses, in whose name they should be signed.
This transaction is one of the most important tasks of the office, and
extreme care should be taken that non-tuberculous patients are not
registered by mistake.




                               CHAPTER X

  Prevention of Tuberculosis—Sources through Which Calls are
      Received—Entering the Home—Telling the Truth to the Patient—Truth
      for the Family—Disposal of Sputum—Danger of Expired Air—Isolation
      of Dishes—Linen, Household and Personal—Disinfectant and Other
      Supplies—Phthisiphobia.


=The Prevention of Tuberculosis.= The object of the nurse’s work is to
prevent the spread of tuberculosis—it is not to cure the disease. In
doing the preventive work, it often follows that the patient himself is
immensely benefited, and his disease apparently arrested. This arrest,
however, is incidental—it is not the real object of the work, which is
the protection of individuals as yet uninfected. In no other branch of
nursing is there so much misunderstanding, so much placing of the cart
before the horse, and so much emphasis laid on the wrong thing. Nurses
themselves when they first begin the work fail to recognize the real
issue, and think that it is the actual care of the patient which is the
thing to be considered. This is totally wrong—_we work through the
patient to gain our ends, but he himself is not the main object_. It is
necessary to grasp this fact firmly, and keep it constantly in mind.
This will not only prevent much disappointment and discouragement, but
it will lay the foundation for more intelligent work.

On entering the home of the consumptive, the nurse has before her two
responsibilities, the family and the patient. The former is infinitely
larger and more important, since it is the family, as yet uninfected,
which must be protected from the patient, or source of the disease.
Instead of “family” substitute the word “community” and we have the crux
of the situation—the protection of the community from the danger to
which it is exposed. This protection may be accomplished largely through
care of the patient, but care of the patient, only, as such, is a
secondary matter. The vital and important concern is the welfare of his
family. To confuse these two issues, and put the patient first, and the
family, which means the community, second, would delay indefinitely the
result we hope to attain. As far as possible, the interests of the two,
patient and family, should be identical, but whenever a choice must be
made between them, the welfare of the community has the right of way.

This is why effective tuberculosis work must place the emphasis on the
control of the last-stage cases, since it is the advanced case which is
of most danger to society. For example: we have two families, one of
which contains a moderately advanced case, whose outlook is favourable,
while the second contains a last-stage case with a hopeless prognosis.
Both patients are equally intractable; the nurse has but a limited time
at her disposal, and must choose between the two, since she cannot
divide her days equally between them. From the point of view of the
individual, care of the earlier case would better repay her time and
effort; from the standpoint of the greatest good to the greatest number,
she must concentrate her efforts on the advanced case, since it is this
one which is immediately dangerous. The earlier case is less of a menace
to those about him; his obstinacy and refusal to follow advice mean loss
of that precious time in which life and death are determined—but if he
chooses, however wilfully, to waste this time, it is his own loss after
all. It involves no one else. On the other hand, much more is involved
in the advanced case. Here the patient’s death is inevitable, but it can
be kept from occurring amid circumstances which would drag down others
with him.

In the majority of cases, the death of the patient is the issue to be
expected, however much it may have been delayed or postponed—a result
saddening and discouraging to those whose previous training has been to
preserve life. What nurses are not trained to see, and what many of them
have neither imagination nor faith enough to see, is the number of lives
that are probably saved through the safeguarding of a dying individual.
It has been said that the world would be infinitely better off if every
consumptive in it could die to-day, since by this loss the people of
to-morrow would be saved. The nurse must cease to reckon in terms of
hundreds of patients—she must reckon in terms of the thousands who come
in contact with these patients. The amount that can be done to protect
these thousands is the standard by which the work must be judged a
failure or a success. If she bears this constantly in mind, she will not
become so easily discouraged.

Therefore, to sum up once more: upon entering the home, the nurse’s
first care is the family, and her second is the patient himself. But it
is by working through the latter that the former may be reached. The
patient himself is the point of attack, and if in the ensuing pages he
becomes so prominent as to delude one into thinking that his welfare
alone is the final goal, he is only made prominent in order that we may
reach our goal more quickly.

=Sources through Which Calls are Received.= The nurse goes to the
patient’s home, in the first instance, at the request of some one who
has sent her. This may be a physician, a dispensary, a neighbour, or she
may even go on her own shrewd suspicion that some one is ill. When the
door is opened to her knock, she must be careful how she explains her
coming. If a municipal nurse, she should never say that she has come
from the Health Department, for this conveys a suggestion of authority
which is often most alarming. Since the patient has been referred to the
Health Department from one of the sources just mentioned, it would be
more tactful to name the agency through which the call was received.

When calls are anonymous, such as by letter or telephone message, or
when the sender gives his name but asks that it be withheld from the
patient, the task of gaining an entrance is often one of considerable
difficulty, and requires much strategy. Calls of this sort should never
be refused, since in this way many advanced cases are brought to light.
It is also a wholesome indication that the community is learning to take
an intelligent interest in an infectious disease, whose presence is
recognized as a menace. These cases can best be managed if the nurse
assumes the responsibility herself, saying that in a roundabout way she
has heard that there is illness in the house, and so has called to offer
her services. As a rule, her offer will be readily accepted, for a case
reported in this manner is usually advanced, and, as we have said
before, when the neighbours diagnose tuberculosis, they are frequently
right.

=Entering the Home.= As a rule, when a nurse presents herself at a house
and explains her errand, the door is opened wide and she is cordially
asked in. In some instances, it is held half-shut, in a dubious manner,
and she is admitted with reluctance. Sometimes it is banged in her face.
It is a great satisfaction to gain an entrance into homes of the latter
class; to win the confidence of such patients is a victory worth having.
The surest formula for entering all homes is a broad smile; to stand on
the doorsteps and grin like a Cheshire cat disarms suspicion, and once
across the threshold, the victory is won.

=Taking the Patient’s History.= The facts concerning the patient must be
gathered in his home, and they are of two kinds, those concerning his
physical and those concerning his social condition. The first thing to
be done is to establish a feeling of trust between the patient and the
nurse. As a rule, all patients are communicative, and a few adroit
questions will open a flood-gate of confidence from which can be
gathered full details concerning their personal and family affairs. This
gives the nurse much of the information which she needs not only for her
charts and records, but also in order to deal intelligently with each
case. For unless she understands the patient, and knows something of his
social and economic condition, she will not be able to give helpful
advice. But the nurse must also bear in mind that tuberculous persons
are frequently shy and sensitive, and it may be difficult to obtain
their true histories. They may be more ready to describe their physical
symptoms than their social condition, and facts about their employment,
hours, wages, life insurance, and so forth are not always forthcoming.
It is inadvisable to make notes in the presence of the patient, for
among the poorer classes there is a fear that their words, when noted in
a book, may in some mysterious manner be used against them.
Occasionally, in a matter of some importance, distrust may be quieted by
asking, “May I just write that down? The doctor will be interested in
that and I want to get it right,” but it is well to remember that
suspicions once aroused are difficult to quiet, and that for the welfare
of the community it is better to teach them to use their sputum cups,
than to antagonize them by too many questions. The nurse should get all
the facts the chart calls for, but with certain patients this may take
considerable time. At each succeeding visit she can ask another question
and a more intimate one, until she collects, little by little, all the
data she requires. But it is a mistake to keep on asking
questions—collecting statistics—at the expense of confidence and
good-will.

It is true that when a patient goes to a dispensary, he is prepared to
answer many questions, but there is this difference—it is he who seeks
the dispensary. When the tables are reversed, when he is not the seeker
but the one sought, he must be handled carefully. There are of course
many patients to whom this does not apply, and who willingly volunteer
every detail of their lives, but these are not the majority. The others,
the more sensitive ones, make up three quarters of the visiting list.
The antagonizing of a patient by tactless questioning is an unfavourable
commentary on the method of handling him.

=Telling the Truth to the Patient.= The most difficult of the nurse’s
duties, and the saddest, is to tell the patient the nature of his
disease. Yet this must be done, for unless he knows from the very
beginning, it is impossible to exact from him that intelligent
co-operation upon which rests his sole hope. Only on the rarest
occasions is there any justification for withholding this knowledge. If
a patient has but a few more days to live, or if a hopeless case is
surrounded by scrupulous care and attention, this information may, if it
seems best, be withheld. But these are exceptional instances. To hide
the truth from an early or moderately advanced case would be criminal.
Apart from the first shock, people are never really injured by being
told the truth, and we all know of hundreds of cases in which lives have
been ruthlessly sacrificed through the policy of silence.

The truth need not necessarily be brutal—it can be made full of hope,
interest, and encouragement. In her efforts to encourage the patient,
however, the nurse must be exceedingly careful never to use the word
“cure.” Tuberculosis is never cured in the sense that typhoid fever is
cured, for example. At best, it is only arrested—that is, brought to a
standstill, to a point where the destruction of the lung tissue goes no
farther. Thus, if a person loses one or two fingers from a hand, a cure
would imply that these lost fingers could be made to grow again. The
lung tissue destroyed by tuberculosis can not be replaced or renewed any
more than lost fingers can be renewed. Yet a lung, in spite of this
loss, is still able to serve its owner well and enable him to lead a
useful and happy life, just as a hand which has lost a finger or two may
still be a fairly useful hand, and serve its owner well. This
distinction between arrest and cure must be made perfectly clear to the
patient, and he must also be taught that whether the arrest of the
disease is temporary or permanent depends in large measure upon himself.
His improvement depends upon his thorough understanding of his illness,
and upon his ability or willingness to co-operate as to treatment.
According to Dr. Minor,[3] it is not so much what a patient has in his
lungs, as what he has in his head; namely, common-sense, which
determines his recovery. Therefore to keep a patient in the dark
concerning his condition, and yet expect him, without knowing the
reason, to do over and over again the tiresome routine things necessary
to improvement, is to expect the impossible.

Footnote 3:

  Dr. Charles L. Minor, Asheville, North Carolina.

In making the best of things, the nurse must never over-encourage the
patient. A half-starved, overworked person, suddenly put on a régime of
fresh air, rest, and abundant food, will often make surprising
advances—up to a certain point. This improvement may be so marked that
it will raise false hopes of its continuance and the nurse must never
jeopardize her reputation and the confidence imposed in her, by
extravagant statements as to what may be accomplished. The overconfident
patient mistakes temporary improvement for permanent cure. Tuberculosis
is like a concealed enemy, crouched and ready to spring the moment one
turns one’s back, and it requires constant vigilance to guard against
it. If this fact could be securely drilled into the patients, there
would probably be fewer relapses.

=Truth for the Family.= If now and then an exception may be made in
informing the patient of his condition, there are no conceivable
circumstances under which this knowledge should be withheld from his
family. The significance and danger of tuberculosis must be fully
explained to all who are exposed to it. It is the “family” who
constitute public opinion as far as the patient is concerned, and we
must depend upon it to keep the patient up to the standard of living
which means his improvement and their protection. The nurse should fully
explain the situation to some older, responsible member of the
household. This can best be done out of the patient’s presence. She must
speak very plainly, using words within the comprehension of her hearers,
so that they cannot fail to grasp her meaning. The patient needs this
knowledge in order to get better—the family need it in order to protect
themselves. It is a sad fact, but a frank appeal to the selfish instinct
is usually productive of better results than one made upon higher
grounds. Both points should always be made, but the instinct of
self-preservation may be aroused with less prodding than is needed to
awaken rudimentary altruism.

=Disposal of Sputum.= The nurse has by this time prepared the way for
the prophylactic supplies, which she carries in her bag. These consist
of a tin cup, fillers, paper napkins, disinfectant, and so forth. She
must teach the patient how to use and dispose of them, as well as their
advantages—the latter reason not being always apparent to the ambulatory
case. She must teach that danger to himself and others lies in the
sputum coughed up from his sick lungs, and that the simplest way to
receive it is in the little tin cup, whose waterproof filler can easily
be burned. To the advanced case, with profuse expectoration, these
light, convenient little cups are a great improvement over the household
spittoon, which should be banished at once. Bed patients, or those too
weak to raise even this light cup to their lips, may be taught to
expectorate into the paper napkins, of which they should be given a
large supply. A simple way of disposing of these napkins is to pin to
the bedclothes a large paper bag (such as are used for groceries), into
which they may be thrown. Failing a paper bag, a cornucopia made of
newspaper will answer the purpose, the object being to let the patient
himself place this infective material in a receptacle which can be
burned in its entirety, without its contents being handled by anyone
else.

The problem of destroying sputum cups and their contents is often
difficult. The proper and only sure way is to burn them, and no other
course should be considered. Yet in summer, when many patients have no
coal fires, but merely gas or oil stoves, many difficulties arise. Under
such circumstances the patient may wrap his cup in a newspaper, place it
in a galvanized iron bucket, and then set it on fire. This is a
nuisance, as well as somewhat dangerous, and since these fillers and
their contents are hard to burn, the simpler method of throwing them in
the gutter becomes an irresistible temptation. To see that these fillers
are properly destroyed requires constant supervision and instruction and
is one of the most important of the nurse’s duties.

The patient should destroy the fillers himself—they should be handled by
no other member of the family, unless of course he is too weak and ill
to do it. Even when very ill, however, it is nearly always possible for
him to remove the filler from the cup and place it in a newspaper, which
is then rolled up by someone else and carried out to the fire. Needless
to say, the nurse must teach those who touch or handle this cup how
important it is to wash their hands thoroughly afterwards.

=Danger of Expired Air.= After giving him the tin cup and fillers, the
nurse must then give the patient a supply of paper napkins, and explain
their purpose. These are primarily intended to hold over the mouth when
coughing. The nurse must explain that bacilli are liberated in great
numbers during these coughing attacks, and that it is harmful to live in
a room filled with these invisible organisms. Most patients, knowing
themselves to be infected, are indifferent to the welfare of those about
them. Therefore, in trying to make him careful, the nurse will have to
appeal to his selfish instincts, and show that what is bad for other
people is equally bad for him, and so diminishes his chances of
improvement.

It is comparatively easy to instruct a patient in the use of his sputum
cup, but to obtain any sort of carefulness in this equally grave
matter—liberation of bacilli in the expired air—is well-nigh impossible.
This is partly due to the nature of the disease—in its most infectious
stages, the patient is so racked with paroxysms of coughing, that it is
impossible for him to keep his mouth covered, or to think of anything
except his own sufferings.

On the street, these paper napkins may be used to spit into, the patient
carrying them home again in the waterproof pocket pinned inside his
coat. Fine details of this sort are difficult to insist upon,
however—the convenience of the street and of the gutter making a
stronger appeal than any newly acquired æsthetic valuations. This is of
minor importance, however; the real danger lies in the home.

=Isolation of Dishes.= The consumptive should have special dishes
provided for him, which should never be used by any other member of the
household. If the family can afford it, they should buy dishes of a
special pattern, unlike those in general use, since in this way the
chances of mixing them are greatly lessened. Otherwise, constant care
must be taken to keep them apart. The patient’s dishes should stand on
their own corner of the shelf, be washed in a separate dishpan, and
dried with a special towel. Once a week, for general cleanliness’ sake,
they should be boiled. Any dish which may have got mixed with them, or
has inadvertently been used by the patient, should be boiled before
being used again in the household. The patient need not necessarily know
that his dishes are isolated, since details of this kind are explained
to the family rather than to the sick man.

If he is a bed patient, it is an easy matter to isolate his dishes,
without his knowledge; when he is up and about, it is much harder.
Patients are particularly sensitive about this, and some families,
rather than risk hurting the feelings of the invalid, prefer to boil the
dishes after every meal. This adds so much to the work of the busy
household that after a time all attempts at isolation are dropped. This
matter calls for considerable vigilance on the part of the nurse.

=Linen, Household and Personal.= All linen, including clothing and bed
linen that has been used by the patient, should be boiled before it is
washed. There seems to be some prejudice against this previous boiling,
as the family are apt to maintain that it makes it more difficult to get
the linen clean afterward. The nurse should overcome their objections,
and emphasize the necessity for the utmost caution in regard to this
infective material.

=Disinfectant and Other Supplies.= At a later visit, the disinfectant
may be given, as well as the waterproof pockets and books of
information. During the first visit, it is better to give only the most
important of the supplies—the tin cup, fillers, and napkins—and to save
the rest for another time. For on her first visit the nurse is a
stranger—later, she becomes a friend. Therefore she will make better
headway if on her first appearance she does not burden the family with
too much instruction and too much detail. It is better to say too little
than too much, better to leave something unsaid until the next time,
rather than overwhelm those she visits with a mass of advice which they
cannot assimilate. Her first visit has been made as the bearer of
distressing news, no matter how gently and carefully it may have been
broken, and the distress and confusion which often arise fill the minds
of her hearers to the exclusion of nearly everything else.

During her later visits, she will have ample opportunity to say all that
should be said—and at each succeeding call she will find that much of
what she said the time before has been forgotten, misapplied, or
altogether ignored. Tuberculosis work means the constant and incessant
repetition of the same thing, trying by every device imaginable to point
the way, to make an impression, to obtain some slight degree of
carefulness which may mean the protection of other people.

=Phthisiphobia.= People frequently reproach the nurse with the fact that
her teaching tends to alarm the patient and his family, and to produce a
community phthisiphobia which works great hardship in individual cases.
As far as the community is concerned, fear of tuberculosis is a good,
wholesome sentiment, and infinitely preferable to ignorance and
indifference. We cannot have too much of a public opinion which declines
to be exposed to this disease, and which will therefore provide the
machinery to cope with it. As far as the family is concerned, we have
never been able to produce _enough_ fear of tuberculosis. It would
greatly facilitate the campaign if the first feeling of alarm and
apprehension could become permanent, instead of very transitory and
fleeting. Tuberculosis is so slow and insidious in its onset,—there is
nothing spectacular, by which we can demonstrate to the ignorant mind
the relation between cause and effect, exposure and infection,—that the
educational method alone is inadequate to deal with the situation. If
the alarmed patient and his household could or would continue the
preventive measures which at first so strongly appeal to them, and which
in the beginning they apply with boundless enthusiasm, we should have
comparatively little difficulty. But the disease is chronic and slow;
the scare wears off, and the cry of “Wolf, Wolf” loses its value. And
then follows a relaxation of prophylactic measures. Each time the nurse
must stir them up anew—encourage, threaten, alarm, coax, bribe,—do
everything in her power to awaken them from their mental apathy and
drowsiness, which, as in morphia poisoning, precedes death.




                               CHAPTER XI

  Inspection of the House—The Patient’s Bedroom—Porches—Gardens and
      Tents—Flat Roofs—Clothing and Bedclothing—Artificial
      Heat—Rest—Fresh Air—Food—Cooking—The Bedridden Patient.


=Inspection of the House.= On her first visit the nurse must inspect
every room in the patient’s home, with a view to knowing what
possibilities it affords for treatment and isolation. Some contain no
facilities whatsoever; some but meagre ones, while in others may be
found excellent opportunities which the patient must be taught to use.
Before advising any change or rearrangement, several factors must be
considered: the stage of the disease, number in family, financial
condition, home surroundings and the institutional facilities of the
community. The course to be taken depends whether or not there is a
hospital, or whether or not the patient must wait some time before
admission. The first object is the protection of the family, but all
those measures which bring this about, offer at the same time the
maximum advantage to the patient himself. To remove him to an
institution is the best way to accomplish both ends. If this cannot be
done, the nurse must endeavour to secure conditions in the home which as
nearly as possible approach those of an institution. The closer this
approximation, the greater the gain to both patient and those who
surround him.

=The Patient’s Bedroom.= The first thing to be considered is the
patient’s bedroom, or sleeping quarters. He should have this room to
himself, sharing it with no one. If this cannot be arranged, he should
at least have a bed to himself. This bed, and that of the other person,
or persons, should be placed at opposite ends of the room, and as far
apart as possible.

The more windows in the room the better; these should be kept open to
their fullest extent. In some houses, where the windows are small, it is
often possible to lift out the entire sash, thereby admitting more air.
The bed should be placed directly at the window, so that the patient may
lay his pillow on the window sill if he chooses. He should be instructed
to sleep facing the opening, in order to get all the air he can. The
nurse should rearrange the furniture as she wishes it, otherwise
misunderstandings may occur. If the family object to her moving it but
promise to do this themselves, she must be careful to inspect the room
again on her next visit, to see that this has been properly done. Even
with families that have been under supervision a long time, it is well
to inspect the bedrooms occasionally, for the patient’s bed always has a
tendency to retreat into a remote corner of the room, especially in
winter.

The floor should be bare, and this, together with all other plane
surfaces should be washed several times a week with hot water and soda.
Great caution must be exercised in making a sanitary sick-room, but, in
her enthusiasm to produce ideal conditions, the nurse must remember that
articles used for months by the patient, and suddenly banished from his
proximity, may be very deadly elsewhere. In advising that carpets and
curtains be removed, she must be careful what becomes of them. If
germ-laden carpets are sold, or given to the neighbour next door, they
would better remain where they are. Poor people find it hard to
withstand the temptation to sell or give away serviceable articles,
which is of course but natural, but the nurse must be on guard against
such occurrences.

To have an ideal sick-room, there is no necessity for its being
depressing by its bleak ugliness, or bare and dismal as a cell. Washable
muslin curtains may be permitted, and there is no objection to pictures
and ornaments in moderation. It is bad enough to have tuberculosis,
without penalizing the patient by removing from him all those little
treasures which give him pleasure and harm no one.

In selecting a good room for the patient, the nurse may find it
necessary to have him exchange with some other member of the household.
In this event, great care must be taken that the room vacated by the
patient is thoroughly cleaned and disinfected before being occupied by
anyone else. There are also circumstances which render it unwise to make
this exchange: for example, say that we have a moderately advanced case,
whose improvement is doubtful. He is occupying a room with one
window—not ideal, but fair enough. There is also another room in the
house, containing several windows, altogether brighter and larger, but
occupied by three or four people, so far healthy and sound. To exchange
rooms under such conditions would be bad policy—it would be of little
advantage to the patient himself, while the other people would be
subjected to overcrowding and bad ventilation, which would decidedly
lower their resistance. Those in prolonged, intimate contact with a
consumptive must not be allowed to reduce their vitality in any way.

