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.
[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.