MY FRIEND
INTRODUCTION
To tuberculosis, more than to any other infectious disease, the parable of the seed and the soil is strictly applicable. Without the tubercle bacillus there can be no tuberculosis, but for tuberculosis to develop, many factors of great complexity and as yet but little understood must facilitate the implantation of the bacillus and augment its growth. It is true that though we may emphasize the rôle of the bacillus, still we cannot completely ignore those personal factors that contribute to make the infection fruitful, and likewise though we focus our attention upon individual resistance, still we cannot keep out of sight the invader that is being resisted. The two viewpoints meet and run together, but are sufficiently separate to lead to different methods in our efforts to eradicate tuberculosis.
On the one hand are those who direct their efforts toward the annihilation of the tubercle bacillus. We are sufficiently instructed about the life history and habits of this organism to lay our plans upon a firm, scientific basis—a basis so firm and at first sight so simple and so plausible that over-enthusiasm led to predictions that have been sadly disappointed. The principles are sound indeed, but in practice their application has met with insuperable difficulties. These obstructions have sharpened our wits to find new avenues that now promise a more ready approach to the goal. To put the matter briefly, the tuberculosis campaign of the past fifteen years has taught us two important lessons: first, that the tuberculous cannot be isolated in their homes; second, that they cannot be cured in or out of sanatoria. I am shocked myself to read these bald statements, particularly the second, and still I am convinced that they are true. Some patients can be isolated in their homes, and many patients recover from tuberculosis and remain well. Tuberculosis is very amenable to treatment and under proper conditions the results of treatment are very gratifying. The difficulty is that the proper conditions are in most instances wanting, and when they are absent sanatorium recovery is almost invariably followed, after a brief period, by relapse. The records of cases with tubercle bacilli in the sputum establish this fact. Concerning the value of statistics of cases without tubercle bacilli in the sputum I entertain the gravest doubt. While I am heartily in favour of treating such patients, the personal equation enters too largely into the diagnosis to give the results convincing value as evidence of the lasting benefits of treatment. Experience has taught me that the educational value of sanatoria has been grossly exaggerated, and that this value is of small account in a broad plan of prevention. Our present knowledge, fortified by the costly experience of the past fifteen years, forces us to believe that the most direct and effective way of dealing with the tubercle bacillus is to isolate as many advanced consumptives as is possible. The hospital, perhaps supplemented by colonies, is the rational method of procedure. Other factors are of importance; all other factors are, but this is the fundamental and essential factor in the campaign.
On the other hand are those who direct their efforts towards cultivating the soil. Reliable studies inform us that ninety per cent. of the human race is tuberculosis infected, and that infection occurs at a very early age, so that at twelve years few children have escaped it. Relatively a small number of those infected subsequently become tuberculous, so that something more than infection is necessary for tuberculosis to develop. What this something is we do not know. Time, manner, frequency, and intensity of infection play an important part. Apparently too there is a wide personal variation in susceptibility. To just what this personal factor is due we are not in a position to say, but certain general facts known about the distribution of tuberculosis afford us a clue to its interpretation. Tuberculosis, like most infectious diseases, thrives under the conditions that poverty induces. Inadequate housing facilities, insufficient food, filth, and sordid care are a few of these. If, as all must admit, the tubercle bacillus is more or less ubiquitous and few escape contact with it, then an important part of our campaign of prevention will be the raising of personal resistance so that when infection occurs it may be successfully overcome. Here is the field for wide social activity. Everything that makes for higher standards of living and for improved personal hygiene is a valuable arm against tuberculosis. Housing laws, child-labour laws, the wage question, municipal recreation centres, the liquor question, social service in all its departments, vacation lodges, open-air schools, factory inspection, and so on and so on, are all indirectly valuable anti-tuberculosis agitation.
It is not my purpose to discuss the relative merits of the various phases of the anti-tuberculosis campaign. The death-rate from tuberculosis is falling steadily and rapidly, and it has fallen most rapidly in just those centres where the campaign has been vigorously pushed on a broad basis. Which phase of the work is responsible for the decrease or deserves the greatest credit, it is impossible to conclude from a study of available evidence. The same statistics are interpreted by one, for instance Cornet, as evidence of the efficiency of sputum prophylaxis; by another, for instance Hoffman, as evidence of the influence of improved economic conditions; by yet another, for instance Newsholme, as evidence of the value of hospitals for advanced cases; and finally by many, for instance Fränkel, as evidence of the undisputed value of all three factors. Which factor one emphasizes will depend largely upon one’s training and the field of activity in which one is engaged.