To arrange a good sanitary room for a patient does not in the least mean
that he will use it. Such a room would doubtless appear well in a
photograph, illustrating the “before and after” phases of the nurse’s
activity, but this does not necessarily mean that the patient is
isolated and harmless. He will probably use his nice room for sleeping
purposes only, and it is what he does with the remainder of his time
that counts. He comes into contact with the household at meals, in the
evenings, and on innumerable other occasions, and the consciousness of
an immaculate bedroom should not lessen the nurse’s anxiety about the
kitchen, the living-room, and the family sofa. There is where the danger
lies.

=Porches.= In some houses we find a porch readily available for the
patient’s use, where he can sleep and spend most of his daylight hours.
It is sometimes difficult to induce him to make use of it, however. We
must also remember that there is a great difference in porches. Some are
narrow, unroofed, exposed to sun and wind, have disagreeable outlooks,
for instance, as on unsavoury alleys, and in other ways are unfit to be
used as living-rooms. They should be used, of course, whenever
practicable, since undoubtedly the patient will get more air, and more
constantly changing air, than if he sleeps indoors. Yet it is well to
realize that a place where the patient is unsheltered, uncomfortable,
and where he cannot sleep or have a quiet mind, is often far less
valuable than a good bedroom which may give him all of these
necessities.

Patients in well-to-do circumstances can equip their porches admirably,
both with awnings and with canvas screens. These latter should roll up
from the floor, rather than down from the roof. Screens and awnings can
be made to order by any awning or sail maker; the price varies with
their construction, from about five dollars upward. To teach a patient
to use a porch for sleeping and also to use it as a living-room should
be the nurse’s constant endeavour. Even an ideal porch is like an ideal
bedroom—only valuable if it is used.

=Gardens and Tents.= Many houses have little yards or gardens, easily
adaptable for open-air living. A tent may be erected for sleeping
purposes, if the space is large enough and the family can afford it.
Women and children are usually afraid to sleep under such exposed
conditions, and in consequence refuse to make use of what would
otherwise be an excellent opportunity. These gardens may be used during
the day, however, and the patient made comfortable in a reclining chair
or lounge. But excellent as they appear theoretically, the extremes of
our climate, excessive heat and cold, often make them unpractical for
the consumptive’s use. Under such circumstances, these little back yards
often become anything but ideal places in which to “take the cure.”

=Flat Roofs.= We also find flat roofs or sheds attached to certain
houses in the tenement districts. These sometimes offer excellent
conditions for long hours out-of-doors, and may also be used as
sleeping-porches. The nurse must be alert to seize all opportunities
which present themselves, and to teach her patients to utilize them.

=Clothing and Bedclothing.= In her effort to teach her patient to sleep
out-of-doors, and to spend most of his waking time there, the nurse must
remember that in winter this is impossible, if he is insufficiently
clad. The vitality of the consumptive is always below par, consequently
he needs much more clothing than would a healthy person under the same
conditions. It is impossible to expect patients to remain out-of-doors
if they are cold and uncomfortable, and before insisting upon open-air
treatment the nurse must see that it is possible for them to take it. If
they lack the necessary clothing—underwear, blankets, sweaters,
overcoats—these may be procured through some charitable association. It
is a part of the nurse’s duties to arrange for this assistance, the
question of which will be dealt with in a later chapter.

=Artificial Heat.= In addition to extra clothing, artificial heat is
nearly always necessary, and this may be procured by means of hot-water
bottles, hot bricks, stove lids, and so forth. The clothing itself may
be sufficiently warm, and a hot brick may be all that is necessary to
keep the patient in the yard, rather than in the kitchen. The patient
must learn to live in the open-air—and the family must also learn that
their safety lies in keeping him there, and is well worth the trouble of
filling a hot-water bottle now and then. A hot kitchen is the worst
place in the world for a coughing consumptive—and a coughing consumptive
is the worst thing in the world for a hot kitchen—and the inhabitants
thereof. It is fortunate that the rule works both ways, so that both
sides may be appealed to.

=Rest.= The three things necessary to improvement are rest, fresh air,
and food. Not one alone, nor two alone, but all three together, if
results are to be obtained. It is very difficult to impress upon the
patient that rest is not exercise, and that nothing is as bad for him as
exertion. He instinctively associates fresh air with exercise, and does
not realize that fresh air and rest is the combination required. If a
physician is in charge of the case, he of course would direct the amount
of exercise to be taken, but if, as often happens, there is no doctor in
attendance, the nurse must use her own knowledge of what is best. In a
sanatorium the usual rule is that all patients with more than 99 degrees
of fever shall stay in bed. After a hemorrhage, absolute rest is of
course indicated.

Therefore the nurse should try to induce her patients to rest as much as
possible—not to walk about, or to drag themselves to a park, and so tire
themselves out. Exertion increases fever, and this will counteract what
benefit might have been gained through the fresh air. They should be
taught to sit comfortably in their gardens, on their front sidewalks, on
their porches, at their open windows. Best of all, they should go
upstairs to their bedrooms, and lie at full length on the bed placed
next to the open window. By thus emphasizing the importance of
rest—synonymous in this case with outdoor rest—the nurse is not only
giving sound advice to her patient, but she is protecting the community
from the ambulatory consumptive.

Whenever possible, the patient should be induced to remain in bed
permanently. The sooner the weary, advanced case gives up his painful
wanderings, stops dragging himself from his own to his neighbour’s
kitchen, or to the hospitable bar, the better for him and for the
community. If he were to go to bed in a hospital, instead of at home,
greater still would be the gain. The part of the community constituted
by his family would be freed from danger, while he himself would be
adequately cared for. Again we are struck by the coincidence of what is
best for the patient being also best for those who surround him.

=Fresh Air.= Fresh air is the second great essential in the treatment of
tuberculosis, and every patient should be taught to spend as many hours
as possible out-of-doors. The nurse must explain in words of one
syllable why this is necessary—that clean, pure air contains life-giving
oxygen, and that to breathe it entails little exertion on the part of
the sick lungs. On the other hand, impure air contains no upbuilding
principle, but greatly taxes the lungs and makes breathing difficult.
Outdoors, every breath of air is clean and pure; indoors, especially in
a closed room, one is soon reduced to rebreathing expired air, with all
its impurities. Just as tainted meat or spoiled fruit or vegetables are
unwholesome, and bad for the stomach and general system, so is impure
air harmful to the lungs and general health. One organ surely deserves
as much consideration as another. And when the lungs become impaired
through disease, it is still more necessary to take care of them. They
need to be strengthened in every way, in order to defy the inroads of
tuberculosis. The nurse must make her points clear and emphatic; if the
patient takes an intelligent interest in his treatment, it will become
less irksome.

But it is not enough to tell the patient why he needs fresh air—the
nurse must show him how to get it. He is singularly helpless and unable
to recognize such ways for himself. Also she must overcome his
objections and bring him to her way of thinking. Thus, he objects to his
porch because it is shaky, or because it may only be reached by passing
through another person’s room. Investigation may prove the shakiness
imaginary, or at least not dangerous, while the other person may be only
too willing to let his room be used as passageway to this desirable
goal. Again, he objects to sitting in the yard, or on the sidewalk, or
even at his window, for fear of what the neighbours may say. It should
be pointed out that his health is more important than their
comments—whatever they may or may not be—and that his interest, not
theirs, should come first. The nurse must plan every little detail; she
must select his chair or sofa; must show how he can be warmly tucked up,
and sit out of the wind or sun, as the case may be. She must teach the
family about the hot brick and how to place it at the patient’s feet—or
two hot bricks, if need be. It is not enough to say: Do thus and so—she
must herself demonstrate how the thing is done. The consumptive is sick
and helpless and needs constant reassuring. If he belongs to the very
poor, he has little to do with, and is so ignorant that he cannot make
the most of what he has. This teaching is one of the chief duties of the
nurse.

=Food.= The third great essential in the trilogy is food. The patient’s
diet is of the utmost importance, since his ability to take and
assimilate nourishing food determines his ability to build up enough
resistance to cope with tuberculosis. Generally speaking, he should be
encouraged to eat every kind of nourishing food that he can digest—for
tuberculosis does not call for a special diet as does typhoid or
diabetes. Anything which specifically disagrees with him should, of
course, be excluded. The question of food values must be considered;
with the poor, this requires careful teaching and explanation. The nurse
should point out the difference between food which merely fills the
stomach, and food which nourishes and upbuilds. In the first class may
be instanced cabbage, turnips, doughnuts, pies—all highly esteemed by
the poor, and cheap and indigestible. In the second class are meat,
eggs, milk, fish, rice, beans, hominy, oatmeal, and so forth. Some of
these nourishing foods—rice, beans, hominy, oatmeal—are no more
expensive than cabbage and pie. The family should be taught the
difference. Very harmful and indigestible are the products of the corner
bakery, the penny candies, the enormous pickles, and the copious strong
brews of tea and coffee which form so large a part of the dietary of
those near the poverty line. Considerable money is spent on these
things—often money enough to provide a wholesome meal, if the family but
knew how to discriminate. In planning a patient’s diet, the nurse will
have to do as much exclusive as inclusive propaganda.

It is not necessary to insist on milk and eggs, certainly not in the
abnormal quantities which a few years ago were considered indispensable
in the treatment of tuberculosis. If a patient likes these and can
afford them, well and good, but they need by no means be made the staple
article of diet. This rich and highly concentrated food has a tendency
to cause indigestion, and since this is one of the gravest and most
distressing complications of tuberculosis, it must be prevented at all
costs. A patient unable to digest his food has but slim chance of
increasing his vitality, and little hope of improvement. Therefore, in
advising raw eggs, the nurse must be very careful; one or two a day will
be sufficient, over and above the regular meals.

Milk should be substituted for tea and coffee. Three or four glasses a
day will be enough, and even that may be too much if the patient eats
well of other things. In place of raw milk, it may be peptonized,
malted, given hot, made into junket, taken in cocoa, or as one of the
flavoured milkshakes, or turned into clabber or buttermilk. These
varieties of milk are good for advanced patients, who may also be given
egg albumen, flavoured with lemon, orange, ginger ale, grape juice, and
so forth. The family must be taught to make these little innovations, in
the ordinary diet, and instruction in these is part of the nurse’s work.

By careful supervision and attention, the nurse can procure a very
satisfactory dietary, one both nourishing and digestible. Three good
meals a day, with a little nourishment between meals and at bedtime (a
glass of milk or its equivalent), will be found quite satisfactory. If a
doctor is in attendance, he will of course arrange such diet as he
thinks best, but if the nurse is left to herself, she will not overstep
the boundaries if she advises some such plan as we have outlined.

As we have said, indigestion is one of the most frequent complications
of tuberculosis. In some cases this can be overcome or relieved by
advising rest in the reclining position for an hour before, and
immediately following meals. If the patient lies flat on the bed or
lounge, this will be more effective that if he sits in a rocking-chair.

=Cooking.= Cooking and the preparation of food also require supervision,
for, especially among the poor, dense ignorance of these important
matters prevails. Through improper cooking, wholesome, excellent food is
often turned into something quite the reverse, indigestible and
injurious to a high degree; or, if not ruined, it may lose so much of
its food value as to be practically worthless. Thus, a hard-boiled egg
or a fried egg (especially if fried on both sides) is less easy to
digest than a soft-boiled one. A good piece of meat may have its entire
value removed by overcooking. All nurses have had training in dietetics,
and this special knowledge is of immense value in public health work,
where for the most part they come in contact with a class of people
whose ignorance of culinary matters is profound.

=Alcohol.= The question of giving alcohol frequently arises in this
work. If a doctor is in attendance, he will prescribe it or not as he
chooses. But if the nurse alone is in charge of the case, and the matter
is left to her decision, we feel that the ruling of the Phipps
Dispensary of the Johns Hopkins Hospital is a wise one to follow—no
alcohol for the consumptive under any circumstances. This means that
there shall be no eggnogs, made with brandy, sherry, rum, etc.; no
sherry with raw eggs—no indulgence in wine, beer, or alcoholic
stimulants of any sort.

=The Bedridden Patient.= When the patient is confined to bed, the
nurse’s task becomes easier. Isolation, therefore better protection to
the family, is more readily secured than when he wanders from room to
room, leaving a trail of germs behind him. It is well to exclude from
the sick-room every one except those in actual attendance upon the
patient; this is especially necessary in the case of children, to whom
the danger is greatest. Neighbours and friends should also be excluded,
and if they refuse to consider the risk, the plea for exclusion should
be made on the ground that visitors are disturbing and harmful to the
patient.

In the sick-room we sometimes find the young children of neighbours,
whose mothers are all unconscious of the danger to which they are
exposed. If through sheer indifference, the patient’s family does not
exclude these children, it would then become the nurse’s duty to seek
out their parents and warn them. When a patient’s household becomes
indifferent to community welfare, the nurse should then extend her
teachings farther afield—into the next house or block if need be—and try
to protect others who are unknowingly exposed to infection.

In brief, these are the duties of the nurse in the home of the patient.
At her first visit, she cannot say everything she wishes, but later it
will be possible to do so. In many cases, the household will be
suspicious, antagonistic, or not inclined to want her, so that she must
feel her way cautiously, step by step. It may take two, three, four, or
even a dozen visits to accomplish her object, and before she can drive
her points home with the requisite vigour. When the situation is acute,
and the danger great, it is difficult and discouraging to make haste
slowly, yet this policy will pay in the end. It is better to proceed
cautiously with an uneasy family, winning them gradually from point to
point, than to arouse their resentment by an impatient enthusiasm which
sees no wisdom in delay.

In dealing with patients, the nurse must speak plainly; it will not do
to insinuate or imply. What she has to say must be said
straightforwardly, in simple words adapted to the intelligence of her
hearers. The situations one encounters in this work are often sad and
trying to a degree, and it would be far easier to insinuate a
disagreeable or painful thing than to speak out plainly. The nurse who
cannot express herself clearly, forcibly, and convincingly will get poor
results. She must be able to meet prejudice with reason, to impose her
view upon another, and to convince the ignorant that what she says is
right.

There is an old fable which all public health nurses should remember—the
old story of the Wind and the Sun, who both tried to remove the
Traveller’s cloak. The Wind tried first, and he blew and blustered, but
his frantic efforts only made the Traveller clutch it tighter. And then
the Sun tried. He shone, blandly, warmly, gently, and in a few moments
off came the cloak. It is the method of the Sun, rather than of the
Wind, which usually wins out.




                              CHAPTER XII

  Care of the Family—Examination of the Family—Taking Patients to
      Dispensaries—Children—Tuberculosis in Children—Open-Air
      Schools—The Danger of Sending Patients to the Country.


=Care of the Family.= We have already said that the first consideration
is the patient’s family, or those individuals who come in contact with
him. Therefore, as soon as he himself is under satisfactory supervision,
the nurse must turn her attention to the other members of the household
who need her even more. A majority of the nurse’s patients are either
advanced or last-stage cases, many of them having a history extending
over months or perhaps even years of illness. If during this time the
nature of the disease has been unknown; or known, and no precautions
have been taken, there is great likelihood that other members of the
family have also become infected. To discover these suspicious cases and
get them examined and under treatment as soon as possible, is one of the
nurse’s first responsibilities. Next, she must give careful attention to
those other members of the family who so far have apparently escaped.
She must not over-alarm or frighten them, but she must keep before them
the fact that they are in close contact with a highly infectious
disease, and that whatever lowers their resistance, increases in like
manner their chances of contracting it. They must employ every means in
their power to raise their vitality to a point where they cannot be
reached. An infectious disease does not, as a rule, gain entrance into a
constitution strong enough to resist it.

To this end, the nurse should pay particular attention to the personal
hygiene of the exposed family. Their bedrooms and sleeping quarters
should receive as careful consideration as do those of the patient.
Every one in the house should be taught the value of fresh air, and the
necessity of sleeping with wide-open windows; the measures needed to get
people well are equally necessary to keep them well.

The family also needs careful instruction as to food and rest: food,
nourishing and well cooked; rest, which should at least mean that at the
end of a day’s work they do not exhaust their vitality in crowded
poolrooms, dance halls, and saloons. The need of recreation is one of
the fundamental needs of mankind, but there is a difference between that
which refreshes and that which undermines the constitution. Whether this
fatigue comes from work, play, or excesses of any kind, it is usually
the worn-out individual who first succumbs to exposure. In all
households there is great need for instruction along these lines. There
are weary, indifferent parents, and heedless boys and girls whose
ignorance of personal hygiene is profound. The fact that much of this
teaching falls on apparently stony ground shows the need for redoubled
effort—which will in time bear fruit. Those in contact with tuberculosis
must be continually on their guard against it—disease does not, as a
rule, attack those who are in sound health.

In this preventive work, the nurse will be greatly aided if she knows
what agencies she can call upon to reinforce her instruction. She must
be familiar with all the forces of social service, and know how to reach
them, and how to place her families in touch with them. Just as she must
have sufficient knowledge of dietetics to suggest rice as a substitute
for cabbage, bread instead of pie; so must she understand the social
agencies within call, and know what substitutes they offer for the
things that she condemns. A great gain will have been made if instead of
the poolroom, the young boy can be given the Settlement club or
gymnasium; or instead of the saloon dancehall, the young girl can be
offered that of the schoolroom or the church. The aim should not be to
deprive, but to substitute. Preventive work consists largely in teaching
how to substitute the harmless for the harmful, the healthful for the
unhealthful. In some communities, no such agencies exist; in others,
they are inadequate to the needs they try to fill. But if they exist,
they should be called upon.

=Examination of the Family.= Every person constantly exposed to
tuberculosis should be examined periodically, whether or not he presents
symptoms. The nurse should endeavour to get all members of the patient’s
household examined. This is sound in theory, but not always feasible in
practice, especially when there are a large number of patients under
supervision. When one is working with small numbers, with ten, twenty,
or a hundred families, it might be possible to get every member of these
households examined, but when one is working with large numbers it
becomes proportionately difficult. In Baltimore some 5000 consumptives
are annually dealt with by the Tuberculosis Division; if every one of
these patients comes in contact with five other persons—a most modest
estimate—that would give us a total of 25,000 people to bring forward
for physical examination. This task would swamp our dispensaries and
leave no time for anything else. After all, it is the positive rather
than the potential cases which are a menace to the community. Thus,
however much we may advocate the need for general examination of all
exposed persons, this course has its drawbacks when it comes to actual
practice. The best we can do is to get the suspicious cases examined.
The examination of those who have no symptoms would furnish interesting
statistics, but they are hardly dangerous enough to the community to
warrant the outlay of time and energy.

To induce a patient to be examined often requires weeks or months of
effort and persuasion. The less the apparent necessity, the more
difficult it often becomes. If a person has no symptoms he will not go,
and if he has symptoms, he is afraid to go, to a physician. Therefore,
whenever it is possible to get exposed persons examined, well and good;
when this is not possible, the nurse may confine her efforts to those
with suspicious symptoms. One of the foremost requisites in this work is
the ability to distinguish between essentials and unessentials, and
having made the distinction, to concentrate on the most important.

=Taking Patients to Dispensaries.= Unless the nurse has abundance of
time and a very light district, it is not well that she should spend
time in taking reluctant patients to a dispensary for examination. To do
this, means to give up from one to several hours, which she can ill
afford to spend in this manner. Nor is it necessary to waste her expert
service in this way—it is always possible to find some one willing to
take these patients, some friendly visitor, settlement worker, or even a
kindly, intelligent neighbour.

=Children.= It is conceded nowadays that people usually become infected
with tuberculosis in the first ten or twelve years of life, or during
childhood. The disease itself may or may not develop in later life,
according to the circumstances or environment in which the individual is
placed. It may light up later, if his resistance becomes lowered, or he
is reinfected, and cannot carry the extra load. For this reason, it is a
vastly important thing to protect children from infection, as well as to
protect those exposed in childhood from later undue strain.

The children the nurse sees are usually those in contact with a
tuberculous father or mother. What is gained if we teach the parent to
sleep alone, and spend part of the time away from them, yet permit him
at other times to remain in close contact with the children?
Intermittent contact, repeated often enough, is as bad as constant
contact. If a mother nurses, feeds, cooks for, and handles her child,
there are untold opportunities of infection. If the parent is
intelligent and unselfish, it may be possible to bring about a relative
degree of carefulness, and a minimum exposure, but there is no such
thing as adequate carefulness while these conditions continue. Among the
very poor, where it is impossible to regulate living conditions, there
is practically no doing away with the danger of infection.

Whenever the parents are sick, selfish, or ignorant; when the children
are undisciplined and uncontrolled, and where the grind of poverty has
reduced ethics to the most primitive basis, one cannot expect much. When
a child is in constant contact with a tuberculous individual, no matter
how careful that individual may try to be, there is always some danger.
By the very nature of his disease, a consumptive cannot be a hundred per
cent. careful. An adult living in contact with tuberculosis may be able
to resist it, a child has infinitely less chance.

The only way to ensure absolute safety for the child is to remove it
from the danger, or to remove danger from it. Either the child must be
removed from the house, or the patient must be removed from the house,
it makes little difference which. The patient may be sent to an
institution, or the child may be sent to a relative, to the country, to
a neighbour, or to one of the child-saving agencies that are to be found
in most communities. We are aware that in advocating this policy we are
advocating what is called by the unthinking “breaking up the home,” as
if tuberculosis had not long ago preceded us in this. Sending away the
parent or the child is merely a belated effort to save what is left of
the home.

Whenever an institution is possible, the patient should go there. In
many communities, however, there are no such facilities, or else their
capacity is limited. In this case, the child is the one to be removed.
This often becomes a matter of extreme difficulty, since it is hard to
overcome the parent’s very natural resistance. In urging this
separation, we are making a choice between two lives—one already doomed,
and the other which may be saved from a similar fate.

=Tuberculosis in Children.= Although children become infected at an
early age, it is often most difficult to obtain a diagnosis for them.
The most competent specialist hesitates to pronounce a child tuberculous
until he has repeatedly examined it, and kept it under constant
observation—and even then he may prefer to call it “suspicious only.” By
the aid of the eye test and the skin test he may finally arrive at a
positive diagnosis, but even then, he may not be sure of the location of
the lesion. The child, therefore, though diagnostically a positive case,
is not necessarily an infectious one.

All these doubts and difficulties in connection with the diagnosis of
tuberculosis in children serve to show that in a way this question may
be called a negligible one, negligible, that is to say, as a menace to
public health. It is important for the individual that a diagnosis be
made, in order to do intensive work in upbuilding his resistance, but he
is negligible as a distributor of infection. About ten per cent. of the
visiting list is made up of children. On entering a home where there are
two children, one tuberculous and one not, the nurse’s efforts should be
concentrated on separating the two—the emphasis being placed on the care
of the one as yet uninfected.

