Increasing the Visiting List. To increase the visiting list—that is, to bring under her care an increasingly larger proportion of the total number of tuberculous patients, even though the list becomes so large and unwieldy that she cannot manage it, should be the ambition of every tuberculosis nurse. At present, in every city in the country, there is so much undiscovered and unreported tuberculosis, that the failure of the nurse to increase the visiting list is an indication of poor work, not an indication that a full round-up has been made of all those suffering from this disease. This is especially true in a new community; a small or stationary visiting list is a sure sign, not necessarily of lazy or unconscientious work, but at least that the undertaking is being managed by someone who does not know how.
To illustrate this: A nurse is sent to a certain house, to see a specified patient. She does her work well—gives him a bed-bath, shows the family what to do, and makes considerable impression along lines of general hygiene. As far as it goes, her work is satisfactory and good. Another nurse, however, sent into this same house, would not only do all these things equally well, but, in addition, she would discover that the patient’s wife was coughing and probably infected, while his old mother, retired in the chimney-corner, was in even worse plight than the patient himself. These suspects, therefore, she sends to the dispensary, where her suspicions are confirmed by the doctor’s findings. Thus, if a community possesses a nurse of the first type, it may rejoice to find the amount of tuberculosis so small. If, on the other hand, it has a woman of the second type, it will become alarmed and anxious at the increasing number of patients who need care and control.
Nothing should diminish the enthusiasm for gaining new patients. The mere fact that a nurse has more than she can manage should never deter her from continually trying to find more. More patients, more patients, and even then, more patients, should be her constant aim—and then the chances are that she has not found all that exist. In Baltimore, when pioneer work was begun under the Visiting Nurse Association, that organization had a visiting list of some 1700 consumptive patients, divided among five nurses. As five nurses represented the largest number the Association could support, and as 1700 patients was only about one-fourth of those who needed care and attention, some other method of caring for the latter had to be devised. It was at this critical moment that the Health Department was persuaded to assume the tuberculosis work of the private association, and to incorporate it as part of the city machinery. If the need for this transfer had never been proved, it is hardly possible that the change would have been made. If the first nurses had confined their visits to the patients they could reasonably manage, and had refused to accept others, it would have been impossible to prove how great the number of infectious patients was, and how inadequate the care given them by the five struggling nurses of the private association. Therefore, each community which undertakes tuberculosis work should endeavour to unearth all the cases that exist, if for no other reason than to show the size of the problem, and the necessity of adequate measures for handling it. New patients, positive and suspicious, should be sought for from every possible source. This is better policy than to confine the work to the conscientious care of a handful of manageable cases.
Social Workers. The agents of the Charity Organization Society, or similar associations, continually come across cases of tuberculosis. The new nurse should canvass all these agencies, and ask that all cases of this kind be referred to her. If a case is not positively diagnosed, that should be no drawback to reporting it; while the agents of these associations are laymen and therefore not able to make diagnoses, laymen, nevertheless, are able to make very shrewd guesses. It is the nurse’s duty to take charge of these doubtful cases, and get them examined and diagnosed by the proper agencies. The mere fact that a patient presents suggestive symptoms makes it all the more urgent that he be examined as soon as possible, and lack of positive diagnosis should be no reason for the agent to withhold, or for the nurse to refuse to take charge of, such a case. To visit a suspect does not necessarily classify him as a consumptive, while not to visit him might be to deprive him of assistance at a most critical time.
In finding cases, extensive co-operation should be invited; almost every one whose work brings him into contact with numbers of people, knows one or two among them who are tuberculous. Thus settlement workers, school teachers, school attendance officers, juvenile court officers, clergymen, Salvation Army workers, and so forth, are all people whose aid and interest should be solicited. It makes no difference whether or not the case is positively diagnosed—any sick person, with the symptoms of a consumptive, is a person whose case should be looked into. It is the nurse’s business to obtain the diagnosis.
