CHAPTER XVI
Hospitals for Advanced Cases—The Careful Consumptive—Chief Duty of the Nurse—Responsibility of the Institution—Home Care of the Advanced Case—Exceptions to Institutional Care—Compulsory Segregation.
Hospitals for the Advanced Case. The crux of the tuberculosis problem lies in the segregation of the advanced case. Until the distributor is removed from his family, and separated from the intimate circle surrounding him, we can make but little progress in the fight against this disease. No community can protect itself from the ravages of tuberculosis until it provides a place to which these advanced cases may be sent. Not only do we need large special hospitals for these patients, but we need special wards for consumptives in connection with every general hospital which receives either city or State appropriations. These special wards would be of even greater benefit to the community than large special hospitals situated in the environs of a city, since it would be easier to persuade a patient to enter an institution just “round the corner” than to go to one far distant from his home. A dying man dreads being separated from his family, and his family is equally reluctant to part from him; furthermore, if a hospital is remote from the city, his family can afford neither time nor carfare for frequent visits. These facts play an important part in influencing a patient’s decision, and due consideration should be accorded them.
It would probably cost less to build and maintain special wards in connection with hospitals already existing than to erect and support an entirely new institution. The greatest objection to special wards is that the coughing of the consumptives is disturbing to the other patients, but if the ward is sufficiently isolated (a separate building, if the hospital is planned on the cottage system) this objection would not apply. Furthermore, these wards would offer good teaching centres, where both doctors and nurses could learn more about pulmonary tuberculosis than the average hospital teaches to-day.
In attempting to secure ground for the erection of a tuberculosis hospital, there is usually great opposition from laymen. They are not only afraid of tuberculosis, but they fear the depreciation of property which may arise in the vicinity of such an institution. Considerable education is required to calm them to a realization that the consumptive sheltered and cared for is less dangerous than the consumptive at large and unrecognized. When it comes to a special ward in connection with a city hospital, we may again encounter great opposition, really from the same reason, though the objections expressed are expense of such a ward, the lack of nursing facilities, that the room is needed for acute diseases, and so on. All of which is a grave commentary, from the people who best understand it, upon the infectious nature of this disease. Yet the medical profession tells us with apparent sincerity that “the careful consumptive is not a menace.” If this be true, where can he be more careful and less of a menace than in a place specially provided for him?
The truth of the matter is, there is not, nor can there be, a careful enough consumptive. The very nature of the disease precludes such a possibility, however much we educate him, or however earnestly he himself may try to co-operate to that end. And for the vast majority of patients, from whom we can obtain but little or only spasmodic co-operation, there is even less to be said. There is one simple method of determining whether or not a patient is careful—it consists in asking the question: Under these circumstances, would I, myself, feel safe? Would I be satisfied as to the safety of my nearest and dearest friend?
At the beginning of the year 1912, the nurses of the Tuberculosis Division of Baltimore had on their visiting lists about 2800 patients. Of these 2020 were positively diagnosed, and had been under supervision for over three months. Undiagnosed cases, and positive ones who had been under supervision less than three months were excluded. These 2020 cases were then classified according to their willingness or ability to follow instructions, the groups being: Fairly Careful, Careless, and Grossly Careless. We purposely omitted a “Careful” class, since adequate carefulness would imply a condition in which there was absolutely no danger, a condition hardly possible with this disease. In Fairly Careful we included all those patients who really tried to follow advice, doing so to the best of their ability. Careless included those who tried intermittently, or who were badly hampered by circumstances. Grossly Careless speaks for itself.
The results of this analysis are here given:
| Patients visited over three months | 194 | ||
| Fairly Careful | 98, or 50.5% | ||
| Careless | 75, or 38.65% | ||
| Grossly Careless | 21, or 10.82% | ||
| Patients visited over six months | 346 | ||
| Fairly Careful | 171, or 49.43% | ||
| Careless | 151, or 43.64% | ||
| Grossly Careless | 24, or 6.84% | ||
| Patients visited over one year | 623 | ||
| Fairly Careful | 300, or 48.15% | ||
| Careless | 267, or 42.85% | ||
| Grossly Careless | 56, or 8.98% | ||
| Patients visited over two years | 857 | ||
| Fairly Careful | 443, or 51.69% | ||
| Careless | 339, or 39.55% | ||
| Grossly Careless | 75, or 8.75% | ||
| Total Number of Patients | 2020 | ||
| Fairly Careful | 1012, or 50.09% | ||
| Careless | 832, or 41.13% | ||
| Grossly Careless | 176, or 8% | ||
It will be noticed that these percentages vary but slightly, or to a negligible extent. Roughly speaking, about half the patients try to be careful, and half do not try, or do not succeed if they attempt it. Furthermore, it will be noticed that the time element has little to do with making a patient careful. The natural supposition would be that a patient visited for one or two years would show a marked increase of carefulness over those who had been under supervision but a few months. Yet there is virtually no difference between them, 50.5% of the three-months class being careful, as against 51.69% of the two-years class. These figures, we believe, show conclusively that long-continued teaching does not necessarily lead to satisfactory results. They also show that the patient left in his own home, even under constant supervision, is unable to achieve a degree of technique which means positive protection to those around him. There is but one conclusion to be drawn from these facts—not that the nurse is useless, but that the patient at large is dangerous. It proves the necessity for hospital care.