The question frequently arises, Should these tuberculous children be
sent to school? Is it well for them as individuals, from the standpoint
of their own health, and is it well for those who are thrown in contact
with them? This decision rests solely with the physician, and can be
made by him alone. As far as danger to others is concerned, it must be
remembered that while a person may be tuberculous, he is not necessarily
infectious, and it is upon the infectiousness of a case that the danger
depends.

It is difficult to care for these tuberculous children. Most nurses
become deeply distressed because of this. The children are frequently
undisciplined, and their parents often weak and lacking in self-control.
The nurse becomes discouraged and annoyed when she sees her directions
unheeded or disobeyed. But, after all, these cases constitute but a
minor part of the problem, and they are not patients who do much harm.
It is sad to stand by and see the individual throw away his chances, or
to see them thrown away for him—but this standing by is part of the
work.

=Open-Air Schools.= During the past five or six years, open-air schools
or classrooms have been established in several of our large cities. This
is an excellent affirmative answer as to whether a tuberculous child
should attend school. At these places, careful, systematic attention is
given the child for several hours a day. Non-tuberculous children are
also admitted—they may be called pre-tuberculous, since they are anæmic,
run-down, undernourished children, who come from homes where
tuberculosis exists in active form. For such cases, the open-air school
does excellent preventive work, in raising the child’s resistance to a
point where it can cope with the exposure at home. These open-air
classes are always in charge of a physician and a nurse; their
management does not come within the range of this discussion, any more
than does that of the hospital or the sanatorium.

The public health nurse must always take advantage of these schools, if
they exist, and must see that her children are sent there. She must
avail herself of every agency and of every opportunity which will
improve or secure the welfare of those under her charge.

Schools of this kind are extremely valuable, but are not the solution of
the tuberculosis problem, any more than the sanatorium for the early
case is its solution. Both of these institutions deal with results, not
causes. To fight tuberculosis, we must strike deep at the cause—the
advanced case who scatters the disease. Open-air schools always make a
strong appeal to people—it is easy to obtain money to support them, and
easy for public sentiment to exaggerate their value in the
anti-tuberculosis campaign. Since the public mind generally grasps but
one idea at a time, it is not well to dissipate its facile interest on
side issues. When a community has established on adequate scale the
machinery for combating tuberculosis, it may then establish such
effective allies as the open-air school. But to bring them on first,
before the fundamentals, is to misdirect public sentiment, and to place
the cart before the horse.

=The Danger of Sending Patients to the Country.= Sooner or later, the
nurse will be called upon to decide whether the tuberculous patient
shall be sent to the country. This will be urged by earnest,
well-meaning people—and sometimes by social workers who should know
better. Needless to say, this policy calls for strong condemnation.
Whatever good the patient himself might gain from going to the country,
must be offset by the fact that the disease is spread elsewhere. To
create new centres of infection is not the result at which the
tuberculosis campaign is aimed.

In his own home, under immediate and constant supervision, it is
difficult to obtain from the patient anything better than relative
carefulness. To get even that requires unceasing vigilance and continual
training, both of the patient and of his family. Therefore, to free him
of this restraint by sending him to a distant farm, would mean his
immediate relapse into carelessness, and a danger to those among whom he
is quartered. To send a consumptive into another household is to send
him where he may infect other people. Pity for the patient should not
obscure our interest in his possible victims.

Moreover, the welfare of the patient himself is not as a rule secured by
this method. These journeys to the “country” are usually to
out-of-the-way little farm-houses, with various shortcomings both as to
food and accommodation. They are often anything but satisfactory places
for a sick man; or, if they happen to possess advantages, the patient
may not know enough to use them. In making these statements, we are not
speaking entirely at random, or from general surmises as to
probabilities. A few years ago, we had on our visiting list some
fifty-five patients who went to the country for the summer. They were in
all stages of the disease, and it is well to note, in this connexion,
that it is usually the advanced case who is most anxious to get away. Of
the fifty-five cases, two were really benefited by their sojourn;
thirteen were temporarily improved, but lost it all within a few weeks
after their return; thirty-two came back to town worse than when they
went away, and eight died while in the country.

Of these fifty-five removals, it is safe to assume that fifty-five
centres of infection were established in consequence. The families where
they were quartered were doubtless unaware of the nature of the disease,
or how to protect themselves in any way. Nor is it likely that any of
these fifty-five farm-houses were afterwards properly cleaned or
disinfected. It was of course impossible to follow the results in these
scattered centres of infection—remote counties of Maryland and
Virginia—but we succeeded in doing so in one instance out of the
fifty-five. In this case, the patient had gone to a farm in Virginia; as
a result of his visit, three members of a hitherto healthy family became
infected, all of whom have since died, as well as the original patient,
the “city boarder” who carried infection among them.

Of course, if patients insist upon going to the country, nothing can
prevent them, although the nurse must do her best to dissuade them. One
patient who had a large airy room in town, decided that she would be
better off on a farm. She was questioned as to conditions at the farm,
and it transpired that she was to occupy an attic room, with one window,
and that this room was to be shared with three other people. It then
became an easy matter to dissuade her from going. It is not always thus
easy to deflect them. Should they insist, they should be given plentiful
supplies, and if the nurse can obtain the address of the family where
they are to stay, she should send full information as to the patient’s
condition. It is a regrettable fact, but when a patient is removed from
surroundings where his condition is known, he is apt to discard his
sputum cup and all other precautions by which he is rendered
conspicuous.

We cannot be too emphatic in refusing to send consumptives to the
country. If a sanatorium or day camp is not available, they would better
remain in the city. If the patient has money, he cannot of course be
prevented from going. If he has no money, no appeal should be made for
funds to send him away. To ask for money for such use is a wrong the
public health nurse should have no hand in. Her business is to prevent
scattering infection, not to aid in it.




                              CHAPTER XIII

  Disinfection of Houses—Value of
      Fumigation—Formaldehyde—House-Cleaning—Burning and
      Sterilizing—Boiling—Carpets, Rugs, and Mattings—Painting,
      Papering, and Whitewashing—Temporary Removals—Vacant
      Houses—Compulsory Cleaning.


=Disinfection of Houses.= One of the most important of the nurse’s
duties is her arrangement for the fumigation and cleaning of premises
that have been vacated by a consumptive. This takes place after death,
or upon the patient’s removal to an institution, to another house, or to
another room in the same house.

Since tubercle bacilli are not confined to the sputum, but are
discharged in great numbers during coughing attacks, and to a less
extent during sneezing, speaking, and so forth, a patient not confined
to one room, but who wanders freely about the house, scatters bacilli
everywhere. No matter how careful he may be about the sputum, the nature
of the disease makes it practically impossible to be equally careful
about the expired air. Moreover, these organisms do not die of
themselves, at the end of a few weeks. They are singularly tenacious and
persist for months, virulent and active. A case is recorded in which
they were found in a room six months after the patient’s removal, alive
and virulent enough to cause tuberculosis in guinea-pigs inoculated with
them. For this reason it takes drastic measures to rid a house of these
tenacious germs.

In indicating the rooms to be fumigated, it is necessary to include all
those that have been occupied by the patient within the past six months.
If he dies in his bedroom, it is not enough to do merely that one room.
It is equally necessary to fumigate the kitchen, in which he sat until
two months ago; the parlour, where he spent a few hours a day, and the
second bedroom, to which he was now and then removed. All are infected,
and all need the utmost care to free them from germs. The family must be
taught why these rooms are dangerous, and made to understand the
necessity for full and complete disinfection. It is better to err on the
side of too much, rather than of too little care.

In Baltimore, the actual fumigation is not done by the nurses, but by
the employees of the Fumigation Division of the Health Department. The
nurse indicates the rooms, instructs the family, and makes all the
preliminary arrangements, after which she reports the premises to the
fumigator, who disinfects them next day. It would be well if this
fumigation could be done by the nurses or by a special corps of nurses;
this would probably ensure more intelligent and conscientious work than
that which the average city employee bestows upon this important task.

As a matter of routine, every death from pulmonary tuberculosis is
reported to the Tuberculosis Division; the nurse in whose district this
death has occurred then inspects the house and arranges for the
fumigation. Four times out of five the patient is already known to us
and already under supervision, which makes the duty easier than if he
were unknown. In either case, however, the nurse visits the home and
arranges all the details.

In like manner, all patients who enter either hospital or sanatorium are
reported to the Health Department, the institutions furnishing their
names and addresses so that the fumigation may be attended to. When a
patient changes his address and moves to other quarters, the nurse is
the only one who knows of this change, hence it is her responsibility to
report these houses and see that they are fumigated. To arrange for all
these fumigations, whether after death or after removal, means that a
large amount of time is spent upon this work of trying to rid the
community of dangerous centres of infection.

=Value of Fumigation.= The actual value of fumigation is a debatable
point. Under the best conditions, its efficacy is not a hundred per
cent.—far from it—while under unfavourable conditions, when poorly done,
its efficacy is so low as to be almost nil. The house whose cracks have
been improperly stopped, and the old house, with open chimneys, loose
windows, and apertures which cannot be closed, are not made safe by this
process. Under such conditions, fumigation not only fails to remove the
danger, but it produces a false sense of security. Unless properly done,
it were better not to do it at all. We should prefer instead to depend
upon vigorous house-cleaning, the use of hot water, soap, and the
scrubbing brush, and the destruction of all infective material.
Moreover, even under the best conditions, formaldehyde has no powers of
penetration. Its action is purely superficial, and only useful for plane
surfaces, such as walls, ceilings, and so forth. The most dangerous
articles, such as clothing, carpets, bedding, and the like, are totally
unaffected by it. We ought to stop teaching that fumigation alone will
clear up these infected houses and make them safe for future habitation.
The public has been misled as to the value of this measure, and allowed
to place far more reliance upon it than has been justified by
experience. It is high time for enlightenment. The most that can be said
for fumigation is that undoubtedly it kills _some_ germs—so many that it
is worth while to continue the practice of it, but too few to afford
adequate protection. It must be supplemented by other and more radical
measures.

=Formaldehyde.= Formaldehyde in one of its preparations is the chemical
most generally used, and is more valuable than sulphur, which is now
discarded. In most cities, the Health Department attends to the
fumigation. In small towns or rural districts, where there is no
fumigating corps, formaldehyde is usually given upon application to the
local or State Board of Health. In some localities, especially in
country districts, there may be no appropriation for this disinfectant,
which the householder must then buy himself.[4]

Footnote 4:

  There are many formaldehyde preparations on the market, simple and
  easy to use, but these may be unobtainable. In this case, an effective
  method is the combination of formaldehyde with potassium permanganate.
  For a room containing 1000 cubic feet of air space (a room 10 feet
  long, 10 feet wide, and 10 feet high), the amount needed is: Potassium
  permanganate, oz. 111.; liquid formaldehyde, pint 1. Place the
  formaldehyde in a large galvanized iron bucket (holding 8 to 10
  quarts), and drop the permanganate into it. The room should be left
  closed for six hours; a longer time is unnecessary, a shorter time
  ineffectual. All cracks, of course, should have been previously
  stopped.

Since fumigation is only a matter of six hours’ duration, it will cause
no great hardship or inconvenience to the family which for this short
period must be turned out of the house. Yet many people complain
bitterly over this trial, and raise every possible objection. They are
willing enough to have one room done, but refuse to allow more. The
nurse must explain that a six hours’ inconvenience is better than
risking health and life, and she should also explain that in insisting
upon fumigation the Health Department is neither arbitrary nor
vindictive. Fumigation is a rather costly affair, and this expense is
incurred, not to annoy but to protect the community. In winning over a
reluctant family she has a chance to do excellent educational work. It
is always better to secure their intelligent co-operation, even though
it take long and patient argument, than to end the discussion by
abruptly informing them that fumigation is compulsory, and will be done
whether desired or not.

=House-Cleaning.= Fumigation must always be followed by most searching
and thorough house-cleaning, which important task must be done by the
family itself. All floors should be scrubbed with hot water containing
lye or soda solution and all washable surfaces should be likewise
treated. This includes furniture, doors, door knobs, windows, stairs,
banister rails, and so forth. The necessity for this house-cleaning
cannot be too strongly emphasized.

=Burning and Sterilizing.= The most highly infective material is the
bedding, mattress, pillows, clothing, and so forth, which have been used
by the patient. Since these articles cannot be made safe by formaldehyde
fumigation, and since most of them cannot be washed and boiled, there
are but two methods of disposal. The most drastic and wasteful is to
burn them, yet this must always be advised unless we can offer the
alternative of sterilization under high pressure steam. To burn
infective material involves a loss which few people can afford, and they
are loth to make the sacrifice; most of these articles, while laden with
germs, are nevertheless serviceable and in good condition. To expect
that they will be burned, therefore, is to expect the impossible. If the
family consent to destroy certain articles, they reserve others, equally
unsafe for use. The only alternative is the municipal sterilizer, and
any community which expects to do effective preventive work must
establish this as a factor of first importance.

In Baltimore there is such a sterilizer, and the use of it is very
simple. When the nurse arranges about the fumigation, she selects at the
same time whatever articles are to be sterilized—pillows, mattresses,
blankets, clothing, and so forth. These are then called for by the men
from the Fumigation Division. They are placed in large canvas bags,
inventoried, labelled, and carried to the sterilizer. Here they are
steamed and dried, and returned a day or two later in good condition.
The householder signs a receipt to this effect.[5]

Footnote 5:

  Certain articles are ruined by sterilization, and the nurse must be
  careful not to include these, or there will be a suit for damages.
  Leather and furs, can never be steamed. Straw mattresses are also
  injured. Nor is it possible to sterilize carpets and matting, because
  of their bulk. The sterilizer should be reserved exclusively for
  material which lends itself readily to treatment of this kind. In
  selecting what is suitable, the nurse should exclude old and filthy
  articles, which should be burned.

Unfortunately, steam sterilizing plants are rare, and in most
communities the nurse will have to protect her patients in other ways.
As we have said before, the only alternative is burning, and this often
works great hardship on many families. With the very poor, the Federated
Charities may be called upon to supply new mattresses, etc., in place of
those that have been destroyed, and as a rule this response is prompt.
Yet there are many cases where the family is too poor to suffer this
loss, yet not poor enough to come within range of a charitable
association. These cases constitute a difficult problem—a problem that
is entirely solved only by the municipal sterilizer.

Except through sterilization, there is no way in which these articles
may be made safe. Carbolizing will not do this, neither will sunshine.
Valuable as sunshine is, it is difficult to secure prolonged exposure,
especially in tenement districts. It is possible, of course, to take a
mattress apart and wash and boil the ticking; feathers or hair may be
sent to an upholsterer, who has means of steaming them. Pillows may be
put into a large wash-boiler, and boiled for half an hour, after which
they may be washed—it will take a week or more before they become
thoroughly dry and usable. All these alternatives involve a great outlay
of time and energy, and we cannot but feel sceptical as to the
thoroughness with which this cleaning is likely to be done. A family
which objects to parting with dangerous articles, and prefers risk to
inconvenience or deprivation, is hardly likely to be scrupulous as to
details of this character.

In Baltimore, before the advent of the steam sterilizer, the amount of
material burned was never more than a third of the amount which should
have been burned. Still, under the circumstances, we were thankful to
have achieved this third. Since the establishment of the sterilizer, we
now succeed in getting over two thirds (70 per cent.) of the infective
material sterilized. This is a triumph for the nurse’s teaching, since
there is no law making sterilization compulsory.

=Boiling.= Everything which can be boiled will of course be made safe,
whether these articles be of wool, linen, china, rubber, etc. Even
blankets may be boiled, although the family will object to this on the
ground that it shrinks them. The nurse must explain that not to boil
them may have consequences even more disastrous. The nurse must never
permit her patients to make indiscriminate bonfires, and wantonly
destroy harmless articles, or those which may readily be made so. We
know one family which destroyed a whole set of dishes, not from painful
association, but from a misdirected desire to do the right thing. For
this reason, the nurse must look over all articles carefully, giving
thoughtful counsel as to the proper disposition of each.

=Carpets, Rugs, and Mattings.= As the sterilizer cannot be used for
carpets, rugs, and mattings, there is nothing to do but advise that
these articles be burned. As a rule, this destruction is agreed to with
more readiness than in the case of pillows and mattresses.

=Painting, Papering, and Whitewashing.= Whenever possible, the rooms
used by a consumptive should be repapered, painted, or whitewashed as
the case may be. The more thorough and complete the measures taken to
eliminate tuberculosis, the greater the chances of success. It is a
costly disease, and costly measures, both as to money, energy, and time,
are required to get rid of it. Half-way methods are poor economy.

=Temporary Removals.= The foregoing directions apply mainly to those
cases in which the patient has either died, or has been permanently
removed elsewhere. If his return is not expected (as when an advanced
case enters the hospital), the amount of cleaning, burning, repapering,
etc., would naturally be as great as that required after death.

On the other hand, when his removal is but temporary and the patient
expects to return home after a few months, the amount of disinfection
would be considerably modified. When he enters a sanatorium, his house
must be fumigated and cleaned, so that for a few months at least the
family may be relieved of danger. Under such circumstances, it would not
be necessary to counsel the destruction of the mattress and bedding that
he is to use upon his return. Meanwhile, no other member of the family
should use these things, although in certain instances it is almost
impossible to prevent their doing so. For such cases the municipal
sterilizer is needed—indeed no community can make much headway against
tuberculosis until it provides a means of removing the danger without
causing loss to the individual.

=Vacant Houses.= When a family’s removal leaves a vacant house, there is
naturally no one left to do the cleaning. The Health Department will do
the fumigation, but the more essential house-cleaning remains undone.
These houses often stand idle for weeks or months before finding a new
tenant. Even if it were possible to discover the landlord or owners (a
task which in itself would require a staff of employees), it is doubtful
whether they would clean these houses themselves, or notify their new
tenants of the need for extra vigilance. Legislation compelling
house-cleaning would be difficult to put through. The landlord feels
relieved of all responsibility when once the fumigation is accomplished,
and that this fumigation is not a hundred per cent. effective is no
concern of his. He, together with the general public, has been misled as
to its true value. Nor is thorough cleaning, painting, and papering an
expense that he would willingly incur. The question of the fumigated but
not necessarily safe house is one that causes considerable anxiety. We
feel that the only way to deal with it, is that the nurse keep these
vacant houses on her visiting list, so to speak, and watch for the time
when they are re-let. This entails considerable loss of time, which she
can ill afford to spare from her patients, but the information she can
give the new tenant will have distinct preventive value. She must tell
the newcomer that he has moved into a house in which there has been
tuberculosis, and that only by the most exact and painstaking efforts
can it be made safe.

=Concessions.= In carrying out this important work, the nurse sometimes
becomes so enthusiastic that her common-sense gives way under the
strain. She wishes to carry her point, without fully realizing the
prejudices, ignorances, sometimes even the comfort, of the family she is
dealing with. After a death, she comes upon a household in a most upset,
distressed, and often irresponsible condition, and she must be very
gentle and patient in her relations with them. She must accomplish what
is necessary, without undue disturbance of their prejudices and
feelings. For example: Orthodox Jewish people observe a mourning period
of several days following death, during which time they wish to remain
undisturbed. Fumigation should be postponed until this time is past. A
few days’ delay will not injure the health of a family which has been
exposed to infection for months. By thus respecting their religious
customs, it will be possible to gain better co-operation as to cleaning
and so forth; co-operation which would have been jeopardized by riding
roughshod over their feelings and beliefs.

Sometimes people raise objections because they have nowhere to go for
the six hours required for fumigation, during which time they must leave
the house. If there is no kindly neighbour to take them in, the nurse
may arrange with a Settlement or other social agency, to give them
shelter. We have often asked for hospitality in this way, and have
always met a ready response. Sometimes, if a house is a large one, it is
possible to have it fumigated in sections, a few rooms being done one
day, a few the next.

=Compulsory Cleaning.= In most communities, fumigation is compulsory.
But there is no regulation whatever concerning the after-care of the
premises—the cleaning, sterilization, and destruction of infective
material. The relatively unimportant part is obligatory, while the
essential part is optional. And that this essential part is done, and
well done, depends almost entirely upon the teachings of the public
health nurse.

If, however, the family remains obdurate, refusing to clean and
disinfect, nothing can be done. Since it is now generally acknowledged
that fumigation falls far short of what it was once expected to do, we
need laws making adequate disinfection compulsory; until such laws are
enacted, we can only rely on the ability of the nurse to teach the
necessity for cleaning and disinfecting. How valuable is this teaching
may be gathered from these figures (_Report_, 1913, Tuberculosis
Division of the Baltimore Health Department): “After death: houses
cleaned, 80 per cent.; bedding, etc., either burned or sterilized, 70
per cent.” With adequate laws, the nurses would make even a better
showing.




                              CHAPTER XIV

  The Tuberculosis Dispensary—Equipment—Medicines—Hours—Consideration of
      Patients—Function of the Dispensary—The Physician’s Service—The
      Physician’s Qualifications—The Physician and the Patient—Duties of
      the Nurse—Tuberculin Classes—The Nurse in Home and Dispensary—The
      Nurse as an Asset to the Community.


=The Tuberculosis Dispensary.= No community can make definite progress
against tuberculosis until it establishes a place where suspicious
patients may be sent for examination and diagnosis. Unless this disease
be promptly and definitely recognized, it is impossible to give advice,
or take authoritative action concerning the treatment of the patient and
his family. If in connection with the dispensary there was also a corps
of municipal physicians, who could visit the patients in their homes,
and examine all suspects called to their attention, diagnoses could be
obtained even more promptly. As it is now, considerable interval often
elapses between the time when the patient is advised to go to a
dispensary and the time when he follows this advice. The existence of a
corps of visiting physicians would prevent such delays. The patient
would be allowed a reasonable time in which to present himself, at the
expiration of which period he would be sought out by the officer of the
municipality. This prompt recognition of tuberculosis would save the
community from an enormous amount of exposure. The time may yet come
when Departments of Health will see the wisdom of such measures.

