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The Official Organ of the Charity Organization Society of the City of New York.

JULY 7, 1900.

I

6

VOL. V.

CONTENTS.

The Care of Families in Illness.

The Housing Problem in London.

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We will suppose that the visitor has been called to a home where there is illness, and that she is making her first visit. We will not now suppose an emergency case, in the hospital use of the term, requiring instantaneous action, but a simple case of illness, let us say, of the mother of a family.

On entering the home of the family and meeting the sick person some little practical service rendered will often do much to establish confidence and an unconstrained feeling. Whatever the most urgent immediate necessity may be, it should be learned as promptly and with as little questioning as possible, and should be relieved without delaywithout stopping for further investigations. By immediate necessity I mean that which is most important

No. 6.

from the patient's point of view, not necessarily that which may seem most important to the visitor. For instance if the visitor finds windows closed, air bad and stifling, and on the bed with the sick mother one or two small children whom she, forgetful of herself, is trying to minister to, it may seem that the first thing to do is to take the children down and open a window. Do not, however, begin thus. Take all the bad air, dirt, and confusion for granted, and pay no attention to them. Ask if there has been a doctor, and if so what he has ordered, and whether the patient is getting what he prescribed. If you find that the doctor has ordered something which the patient has not been able to get for herself, on account of the expense, and which you are able to procure for her, such as an ice-bag or some other appliance; or if there is a prescription waiting to be filled because they have not yet succeeded in borrowing the money to pay for it, get it, and thus relieve the anxiety of the moment. Next inquire whether the patient has the proper nourishment, supplementing the inquiry with your own eyes; and if not, send out and get a quart or two of milk, or a jar of beef extract, or a fresh egg, and give her a cup of nourishment. After this the window may be opened and the children taken away from the bed. If a flock of curious neighbors has come in ask all to go out save, perhaps, one, who should be chosen with reference to her appearance of hav

ing common sense and kindness. You can now sit down and get acquainted; and if the patient is too weak to talk, make your inquiries from one of the family, or, if there is no one else, from the neighbor.

To be able to plan the best course for the family where there is illness, all the circumstances of the family must be learned. There are, however, some special inquiries relating to the illness. Learn the doctor's name, address, and whether he is free or pay; how often he comes; what amount of interest he takes in the affairs of the family; whether he has given any advice outside of mere treatment, as to seek hospital care, or to call a nurse. When he can be seen in case it is desirable to confer with him. Get as much light as possible upon the cost of the illness so far; whether it has been necessary to run into debt, or whether savings have been encroached upon. Inquire into the care she has had and how nearly adequate it has been. Find out especially what the neighbors and relations have done, and how far they may be counted upon to continue their aid. Their voluntary services should be encouraged. If they receive the impression that by the coming of the visitor they are dismissed from all further interest, and that everything will be done by the charitable society, they will drop away and leave to the visitor complexities with which she, if inexperienced, may be quite unable to cope alone, but which, under friendly cooperation, resolve themselves into manageable details.

The advisory powers of the neigh bors are not to be despised. They know all one another's affairs, and often see homely, practical expedients and ways out of trouble which the visitor would not think of. While, of course, their views should not be accepted blindly, and in

some cases not at all, yet sensible suggestions are often to be had from them. They are not to be learned by having a crowd in the room all talking at once, but by conferring individually with those in whom the patient feels special confidence.

It does not often happen that the visitor can come to final conclusions, or plan out the whole management of a case upon the first visit; nor would it always be wise to do so. However, in illness, more than in almost any other situation, should the visitor be able to imagine herself in the invalid's place. Do not go away without doing something definite, something which will relieve the anxiety of mind of the sick one, and give her confidence. Make some provision for the next twentyfour hours-either by ordering nourishment and stimulant, or by providing an attendant, or by promising to send clean clothing or appliances, or perhaps by doing all these, if they are necessary.

When it is a question of hospital versus home care, the problem will be easiest in case of a child; more difficult in case of a father who is a wage-earner; and most difficult in the case of a mother with small children. Hospital care would be advisable under such circumstances as the following, speaking generally, but not now with reference to whether the patient is a child or an adult:

a. When the illness is of such a nature that some definite treatment is required which can not be had at home, or some condition necessary for recovery can not be complied with. Examples: a fractured leg which needs to be suspended, and a case of brain trouble where the surroundings are inevitably noisy. In this case one should not be influenced by the fact that the home might be fairly comfortable, and the family intelligent and kind.

b. When the expenses of illness are likely to constitute a drain which might involve the family in debt beyond their power of recovery. In such a case, although the illness itself might be of such a character that it could be taken care of at home quite satisfactorily, this fact should not be held important. It would seem unnecessary to make this statement, yet actual experience shows that it is often extremely difficult for the family of a sick person to foresee the financial disaster which we know often comes upon them as the result of a long illness.

