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.