Until that time, the special dispensary represents the only means of
obtaining a diagnosis; it is the only place where patients may freely be
sent, and where an expert and frank opinion may be had. Such a
dispensary may be established in connection with the general dispensary
of a hospital, or by the local Health Department, or it may be supported
by the same group of people or association which supports the special
nurse. In Baltimore, we have had dispensaries of all three kinds, and
the nurses have worked in connection with each one, on exactly the same
terms.

=Equipment.= The great tuberculosis dispensaries run in connection with
the large hospitals and medical schools are usually very completely and
elaborately equipped. They contain large waiting rooms, examining rooms,
special rooms for the giving of tuberculin, for X-ray examinations, for
throat examinations, for laboratory work, and so forth. All these are
needed in teaching centres, where it is necessary to collect certain
scientific data. But for the purpose of making an ordinary physical
examination a simpler equipment will do equally well.

In Baltimore there are several small municipal dispensaries, all under
the control of, and managed by, the Department of Health. They are
situated in different parts of the city, readily accessible to the
patients of different localities. Each dispensary consists of two or
three rooms, which are in the same building which houses the Federated
Charities, and other social agencies. This arrangement has several
advantages, from the point of view of both economy and co-operation. To
have rented similar rooms in another building or in a private house
would have meant a much greater outlay of money, to say nothing of the
opposition encountered in obtaining the use of these rooms for
dispensary purposes.

The furnishings of these little municipal dispensaries are extremely
simple, but they lack nothing of comfort and convenience. The outer or
waiting room contains two or three dozen chairs, or benches to
accommodate an equal number of people. A corner of this room is screened
off for the nurse’s table, where she keeps her charts and records, and
writes the patients’ histories. A couple of filing cabinets, a medicine
closet, and a pair of scales complete the outfit.

[Illustration: Waiting Room in Municipal Dispensary]

The inner, or examining room, is also simple and inexpensively
furnished. It is divided into several compartments by means of gas
piping, each compartment being large enough to hold a revolving stool
and a wicker lounge. Unbleached muslin curtains hang from these gas-pipe
rods, making several little cubicles in which the patients are examined.
It is thus possible for the doctor to examine a patient in one cubicle,
while another patient undresses in the adjoining one—an arrangement
which saves considerable time. Sheets, towels, and blankets complete the
necessary furnishings, which may be cheap or costly according to the
means available. The doctor’s table stands in one corner of this
examining room.

This is not necessarily the last word as to what tuberculosis
dispensaries should be, but we have found the ones described practical.
No tuberculin tests are given here, and all sputum examinations are made
at the Health Department laboratory.

=Medicines.= A supply of simple drugs is kept in the medicine closet.
This includes a few of the standard tonics, such as iron, quinine and
strychnia, nux vomica, gentian and alkali, and so forth; there are also
cough syrups, and heroin, codeine, cascara, etc. The tonics are usually
bought in large quantities, in gallon jugs, and in her leisure moments
the nurse pours them into four- or six-ounce bottles. If these bottles
are filled by the druggist, the expense is somewhat greater. This
medicine is given free of charge, although now and then a patient may
wish to make a small payment of ten cents or so. In themselves, these
drugs cannot be said to constitute treatment, yet it has been found
advisable to dispense them. Patients are so accustomed to being dosed,
that they have no faith in an institution which does not prescribe for
them. It is above all things necessary to make these dispensaries
popular, so that patients will freely seek them, and recommend them to
their friends. Only through wide publicity and extensive patronage can
they become effective factors in the fight against tuberculosis.

[Illustration: Examining Room in Municipal Dispensary, showing the room
divided into cubicles, by means of gas-piping]

=Hours.= The hours at which a dispensary is open will depend somewhat
upon its location, also upon whether or not the physician’s services are
volunteered; in the latter case, it will depend upon the time he is able
to give to it. If it is open in the morning, the workingman cannot
attend without losing a whole day from his work, nor are these hours
convenient for schoolchildren, or for the busy housewife who does most
of her work before noon. If the dispensary is open in the afternoon, all
three classes of patients may be accommodated; the workingman will lose
half, not an entire day, while women and children can attend with no
inconvenience at all. Afternoon hours, say from two till five, not only
permit patients to be examined by daylight instead of artificial light,
but the doctor will be further aided in his diagnosis by the presence or
absence of that characteristic symptom, an afternoon temperature. Night
clinics are necessary in certain localities, when they may be patronized
by men and women, employed during the day, who would otherwise be unable
to come to them.[6]

Footnote 6:

  Night clinics are in existence in New York, Hartford, Boston, Chicago,
  and other cities, and are well attended.

=Consideration for Patients.= The first consideration of the dispensary
should be the comfort and welfare of the patients. We have known many
dispensaries where the first consideration was the experience of the
students or physicians, the patient being regarded merely as good
clinical material. In dispensaries connected with medical schools, which
are essentially used for teaching purposes, this condition is
unfortunately necessary, yet we cannot believe that it is necessary to
the extent to which it is sometimes carried. We have often known of
“interesting” cases being held up for hours, in order that they might be
examined by certain men, or groups of students; moreover, this
detention, prolonged examination, and exposure often took place when the
patient was very weak, when he lost his job through the delay, or when a
husband’s dinner, a nursing baby, or a houseful of children made such
detention intolerable. Patients often refuse to return to a large
dispensary on the ground that “they keep you all day, everyone in the
place examines you, and you get so tired and sick you have to stay in
bed for a week afterward.” This lack of consideration—failure to look
upon the patient as a human being—is what tends to make dispensaries
unpopular. We have known patients to come straight from such an
experience and deliver themselves into the hands of a quack. However
necessary it may be to use certain dispensaries as teaching centres, the
tuberculosis campaign demands clinics of another kind. If the
tuberculosis dispensary is to be a factor in the fight against this
disease, it cannot afford to be a training school as well—it should be
in charge of men already trained.

=Function of the Dispensary.= It follows, then, that the function of the
municipal dispensary is of necessity different from that established for
teaching purposes. The larger dispensary serves a double purpose, the
little dispensary serves but one; it is an examining station for making
diagnoses. Here the patient should come as informally as he would to a
doctor’s office, and here he should be able to consult experienced men.
We feel that the informality of these little clinics constitutes their
strong point. The patients are not afraid of them, and their great
advantage lies in their social rather than their scientific value. They
are merely places where a communicable disease may be discovered at the
earliest possible moment.

=The Physician’s Service.= If a community decides to establish a
dispensary, the first step must be to secure the services of a
physician. At first this may be voluntary, and many doctors will gladly
offer an hour or two of their time, once or twice a week. Should there
be great pressure of work, it may be possible to find several men
willing to offer their time. But however willingly and freely
offered—for most physicians are generous in response to calls of this
sort—it must be remembered that, after all, this service is gratuitous.
The busy physician will often be obliged to side-track his dispensary
obligations, in favour of urgent private calls. This is only to be
expected, yet too many such side-trackings are bad for the dispensary.
The patients lose confidence in it; it is discouraging for a roomful of
sick people to find no one to receive them.

Experience teaches us to look askance at all volunteer work, no matter
how generously or sincerely offered. Under certain conditions it may
have to be accepted, but whenever possible, the physician in charge of
the dispensary should be paid. It is fairer to him, and fairer to the
patients.

The Health Department of Baltimore has three special tuberculosis
dispensaries, each open twice a week, for two hours at a time. The
physician in charge is paid a good salary, and as a result, the
regularity of his attendance is in sharp contrast to that in certain
other dispensaries, where the work is done by well meaning but
overworked men who volunteer their services. Tuberculosis is a disease
that cannot be overcome by volunteer work or economical methods.

=The Physician’s Qualifications.= The success of the dispensary depends
upon the ability and character of the physician in charge. He should be
able to make a diagnosis by means of auscultation and percussion,
without hesitating to commit himself until a sputum examination reveals
the bacilli.[7] For if finding the bacilli is to be the sole test by
which tuberculosis may be recognized, it would be possible for the nurse
to obtain specimens of sputum from her patients and submit them to the
laboratory direct—thus doing away with the doctor and proving the
dispensary superfluous.

Footnote 7:

  See Chapter IX., page 109.

Nor is this all. The physician must have a strong social sense, and be
able to inspire his patients with confidence. In no other work does the
personal character play so large a part, and this applies to the doctor
as well as to the nurse. One of our patients, enthusiastic in her praise
of one of the dispensary men, summed this up with homely accuracy: “He
couldn’t have been nicer to me if I’d paid him fifty cents in his
office.”

=The Physician and the Patient.= After the patient has been examined,
the doctor carefully explains to him the nature of his disease, and the
precautions necessary. Since these directions must often be brief and
hurried, he will further add that he is sending a nurse to the patient’s
home, to act under his orders, and see that certain directions are
carried out. In this manner, the doctor prepares the way for the nurse’s
visit, and gives her an authority which greatly facilitates her work.
With this assistance, it is far easier to gain the patient’s confidence
than if it has been forgotten or withheld. The orders concerning the
patient are then given to the nurse, and if these include admission to
an institution, it is her duty to arrange all the necessary details, and
so relieve the physician of much time-consuming work.

=Duties of the Nurse.= If a community has a special dispensary as well
as a special nurse, the nurse’s duties are twofold, and should include
not only the home supervision of the patients, but attendance at the
dispensary as well. She is the connecting link between the two. In this
way, her intimate knowledge of home conditions is placed at the
physician’s disposal, who is then able to give sounder advice and deal
more intelligently with his patients if he has some knowledge of their
environment.

The nurse’s presence at the dispensary is often a considerable
assistance in persuading patients to come. Patients are often frightened
and shy, and dread the unknown, consequently it is better if the nurse
can give them the comforting assurance that she will be on hand to
welcome them. From her knowledge of their home conditions, she also
knows which cases can afford to wait, and which should be taken out of
turn and given immediate attention. It is thus possible to deal with
them in a personal and intelligent manner. Since at present the control
of tuberculosis lies largely with the patients themselves, and depends
almost wholly upon their good-will and co-operation, it is necessary to
establish this co-operation as firmly as possible.

The duties of the nurse consist in taking the history of the patient;
taking his weight and temperature, and preparing him for physical
examination. If the patient is a woman, she must be present while this
examination is made. She also gives such drugs as may have been
prescribed. On his arrival, each patient receives a paper napkin to hold
over his mouth during coughing attacks, and to use for expectoration. A
special receptacle should be provided for these soiled napkins, and they
should afterwards be burned. The nurse should come to the dispensary
half an hour before it opens, in order to put it in readiness,—to take
out the charts and histories, attend to the drugs, place towels and
sheets in the examining rooms, and so forth. Whenever the clinic becomes
large enough to require it, it will become necessary to place the
clerical work in charge of a clerk.

In these informal clinics considerable trouble is often caused by
patients who arrive just before closing time, and expect to be examined.
It is unwise to encourage this sort of tardiness, and a time limit
should be set and strictly adhered to. All patients arriving after a
specified hour should be directed to come another day, except such
patients as are recognized by the nurse as worthy of exception from this
rule. The most frequent offenders are not the patients who come from a
distance, but those who live just around the corner. Unless punctuality
be insisted upon, there will be endless overtime work for both doctor
and nurse.

=Tuberculin Classes.= At some of the large dispensaries, selected cases
are formed into what are called Tuberculin Classes, and given special
treatment. These patients are very carefully chosen, both from a
financial as well as a physical standpoint, and intensive work, of a
curative rather than a preventive nature, is put upon them. The
treatment is carried out in their homes, where as nearly as possible
sanatorium conditions are attained. Unruliness, or failure to comply
with the regulations, means being dropped from the class. These patients
live on a carefully planned routine, carried out under close supervision
of both doctor and nurse. They report to the dispensary at certain
intervals, once a week or so, and there tuberculin is administered,
weights taken, and examinations made. Each patient keeps a little book
containing a daily record of his doings, including the number of hours
spent in the open-air, food—kind and amount, exercise, temperature,
cough, and other symptoms. This book is presented at each visit to the
dispensary, and the nurse also inspects it when she visits his home.
These class patients often do extremely well, and excellent results are
often obtained. Like all work of a curative nature, however,—in which
the subjects are carefully selected and as carefully rejected,—it deals
with so few people that it makes no real impression on the situation.
The tuberculosis problem is, what can be done for a thousand patients,
not for twenty. It is always possible to select a handful of cases and
maintain them indefinitely at a high level of health, by a considerable
outlay of money, energy, and time—an expenditure from which the
community as a whole derives little benefit.

To establish a tuberculin class is purely a physician’s affair, and all
directions in regard to it come from the doctor himself.

=The Nurse in Home and Dispensary.= When the staff is large and there
are several nurses, it may seem advisable, upon first consideration, to
assign one nurse solely to dispensary duty, and leave the others to work
in the homes. It is a better plan, however, to let all the nurses
combine service of both kinds, as the single nurse in the small
community must do. The intimate connection between home and dispensary
should never be broken—it is much too valuable. Moreover, as far as the
nurse herself is concerned, the monotony of dispensary work becomes
extremely wearing, and it is well to vary it with duty in the home. It
is a regrettable fact that a nurse confined to mere mechanical routine,
is apt to lose that fine understanding and sympathy which she needs in
her work, and which is always lost whenever human beings become merely
“cases.”

In Baltimore this service is arranged in the following manner: There are
three Municipal Dispensaries, and one other clinic, managed on the same
lines, although not connected with the Health Department. These are
situated at the boundary lines of two or more adjoining districts, and
are thus accessible to the patients as well as the nurses of the
adjacent areas. All four clinics are served by certain nurses of the
Health Department, who are on duty on alternate days or alternate weeks,
as the case may be. Thus, the nurse from any one district is on
dispensary duty for two afternoons a week, every other week. This
deprives the home of her services to only a very slight extent—a
deprivation which is counter-balanced by her increased opportunities for
effective work. We should never advocate any greater curtailment of home
work, however, since the home, or centre of infection, is always the
chief point of attack.

From another standpoint it is well that the nurses combine both kinds of
service. Through sickness or other reasons, it may become necessary to
substitute one nurse for another, and it is an advantage to have nurses
trained and able to relieve each other when necessary.

=The Nurse as an Asset to the Community.= We have hitherto considered
the nurse as a public health nurse, or servant of the entire community.
Whether supported by public or private funds, whether connected with the
Health Department or a private association, we have considered her as
ready to answer all calls made upon her. We have regarded her as at the
service of all physicians, dispensaries, institutions, social workers,
and laymen, ready to respond to all calls without hesitation or
discrimination. Her unattachment to any claims but those of the
community as a whole gives her this broad field.

If, however, her work be limited to the patients of any one institution,
association, or sect, she is no longer an asset to the community. For
example, if she is employed by a certain dispensary to visit its
patients only, her work is circumscribed. Her usefulness will be
restricted—her service will be valuable to the physicians of such an
institution, and she will collect data for their records, but her duties
will be localized for the good of the dispensary, rather than for
society as a whole. The same would be true if she be employed by a St.
Vincent de Paul Society to care for Catholic consumptives, or by a
Jewish organization to follow up Jewish patients—any arrangement through
which she visits one patient in a block, but refuses the case next door,
means a narrow field of service. She then becomes the nurse of an
institution, or a sect, rather than a public health nurse. The object of
her work is not the welfare of the community, but the welfare of certain
individual patients. Incidentally, her work may benefit the community,
but it falls far short of its possibilities. It must be supplemented by
new agencies, with the consequent duplication and waste of effort that
this always involves.

Our experience in Baltimore will illustrate this point. In 1904, when
tuberculosis nursing was first organized, two nurses were placed in the
field. One was attached to the dispensary, of the Johns Hopkins
Hospital, the other placed in charge of the Visiting Nurse Association.
Between them the city was divided into halves, one nurse working in the
eastern, the other in the western portion of the town. The dispensary
nurse visited only patients who had been to the dispensary. The nurse of
the Visiting Nurse Association visited not only dispensary cases, but
_all patients reported from whatever source_. Thus, in East Baltimore,
if two consumptives lived in the same tenement, one a dispensary case
and the other under no supervision at all, only one of these two was
visited. In West Baltimore, both patients were cared for on equal terms.
At the end of a year, another nurse was added to the Visiting Nurse
Association staff, but not to the dispensary. The city was then
redivided, this time into thirds, and again the patients were cared for
under the same conditions. The dispensary nurse served the Johns Hopkins
Dispensary; the Visiting Nurses served the dispensary and the community
as well. Finally, in 1910, the tuberculosis work of the Visiting Nurse
Association was taken over by the city, thus creating a new municipal
department, the Tuberculosis Division of the City Health Department. At
that time the dispensary nurse gave up visiting in the homes of the
patients, and confined herself entirely to routine dispensary duties.
This left all visiting work to the Health Department nurses, who were as
punctilious in making reports to the dispensary as was the dispensary
nurse herself. By this arrangement, the Phipps, in common with every
other dispensary in the city, has had a large staff of nurses placed at
its disposal. Both the dispensaries and the community gain through this
co-operation.




                               CHAPTER XV

  The Nurse in Relation to the Institution—Reports Made to the
      Institution—Procuring Patients for it—The Value of the
      Sanatorium—Sanatorium Outfit—Return from the Sanatorium—Work for
      the Arrested Case—Light Work—Outdoor Work.


=The Nurse in Relation to the Institution.= As the nurse is the
go-between from patient to physician, and from patient to dispensary, so
also does her service link together patient and institution. This, of
course, is only possible if she is a public health nurse—not if she is
the agent for one institution alone, or if she is employed to serve one
set of people instead of the community as a whole. Just as she should be
at the service of every physician, dispensary, and layman who chooses to
call upon her, so in like manner should she serve both hospital and
sanatorium. She will act as beater-up in the matter of sending patients
into these institutions; will arrange all details connected with their
admission, and finally, upon their discharge, will take them again under
her supervision and care. By this co-operation, the patient himself
profits, likewise the community, while the institutions are enabled to
keep in touch with their discharged cases, learn of their condition,
and, through the nurse’s reports, add to their histories and records
from time to time in a way which will greatly enhance their value.

There is complete co-operation between the various institutions of
Baltimore and the nurses of the Health Department. Of the five
institutions near the city, four admit both early and late cases, while
one is for advanced cases only. Whenever a patient is admitted to or
discharged from one of these institutions, either hospital or
sanatorium, the Health Department is at once notified of the fact.
Following admission, the nurse visits the home and arranges for the
fumigation. Two thirds of the patients admitted are already known and
under supervision, but whether known or unknown, the visit is made and
fumigation arranged for in the usual manner. In homes where the patient
is unknown, the nurse often finds suspicious cases, which she sends for
examination and diagnosis. By means of this sharp look-out the visiting
list is considerably augmented.

When the discharge of a case is reported, the patient may or may not
have been under previous supervision. If already on the visiting list,
the nurse merely resumes her visits. If not on the list, he is taken on
at once. Needless to say, the physician in charge of the institution
should prepare the way for the nurse’s coming, as should the physician
of the dispensary. If he forgets to do so, the nurse may have some
difficulty, especially with patients discharged in good condition, who
see no need for her services. When discharged in bad condition, the
reason is obvious enough, but in either case co-operation with the
institution is necessary.

=Reports Made to the Institution.= The reports made to the institution
vary in accordance with the wishes of the physician in charge. Sometimes
they are informal, made on certain specified cases; sometimes they are
extensive and deal with large numbers of individuals. The value of these
reports is indicated by the following examples: Two months ago a young
girl was admitted as a paying patient, but she is now at the end of her
resources, which consisted of a small fund subscribed through
contributions of her fellow-workers. If she is to remain longer at the
sanatorium, she must be transferred to the free list. Or we find that a
young man, admitted erroneously to the free list, is in a position to
pay; in justice to the institution and those who perforce must accept
its hospitality, this patient should be transferred to the paying side.
Or we receive a letter from the superintendent, saying that a certain
patient has failed to arrive on the day specified, and asking us to look
into the matter. Upon investigation we may find that a death in the
family, an accident, or the lack of railway fare has been the cause of
his non-arrival. Provision for him to go can then be made—his place is
not forfeited, but held for him until a more favourable time. These
personal relations between the nurse and the institution bring a great
sense of cordial understanding and mutual good-will.

The more extensive reports are managed as follows: Once a year, or
oftener if necessary, certain institutions send to the Health Department
a full list of their discharged patients, whom they wish looked up. The
names and addresses are written on separate slips of paper, which
contain a printed list of questions to be answered. These are
distributed among the nurses of the different districts, each nurse
being responsible for the patients in her own territory. Within a week
or ten days all the slips are filled in, and a full return made on all
cases submitted for investigation. This involves little extra work on
the part of the nurses, since in nearly every instance the patients are
already under supervision—and if through any oversight they are not, it
affords a means of finding them. The superintendents of the various
institutions find this a satisfactory way of keeping in touch with their
ex-patients, and we think that this work is well within the field of the
visiting nurse. Each gains by this co-operation—the Health Department,
which wishes to supervise all consumptive patients, and the institution,
which wishes accurate data for its reports. In effective social work the
keynote of success is reciprocity.

=Procuring Patients for the Institution.= In still another way does the
nurse serve the institution and that is by procuring patients for it.
Large, well organized, and well equipped institutions have little
difficulty in filling their beds, but this is often the reverse with
those less known and less attractive. It takes much persuasion to induce
a sick man to leave his home, and it often takes still more to persuade
his family to let him go. To point out the necessity for institutional
care, and induce the patient to take advantage of this, is the chief
duty of the public health nurse. Only when she does this duty thoroughly
and well does the demand for hospital beds exceed the supply. For
example: in Baltimore, before the nurses went on duty, the large
hospital for advanced cases was never more than half full. The community
was not well enough educated to take advantage of it. Since the nurses
have been on duty, however, not only has this hospital been filled to
capacity, but the capacity itself has been enlarged to nearly
double—while a long waiting list is constantly maintained. A small
sanatorium was recently opened in Maryland, with a capacity of twenty
beds; at the end of five months, it had only five patients. The nurses’
aid was solicited, and within a week it was full. This situation has
also occurred in other cities, which found themselves equipped with
excellent hospital accommodations, which the patients refused to make
use of. Co-operation between the institution and the municipal or
visiting nurses would doubtless have promptly remedied this state of
affairs. Incidentally we may observe, the better managed and more
comfortable the institution, the less difficulty there is in keeping it
full. It must offer substantial advantages over the home—attractions
which even the most ignorant and prejudiced must be trained to
appreciate.

