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.