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.