=The Value of the Sanatorium.= The sanatorium for the treatment of
hopeful cases is by no means as valuable as was at first expected. The
cure of tuberculosis is at best very problematical, and the sanatorium
is chiefly useful to those who can control their environment upon
discharge. Unless this can be done, treatment will be of little avail,
although it will delay the inevitable end. The patient who comes from
the alley and returns to the alley is foredoomed. And as most patients
come from the alley, figuratively speaking, and are afterwards obliged
to return to it, the results obtained by these sanatoriums are by no
means commensurate with the expense involved in maintaining them.
Whatever benefit is derived from them is for the individual, rather than
for the community.

In the tuberculosis campaign, the sanatorium occupies a place of
secondary importance. We could fight quite as successfully without
it—possibly better, since the money devoted to the upkeep of these very
costly institutions could then be diverted to more radical purposes.
However, the sanatorium exists, and every patient should be given his
individual opportunity. It is usually more difficult to get a patient
into a sanatorium than into a hospital. The former is for early or
moderately advanced cases, who have a reasonable chance of improvement,
therefore it would seem a simple matter to induce them to go. Yet to
persuade a patient that he needs such treatment, especially when he
feels well and has few symptoms, is often a difficult task. The peculiar
psychology of the consumptive, his optimism and refusal to believe that
he has tuberculosis, is as well marked in the early as in the later
stages of the disease. On the other hand, the difficulty is often of an
economic nature. When the patient stops work, his income ceases, and
this often determines his refusal. This is why many patients work until
they drop in harness. Through the Charity Organization, or other similar
agencies, it is possible to solicit aid for a certain number of these
cases, and this must always be done. Such relief, however, is very
uncertain, and latent periods of considerable duration often intervene
between the time it is asked for and such time as it may be given. Even
when given, it very seldom approximates the wages that the patient
himself has been able to earn. Thus, a patient earns twenty dollars a
week; with luck, we may obtain for his family an income of eight or ten.
This is no reflection upon the Charity Organization Society, which has
probably pulled every conceivable wire in order to raise even that
amount—but it explains why the patient refuses the sanatorium and hangs
on to his job until he can work no longer.

In many cases on the other hand, there is no question of poverty to
contend with—neither the wage-earner’s reluctance to stop work, nor the
mother’s unwillingness to leave a houseful of little children. Instead,
we must contend with ignorance, prejudice, and mental inertia—a moral
alley quite as dark as that of the slum. One of the most discouraging
features of this work is having to stand by and see the patient throw
away his chances. Tuberculosis waits for no one, and it requires not
only physical, but mental and moral strength to resist it. Before we can
remake and reconstruct a supine individual, the disease wins out in the
race.

There is one consolation, however; hopeful cases are usually far less
dangerous than advanced ones. The refusal of sanatorium treatment is a
loss to the individual only. Furthermore, we have this grim solace—when
they finally consent to go, after weeks and months of delay, they do so,
too late to help themselves, it is true, but at a time when they are
most dangerous to other people.

=Sanatorium Outfit.= When a patient enters a sanatorium, the nurse must
see that he is supplied with clothing heavy and warm enough for outdoor
living. If he has money, he should be instructed what to buy. If he has
none, these things must then be procured through some charitable
association. No patient should be permitted to enter a sanatorium unless
properly equipped, and frequently his decision against going is due to
lack of such equipment.

In winter, he naturally requires much more than in summer. Roughly
speaking, his wardrobe should contain at least two changes of flannel
underclothing, a sweater, overcoat, woollen cap, woollen gloves,
overshoes, flannel night clothing, a dressing-gown, toilet articles, and
a hot-water bottle. Some institutions have a printed list of the
articles required, which is sent to the patient when his application is
accepted. A steamer rug is usually necessary, a cheap substitute for
which may be found in the large horse-blanket, sold in saddlery shops.

=Return from the Sanatorium.= When a patient returns from a sojourn in
an institution, he may or may not be better, but he has certainly
received a liberal education in what to do, and how to take care of
himself. Often, however, he is totally unable to apply this knowledge,
or to adapt his home environment to his needs. So carefully is the
institutional life planned, and so smoothly does he fit into it, that he
has no conception of the time and thought that have gone into this
planning. When he comes home, he knows theoretically what to do, but in
comparison with the institution his home surroundings seem so poor and
so inadequate, that he becomes hopelessly bewildered and confused. It is
at this point that the nurse has her great opportunity. She teaches him
to apply what he has learned, and how he may approximate sanatorium
conditions and routine. She goes to work much as she does upon her first
visit to the home, but this time she is working in a soil already
ploughed. The patient himself may be almost as helpless, but he will
follow suggestions, and co-operate with an intelligent enthusiasm gained
through his sanatorium education.

=Work for the Arrested Case.= When a patient returns from the sanatorium
able to work, the question of employment is a serious one. Our
experience has been that of Dr. Lyman:[8] as a rule, unless it is an
exceedingly injurious employment, it is better to let him return to his
former occupation than to seek a new one. He understands his old work,
and for this reason it will be easier for him than one to which he is
unaccustomed. The difficulty of finding suitable employment for arrested
cases, and the number of relapses that occur in consequence, serve once
more to emphasize the value of prevention rather than cure.

Footnote 8:

  Dr. David R. Lyman, Wallingford, Connecticut.

There is one point which must always be brought out. It is not so much
what the patient does with his working hours, as what he does with his
leisure hours, which determines his ability to hold his own. An arrested
case may work eight or ten hours a day, in office, factory, or shop, and
still remain well, provided he spends the remaining hours of the
twenty-four in a proper manner. The ex-sanatorium case, rejoicing in his
apparently restored health and in his regained liberty, feels that he
can resume life on exactly the same terms as before. This he can never
do. He has tuberculosis, and he always will have tuberculosis, although
it may be latent at the moment. The fact that it is quiescent does not
mean that it will not light up again at the slightest indiscretion. He
must bear this fact constantly in mind and order his life accordingly.
If he expects to work and remain well, he cannot burn the candle at both
ends, even in the mildest manner. He must forego late hours, moving
picture shows, poolrooms, saloons, dance halls—everything, no matter how
harmless in itself, which places an extra strain upon his vitality. At
the end of the day’s work he should rest quietly, preferably in the
open-air. Eight or ten hours’ sleep at night is a necessity. The most
critical time in a patient’s career is that which follows his return
from a sanatorium, and it is at this particular moment that the nurse’s
supervision and encouragement are so greatly needed.

=Light Work.= Many patients return from the sanatorium, unable to work
at their former occupation, yet sufficiently strong to do “light work,”
if such a thing can be found. In my experience, suitable “light work”
for these cases has yet to be discovered. We all know of patients who
have been given easy positions as night watchmen, elevator-men,
corridor-men, office work, gardening, and so forth, and who have done
well at such employment. The number of such positions, however, is so
small and so out of proportion to the number of those who seek such
occupation that it forms no adequate answer to the question; what light
work can we find for the arrested case? Our present industrial system,
which produces the class of people from which the consumptive is so
largely recruited, also fails to provide proper employment for him after
his so-called recovery. The pressure of this system makes it
sufficiently difficult for an able-bodied man or woman to find work that
pays, or even any work at all, but to find such work for the handicapped
is almost impossible. Light work means light pay, and light pay means an
insufficiency of food, clothing, and shelter, all three of which are
needed for the maintenance of health. In these days when the physically
fit cannot always earn a living wage, what chance has the poor
consumptive?

=Outdoor Work.= Another favourite fallacy is the advantage of outdoor
work for the returned patient. The sole value of outdoor work lies in
the opportunity to breathe fresh air, but this benefit may be more than
offset by the strain of long hours, exposure to heat, cold, and rain,
the lifting of heavy weights, and so forth. All these objections apply
to farm-work, driving delivery or freight waggons, the occupation of
motorman, conductor, and so forth. Now and then, patients undertake work
of this character and do well at it, but we cannot but believe that this
is in spite, of, rather than because of, their occupation.

In summing up the nurse’s value to these discharged cases, we find her
able to give immense assistance at a most crucial period in the
patient’s life. By this help and advice, she can often prevent his
relapse, or at least delay it for a long time. Her supervision provides
incentive and encouragement, and her careful watchfulness, both of the
patient and his household, is of value in detecting further danger
signals. If, as too often happens, he is eventually swept under by
currents too strong for him, she is still on the spot, tried counsellor
and friend, to make safer and easier the downward path.




                              CHAPTER XVI

  Hospitals for Advanced Cases—The Careful Consumptive—Chief Duty of the
      Nurse—Responsibility of the Institution—Home Care of the Advanced
      Case—Exceptions to Institutional Care—Compulsory Segregation.


=Hospitals for the Advanced Case.= The crux of the tuberculosis problem
lies in the segregation of the advanced case. Until the distributor is
removed from his family, and separated from the intimate circle
surrounding him, we can make but little progress in the fight against
this disease. No community can protect itself from the ravages of
tuberculosis until it provides a place to which these advanced cases may
be sent. Not only do we need large special hospitals for these patients,
but we need special wards for consumptives in connection with every
general hospital which receives either city or State appropriations.
These special wards would be of even greater benefit to the community
than large special hospitals situated in the environs of a city, since
it would be easier to persuade a patient to enter an institution just
“round the corner” than to go to one far distant from his home. A dying
man dreads being separated from his family, and his family is equally
reluctant to part from him; furthermore, if a hospital is remote from
the city, his family can afford neither time nor carfare for frequent
visits. These facts play an important part in influencing a patient’s
decision, and due consideration should be accorded them.

It would probably cost less to build and maintain special wards in
connection with hospitals already existing than to erect and support an
entirely new institution. The greatest objection to special wards is
that the coughing of the consumptives is disturbing to the other
patients, but if the ward is sufficiently isolated (a separate building,
if the hospital is planned on the cottage system) this objection would
not apply. Furthermore, these wards would offer good teaching centres,
where both doctors and nurses could learn more about pulmonary
tuberculosis than the average hospital teaches to-day.

In attempting to secure ground for the erection of a tuberculosis
hospital, there is usually great opposition from laymen. They are not
only afraid of tuberculosis, but they fear the depreciation of property
which may arise in the vicinity of such an institution. Considerable
education is required to calm them to a realization that the consumptive
sheltered and cared for is less dangerous than the consumptive at large
and unrecognized. When it comes to a special ward in connection with a
city hospital, we may again encounter great opposition, really from the
same reason, though the objections expressed are expense of such a ward,
the lack of nursing facilities, that the room is needed for acute
diseases, and so on. All of which is a grave commentary, from the people
who best understand it, upon the infectious nature of this disease. Yet
the medical profession tells us with apparent sincerity that “the
careful consumptive is not a menace.” If this be true, where can he be
more careful and less of a menace than in a place specially provided for
him?

The truth of the matter is, there is not, nor can there be, a _careful
enough_ consumptive. The very nature of the disease precludes such a
possibility, however much we educate him, or however earnestly he
himself may try to co-operate to that end. And for the vast majority of
patients, from whom we can obtain but little or only spasmodic
co-operation, there is even less to be said. There is one simple method
of determining whether or not a patient is careful—it consists in asking
the question: Under these circumstances, would I, myself, feel safe?
Would I be satisfied as to the safety of my nearest and dearest friend?

At the beginning of the year 1912, the nurses of the Tuberculosis
Division of Baltimore had on their visiting lists about 2800 patients.
Of these 2020 were positively diagnosed, and had been under supervision
for over three months. Undiagnosed cases, and positive ones who had been
under supervision less than three months were excluded. These 2020 cases
were then classified according to their willingness or ability to follow
instructions, the groups being: Fairly Careful, Careless, and Grossly
Careless. We purposely omitted a “Careful” class, since adequate
carefulness would imply a condition in which there was absolutely no
danger, a condition hardly possible with this disease. In Fairly Careful
we included all those patients who really tried to follow advice, doing
so to the best of their ability. Careless included those who tried
intermittently, or who were badly hampered by circumstances. Grossly
Careless speaks for itself.

The results of this analysis are here given:

 Patients visited over three months                                  194

                                    Fairly Careful     98, or 50.5%
                                    Careless          75, or 38.65%
                                    Grossly Careless  21, or 10.82%

 Patients visited over six months                                    346

                                    Fairly Careful   171, or 49.43%
                                    Careless         151, or 43.64%
                                    Grossly Careless  24, or  6.84%

 Patients visited over one year                                      623

                                    Fairly Careful   300, or 48.15%
                                    Careless         267, or 42.85%
                                    Grossly Careless  56, or  8.98%

 Patients visited over two years                                     857

                                    Fairly Careful   443, or 51.69%
                                    Careless         339, or 39.55%
                                    Grossly Careless  75, or  8.75%

 Total Number of Patients                                           2020

                                    Fairly Careful         1012, or
                                                             50.09%
                                    Careless         832, or 41.13%
                                    Grossly Careless    176, or  8%

It will be noticed that these percentages vary but slightly, or to a
negligible extent. Roughly speaking, about half the patients try to be
careful, and half do not try, or do not succeed if they attempt it.
Furthermore, it will be noticed that the time element has little to do
with making a patient careful. The natural supposition would be that a
patient visited for one or two years would show a marked increase of
carefulness over those who had been under supervision but a few months.
Yet there is virtually no difference between them, 50.5% of the
three-months class being careful, as against 51.69% of the two-years
class. These figures, we believe, show conclusively that long-continued
teaching does not necessarily lead to satisfactory results. They also
show that the patient left in his own home, even under constant
supervision, is unable to achieve a degree of technique which means
positive protection to those around him. There is but one conclusion to
be drawn from these facts—not that the nurse is useless, but that the
patient at large is dangerous. It proves the necessity for hospital
care.

The hospital for a patient to die in appeals less to public sympathy
than as a place in which he may get well. But it is better economy. Care
of the open case, during his last and most infectious stages, is care
which strikes at the very root of the evil. Until this fact is realized
and full provision made for these cases, it will be a waste of time and
money to spend them on superficial or half-way measures. If our goal is
the elimination of tuberculosis, we should concentrate our efforts upon
radical and fundamental methods.

At present, however, we can conceive of no community sufficiently
advanced or far-seeing to make adequate provision for these last-stage
cases. Therefore, the patients who make up the difference between the
number of those needing hospital care, and those receiving hospital
care, must be cared for in their homes by the nurse. Never for a moment
should home supervision be considered a satisfactory substitute for
hospital accommodation. The nurse’s efforts, no matter how thorough and
conscientious, can never entirely remove the danger. Her care often
lessens it to a marked degree, but never absolutely eliminates it. It is
at best a makeshift, a stopgap—better than nothing, often much better
than nothing, but never for a moment the proper alternative to removing
the patient from his home. No one knows better than the nurse herself
the inadequacy, the futility, of even the closest supervision.

=Chief Duty of the Nurse.= For this reason, the chief, the absolutely
most important duty of the nurse is to induce the infectious patient to
go from his home into an institution. To accomplish this end, she must
bring every effort to bear upon the patient and his family, and appeal
to them from every conceivable angle. This is her one great duty—the
paramount reason for her existence.

To accomplish this, is as difficult as it is important. A patient does
not willingly give up his home, however poor and humble it may be, while
his family often cling to him with an obstinacy open to no argument. As
a rule, the difficulty of removing him is in inverse ratio to his
intelligence, and to the danger to those surrounding him.

=Responsibility of the Institution.= In overcoming this prejudice, a
great deal depends upon the character of the institution itself. It is
not enough to establish hospitals:—they must be attractive and
comfortable to such a degree that they become highly desirable to
prospective patients. They must be well run, well managed, the food must
be good, and the patients well treated. To obtain segregation, we must
have hospitals which offer great advantages over the home.

=Home Care of the Advanced Case.= If there are no hospital facilities,
it then becomes the nurse’s duty to give nursing care to the bed-ridden
patient. This is also done when the hospital accommodations are limited,
and the patient must wait to be admitted. During this waiting period,
which may extend over weeks, he should be visited every day (or at least
as often as the work will permit), and given such care as he requires,
including bed-baths, care of the back, and so forth. The nurse must also
teach some older, responsible member of the family how to care for him
in the intervals between her visits. Sometimes, when a vacancy finally
occurs, the patient may be contented with home treatment and refuse to
enter the institution, or his family may refuse to let him go. The nurse
must do her utmost to persuade them. She must explain that in the
hospital he will receive constant, not intermittent care, and that her
work will only permit her to render nursing service to those who cannot
otherwise be provided for. Should he still refuse, she must continue her
visits of supervision, but must stop all nursing care. No premium
whatever should be placed on his remaining at home. This may seem like a
harsh and unfeeling policy, but it is the only course to pursue when we
take into consideration the fact that the institution is the proper
place for an infectious disease. If a patient has become accustomed to a
daily bath and other attentions, he will miss them; when he misses them
badly enough, he will consent to go where they may be had. This plan
does not mean that the nurse neglects the patient,—if he suffers, it is
through choice. An excellent alternative has been offered, and his
refusal to accept it should not entitle him to continue infecting his
family, assisted by the nurse to do it in comfort.

=Exceptions to Institutional Care.= A few exceptions may be made in
advising institutional care. For example, if a family is in good
circumstances, with excellent home conditions, and the patient is
surrounded with every care and attention, it would hardly be necessary
to counsel his removal. On the contrary, with our present lack of
hospital facilities, to urge such a patient to leave his home might mean
taking a hospital bed from another who needed it infinitely more. Again,
if a tuberculous child is being cared for by his mother, or some one
equally unlikely to contract the disease, it might not be worth while to
remove him. An exception might also be made in the case of a childless
couple, advanced in years. The nurse must use her judgment and
common-sense in such cases, where the chances of infection are slight,
or non-existent. On the other hand, if there is ample hospital
accommodation, and cases like the above ask for admission, they should
always be taken in.

The cases in which separation is imperative are those in which there is
great exposure, inability to control the home surroundings, extreme
poverty and neglect, or undue and prolonged strain upon other members of
the household.

=Compulsory Segregation.= Not until our hospital facilities are so large
that we can accept every case which applies for admission, can we
consider forcing people to enter these institutions against their will.
It is illogical to consider compulsory segregation, while we cannot
accommodate all those who voluntarily ask for it. The patient who
refuses to go to an institution is probably no more dangerous than he
who clamours in vain for a bed. The docile, well intentioned, kindly
consumptive is doubtless as much a menace as the selfish, vicious,
avowedly careless one; in fact, the former may be more harmful, since
his kindly nature surrounds him with friends, whereas the latter forces
people to avoid him.

As for the tramp, the homeless man who wanders from pillar to post,
sleeping in saloons and lodging-houses, he is far less of a menace than
people suppose. He comes into but casual relationship with his fellows,
and no one is in prolonged and intimate contact with him, as is the case
of the man in the home, the centre of the family circle. Until we can
accommodate the latter, we must let the former do as seems best to him.
If ten anxious people are clamouring for every hospital bed at our
disposal, why force it upon the reluctant one who refuses? When we can
handle the problem of voluntary segregation, it will be time to consider
compulsory measures.




                              CHAPTER XVII

  The Problem of Giving Relief—The Giver of Relief—Co-operation between
      Agent and Nurse—General Rules for Nurses and Agents—Conditions of
      Asking for Relief—Wrong Conditions of Relief-Giving—Incidental
      Assistance—Withdrawal of Relief—Supplying Milk and Eggs.


=The Problem of Relief-Giving.= Giving financial assistance or relief to
patients on or below the poverty line is a question which sooner or
later confronts the nurse who undertakes social work. Long hours,
overwork, and low wages produce a class of people who offer little or no
resistance to disease, and when tuberculosis once gets a foothold
amongst them, it is passed on from one devitalized individual to
another. This is why it is necessary to remove a disease-distributor
from among a group of highly susceptible individuals. For example: let
us take a family consisting of father, mother, and four children. The
father contracts tuberculosis and stops work—his income also stops. Even
at best, it was a pitifully inadequate income, and in consequence the
entire family is undernourished, anæmic, and generally run down. With
the income gone, their resistance is still further lowered, and their
chances of infection are correspondingly increased. The result is a
patient surrounded by a group of people able to offer but slight
opposition to this insidious disease. The environment, bad as it was
originally, grows worse. The family moves into smaller, fewer, cheaper
rooms, and food, heat, clothing are all reduced to a minimum. This
increasing poverty means diminished vitality, and heightened
susceptibility to the threatening danger. In attempting to relieve this
situation we are dealing not with a simple, but with a twofold
problem—poverty, plus an infectious disease.

Because of its complex nature, the question of giving assistance is a
difficult and delicate matter. In our efforts to relieve distress and
want, we must be careful to do nothing which will result in spreading
tuberculosis. The paramount consideration is the prevention of
infection, and for this reason, relief should be made conditional upon
the removal or reduction of the danger. If we keep this idea firmly
before us, the problem will be much simplified.

In Baltimore, from one third to one half of the families under
supervision are on or below the poverty line. This means that they are
registered on the books of some charitable association, and are, or at
times have been, dependent upon these organizations for food, rent,
fuel, clothing, or other assistance. In other words, the gap between the
income and the cost of living has needed to be bridged over by outside
aid. In a new community when the nurse’s first patients are the “poor
people” of the locality, she will find that nearly a hundred per cent.
of her cases are on the poverty line. This was our experience in
Baltimore, when the work was first organized, but now that it is well
established the percentage is much reduced. The nurses are now working
in homes where economic conditions are not acute, hence the number of
those receiving or rather of those needing relief (the terms are not
always synonymous) is less than a few years ago. Still, distressing
poverty is found in from one half to one third of the families, which
means that the problem of fighting tuberculosis is gravely complicated.

=The Relief-Giver.= When people need financial assistance, the question
arises, by whom shall it be given? a point which provokes much
discussion. Many people think that the nurse should give this relief,
because of her intimate knowledge of the home conditions of the families
under her charge—a knowledge far more extensive than that gained in any
other way. Some think if she is socially trained, _i.e._, supplements
her hospital training by a course in a school of philanthropy, that she
can combine the duties of both nurse and charity organization agent, and
become in this way a most effective social worker. By this combination,
the family will be spared the infliction of two visitors, nurse and
agent, a desirable result, since the advice given by these two workers
is often flatly contradictory. Other people think that instead of having
a nurse, it would be better to have a graduate from a school of
philanthropy, with a training supplemented by a six months’ hospital
course. The superficial nature of this course is sufficient commentary
on its value. Moreover, more than one half of the patients with
tuberculosis do not come within the reach of a relief-giving agency.

