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.