Dispensaries. If there is a hospital or dispensary (not necessarily a tuberculosis dispensary), the nurse should visit these institutions and ask to have all positive and suspicious cases referred to her. Since the patients who come to these places are usually those of the poorer classes, the doctors will not be likely to object to giving their names to the nurse. Indeed, they may be glad to accept the assistance she offers. One visit to these institutions, however, is not enough. Every week or two the nurse must present herself and renew her request for patients—she must not trust to the busy physician to report them by letter or telephone. Even when tuberculosis work is conducted on a large scale, as in Baltimore, it is always part of the nurse’s duty to visit these institutions regularly, to remind the doctors of their existence and of their unquenchable desire for more patients.
Patients’ Families and Friends. After the nurse is well established, and her position in the community recognized and assured, she will find that a certain number of new cases are referred to her through the families and friends of those already on her visiting list. This is a high tribute, and should be valued accordingly. She should not rely entirely upon this voluntary assistance, however, but from time to time should question her patients, and find out whether they have any friends who are ill, who would like to be visited. Surprising revelations often follow. There was in Baltimore one old coloured woman who took special pride in discovering patients, and who made an indefatigable agent in hunting up cases in the neighbourhood. The accuracy of her diagnosis was wonderful—her son had died of tuberculosis, so she knew all the symptoms, and she did not refer us to a single case, which, upon examination, failed to be tuberculous. We must remember that while in its early stages tuberculosis is difficult to detect, when it is so advanced that a layman can recognize it, in nine times out of ten he is right. And as these advanced cases are the chief distributors of the disease, the alert nurse should be keen to learn of these patients through any source that presents itself. Of course many calls from such sources send one on mere wild-goose chases, but it is better to go on a dozen fruitless errands, than to overlook one real case of tuberculosis.
Nurse’s Cases. A large proportion of her cases will be unearthed by the nurse herself. In Baltimore, the nurses themselves discover nearly thirty-three per cent. of the cases under supervision. Thus, on being sent to see a certain patient, before her visit is over the nurse may discover one or two others of the family whose condition is such as to call for immediate examination. The nurse should look with suspicion upon every member of a household which has been exposed to tuberculosis. The prolonged and intimate contact which is necessary for the transmission of this disease has unfortunately, in most families, existed for months before her arrival. The nurse should be particularly keen in questioning the parents of tuberculous children since it is from the parents that most children contract this disease.
Physicians. In considering the various sources from which patients are recruited, we have purposely left until the last that which most people would have deemed the first and most important source of all, namely, the physicians of a community. While the medical profession has blazed the way, and has indicated the paths along which the work must be carried on, it is unfortunately only the greater men in the profession who have done this. The others, through ignorance, through indifference, or through that spirit which according to Dr. Cabot makes medicine “the greatest profession, the meanest of trades,” have succeeded in placing effective if temporary barriers in the path of the anti-tuberculosis worker. The rigid adherence to the old Hippocratic oath, by which the physician was sworn to keep inviolate the confidence of his patient, and to place foremost the welfare of the individual, has for the most part been very nobly lived up to. This oath, however, antedates our knowledge concerning infectious and communicable disease. With the knowledge as to the nature of transmissible diseases, there has come a change in medical ethics, a change manifested by laws in which the welfare of the community is placed above that of the individual. We see this reflected in the regulations governing diphtheria, smallpox, scarlet fever, and so forth—diseases which are distinctly the concern of the community, as well as of the patient himself. But with tuberculosis, which has but recently become recognized as a communicable disease, we find a halting reluctance to consider anything but the rights of the individual. This feeling is particularly strong among physicians of an older generation, hold-overs from a passing régime. To such as these the nurse is nothing less than an impertinence. Even if physicians of this sort are unable to see their patients oftener than once or twice a year, or know them to be in need of supplies which the nurse will gladly furnish, they refuse to call upon her, and consider her advent as intolerable.
Again, there are physicians who do not object to the nurse on this score, but who resent her as a subtle menace to their practice. They feel that if a layman is able to preach rest, fresh air, and food, and distribute prophylactic supplies, that the ground will be cut out from under them, and that they will lose a chronic and fairly lucrative class of patients. As a matter of fact, the physician who preaches this simple doctrine has nothing to fear from the tuberculosis nurse—if her words echo his they only add force.