These two people, nurse and agent, are both specialists in their own
lines, and they are equally needed. They have had a different training
and are equally valuable in the field of social service. Even if it were
possible, we should not like to see these two offices combined in one
person—somewhere there would be a loss. It is difficult enough to get a
first-class tuberculosis nurse, and it is equally difficult to find a
first-class charity organization agent. How much more difficult to find
these combined in one person. There is full warrant for saying that
under no circumstances whatever should the nurse become a relief-giver,
or even remotely identified as such. In the foregoing pages we have
learned something of the extent and responsibility of her work, and if
she concentrates her attention upon bringing it to the highest degree of
efficiency, she will find time for nothing else. Moreover, if she
becomes known as one able to give material assistance, her value as a
public health nurse will decline. That she can give or withhold relief
will become known to her patients, who will follow or reject advice
according to what they receive from her. Her prestige as impartial,
disinterested adviser will at once diminish, and the force and authority
of her opinion be lost. Never, even by the gift of a five-cent piece,
should she jeopardize her unique position. The well-to-do patients will
scorn her services, and resent the implication of her visits, while the
others will follow advice when they are bribed, so to speak, and do as
they like when for any reason this bribe is withdrawn. And other
patients will be disobedient or resentful if they cannot obtain what
their neighbours have, or what they believe themselves entitled to.

=Co-operation not Interference.= To concentrate on one’s specialty is
all we should ask of anyone. Any social agency which scatters instead of
concentrates, produces superficial work, which is open to well-deserved
criticism. As well expect a nurse to become a kindergarten teacher,
because she sees the need for kindergartens, or to become a playground
teacher or settlement worker, as to take upon herself the rôle of
charity-organization agent. _And the reverse of this is true._ We should
not expect a relief-giver to undertake a nurse’s duties. It is not the
combination of various effective qualities in one person, but the
co-operation of various effective persons or specialists, which counts
in social service. Furthermore, each set of workers should recognize its
own limitations. The line of demarcation should be sharply drawn between
the work of one agency and that of another.

One sometimes encounters an intense zeal which causes one social worker
to try to do her own, and everyone else’s work as well; or even worse
than this, to neglect her own work in order to do that of another
person. All social workers should learn where to stop—where to transfer
the case to someone else better fitted to deal with another phase of it.
We sometimes hesitate to call in other agencies, because they do not
recognize their boundaries. Co-operation should be substituted for
rivalry and interference; when this is brought about, petty bickerings
and jealousies among the social agencies will cease.

To become an effective co-operator, instead of a critical interferer,
the public health nurse must familiarize herself with all the agencies
in the wide field of social service. She should try to understand the
object and method of their work, and to know where her own work
interlocks with theirs. In a way, they are all interdependent, one upon
the other, and have the same object in view—to relieve distress and
raise the sum total of human happiness. Whether their work is effective
or superficial is not our concern. The nurse should understand what each
of them has to offer, and by picking here and there among them, secure
valuable assistance for the families under her charge. She can thus
reinforce her own efforts, and supplement her own work in behalf of
their well-being and security.

Since nurses come in almost daily contact with the Charity Organization
Societies it should be part of their duties to attend the local district
meetings of these associations, for during the discussions which take
place, the nurses are able to give most helpful information concerning
their own cases, while in regard to other cases, not complicated by a
communicable disease, they learn much as to the methods and theory of
relief-giving. For this reason, these district meetings are useful to
both nurse and agent alike; the interchange of opinion enlarges the
outlook of both workers, and each gains an insight into the difficulties
of the other’s work. This interest and understanding promotes good
feeling, tolerance, and personal friendliness—the basis of successful
team work.

=General Rules for Nurses and Agents.= In a small community in which
there is but one nurse and no Charity Organization Society or its
equivalent, it is well to form a Relief Committee, to whom the nurse may
refer such of her cases as need assistance. In cities where
relief-giving organizations are already established, a few general rules
should govern the relation between nurse and agent; the observance of
these will prevent much trouble and misunderstanding. Under no
circumstances should the nurse give material assistance—neither money,
food, clothing, nor anything of the sort. When these things are needed,
the agent should be asked for them, and no case is so acute but that it
may wait until this consultation takes place. In a city where there is
no emergency or night bureau, it may be necessary to make an occasional
exception to this rule, in which case the nurse may tide the patient
over till the following morning, when the agent may be conferred with.
Such instances will be so rare, however, that they are merely noted as
exceptions to the general rule—under no consideration whatever should
the nurse give any material relief.

It sometimes happens that the nurse has been given a small sum to buy
food, clothing, or special articles for some of her patients. This fund
was perhaps intended for a specified case, or to be used at discretion.
It is wiser to give this money to the agent, with the request that it be
spent (if circumstances warrant) as the nurse suggests. This course may
involve additional trouble, a little extra work for both nurse and
agent, but it is necessary to be extremely punctilious in order to avoid
serious misunderstandings.

When a nurse has been in the work a long time, and is dealing with
agents whom she knows and understands, a feeling of mutual trust and
dependence will arise. Under such circumstances, both may take far more
leeway than should be granted a new worker—but unfortunately this happy
and comfortable state is not always reached. The safest plan is that
each should follow her own line with utmost precision, being rigidly
careful not to overstep the boundaries between her own and another’s
duties.

For example: a benevolent individual may give the nurse an overcoat, to
be used for any patient who needs it. The nurse knows a patient who is
expecting to enter a sanatorium in a few days. Her first inclination
would be to give him the coat and say nothing. Apparently it concerns no
one but herself and her patient. In adherence to the rules laid down,
however, she must first consult the agent before giving away the coat.
This consultation may reveal the fact that the family (new to the nurse)
is well known to the Federated Charities, and that but a short time ago
this patient was given an overcoat which he sold for drink. At this
time, be it said, he was not known to be tuberculous. Of course, this
constitutes no argument against giving him another chance, inasmuch as
he depends upon it to enter the sanatorium, but it gives the nurse a
side light on her patient’s character. She should make sure that he will
not play fast and loose again; also upon entering the sanatorium the
physician must be informed that the man is addicted to alcohol—a
tendency to be considered in his treatment.

Tuberculosis, like poverty, is a chronic condition, and the delay
required for wholesome co-operation will seldom prove fatal.

The agents, likewise, should be governed by one very simple rule, which
will obviate all misunderstandings and ill feeling. This rule should
be—no advice, suggestions, or interference in regard to medical
attention, nursing, or treatment. All this lies strictly within the
nurse’s province and should be left absolutely to her. For example: if
an agent enters a house and finds a consumptive, she should make no
suggestions as to changing doctors, going to this or that dispensary, or
to such and such an institution. If the case is already known to the
nurse, the agent may consult her, and find out what plans and
arrangements have been made and then aid in bringing them about. If the
case is unknown to the nurse, the agent should report it at once,
leaving the nurse to take all necessary steps as to diagnosis and
treatment. Grave results often follow the abuse of this one simple rule.
For example: an agent enters a patient’s home, and finds him in charge
of a certain doctor. Without knowing anything of the circumstances, she
may advise him to change doctors, go to a dispensary, or even to a
sanatorium. She does not know that the patient is in charge of a
physician with a large private practice, and that this is the first time
he has called upon the tuberculosis nurse. His co-operation and help in
the tuberculosis campaign depends upon the way this first case is
handled. His indignation at finding the nurse has played him false (for
it is apt to be the nurse who is credited with these objectionable
things) may be so great that months of explanation cannot wipe it out.
As we have said before, tuberculosis is like poverty—a chronic
complaint—and the delay needed for co-operation will not prove fatal.

If nurses and agents will follow strictly this one simple rule—the
former to give no material assistance, the latter to offer no advice
concerning the patient’s treatment—the chief cause of friction between
these two sets of workers will be eliminated.

=Conditions under which Relief is Asked.= The nurse who visits a family
every week or two is in a position to know when they have come to the
end of their resources and need relief. When this point is reached, she
should report the case to the agent of the Federated Charities. She must
always bear in mind that her chief work is the prevention of
tuberculosis; it is not necessarily the prolongation of human life,
although the two are sometimes coincident. Relief should be asked for if
it brings about the prevention of tuberculosis, but under no
circumstances if it means increased opportunities for scattering the
disease. Under the latter conditions, assistance should be withheld or
withdrawn as the case may be.

For example: we have a family consisting of father, mother, and several
children. The income ceased when the father, the wage-earner, became too
ill to work. The family is in great need of fuel, rent, and groceries.
The giving of this assistance should be made conditional upon the
removal of the danger—that is, upon the patient’s going to an
institution where he will be better cared for than in the home. By
insisting upon this removal, the Federated Charities can play an
important part in the suppression of tuberculosis.

Suppose there are no hospital facilities, and it is necessary to keep
the patient at home. In this case, the most susceptible members of the
household, namely, the children, should be removed. To place out
children is a difficult matter, since it is hard to get the parents’
consent; this can be done, however, with time.

If this turns out to be impossible, relief may be given on condition
that the strictest precautions are observed. This assistance may be
given as long as both patient and family follow rigidly all directions
given by the nurse; failure to do so should be a signal for the
withdrawal of all aid. To assist the patient who has no choice but to
remain at home, means to give relief under the least favourable
conditions, but it must answer when there are no hospital facilities.
When such facilities exist, no alternative should be permitted. When a
family reaches the point where outside interference—social
interference—is needed, we think it not unreasonable that this
assistance should be given upon terms which tend to promote, rather than
diminish the welfare of its members.

=Wrong Conditions of Relief-Giving.= Relief is sometimes given in a way
that makes it defeat preventive work, and tends to create new sources of
infection. For example: we recall a case in which the father of a family
was in the last stages of consumption. His wife took in washing, and was
general drudge for the patient and five small children. This man refused
to go to a hospital, and also refused to use his sputum cup, or take any
other precautions. Most of his time was spent in bed, and beside him in
the bed were his two small children, whose presence gave him pleasure.
Neither doctor, nurse, nor agent could bring about a better state of
things, yet the family was desperately poor and in great need of help.
In consequence, assistance was given upon the patient’s own terms of
being allowed to carry out his right to infect his family. Groceries
were given in large amounts, and the patient himself was supplied with
abundant milk and eggs, which kept him alive for weeks beyond the point
where his own manner of living would have ended the matter. Soon after
his death, one of the children died of tubercular meningitis, while his
wife developed a pulmonary lesion. All the family are now public
charges.

We recall another case: The family consisted of the patient, his wife,
and eight children. The patient was grossly careless, declining to
observe the slightest precautions, and flatly refused to enter a
hospital. After his death, his wife and five of the eight children were
found to have tuberculosis. During the last six months of his life, a
certain agency had poured in unceasing relief, thereby subsidizing a
centre of infection.

Still a third case is that of a widow, with two small children. She
would not part from these children, and refused to go to a hospital, or
to let them go to the country. A separate bed was provided, so that for
part of the time at least the children might be away from her, but she
declined to let them occupy it. She kept them in bed with her. Neither
would she use a sputum cup nor follow advice in any way. All this time,
some benevolent old ladies kept her well supplied with groceries, milk,
eggs, coal, rent, and so forth, by means of which assistance she was
able to drag out a moribund existence for eight or ten months. Pitiful
as this case was, the utter selfishness and immorality of this sort of
“mother love” is something which should repel rather than attract the
sympathies of thinking people.

These are perhaps extreme instances, yet in a lesser degree this is what
usually happens unless relief is made conditional upon removal of the
danger. Charitable associations should be careful not to act as
accessories in the spread of tuberculosis, and should not prolong
conditions under which this is practically inevitable. If centres of
infection are thus perpetuated, through sources over which the
associations in question have no control, nurse and agent, at least,
should not countenance such “benevolence.”

=Incidental Assistance.= There are many occasions when the nurse should
ask for relief, and when this should be freely and generously given.
When a patient enters an institution, it may be necessary to pension his
family during his absence; assurance of their welfare will enable him to
leave with an easy mind. Unless such provision is made, we are
threatened with the alternative of seeing him sit at home, unable to
work, but engaged in the minor though highly dangerous occupation of
caring for the children while his wife goes out to service.

Relief may also be of a temporary nature. While a patient waits for
admission to a hospital he may be too sick to remain alone at home. This
may mean that his wife, the breadwinner, is forced to give up work in
order to care for him. Assistance should be given during this waiting
period, after which time the wife will return to her employment and the
family affairs readjust themselves.

Again, we may have a family in which the patient himself is the only one
who needs help, the income sufficing for all ordinary demands, but not
for the extraordinary demands of illness. While awaiting admission to an
institution, it may be necessary to give him extra food, extra clothing
or bed clothing, an overcoat, railway fare, or something of like nature,
either to make him comfortable, or to facilitate his removal when the
time comes. The patient must not be allowed to suffer during this
enforced wait, but this assistance must not be interpreted as
encouragement to remain at home.

In the foregoing instances, relief has been conditional upon removal. We
must sometimes give assistance under other circumstances. If there are
no hospital facilities, or if he will not avail himself of them, we are
doing good preventive work if we give the patient an extra bed, since
this may result in his partial separation from the children or other
members of the household. Extra clothing may also be given under like
conditions. On the other hand, if we gave milk and eggs to the patient,
we should be supplying food which would maintain indefinitely a centre
of infection. (Good preventive work may be accomplished by ample feeding
of the other members of the household, thus increasing their resistance.
In this case we should be sure that this food is taken by the children,
or by those for whom it was intended, since otherwise it would be
wasted.) Let us put the matter very frankly: it is wrong to prolong a
patient’s life, unless at the same time we can make him harmless to
those about him. If the two are coincident, well and good. If not, then
the shorter the exposure, the better for all those who must submit to
it. We repeat what was said at the beginning of the chapter: the patient
on the poverty line is surrounded by a group of individuals whose
vitality is at a very low ebb. Our first duty is to protect these
individuals.

=Withdrawal of Relief.= When relief is given with the understanding that
certain conditions be complied with, it should be withdrawn if this
compact be violated. The nurse is in a position to know of any breach of
faith, and should notify the agent accordingly. The objection is
sometimes raised that assistance given in this way is a bribe, or a
threat, or a means of coercion, and is therefore wrong. This rather
overstates the case. Let us say, rather, that under these circumstances
we have in our hands a powerful lever, by which mountains of ignorance
and prejudice may be removed. By the use of this lever, we can work
quickly and well for the best interests of the family and the community.
We constantly see families who are not on the poverty line, and over
whom we have no control, yet who are equally obstinate, ignorant, and
dangerous, and regret infinitely that we have no such lever as in the
case of patients who are below the poverty line.

When asking for relief, the nurse must be sure that her patients will
take advantage of it, and that she is not sending the agent on
wild-goose chases. Patients have sometimes been supplied with cots,
window-tents, reclining chairs, and other similar and expensive
articles, which they subsequently declined to use. An indifferent,
careless patient, unwilling to co-operate in any way, is not one for
whom to demand such an outlay.

=Milk and Eggs.= Ten years ago, milk and eggs for consumptives was an
integral part of the tuberculosis campaign. In those early days, they
were considered as necessary as was fresh air itself. They were
prescribed as a matter of routine, and if the patient could not afford
to buy them, they were at once supplied by some charitable association.
We have come a long way since then.

Attention has already been called to the fact that, in the past few
years, medical opinion has undergone a great change as to the value of
milk and eggs. This rich and highly concentrated food is considered far
less advantageous than was at first supposed. By reason of their fat
content (especially the case with eggs), they tend to cause indigestion,
always a serious complication in pulmonary tuberculosis. For this
reason, the old idea of living on enormous quantities of milk and eggs
has been largely abandoned. Some sanatoriums do not give them at
all—other food is substituted, equally nourishing but less apt to upset
the stomach. Yet the idea that they are necessary for consumptives dies
hard.

In Baltimore, there is now no question of providing them. During the
past year, nearly five thousand consumptives passed under the
supervision of the Tuberculosis Division; we asked that milk and eggs be
given to only thirty-eight of this number. Of these thirty-eight cases,
thirteen were advanced, waiting admission to a hospital; two were early
cases, waiting admission to a sanatorium; nine were suspects, and extra
nourishment was needed in order to facilitate diagnosis; and fourteen
were chronic cases, to whom this diet was given as a valuable tonic.

Quite apart from their value, the real reason that we have ceased to
give milk and eggs is because of our policy of removing the patient to
an institution. The furnishing of this diet, or of anything else which
tends to keep him at home, is something we do not endorse. We do not
wish to place any premium upon the home, or to offer any inducements to
remain in it. If our patient wants milk and eggs, we can send him where
they may be had.

If there is no hospital for the tuberculous patient in a community which
is able to furnish one, the maintenance of the patient by charity as a
centre of infection, makes little difference, one way or the other. In
this case, the absence of a hospital means that the community is merely
sentimentalizing and pottering over the tuberculosis problem.




                             CHAPTER XVIII

  Home Occupations of Consumptives—Sewing and Sweatshop Work—Food—Milk
      and Cream—Lunch Rooms and Eating-Houses—Laundry Work—Boarding- and
      Lodging-Houses—Miscellaneous Occupations—Summary—The Consumptive
      Outside the Home—Cooks—Personal Contact in the Factory—Supervision
      Outside the Home.


=Home Occupations of Consumptives.= Up to this point we have considered
the patient solely in relation to his own family, or to those with whom
he comes in immediate, constant contact. The people surrounding him are
in their turn infected, transmitting the disease to others who in like
manner are intimately exposed. Roughly speaking, all of this infection
takes place within the four walls of the home. The home, therefore, is
the centre of infection,—the focus from which tuberculosis radiates into
the community. The further one is removed from this focus, the less the
danger.

There are certain ways, however, in which danger from the home threatens
people who live outside, people in no wise connected with the patient,
and unaware of his existence. This occurs when the patient leaves his
home to seek employment in the community, or when he makes or handles
certain articles which go forth into the community as carriers of
bacilli. Infections of this sort may be termed accidental. They are
infrequent as compared to house infections, but infrequent as they are,
they should be prevented.

In Baltimore, nearly fifty per cent. of the patients under supervision
are able to work. They seek a livelihood in office, factory, shop,
hotel, and private home. We also find that nineteen per cent. of the
families under supervision carry on some sort of gainful occupation
within the confines of their own homes. As a rule, the patients who
conduct these little home industries or occupations are more advanced
cases than those able to find employment in shops and factories. In some
instances, this home industry was carried on before the patient became
ill; in others, by far the greater number, it is the direct result of an
illness which has modified his earning power and compelled him to eke
out a scanty income by this means. In many cases the actual work is not
done by the patient himself but by some other member of the household.
Sometimes these industries are not dangerous to other people, or the
risk is so slight as to be negligible. At other times, the menace is
grave. Each case must be considered upon its individual merits—one must
not generalize and condemn in wholesale fashion.

=Sewing and Sweatshop Work.= A number of our patients are dressmakers,
or do factory sewing at home. Much has been written about the danger of
clothing made under such conditions, either by the patient himself or by
other members of his family. This output is not as dangerous as many
people suppose, although such an admission would deprive the campaign of
much picturesque photography. Much of this clothing is of washable
material, such as cotton shirts, blouses, overalls, and the like,
therefore any germs they might carry would be removed in the first
washing. The danger has also been exaggerated in the case of woollen
materials, such as coats, trousers, etc. Any organisms contained in
these articles would soon die, or their virulence become so attenuated
that little harm would result. This also applies to artificial flowers.
It is not the occasional dose of bacilli, conveyed in this or any other
manner, but the large and repeated implantations which do the damage.

Infected clothing doubtless plays considerable part in the spread of the
acute contagious diseases, such as measles, diphtheria, and scarlet
fever, but in tuberculosis the risk is so slight that it may almost be
called non-existent. Under such conditions, the danger is not to the
wearers, or probable buyers, but to workers who make this clothing while
in contact with the consumptive himself.

=Food.= There are other home occupations about whose danger to the
public there can be little doubt. Many patients keep small grocery
stores, confectionery shops, and lunch rooms, and prepare and handle
foodstuffs of all kinds. Again we must discriminate. The consumptive who
sells tinned foods (which he does not handle), or meat, fish, or
vegetables which are cooked before they are eaten, is not necessarily
spreading disease among his customers. On the other hand, he who sells
and handles milk, cream, ice-cream, bread, cake, candy, and so forth, is
a decided danger to all who buy his wares. The alimentary tract is one
of the main portals of entry for the tubercle bacilli, and every
precaution must be taken to prevent the contamination of food. The
patrons of these little shops are the people of the neighbourhood, who
are regular customers, and their health is endangered not by occasional
but by repeated doses of germ-laden food.

=Milk and Cream.= There is an ordinance in Baltimore forbidding the sale
of milk and cream in a house where there is an infectious disease; this
includes tuberculosis. In order to sell milk, it is first necessary to
obtain a permit from the Health Department, but this permit may be
revoked whenever occasion demands. If the nurse finds that one of her
patients is selling milk (as is often done in connection with a small
grocery business), she reports this fact to the Health Department. It
may be that the patient himself never comes near the shop, and is out at
work or away all day. This sometimes happens, but not often. Usually he
waits upon the customers himself, selling milk in penny amounts, with a
dirty finger inside the measuring cup. Or he may be too ill to attend
the shop, but sits or lies in an adjoining room, so that his wife may
wait upon him and upon the customers alternately. Under such conditions,
the danger may be almost as great as if he himself handled the milk,
since she does not take time for proper cleanliness.

To revoke a permit usually occasions considerable hardship, and the
reduction of an already pitiful income. Yet summary measures must be
taken unless the milk is sold without risk to the purchasers. The
patient should be removed to a hospital, and the family must choose
between letting him go and giving up the permit. When there are no
hospital facilities and the permit must be withdrawn, leaving the family
under financial stress, the nurse should ask assistance of the Federated
Charities. This assistance, however, should never be offered as an
alternative to removing the patient to a hospital.

There are other foods besides milk and cream liable to contamination,
the sale of which is not controlled in any way. Thus as we have seen,
while a consumptive may be prohibited from selling milk, he may sell
ice-cream without let or hindrance. And furthermore, an ice-cream cone
or “snow-ball,” handled by dirty, germ-laden fingers, is most often sold
to the most susceptible of all customers—the child.

=Lunch Rooms and Eating-Houses.= Many patients earn their living by
keeping eating-houses, oyster-parlours, ice-cream saloons, and so forth.
There is danger to the customer whenever the cooking and serving of food
are done by a consumptive, or by those in contact with a consumptive. A
community to be well protected should enact comprehensive legislation
controlling every aspect of the food supply, and special emphasis should
be laid upon the handling of food by those with a transmissible disease.