The hospital for a patient to die in appeals less to public sympathy than as a place in which he may get well. But it is better economy. Care of the open case, during his last and most infectious stages, is care which strikes at the very root of the evil. Until this fact is realized and full provision made for these cases, it will be a waste of time and money to spend them on superficial or half-way measures. If our goal is the elimination of tuberculosis, we should concentrate our efforts upon radical and fundamental methods.
At present, however, we can conceive of no community sufficiently advanced or far-seeing to make adequate provision for these last-stage cases. Therefore, the patients who make up the difference between the number of those needing hospital care, and those receiving hospital care, must be cared for in their homes by the nurse. Never for a moment should home supervision be considered a satisfactory substitute for hospital accommodation. The nurse’s efforts, no matter how thorough and conscientious, can never entirely remove the danger. Her care often lessens it to a marked degree, but never absolutely eliminates it. It is at best a makeshift, a stopgap—better than nothing, often much better than nothing, but never for a moment the proper alternative to removing the patient from his home. No one knows better than the nurse herself the inadequacy, the futility, of even the closest supervision.
Chief Duty of the Nurse. For this reason, the chief, the absolutely most important duty of the nurse is to induce the infectious patient to go from his home into an institution. To accomplish this end, she must bring every effort to bear upon the patient and his family, and appeal to them from every conceivable angle. This is her one great duty—the paramount reason for her existence.
To accomplish this, is as difficult as it is important. A patient does not willingly give up his home, however poor and humble it may be, while his family often cling to him with an obstinacy open to no argument. As a rule, the difficulty of removing him is in inverse ratio to his intelligence, and to the danger to those surrounding him.
Responsibility of the Institution. In overcoming this prejudice, a great deal depends upon the character of the institution itself. It is not enough to establish hospitals:—they must be attractive and comfortable to such a degree that they become highly desirable to prospective patients. They must be well run, well managed, the food must be good, and the patients well treated. To obtain segregation, we must have hospitals which offer great advantages over the home.
Home Care of the Advanced Case. If there are no hospital facilities, it then becomes the nurse’s duty to give nursing care to the bed-ridden patient. This is also done when the hospital accommodations are limited, and the patient must wait to be admitted. During this waiting period, which may extend over weeks, he should be visited every day (or at least as often as the work will permit), and given such care as he requires, including bed-baths, care of the back, and so forth. The nurse must also teach some older, responsible member of the family how to care for him in the intervals between her visits. Sometimes, when a vacancy finally occurs, the patient may be contented with home treatment and refuse to enter the institution, or his family may refuse to let him go. The nurse must do her utmost to persuade them. She must explain that in the hospital he will receive constant, not intermittent care, and that her work will only permit her to render nursing service to those who cannot otherwise be provided for. Should he still refuse, she must continue her visits of supervision, but must stop all nursing care. No premium whatever should be placed on his remaining at home. This may seem like a harsh and unfeeling policy, but it is the only course to pursue when we take into consideration the fact that the institution is the proper place for an infectious disease. If a patient has become accustomed to a daily bath and other attentions, he will miss them; when he misses them badly enough, he will consent to go where they may be had. This plan does not mean that the nurse neglects the patient,—if he suffers, it is through choice. An excellent alternative has been offered, and his refusal to accept it should not entitle him to continue infecting his family, assisted by the nurse to do it in comfort.
Exceptions to Institutional Care. A few exceptions may be made in advising institutional care. For example, if a family is in good circumstances, with excellent home conditions, and the patient is surrounded with every care and attention, it would hardly be necessary to counsel his removal. On the contrary, with our present lack of hospital facilities, to urge such a patient to leave his home might mean taking a hospital bed from another who needed it infinitely more. Again, if a tuberculous child is being cared for by his mother, or some one equally unlikely to contract the disease, it might not be worth while to remove him. An exception might also be made in the case of a childless couple, advanced in years. The nurse must use her judgment and common-sense in such cases, where the chances of infection are slight, or non-existent. On the other hand, if there is ample hospital accommodation, and cases like the above ask for admission, they should always be taken in.
The cases in which separation is imperative are those in which there is great exposure, inability to control the home surroundings, extreme poverty and neglect, or undue and prolonged strain upon other members of the household.
Compulsory Segregation. Not until our hospital facilities are so large that we can accept every case which applies for admission, can we consider forcing people to enter these institutions against their will. It is illogical to consider compulsory segregation, while we cannot accommodate all those who voluntarily ask for it. The patient who refuses to go to an institution is probably no more dangerous than he who clamours in vain for a bed. The docile, well intentioned, kindly consumptive is doubtless as much a menace as the selfish, vicious, avowedly careless one; in fact, the former may be more harmful, since his kindly nature surrounds him with friends, whereas the latter forces people to avoid him.
As for the tramp, the homeless man who wanders from pillar to post, sleeping in saloons and lodging-houses, he is far less of a menace than people suppose. He comes into but casual relationship with his fellows, and no one is in prolonged and intimate contact with him, as is the case of the man in the home, the centre of the family circle. Until we can accommodate the latter, we must let the former do as seems best to him. If ten anxious people are clamouring for every hospital bed at our disposal, why force it upon the reluctant one who refuses? When we can handle the problem of voluntary segregation, it will be time to consider compulsory measures.