The Tuberculosis Nurse: Her Function and Her Qualifications / A Handbook for Practical Workers in the Tuberculosis Campaign

by Ellen N. La Motte

And if the physicians, required by law to instruct and keep careful watch over their consumptive patients, had been able to do this, why has it become necessary to place tuberculosis nurses in the field, designed to give just such service? Is the special nurse better fitted to explain the nature and danger of the disease? Is she a more efficient distributor of prophylactic supplies? To all these questions there should be but one answer—there is, or should be, no difference between the two. The private practitioner should be as well able to make a sure diagnosis as the municipal physician. He should be as ready to report the case. The private practitioner should be as capable a teacher, as careful a distributor of supplies, as alive to the danger of tuberculosis as the municipal nurse. The only difference between these two groups of people is that one acts and the other does not—or acts in such intermittent and irregular manner as to be productive of no results. And it is because of this lack of action on the part of the physicians in private practice, their failure to recognize, report, teach, and continually supervise consumptive patients, that our cities are placing the care of tuberculosis under municipal control. The care of tuberculosis is gradually being withdrawn from the man in private practice, and placed in the hands of specialists, who devote their entire time to the welfare of the community. And although now as always the latter solicit the support of the private physician, if he withholds his co-operation they can do without him, and reach their goal through other means.

Impossibility of Fulfilling this Obligation. We may ask why the private practitioner is being supplanted by municipal control. Undoubtedly he once held the key of the tuberculosis situation, as he holds it of many other problems involving the public health. He is being supplanted for two reasons: because of the peculiar nature of tuberculosis, and because of the failure of the medical profession to act as a united whole.

Failure because of the Nature of Tuberculosis. Let us first consider the nature of the disease. Tuberculosis is a prolonged, chronic disease, which may be drawn out over a period of months or years. The patient has many ups and downs, being sometimes so ill that he places himself under the care of a physician, sometimes so much better that he does not see a doctor for months. We have known patients who have not been to a physician for years, yet during that time they were infectious cases, as proved by sputum examination. During a hiatus of this kind, how can we possibly hold the doctor responsible for the tuberculous patient? How can we hold him responsible for the conduct, training, and surroundings of a case he never sees? Undoubtedly a very large number of patients pass completely from under the observation of their physicians, and are utterly lost to them. With the best intentions in the world, the private practitioner cannot follow and supervise a disease of this character, not acute, but chronic and ambulatory in nature. If he attempted this, it would leave him little time for anything else.

Nor can we assume that the patient who closes his account with one doctor necessarily places himself in the hands of another. He frequently drifts along without any medical advice whatsoever, and only seeks it again when his symptoms become alarming. These facts alone, exclusive of all other considerations, show the necessity for centralized control of these ambulatory patients.

Tuberculosis is largely a disease of the poor, as we have remarked before. A poor consumptive must consider the spending of every dollar, and the doctor’s fee is a matter of grave importance. For this reason, the patient will pay just as few visits to the physician as he possibly can. A doctor who sees a case only once or twice may well hesitate to pronounce it tuberculosis, and may wish to keep the patient under observation for a time, but the poverty of the patient prevents this.

Again, patients of the poorer classes continually change their doctors. Unlike people in more fortunate circumstances, they have no one physician to whom they always turn when in trouble. To such as these, the “family doctor” is unknown. Their fickle interest is attracted by the newest shingle, and they pay a visit or two to its owner and they depart. We knew one patient who visited five different doctors within the week. Small wonder that the doctor forgets these patients—mere transients—and that, even if he has time to diagnose them, he does not consider himself their physician, or responsible for them in any way. It is for just such cases, however—those patients who come into fleeting and haphazard relation with their physician, that municipal control is required. It is no reflection upon the private practitioner that he has failed to make headway against tuberculosis. It simply proves that people with this disease must be watched and cared for by those who are able to devote their entire time to it.

So much for the disease itself, and for the sociological and psychological conditions which complicate it, and make it a matter which cannot be handled successfully by the man in private practice. For no matter how conscientious he may be, or how willing to assume the full responsibility imposed by the State, he cannot do this when the patients refuse him the opportunity. He cannot follow them up at the expense of his private obligations. While the State expects service from those whom it licenses to practise, it does not expect the impossible.

Failure through the Personal Equation. We must now consider the second reason for removing tuberculosis from private into public control. For while the nature of the disease itself explains in large measure why it cannot be dealt with by the private practitioner, that is not the entire explanation. And here we must put the blame where it belongs—at the door of the physician himself.

When we think of the medical profession, we unconsciously think of its finest members—not only of the leaders in thought and achievement, but the numbers of highly educated, advanced, efficient, and conscientious men who form so large a part of it. In thinking of these, however, we are apt to overlook men of another sort, who are less well equipped, or who are imbued with commercialism, yet who are none the less members of this great profession. Yet even the least of these is armed, and has the sanction of the State in bearing these arms, which may be used either against a common enemy, or in a guerilla warfare in behalf of his own interests. The wide diversity among its individual members is the reason why the medical profession has been unable to act as a united whole in the warfare against tuberculosis.

In the first place, all physicians, no matter how well they may be trained, are not necessarily good teachers. No matter how keenly aware of the danger of tuberculosis, they are often unable to impress it upon their patients. Again, the busy physician has usually too little time to be a careful teacher. When conscious of a crowded waiting-room, or of the urgency of his next call, he is unable to give any but the most superficial and hurried instructions about the nature of tuberculosis, or the use of the prophylactic supplies. He does not realize that that which is obvious to him is frequently unintelligible to those less enlightened. We have often found patients possessing bundles of prophylactic supplies, given conscientiously enough, but without sufficient instruction to enable them to fold the fillers or to dispose of them afterwards. We recall one such case, where the doctor had given his patient a package of supplies, but had hurried off without opening the bundle or explaining its contents. A week later, we found the package still unopened. The patient, however, had torn a small hole in the wrapper, through which opening he had seen enough to convince himself that the strange objects within were no concern of his. We do not mean to say that no physicians are good teachers, but we do say that even where they are, and are moreover highly conscientious men, that they frequently give inadequate instruction to the patients under their charge, because they are too busy.