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.