Being a physician and by training accustomed to view problems from a medical standpoint, it is natural that I should emphasize the attacks upon the bacillus. As I have said, it seems to me to be firmly established that the most efficient, the most direct, and the cheapest way to enforce isolation and prevent infection is by hospital segregation of cases of advanced pulmonary tuberculosis. While early diagnosis, sanatorium treatment, and education are valuable features of the campaign, their value will be but slight if this one essential feature is neglected. Indeed I am inclined to see the chief value of economic improvement in the indirect influence this improvement exercises upon the facility for infection. With economic advance the æsthetic value of general and personal hygiene grows apace, and the dictates of ordinary cleanliness offer a very strong barrier to infection. Poverty itself does not produce tuberculosis, but the conditions that poverty fosters do, and the advantages of better living reside not so much in an improved personal fitness as in the eradication of the conditions that facilitate infection. This view is in accord with what we have learned of other infections. Plague has been notoriously a scourge to the poor. To improve living conditions lessens plague, and this general fact was known before we learned that cleanliness produced results indirectly by eliminating rats. Malaria has always been particularly prevalent amongst labourers living in unprotected huts. To improve living conditions reduces malaria, but we gain the result more surely and directly by an intelligent campaign against mosquitoes. Unfortunately, we are not sufficiently instructed about tuberculosis to pick out of the whole mass of ills that poverty entails those few essential features that control infection. Perhaps some day we will, and then we shall be able to manage the social campaign more efficiently and economically. For instance, we are quite at sea to know what prophylactic use to make of the firmly grounded fact that tuberculosis infection establishes a strong resistance to reinfection. Upon an analogous principle rests the conquest of smallpox by vaccination. No doubt this immunity reaction has an important influence upon the development of tuberculosis, but as yet we know too little about it to control it and use it to advantage in our fight with the disease.
In the anti-tuberculosis campaign the nurse must look to medical science for the plan and inspiration of her work. Her attitude in the tuberculosis campaign must always conform to the medical attitude, although she may and indeed has added valuable material for building up this attitude. It is because this intimate relation exists that I have briefly outlined the medical impression of the tuberculosis campaign. It is quite natural that it should represent at the same time the nurse’s attitude. My object was to point out the numerous factors concerned in the anti-tuberculosis crusade, their interrelation, and the quite natural and necessary specialization that must occur. The field of the nurse and particularly the municipal nurse is circumscribed, but it is large enough to engage all her energy and devotion. It is not necessary nor even desirable that she should diffuse her interest and energy over the adjoining fields.
For more than ten years Miss La Motte and I have been engaged in working at the same problems, from the same broad though different personal viewpoint. Our work has brought us into almost daily contact. I acknowledge, with gratitude, the many valuable suggestions that I have borrowed from her experience, and in reading her book I note with the greatest satisfaction what I believe to be evidence of influence from the experience I have gained. It is a pleasure to find that after years of arduous work we agree at least upon what is the fundamental problem of the tuberculosis campaign, namely—institutional care of the advanced cases of pulmonary tuberculosis. I think it is right and proper that Miss La Motte has made this fact the guiding principle of her book, and that she has shown the relation of nursing activity to its furtherance, and that she has held all other phases of tuberculosis work subservient to it. To avoid misunderstanding it may be necessary to point out that other features of the anti-tuberculosis campaign have been merely touched upon or entirely ignored. This apparent slight is not offered, I am sure, as a reflection upon the value of these features; they are omitted simply to accentuate more boldly the dominant idea of the nurse’s work.
Another noteworthy feature of the book is the purely personal and local character of the experience presented. It details the problems that have offered themselves here in Baltimore, how these problems have been met, and how an effective nursing staff has been built up, first under private and then under municipal control. What has been accomplished abroad and in other localities in this country is not considered. In a way this is a disadvantage, for the book loses somewhat in breadth and erudition. However, I am convinced that what may be lost in this respect is more than compensated for by the gain in force and conciseness. After all, the fundamental problems are the same everywhere, and though local conditions will necessitate adjustment of details, still I believe the adjustment will be stimulated and facilitated more by a spirited account of what has been done under specific conditions than by a colourless review of the whole field of activity.