Therefore the nurse should try to induce her patients to rest as much as possible—not to walk about, or to drag themselves to a park, and so tire themselves out. Exertion increases fever, and this will counteract what benefit might have been gained through the fresh air. They should be taught to sit comfortably in their gardens, on their front sidewalks, on their porches, at their open windows. Best of all, they should go upstairs to their bedrooms, and lie at full length on the bed placed next to the open window. By thus emphasizing the importance of rest—synonymous in this case with outdoor rest—the nurse is not only giving sound advice to her patient, but she is protecting the community from the ambulatory consumptive.
Whenever possible, the patient should be induced to remain in bed permanently. The sooner the weary, advanced case gives up his painful wanderings, stops dragging himself from his own to his neighbour’s kitchen, or to the hospitable bar, the better for him and for the community. If he were to go to bed in a hospital, instead of at home, greater still would be the gain. The part of the community constituted by his family would be freed from danger, while he himself would be adequately cared for. Again we are struck by the coincidence of what is best for the patient being also best for those who surround him.
Fresh Air. Fresh air is the second great essential in the treatment of tuberculosis, and every patient should be taught to spend as many hours as possible out-of-doors. The nurse must explain in words of one syllable why this is necessary—that clean, pure air contains life-giving oxygen, and that to breathe it entails little exertion on the part of the sick lungs. On the other hand, impure air contains no upbuilding principle, but greatly taxes the lungs and makes breathing difficult. Outdoors, every breath of air is clean and pure; indoors, especially in a closed room, one is soon reduced to rebreathing expired air, with all its impurities. Just as tainted meat or spoiled fruit or vegetables are unwholesome, and bad for the stomach and general system, so is impure air harmful to the lungs and general health. One organ surely deserves as much consideration as another. And when the lungs become impaired through disease, it is still more necessary to take care of them. They need to be strengthened in every way, in order to defy the inroads of tuberculosis. The nurse must make her points clear and emphatic; if the patient takes an intelligent interest in his treatment, it will become less irksome.
But it is not enough to tell the patient why he needs fresh air—the nurse must show him how to get it. He is singularly helpless and unable to recognize such ways for himself. Also she must overcome his objections and bring him to her way of thinking. Thus, he objects to his porch because it is shaky, or because it may only be reached by passing through another person’s room. Investigation may prove the shakiness imaginary, or at least not dangerous, while the other person may be only too willing to let his room be used as passageway to this desirable goal. Again, he objects to sitting in the yard, or on the sidewalk, or even at his window, for fear of what the neighbours may say. It should be pointed out that his health is more important than their comments—whatever they may or may not be—and that his interest, not theirs, should come first. The nurse must plan every little detail; she must select his chair or sofa; must show how he can be warmly tucked up, and sit out of the wind or sun, as the case may be. She must teach the family about the hot brick and how to place it at the patient’s feet—or two hot bricks, if need be. It is not enough to say: Do thus and so—she must herself demonstrate how the thing is done. The consumptive is sick and helpless and needs constant reassuring. If he belongs to the very poor, he has little to do with, and is so ignorant that he cannot make the most of what he has. This teaching is one of the chief duties of the nurse.
Food. The third great essential in the trilogy is food. The patient’s diet is of the utmost importance, since his ability to take and assimilate nourishing food determines his ability to build up enough resistance to cope with tuberculosis. Generally speaking, he should be encouraged to eat every kind of nourishing food that he can digest—for tuberculosis does not call for a special diet as does typhoid or diabetes. Anything which specifically disagrees with him should, of course, be excluded. The question of food values must be considered; with the poor, this requires careful teaching and explanation. The nurse should point out the difference between food which merely fills the stomach, and food which nourishes and upbuilds. In the first class may be instanced cabbage, turnips, doughnuts, pies—all highly esteemed by the poor, and cheap and indigestible. In the second class are meat, eggs, milk, fish, rice, beans, hominy, oatmeal, and so forth. Some of these nourishing foods—rice, beans, hominy, oatmeal—are no more expensive than cabbage and pie. The family should be taught the difference. Very harmful and indigestible are the products of the corner bakery, the penny candies, the enormous pickles, and the copious strong brews of tea and coffee which form so large a part of the dietary of those near the poverty line. Considerable money is spent on these things—often money enough to provide a wholesome meal, if the family but knew how to discriminate. In planning a patient’s diet, the nurse will have to do as much exclusive as inclusive propaganda.
It is not necessary to insist on milk and eggs, certainly not in the abnormal quantities which a few years ago were considered indispensable in the treatment of tuberculosis. If a patient likes these and can afford them, well and good, but they need by no means be made the staple article of diet. This rich and highly concentrated food has a tendency to cause indigestion, and since this is one of the gravest and most distressing complications of tuberculosis, it must be prevented at all costs. A patient unable to digest his food has but slim chance of increasing his vitality, and little hope of improvement. Therefore, in advising raw eggs, the nurse must be very careful; one or two a day will be sufficient, over and above the regular meals.
Milk should be substituted for tea and coffee. Three or four glasses a day will be enough, and even that may be too much if the patient eats well of other things. In place of raw milk, it may be peptonized, malted, given hot, made into junket, taken in cocoa, or as one of the flavoured milkshakes, or turned into clabber or buttermilk. These varieties of milk are good for advanced patients, who may also be given egg albumen, flavoured with lemon, orange, ginger ale, grape juice, and so forth. The family must be taught to make these little innovations, in the ordinary diet, and instruction in these is part of the nurse’s work.
By careful supervision and attention, the nurse can procure a very satisfactory dietary, one both nourishing and digestible. Three good meals a day, with a little nourishment between meals and at bedtime (a glass of milk or its equivalent), will be found quite satisfactory. If a doctor is in attendance, he will of course arrange such diet as he thinks best, but if the nurse is left to herself, she will not overstep the boundaries if she advises some such plan as we have outlined.
As we have said, indigestion is one of the most frequent complications of tuberculosis. In some cases this can be overcome or relieved by advising rest in the reclining position for an hour before, and immediately following meals. If the patient lies flat on the bed or lounge, this will be more effective that if he sits in a rocking-chair.
Cooking. Cooking and the preparation of food also require supervision, for, especially among the poor, dense ignorance of these important matters prevails. Through improper cooking, wholesome, excellent food is often turned into something quite the reverse, indigestible and injurious to a high degree; or, if not ruined, it may lose so much of its food value as to be practically worthless. Thus, a hard-boiled egg or a fried egg (especially if fried on both sides) is less easy to digest than a soft-boiled one. A good piece of meat may have its entire value removed by overcooking. All nurses have had training in dietetics, and this special knowledge is of immense value in public health work, where for the most part they come in contact with a class of people whose ignorance of culinary matters is profound.