=Laundry Work.= Another home occupation is laundry work—unskilled labour
requiring no capital and largely resorted to, especially among negroes.
This is heavy work, hence not always done by the patient, but often by
some other member of the household. Whether the patient irons the clean
clothes or sits coughing in the same room where this is done (we have
often seen newly ironed clothes spread upon the bed of a last-stage
case), the result is much the same. Under such circumstances clothes
become contaminated. Since this sort of laundry work is usually done for
regular customers, they week after week wear clothing that has come from
an infected house. It is dangerous to sleep constantly on pillow cases
that have been coughed on by a consumptive, and to use towels and
napkins that have been subjected to a like infection.

Since there are no laws to govern conditions of this sort, the question
arises, what is the nurse to do in such a case? Must she look on and say
nothing, or must she warn those for whom this laundry work is being
done? It would be futile to argue with the patient’s family—they would
refuse to recognize the danger to others, seeing instead the financial
loss from giving up the work. The nurse must first try to remove the
patient to a hospital, thus doing away entirely with the danger. Failing
in this (through lack of hospital facilities), the family may be willing
to give up the work on condition that an income be substituted by some
charitable agency. Simple as the latter course may seem, so many
obstacles to procuring this aid will arise, that it offers no practical
solution of the matter. If the home surroundings cannot be altered and
the danger reduced, then the patrons or customers should be told of the
conditions under which their laundry work is done. It is not always
possible, however, to locate these customers, since the patient is very
wary of giving information upon this subject. Whenever possible,
nevertheless, they should be told; if they prefer to continue the risk,
they are at least not in ignorance of it.

It is deeply regrettable that exposure to infection by tuberculosis is
still an optional matter, and that the necessary curtailment of
individual liberty has not yet been made in regard to all opportunities
for it. In the case of impure milk, for instance, the law at least makes
an effort to curb the preference which any individual may entertain for
it.

=Boarding and Lodging Houses.= There are other home occupations in which
the menace is of a personal nature, and does not come through
contaminated articles. Many patients take in boarders—an occupation
which frequently entails considerable overcrowding of the home. This
brings healthy individuals directly within the danger zone, and subjects
them to the same risks incurred by the family itself. Other patients
take in lodgers; here the risk is less, because meals are not included.
In either case, there is great personal exposure, with equally great
opportunities of infection.

=Summary.= To sum up: Among 3107 patients under supervision, we find
608, or 19 per cent., carrying on some sort of gainful industry within
the confines of their own homes. The resultant danger is of two kinds:
from personal contact with the patient, and the remoter possibility of
infection through articles which he makes or handles. The most serious
risk is that incurred in boarding- and lodging-houses, where the inmates
are subjected to a high degree of personal exposure. In other
occupations there may be some personal risk, but it is slight and
transitory, and therefore insignificant. In considering contaminated
articles, we find there also two classes: those dangerous to a high
degree, and those but slightly so, if indeed they may be called
dangerous at all. Among the former, the most harmful are the
contaminated foodstuffs, in which the risk is almost as great as through
personal contact. Next comes laundry work, where the risk is in the
repetition of infection, as in the use of household linen. Then comes
the output of clothing, cotton and woollen, where also the risk is
slight. In the case of other articles handled by the consumptive the
risk involved is so insignificant as not to be worth mentioning.

The following table shows the nature of these various Home Occupations,
ranged in order of their risk to the community:

             Personal:      Boarders            104
                            Lodgers              18 122
                                                ———

             Food:          Bakeries              4
                            Confectioneries       4
                            Cook shops            6
                            Groceries            73
                            Oyster-parlours       1
                            Saloons              13 101
                                                ———

             Clothing:      Laundry work            222

                            Sewing              109
                            Millinery             1
                            Tailor shop           4 114
                                                ———
             Miscellaneous: Barbers               8
                            Basket-maker          1
                            Cigar store           2
                            Cleaning and Dyeing   1
                            Drygoods             10
                            Second-hand shop      1
                            Shoemaker            21
                            Umbrella-mender       1
                            Wall-paper shop       1  46
                                                ———

                                         Total,         605

=The Consumptive Outside the Home.= We must now consider the patient who
is employed outside the home. As we have said before, nearly fifty per
cent. of our patients are able to work. The danger to the public is of
two kinds, that arising through personal contact, and through certain
articles which the consumptive may make or handle. In the latter case,
just as we find it among the home occupations, the risk to the community
depends upon the articles themselves. Whatever affects food, is far more
dangerous than the contamination of articles not taken into the
alimentary tract.

To prevent the possibility of food infection, we should enact and
enforce laws forbidding the employment of consumptives in any factory,
shop, or establishment of any kind in which food is either prepared or
sold. This would include candy factories, bakeries, cake, biscuit, and
cracker factories, canning and preserving establishments, as well as
dairies, restaurants, lunch rooms, sodawater stands, candy shops, and
the like. We must never forget that the home is the chief centre of
danger, the place responsible for the vast majority of infections, and
that every infection which occurs outside the home is accidental, so to
speak. Yet accidental infections, while relatively few in number, are
still plentiful enough to make it necessary to safeguard the community
in every way. An effective tuberculosis campaign demands the stoppage of
all leaks.

For example: on our visiting list was a girl employed in a biscuit
factory, packing cakes. She was an advanced case, and every now and then
had a hemorrhage which compelled her to stop work, though sometimes only
for a few hours. Between hemorrhages, she worked steadily. The cakes
packed under these conditions doubtless carried a full quota of germs.
We tried to induce her to go to a hospital, but she declined. The
manager was appealed to but he wanted to keep her—she was a quick
worker; besides, he did not have to eat the cakes—so he refused to add
his influence to ours to get the patient to an institution. The public
should be protected by law from the possibility of such infection.

The saving phase of the situation is this: while the patient who keeps a
bakeshop and sells his wares day after day to practically the same
customers, fulfils the condition that repeated implantations are
necessary to contract the disease; on the other hand, the cakes
distributed by a factory cover a wider range of territory—thus, while
many more people get doses of germs, the doses themselves are probably
too small to be harmful. This also may be said for other kinds of
foodstuffs, handled in factories by tuberculous persons; these articles
are distributed so widely that no individual consumer is really
endangered. In this way, the risk is minimized. But still we must
remember that every factory in the country has its tuberculous
employees, with their output of bacilli to be reckoned with. The
consumer is thus threatened on every side. No wise community should
tolerate such chances of infection.

=Cooks.= There is considerably more danger from the tuberculous cook
employed in a private family. Under such conditions the household is
steadily infected day by day, not through personal contact, but by
small, repeated doses of bacilli received into the alimentary tract.

If typhoid fever permitted a patient to work—if it were a chronic
instead of an acute disease—we should consider it a highly dangerous
expedient to permit such a patient to handle food in any way, and we
should be exceedingly wary of restaurants which employed typhoids as
cooks or waiters. This argument applies with equal force to
tuberculosis. In typhoid, there is but one portal of entry—the digestive
tract. In tuberculosis there are two—the respiratory as well as the
alimentary—and they are equally important.

=Personal Contact in the Factory.= While the patient in the factory is a
menace, he is less dangerous than the patient in his home. A man well
enough to work is seldom in the most advanced and infectious stages of
tuberculosis. Moreover, his fellow-workers, unlike the members of his
household, are not in constant but rather in casual and intermittent
contact with him. These two conditions tend to diminish the risk to his
associates; still, it always exists. The consumptive does not seek
employment from a malicious desire to spread tuberculosis—he seeks it
because of economic conditions compelling him to work until he falls in
harness. We must recognize this driving necessity, but at the same time
we must protect the workers who perforce surround him. They too are
impelled by the same need, and their rights equal his.

When a patient is visited at home, he and his family are often
stimulated to a high degree of carefulness. The patient uses a sputum
cup for his own convenience, and the family insist upon this for their
own interest and safety. The result is a lessening of danger, and an
improvement upon a neglected and uninstructed case. In the factory,
these conditions are reversed. His cup is no longer a convenience, and
he dreads being conspicuous through its use. Moreover, since his illness
is unknown to his fellow-workers, there is no one to insist upon
precautions of any kind. The result is that we maintain in the factory
conditions which we seek to abolish in the home. We give one set of
people information whereby to protect themselves, and we withhold this
information from another group of people who need it almost as much,
which is illogical and stupid and costly. Enormous sacrifices have been
made to this policy of silence, and it is time for these sacrifices to
cease.

Those in contact with a consumptive, whether this contact takes place in
the home or in the factory, are entitled to know the nature of his
disease. It is not the degree of consanguinity, but the degree of
contact which should determine this knowledge. We cannot trust the
patient to protect others—it is a trust too often violated. We must
surround him in the shop with a public opinion even more potent than
that which he finds at home. His fellow-workers will be less tolerant of
breaches of technique, will make less excuse for whims and temper, than
does the tired family. We knew of one patient who insisted on spitting
on the floor—at home; when his wife remonstrated, he knocked her down.
In the shop, such conduct would cost him his place, and rightly.

=Supervision Outside the Home.= Whenever the infectious case is at large
in the community, his whereabouts should be known to those most exposed
to the danger. This applies alike to employer and employee. The head of
the department in which the consumptive is at work should see that those
in contact with him know of his condition. The patient should be
compelled to use his sputum cup when he expectorates. Knowledge of the
patient’s condition does not necessarily mean that he should be
dismissed—it should merely mean that he will be held up to the required
standard of carefulness. For example: the Baltimore Health Department
received a letter from a certain firm in the city, stating that many
cases of tuberculosis had developed among the employees on a certain
floor in their factory—and on this one floor alone. This led them to
suspect that a consumptive might be among these workers, distributing
the disease. A list of all the employees was submitted. Investigation
promptly showed that on this particular floor was a chronic case of
tuberculosis of long standing, a man who had been under supervision at
home for several years. In his home, this patient was exceedingly clean
and punctilious in the use of the sputum cup; at his work, however, he
was absolutely the reverse. On receipt of this information, the employer
had a sound talk with this man, which resulted in the use of the sputum
cup and all other precautions. The patient did not lose his place, but
he was no longer permitted to jeopardize the health of his
fellow-workers.

Patients with chronic tuberculosis are also found in domestic service,
and go in and out of private homes, carrying infection with them. This
danger is especially great in the South, where there is a large negro
population, and we constantly find consumptives employed as cooks,
housemaids, nursemaids, and butlers, as the case may be. For the most
part, the employers are entirely ignorant as to their condition. In
these cases, just as in the factory, office, department store, and so
forth, the employer should be notified of the presence of tuberculosis.

To give this information should be the duty of the Health Department.
The municipal nurses are aware of the facts, and they also know when a
patient changes his occupation, or place of employment. But to give this
information without following it up, would not be enough. To notify an
employer of the presence of a tuberculous worker, would not necessarily
mean that any action resulted. A poor workman might be summarily
dismissed, and a good one retained, without those in his vicinity being
enlightened as to the nature of his disease. To make this information of
value, it would be necessary to supervise the patient in the factory,
just as he is supervised in the home. This double supervision would
demand a greatly increased staff of nurses, since factory visiting
should not be done through curtailment of the nurse’s other duties. We
must once more emphasize the fact that the home is the fountainhead of
tuberculosis, and that every infection which occurs outside the home
circle (or its equivalent) is practically an accidental infection. But,
as we have already said, a comprehensive plan for checking tuberculosis
must include the stoppage of all leaks, and the unknown, unsupervised
consumptive, at large in the community, is a leak which should be
recognized by common-sense.

Yet certain conditions must be complied with before we can extend this
municipal supervision. Outside-the-home supervision will create an
enormous amount of phthisiphobia. Consumptives are now tolerated because
their presence is either unknown or but dimly guessed at; when this
ignorance is dispelled—as it must be if the nurse visits them at their
places of employment, and their presence and numbers are made known, a
great wave of fear will spread over the community. Such a result is
inevitable when for the first time the public realizes, suddenly and
concretely, the extent to which it is threatened. Tuberculous workers
will be discharged by hundreds, and there will be widespread suffering
in consequence.

On the other hand, however, thousands of non-tuberculous workers will be
relieved of a great danger. Our factories already produce workers so
worn out and devitalized as to fall ready victims to any disease that
presents itself. Would not these same factories be somewhat less
dangerous if swept clear of consumptive employees?[9]

Footnote 9:

  However bad certain factory conditions may be, these of themselves
  cannot produce tuberculosis any more than they can produce scarlet
  fever or diphtheria. The disease itself must be brought into the
  factory by a carrier—someone who is himself infected.

Outside-the-home supervision is the next logical step in the
anti-tuberculosis campaign. But valuable as this would be, from the
point of view of the general health, it cannot be done until the
community is prepared to care for all who would undoubtedly suffer as a
result. Some patients, of course, would not lose their situations, but
the majority would be turned adrift without a moment’s hesitation. These
the community must take charge of. Therefore, before we can supervise
tuberculosis beyond the boundaries of the home, we must have ample
hospital facilities. Hospital accommodation must be so extensive, so
complete, and so excellent that institutional care can be given to all
who need it.

In this way, the community will be relieved automatically of a vast
amount of danger. Patients will either seek institutional care, or, if
they continue at work, will do so under conditions which do not
jeopardize other people. For the reaction from the first intense
phthisiphobia will be a demand for carefulness on the part of the
consumptive, and sane toleration of him.

The one objection to this policy of supervision and publicity is the
seeming interference with the personal liberty of the individual, but to
curtail the liberty of the patient to transmit a communicable disease,
is to increase the liberty of hundreds to escape it. There should be no
question as to which has the superior claim.




                              CHAPTER XIX

  Municipal Control—The Danger of “Political” Control—“Politics” in the
      Co-operating Divisions—Results in Baltimore—Tuberculosis and
      Poverty.


=Municipal Control.= Tuberculosis is a communicable disease in which the
patient himself must be relied upon to protect the community. We depend
upon him for whatever protection he chooses to give, and whether this is
much or little is determined by his circumstances, temperament, and
environment. Whenever his ability or good-will breaks down, we are at
his mercy. We may try to overcome his ignorance by education; to
substitute ethical for unethical standards, and in a more or less
unsatisfactory way to reconstruct his immediate surroundings. But the
success of these efforts depends, in the last analysis, upon the patient
himself. The public is exposed to a communicable disease, the control of
which lies with the transmitter.

For this reason, a disease which may be contracted by a neighbour
becomes as much his affair as it is that of the patient or possessor.
Should the interests of the two conflict, it is obvious that we must
have some impartial arbiter to decide between them. At such a point—the
right of one person to transmit, of another to acquire an infectious
disease—the matter becomes one of public as well as private concern. The
arbiter between these two interests should be the Health Department of a
community, and the control of all infectious diseases should be placed
completely under the municipality.

In the first chapters of this book, we considered the special nurse as
supported by a group of private individuals, in connection with some
privately maintained association. Social experiments frequently begin in
this way; when their value is proved, it should be the aim of the
promoters to transfer this special work to the department of the
municipality in which it belongs. Upon looking over the various
municipal departments, we realize that much of what is now freely
recognized to be municipal work, was originally carried on through
private enterprise and initiative. This is the case with school nursing,
playground work, juvenile court and probation work; which in many cities
has passed through the stage of private enterprise and become firmly
incorporated into the city machinery. In all public health nursing, the
aim of the founders should be, first to prove its worth to the
community, and then make the community (municipality) assume full charge
of it as soon as possible. It is particularly necessary to transfer
tuberculosis work from private to municipal control.

=The Danger of “Political” Control.= The question of doing this,
however, is often a matter of great concern to the founders. They are
usually deeply interested in the work, and have maintained it upon a
basis of efficiency, in spite of many obstacles. They fear, and often
rightly, that to transfer it to the municipality will be to transfer it
from the basis of efficiency in its own line, to the basis of politics,
and they dread that sinister condition known as “political control.” And
yet the administration of public affairs is not necessarily “political”
in the bad sense of the term. On the contrary, municipal control may,
and in many cities does mean, that work is conducted with the force,
authority, and financial backing of a great department, such as the
Health Department. Under such conditions, it can attain a far greater
degree of efficiency than could ever have been reached through private
administration. Under municipal control, it is possible to have a large
staff of nurses and pay them good salaries—which latter always means a
wide choice of applicants. It is also possible to establish many and
well equipped dispensaries, in charge of salaried, qualified physicians.
Money will be forthcoming for all necessary expenses connected with the
development and extension of the work—in short, the financial handicap
will be removed, and the work can go forward with increased facilities,
enlarged opportunities, and heightened dignity and authority.

On the other hand, if the administration of the Health Department is “in
politics,” the reverse of this will take place. Unfortunately, in many
American cities, the business of “politics” is the business of providing
people with jobs at the taxpayers’ expense, regardless of the fitness of
the applicant. Many of our cities are managed in this way. Moreover, in
the same city, this corruptness may affect certain departments only,
some being negligently and dishonestly conducted, others cleanly and
efficiently. Or we may find both conditions existing in a single
department, some of whose branches or divisions may be well conducted
and on a high level, while other divisions may be grossly mismanaged and
worthless. If a Health Department is hampered by politics, either as a
whole or in certain mismanaged branches or divisions, it is useless to
expect results. Placed under such a handicap, tuberculosis work would
fail. Not only would the taxpayers’ money be wasted, but the community
would suffer through a false sense of security, gained through its faith
in, or rather its ignorance concerning, a badly conducted department. To
trifle with the health of a community is a criminal act, and a Health
Department which is “in politics” is the most immoral of all corrupt
city departments.

Evil results of a Health Department being “in politics” may be of
several sorts. For example: the Superintendent of Nurses may be an
inexperienced, incapable woman, appointed by a ward politician to clear
off political debts. A ward politician is hardly one whose judgment—in
nursing matters at least—should be relied upon.

On the other hand, the Superintendent herself may be capable and
efficient, but she may not be permitted to select the members of her
staff. Instead of being able to choose them herself, according to their
fitness and ability, she must accept any unqualified woman whom the ward
boss may appoint. A staff of incompetent nurses, appointed without
regard to character or education, is not a force from which to expect
results. Moreover, nurses chosen in this manner feel that they are
“protected” and can do as they like, subject to neither restraint nor
discipline. This means that their work cannot be controlled, corrected,
or directed in any way. Dismissal can be made only for the most flagrant
offences—not for any such trifle as incompetence, laziness, or
stupidity. When the Superintendent’s hands are thus tied—when she cannot
select her nurses, cannot control them, and cannot dismiss the worthless
as well as the unscrupulous, the result is a low grade of work. No able
and self-respecting woman could hold the position of superintendent
under such circumstances, thereby making herself responsible for work
which she cannot control.

The acceptance of registered nurses only, and the requirement of Civil
Service Examination in addition, would do much to raise the level of
efficiency. These requirements, however, valuable as they are, would by
no means ensure the suitability of the applicant, or guarantee the
selection of nurses best adapted to public health work. Over and above
this, the Superintendent should have free choice in selecting her
workers, not only from the point of view of education, but also that of
personal worth.

=“Politics” in the Co-operating Divisions.= Sometimes the Tuberculosis
Division itself may not be on a political basis, but the various other
divisions of the Health Department may be conducted in such a manner as
to nullify much of the nurses’ work. For example: much depends upon the
co-operation of the Fumigation Division. If the men employed to fumigate
houses do their work badly or improperly—if they are too lazy to stop
chinks and crevices, thus permitting the disinfectant to leak out; if
too ignorant to properly measure the rooms, and unable to calculate the
necessary amount of formaldehyde, this work will be valueless. Worse
still if they are the kind that can be “bought off” and so shirk work
entirely.

Or the trouble may be with the Sterilization Division, where the duty of
the employees is to carry mattresses, etc., from the patient’s home to
the city sterilizer. When there is no law compelling this sterilization,
and it is an optional matter with the householder, if done, its doing is
altogether the result of the nurse’s teaching and advice. If the waggon
drivers are lazy and do not wish to carry the heavy mattresses, they can
shirk work by means of false excuses often difficult to detect. For
example: they can report that when a certain mattress was called for,
the family had changed their minds about having it sterilized and
refused to have it done. Upon investigation, we find that this refusal
was at the instigation of the waggon driver himself—he had assured the
family that sterilization was an unnecessary and stupid proceeding. To
ignorant minds, one Health Department employee is as good as another,
and when the advice is conflicting, they choose that which best pleases
them.

Again, the fumigators or drivers may report that they cannot get into a
certain house; the key could not be found; there was no one to admit
them, or give them the articles to be removed. In innumerable ways they
may compel the nurse to return again and again to the same house, to
make arrangements which they try to frustrate by every conceivable
device.

If, therefore, the employees of the various co-operating divisions are
mere jobholders—if they are neither honest nor intelligent, nor
interested in anything but pay-day—it is a heartbreaking task for the
honest and efficient division to work with them. All of these activities
interlock, and must work together to gain a common goal. If all are
operated at their highest level, working in close and intelligent
accord, then indeed we may expect results. But if the reverse is the
case—if the co-operating divisions are a drag and a hindrance—then the
task is overwhelming. The weak are corrupted and the strong discouraged.

Those responsible for placing tuberculosis work under the city’s
administration—where it rightfully and logically belongs—should continue
their interest still further. It is not enough to transfer it from
pioneer, private control, and then drop the responsibility.

If a Health Department is clear of politics, and all its divisions work
together harmoniously, magnificent results may be obtained. Power,
prestige, and efficiency is a combination which results in forceful
work.

=Results in Baltimore.= Results have been achieved in Baltimore by
reason of a well-managed Health Department, acting in close co-operation
with the institutions of both city and state. The tuberculosis machinery
consists of a staff of seventeen special nurses; three special
dispensaries with a physician in charge; a laboratory for sputum
examinations; a fumigation corps and a steam sterilizer. With this
force, we work in connection with three other tuberculosis dispensaries,
and six institutions for the care of early and advanced cases. Some of
these institutions are maintained by state appropriations, others by
both public and private funds. The co-operation between these
institutions and the Health Department is absolute; if the control was
all through one, instead of a dozen different centres, it could not be
more complete or harmonious. Failure in any one direction is felt down
the line, consequently each is stimulated to its best effort. Thus, the
nurse knows that if she fails to persuade her patient to enter the
hospital, the hospital is useless, or that if the bad food of the
hospital drives the patient back again to his home, the nurse’s work
goes for nothing. Each reacts upon the other, and as all are working for
the same end, there is constant incentive to become a strong, rather
than a weak link in the chain. The results obtained cannot be measured
in terms of individuals—we cannot point to so many patients improved, so
many working, and so forth. Individual welfare is too shifting and too
questionable a standard by which to judge. The only absolute standard is
that afforded by the death-rate. A declining death-rate means also a
decreasing morbidity—fewer people die of tuberculosis and fewer are
infected. While our tuberculosis death-rate is still enormously high, it
is nevertheless falling year by year. Thus we see:

                                Deaths
                                 from
                               Pulmonary
                               Tuberculosis:

                               1909 1400
                               1910 1234
                               1911 1165
                               1912 1189
                               1913 1129

There is nothing spectacular about this. It is heartbreakingly
slow—needlessly, uselessly slow work. Yet it is progressing in the right
direction.

=Tuberculosis and Poverty.= Throughout the foregoing pages we have
considered the direct method of dealing with tuberculosis—the removal or
segregation of the distributor. But there is also an indirect method of
dealing with tuberculosis, namely the abolishment of poverty.
Tuberculosis recruits full fifty per cent. of its ranks from people of a
certain social level—the very poor. This class is composed of people
habitually overworked, underpaid, and subject to all the deteriorating
influences of unsanitary and vicious environment, and to the ignorance
and degradation which follow in the wake of extreme distress. The root
cause of these conditions is our present unjust economic system, which
produces an excess of luxury and frivolity on the one hand, and on the
other an army of people who must forego the barest necessities of life.
One class is maintained at the expense of the other. Every movement
which seeks to abolish this injustice, and to substitute a fairer and
more equable system, is a movement which at the same time tends to raise
the standard of public health. Any legislation, social or revolutionary,
which makes for the improvement of industrial conditions, raises the
level of public health through raising the welfare (_i.e._, resistance)
of the individual. Therefore, sweeping readjustment of social and
economic conditions would automatically eliminate an enormous amount of
disease, by reducing the number of highly susceptible individuals. To
increase the number of people with high resistance—or to decrease the
number of people with low resistance, whichever way one chooses to put
it—would probably diminish the amount of tuberculosis by about one half.

This indirect method—the readjustment of social conditions and the
abolishment of poverty—valuable as it would be, would still leave the
problem unsolved. Even diminished by one half, the amount of
tuberculosis would still be formidable, and we should have to attack it
as vigorously as ever, if not to the same extent. The disease would
still exist, just as it now exists in well-to-do families in small
towns, in rural districts, and in other circumstances attributable to
neither poverty nor bad industrial conditions.

A thousand years ago, industrial conditions were as distressing as those
which exist to-day—yet in those days the poor staggered under the
additional burden of leprosy. A hundred and fifty years ago poverty was
complicated by smallpox, the scourge of Europe. The rigid segregation of
lepers in the Middle Ages relieved the situation of leprosy, while the
discovery of vaccine has practically eliminated smallpox. The submerged
classes, while their economic condition remained unchanged, were at
least relieved of the added weight of these two great diseases. So in
our present fight against tuberculosis. An aggressive campaign against
this disease will not necessarily improve industrial conditions, but
those who suffer most from these conditions will be relieved of one more
handicap.

In our present warfare against tuberculosis we are not impelled by the
blind fear that made society in the Middle Ages demand segregation, and
refuse to tolerate an infectious disease at large in the community. Nor
has any vaccine or similar agent been discovered by which the disease
may be wiped out. Instead, we must depend upon a campaign of
education—wholesale, widespread education, conducted amongst all classes
of society. We know the path to be travelled, and the machinery by which
we may gain our ends. If at any time we become impatient with our slow
rate of progress, we can accelerate our speed by the extension and
multiplication of the three fundamental agencies in the
anti-tuberculosis campaign—the Hospital, the Dispensary, and the Public
Health Nurse.




                                 INDEX


                                   A

 Advanced cases, 46–47, 119, 145, 223, 224–227;
   see _Patients_ and _Segregation_

 Air, fresh, 145–147

 Alcohol, 151

 Ambulatory cases, 33, 34, 38, 79–80;
   see _Patients_

 Anti-tuberculosis campaign, 1–3;
   fundamental agencies in, 286

 Anti-tuberculosis Society, 5–6

 Arrested cases, 2;
   nursing as work for, 13–14;
   see _Patients_


                                   B

 Bacilli, tubercle, articles infected by, 253;
   distribution of, 169, 262–266;
   presence or absence in sputum, 107–108, 111;
   tenacity of, 170

 Badges, 31

 Bag, nurse’s, 41;
   supplies carried in, 42–46, 108

 Baltimore, branch offices for tuberculosis nurses, 39;
   co-operation of nurses with institutions, 202, 204–205, 281–282;
   dispensaries, 92, 151, 186–187, 192, 198–199, 201–202;
   examination of nurses, 12;
   forms used for charts, etc., 50–59;
   Health Department, 42, 157, 170–171, 174, 176, 183–192, 204, 206,
      250, 256, 267–268, 279–282;
   milk and eggs for patients, 250;
   nurse’s bag, 41;
   nurses’ districts, 39 _note_;
   occupations of patients, 253, 261–263;
   ordinance in regard to selling milk, 255–256;
   organization of tuberculosis work, 200–202;
   poverty, 231–232;
   registration of cases, 112;
   salary of tuberculosis nurse, 21;
   sick-leave, 28;
   supplies for patient, 42;
   Tuberculosis Division, 171, 183, 201–202, 250;
   uniforms, 30–31;
   vacations, 28;
   Visiting Nurse Association, 8, 39, 42, 65, 201, 202

 Bed, for advanced cases, 145;
   placing of, 144

 Bed clothing, 144

 Bedding, disinfection of, 175, 176

 Bedroom, patient’s, 137–140

 Board of examiners for nurses, 11

 Board of Health of Maryland, 42;
   furnishes formaldehyde, 173

 Books of instruction, 44


                                   C

 Cabot, Doctor, quoted, 70

 Calls, night, 16;
   sources from which received, 121

 Calmette test, 111

 Card index, 53–54

 “Careful consumptive,” the, 220–223

 Carpets, infected, 178–179

 Cases, tuberculosis, see _Advanced_, _Ambulatory_, _Arrested_, and
    _Discharged cases_; and _Patients_

 Cases, undiagnosed, 63, 99–101

 Charity Organization Society (or Federated Charities), 39, 66, 98, 108,
    109, 176, 210, 236–237, 239, 241, 242, 245;
   rules for agents of, 237–241

 Charts, patients’, 49–54, 58–60

 Children, care of tuberculous, 163;
   diagnosing, 161–162;
   infection of, 95, 111, 151–152, 159–164;
   open-air schools for, 163–165;
   sending to school, 162–163;
   pre-tuberculous, 163

 Classes, tuberculin, 196–197

 Cleaning should be compulsory, 182–183;
   see _Disinfection_

 Clothing for tuberculous patients, 142–143, 211–212

 Cooking, supervision of, and instruction in, by nurse, 149–151

 Cooks, infection from, see under _Infection_

 Co-operation, between institutions and nurse, 203, 205–208;
   of newspapers in tuberculosis work, 5;
   of organizations for social work and nurse, 35–36, 143, 156–157,
      176–177, 182, 210;
   wrong methods of, 33–34;
   see also _Charity Organization Society_ and _Social Workers_

 Country, the, for tuberculous patients, 165–168

 Cullen, Doctor Victor F., quoted, 108

 Cure of tuberculosis, 4, 125–127, 208–209


                                   D

 Daily reports, 55–57

 Day sheet, 57

 Death of patient, 49, 119, 120;
   reporting, 53, 171

 Diagnoses, erroneous, 92–97, 101;
   lack of, 63;
   “lay,” 68–69, 100;
   necessity for formal, 115–116;
   obtaining, 105–107, 184–185;
   from sputum, 107–109;
   value of recording, 114–115;
   volunteered by physicians, 106

 Diet of patients, 147–150, 249–251

 Discharged cases, 204–205, 207, 209;
   see also _Arrested cases_

 Disinfectants, 43–44, 133, 173 _note_

 Disinfection, by boiling, 131–132, 177, 178;
   by burning, 175, 178, 179, 183;
   by cleaning, 138, 172;
   by fumigation, 170–173, 176, 179, 180, 181, 182, 183;
   by painting and papering, 179;
   by steam sterilization, 175–177;
   effects of, on materials, 176 _note_

 Dispensaries, general, 107;
   tuberculosis, consideration for patients at, 189–190;
   equipment of, 186–188;
   establishment of, 105, 185;
   hours, 188–189, 196;
   importance of, 286;
   necessity for, 105, 184–185;
   nurses’ work in, 194–195, 197–199;
   obtaining patients from, 67–68;
   physicians’ work in, 191–194;
   reports made to, by nurse, 202;
   taking patients to, 159;
   see also _Baltimore_, _Diagnosis_, _Nurse_

 Districts, 35–36, 39 _note_

 Duplication of work, 33–34


                                   E

 Education unsuccessful as preventive measure, 2–3

 Examination of patients, nurses, etc., see _Diagnosis_, _Dispensary_,
    _Families_, _Health Department_, _Nurse_, _Patients_, _Physician_,
    _Sputum_

 Expenses of nurse, 24–26

 Eye test, 111


                                   F

 Factories, spreading of tuberculosis in, 266–267, 271 _note_;
   supervision of patients in, 267;
   see also _Patients, occupations of_

 Families of patients, co-operation with nurse, 127, 174;
   examination of, 157–158;
   hygiene of, 155;
   infection of, 68–69, 97;
   relations with nurse, 152;
   recreations of, 155–156;
   respect for customs of, 181–182;
   see also under _Children_ and _Nurse_

 Food, importance to patient of proper, 147–150;
   see also under _Diet_, _Infection_, _Nurse, instruction by_

 Formaldehyde, formula for, 173–174 _note_

 Forms, see _Charts_, _Records_, _Reports_

 Fumigation, see under _Baltimore_, _Disinfection_


                                   H

 Hamman, Doctor Louis, quoted, 111

 Health Department, badges, 31–32;
   co-operation with institutions, 205–207;
   dispensaries, 185;
   examination of sputum by, 187;
   laws in regard to tuberculosis, 76–77, 112;
   notifying employers of tuberculosis patients, 269;
   physicians of, 89;
   politics in, 275–278;
   registration of cases with, 112, of deaths, 171;
   reports from institutions to, 206;
   supervision of discharged patients through, 207;
   supplies provided by, 42;
   visiting physicians needed by, 184–185;
   see also under _Baltimore_, _Disinfection_

 Heat, artificial, in outdoor treatment, 143, 147

 Histories, see under _Patients_

 Home, “breaking up the,” 161;
   care of advanced patients at, 225–227;
   conditions in patients’, 139, 148, 160, 163;
   entering patients’, 31, 118, 122;
   see _Infection_

 Hospitals, for advanced cases, 207–208, 218–219;
   importance of, in tuberculosis, 223, 271, 286;
   opposition to building of tuberculosis hospitals, 219–221;
   sending patients to, 207–208;
   special wards for tuberculosis, 218–219

 Houses, inspection of, by nurse, 136–137;
   vacant, watched by nurse, 181


                                   I

 Infection, of children, 159–160;
   sources of, 140, 159–160, 165–168, 252, 255–268;
   see also under _Advanced cases_, _Ambulatory cases_, _Bacilli_,
      _Children_, _Factories_, _Families_, _Patients_

 Institutions, see _Hospitals_ and _Sanatoria_

 Instruction, books of, 44;
   of patients and families, 127–133, 142–148;
   see also under _Nurse_


                                   L

 Landlord, irresponsibility of, 180–181

 Laws, for proper disinfection, 183;
   for protection from infection, 264;
   for registration and reporting of tuberculosis cases, 7, 111–112;
   State, in regard to tuberculosis, 76, 77

 “Light work” for tuberculosis patients, 215–216

 Lyman, Doctor David R., quoted, 213


                                   M

 Maryland, State Board of Health, quoted, 213;
   neglect of law for registration of tuberculosis cases, 113;
   Tuberculosis Association, 8 _note_

 Milk, infection through, 255

 Milk and eggs, see _Diet_

 Minor, Doctor Charles L., quoted, 126

 Municipal control of tuberculosis work, 77–86, 89–91, 274–275;
   see also _Baltimore_


                                   N

 Napkins, paper, use of, 130–131

 Newspapers as agents in tuberculosis work, 5

 Nurse, the tuberculosis, “asset to community,” 199;
   access to cases, 121–122;
   calls, 121–122;
   character, 16–19;
   co-operation with physician, 88, 103, 109;
   discovering cases, 67;
   dispensary work, 194–199;
   district, 35–36;
   duties of, 46, 48–49, 52, 53–56, 58–59, 62–70, 100–101, 105, 106,
      108–109, 122, 128–137, 149–153, 154–157, 169–170, 181–183,
      204–205, 207–208, 211–212, 213, 216–217, 224, 258–259;
   establishment of, 7–10, 89;
   expenses, 24–26;
   function, 117–118, 224, 247–248;
   giving relief, 232–233, 237, 241–242, 245–248;
   health, 12–15;
   hours on duty, 14, 36;
   instruction of patients and families, 127–131, 133–148, 155–156, 172,
      174, 178, 183;
   lunches, 40–41;
   noon hour, 40–41;
   office, 38–40;
   physical examinations, 12–13;
   relations with patients and families, 18, 123, 133, 152–153, 181–182;
   relations with physicians, 71–73, 87–89, 92–94, 99–104, 123;
   responsibility to community, to patient and family, 118;
     to organization, 89;
   salary, 20–23;
   sick-leave, 27–28;
   social worker as nurse, 233–234;
   time off, 14–16;
   training of, 10–12, 62;
   uniforms, 28–31;
   vacation, 26–27;
   visits, 36–38;
   visiting list, 63–70;
   see also under _Baltimore_, _Charts_, _Children_, _Co-operation_,
      _Diagnosis_, _Diet_, _Disinfection_, _Dispensaries_, _Families_,
      _Health Department_, _Home_, _Registration_, _Reports_, _Visiting
      Nurse Association_


                                   O

 Occupations of patients, see under _Infection_

 Office of tuberculosis nurse, 38–40

 Open-air, schools, 163;
   treatment, 140–143

 Organizations, see under _Charity Organization Society_, and
    _Co-operation_

 Outdoor work for tuberculosis patients, 216


                                   P

 Patients, bed-ridden, 151–152;
   carelessness of, 97, 214–222, 266–268;
   changing physicians, 80–81, 92–96, 98–100;
   charts, 48–53;
   co-operation with nurse, 248–249;
   discharged, 204–207, 212–215;
   employment of, 262;
   examination of, 158, 190;
   histories, 123–124;
   home occupations, 261–262;
   isolation of, in homes, 151–152;
   limitation of, 33, 200;
   objection of, to institutions, 210–211;
   outdoor treatment, 144;
   rest for, 143–144;
   sending to country, 165–168;
   supervision outside the home, 267–272;
   supplies for, 42–43, 45;
   telling the truth to, 124–127;
   see also _Advanced_, _Ambulatory_, and _Arrested cases_, _Baltimore_,
      _Children_, _Diet_, _Dispensaries_, _Families_, _Health
      Department_, _Home_, _Injection_, _Instruction_, _Nurse_,
      _Segregation_, _Relief_

 Phipps Dispensary, see _Dispensaries_ under _Baltimore_

 Phthisiphobia, 14, 134–135, 270–272

 Physicians, incompetent, 93–97, 101–104;
   municipal, 90;
   standards of, 83;
   reporting tuberculosis cases, 113;
   State requirements of, 75–76;
   “unethical practitioner,” the, 72, 84, 85;
   see also under _Diagnosis_, _Dispensaries_, _Nurse_, _Patients_

 Pockets, waterproof, 44

 Poverty, relation to tuberculosis, 3–4, 61, 80–81, 230–232, 265,
    283–285

 Prevention of tuberculosis, 4, 120, 155–156, 159–161, 247–248;
   see also under _Disinfection_, _Nurse_, etc.


                                   R

 Records and reports, 48–58

 Registration of cases, cards for, 116;
   laws for, 76, 111–113;
   value of, 114–115

 Relief, conditional, 231;
   not to be given by nurse, 234;
   obtained by nurse, 143, 210, 245–246, 257;
   proper use of, 248–249;
   rules for agents and nurses, 237–241;
   withdrawal of, 248;
   see also _Nurse_, _Co-operation_, _Patient_

 Reporting cases to the Health Department, 7, 56–59, 171, 205–207


                                   S

 Salary of tuberculosis nurse, 20–22, 24

 Sanatorium, outfit for, 211–212;
   value of, 208–209, 213

 Segregation, 4–5, 218–220, 223–229

 Sick leave, 26–28

 Skin test, 110

 Social agents and workers, 35–36, 62, 66–67, 165, 234–239

 Sputum, cups, 42–43;
   disposal of, 128–130;
   examination of, 9, 40, 107–108;
   see also under _Infection_ and _Instruction_

 Sterilization, see under _Disinfection_

 Superintendent of nurses, 13, 15, 24, 59–60, 116

 Supplies, nursing, 46;
   prophylactic, 42–45, 76–77, 133


                                   T

 Tests, tuberculin, 110–111

 Tuberculin classes, 196–197

 Tuberculosis, abolition of, 223, 283–284;
   arrest of, 125–126;
   campaign against, 1–6, 285–286;
   character of, 79;
   cure, 2–4, 125, 208–209;
   deaths from, 283;
   difficulties in dealing with, 79–82, 85–86;
   municipal control of, 85–86;
   number of cases in given community, estimate of, 63;
   see also _Bacilli_, _Infection_, _Prevention_, _Poverty_

 Tuberculosis Division, see under _Baltimore, Health Department of_


                                   U

 Uniforms, 28–29


                                   V

 Vacations for tuberculosis nurses, 26

 Visiting list, 63–66

 Visiting Nurse Association, 8, 9;
   see also under _Baltimore_ and _Co-operation_

 Visits by tuberculosis nurse, 36–38


                                   W

 Wards, special, for tuberculosis patients, 218–220

 Windows in patient’s room, 137, 144

 Work done by tuberculous patients: “light work,” 215;
   outdoor, 216,
   see also under _Infection_ and _Patients_

------------------------------------------------------------------------




                                    A

                            Medical Dictionary

                                for Nurses


  Giving the Definition, Pronunciation, and Derivation of the principal
  terms used in medicine, together with supplementary tables of weights,
 measures, chemical symbols, etc. arranged with special reference to use
                        by the nursing profession

                              By Amy E. Pope

    Formerly Instructor in the Presbyterian Hospital School of Nursing
           Author of “Anatomy and Physiology for Nurses,” etc.

                  _12^o. Illustrated. 288 pages. $1.00_

              _In full flexible Morocco, Thumb Index. $1.60_

No one could be better fitted to produce this book, filling a long-felt
want, than Miss Pope, because of her large practical experience as a
nurse, instructor, and author. Without question this volume must quickly
be recognized as indispensable to the students of her great profession.

                           _All Booksellers_

             NEW YORK                             LONDON
               2–4–6    =G. P. Putnam’s Sons= 24 Bedford St.
            W. 45th St.                           Strand




                               Text-Book

                                   of

                         Anatomy and Physiology

                               For Nurses


                                   by
                              Amy E. Pope

  Author, with Anna Caroline Maxwell, of “Practical Nursing,” and Former
      Instructor in Practical Nursing and Dietetics in the Presbyterian
      Hospital School of Nursing.

           _Crown 8^o. With 135 Illustrations, many in color
                       $1.75 net. Postage extra_

The object of this work is to provide a text-book containing more
physiology than the books on anatomy and physiology hitherto provided
for nurses. The book is very fully illustrated and contains a number of
questions for each chapter; also an extensive glossary, which includes a
detailed explanation of all the chemical and physical terms used.




                           Practical Nursing

                         A Text-Book for Nurses

                        By Anna Caroline Maxwell

     Superintendent of the Presbyterian Hospital School of Nursing

                                  and

                           Amy Elizabeth Pope

  Formerly Instructor in the Presbyterian Hospital School of Nursing;
      Instructor in School of Nursing, St. Luke’s Hospital, San
      Francisco, Cal.

      _Third Edition, Revised. Crown 8^o. About 900 pages. With 91
                         Illustrations. $2.00.
                             Postage extra_

Over 50,000 copies of _Practical Nursing_ had been sold up to January
1st, 1914. This new edition has been entirely reset, revised, and
enlarged, and contains over 50 per cent. more material than the previous
editions. An important feature of the new edition is, that the authors
have not confined themselves to one method of treatment where experience
has shown that other methods may be more effective in certain cases.
Detailed instructions have been given, thus bringing the book in line
with the latest developments in practical nursing.




                A Text-Book of Materia Medica for Nurses


                              Compiled by

                            Lavinia L. Dock

   Graduate of Bellevue Training School for Nurses, Secretary of the
   American Federation of Nurses and of the International Council of
                              Nurses, etc.

        _Fourth edition, revised and enlarged. 12^o. net, $1.50_

“The work is interesting, valuable, and worthy of a position in any
library.”—_N. Y. Medical Record._

“It is written very concisely, and little can be found in it to
criticize unfavorably, except the inevitable danger that the student
will imagine after reading it that the whole subject has been mastered.
The subject of therapeutics has been omitted as not a part of a nurse’s
study, and this omission is highly to be commended. It will prove a
valuable book for the purpose for which it is intended.”—_N. Y. Medical
Journal._

                  *       *       *       *       *

                          G. P. Putnam’s Sons
                          New York      London

------------------------------------------------------------------------




                          TRANSCRIBER’S NOTES


 1. P. 173, the portions listed in “Potassium permanganate, oz. 111.;
      liquid formaldehyde, pint 1.” are unlikely to be correct. Did not
      alter the passage.
 2. Silently corrected obvious typographical errors and variations in
      spelling.
 3. Retained archaic, non-standard, and uncertain spellings as printed.
 4. Re-indexed footnotes using numbers.
 5. Enclosed italics font in _underscores_.
 6. Enclosed bold font in =equals=.
 7. Denoted superscripts by a caret before a single superscript
      character or a series of superscripted characters enclosed in
      curly braces, e.g. M^r. or M^{ister}.