Warnings as to the expense are often given in vain, to be regretted later. It is a pity that physicians often do not realize this side of the family's position. Even although Even although they have no personal interest in keeping the patient at home, and are treating him free; yet they often, simply by failing to grasp any but the professional aspect of the case, nullify all the visitor's efforts by assuring the family that hospital is not necessary, that the patient will recover just as well at home. This may be quite true, but at the end of the illness the family is ruined, and becomes a burden on charity. I have known of illnesses in tenement-house families which have cost $60, $75, and $100, and even sometimes $200 or $300.

c. When the presence of the patient in the home or the attendant overwork and care is likely to break down or definitely injure the health of another member of the family. This, too, is often overlooked. It can never be anything but a mistake to make one person ill while trying to make another one well. Such conditions might be caused by various contagious diseases, although I do not refer to them exclusively.

d. Hospital is of course advisable when poverty is so extreme that al

most the whole cost of the case comes upon charity, or when crowding is so close that the invalid can not have the necessary privacy.

To consider individuals as such it may be said, generally, that one should hesitate to advise hospital in the case of a nursing infant unless the mother could go with it; only in very exceptional circumstances would it be best to remove it, and such a decision should be made only. by a responsible physician.

With older children one need not hesitate to advise the hospital. Children are happy in the hospital, and do well. The parents are often loth to part with them, believing they will be homesick and fret. This, however, is a mistake.

A sick man--husband or father-may also be freely urged to go to hospital. The task of nursing him will only be an added burden for the wife, who may need to take his place for the time as a wage-earner; and money laid out upon medicine, medical attendance, etc., for him in the home might be better applied to the support of the family during his absence.

In the case of the sick mother the circumstances are very different. If her removal to hospital does not involve breaking up the family, then she may be advised purely from the medical standpoint, as is best for herself. If daughters or a sister can keep the home together, well and good. If, however, the home depends on her, she will be unwilling to go, and the question of what is best for her solely from a professional point of view cannot come first.

All the circumstances must be carefully balanced. The nature and severity of her disease and its prob able duration; her chances for recovery at home; her chances in hospital; the costs involved in her care at home, and in the care of the family in case of her removal,

whether the life and comfort of the family will be likely to suffer demoralization if she remains, as sometimes happens; what the probable effect on their moral and material well-being would be if the home were broken up; what would become of the husband, the children, and the furniture; and how they could again be re-united.

Speaking generally, one may say that the home should be broken up only as a last resort. One would in every way try to manage so that this shall be avoided. It should, however, be noted that if the husband is obliged for any length of time to cease wage-earning in order to perform the duties of nurse and housekeeper, no good object is gained. The patient is at a disadvantage, and all the disorganization which you aim to avoid will fall upon the family sooner or later, so that this arrangement is never anything but a mistake or a misfortune. Rather than adopt it, the mother should be persuaded to go to hospital.

Breaking up the home need not of necessity mean final break up. The little children should be placed out with the most conscientious relatives, or in a suitable institution. As a nurse, I would say that the care of good relatives or friends would be better for them than any but really ideal institutions, but that fairly good institutions are better than bad relatives. The older children and father can look after themselves in the rooms; if there are no older children, the father could sleep in his rooms and get meals outside; or, if able to pay the rent, he can lock up his rooms and live elsewhere. If there is no father, all the children will have to be provided for, and the furniture stored away. To engage and pay a woman to come in and take charge of rooms and children might be a good plan, if the ideal woman could be had-trustworthy,

intelligent, and industrious. It is so hard to find her, however, for such a position, at least in large cities, and her wages would be so considerable, that this is practically out of the question.

It is, perhaps, not necessary to mention mention the necessity of being thoroughly familiar with the specialization and limitations of hospitals. incurable and chronic homes, and other institutions, in order to know just where to apply in certain cases. Some hospitals, for instance, will not admit patients with puerperal sepsis; others will not admit phthisis. One needs to be become experienced in the classification of cases, in order not to lose prestige with the hos pitals by asking them to take the wrong ones-a procedure that wastes time and causes trouble.

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When the patient, for proper reasons, does not go to hospital. she should be well and generously cared for at home. We do not find that it pauperizes people to supply their needs quite freely during illness, or, if they can themselves provide the needs, to bestow various little luxuries upon them. Well-todo people receive many gifts, in illness, of food, conveniences, and comforts. Why not the poor also? Nor do I think that it is improper for several charitable agencies to contribute at the same time toward one sick case, if one alone can not well take the whole cost, provided that they agree together and work co-operatively. They may each be specialized to give one kind of thing, and their united gifts will supply all the patient's needs. One society, for instance, will give milk daily; another will agree to pay a month's rent; another has wine, jelly, or fruit to distribute; another keeps bed linen and appliances. Of course, there may be places where all these functions are united in one society.

Adequately to care for the sick poor in their own homes the following conditions should be complied with:

1. The patient should have a bed alone. If necessary a cot may be loaned.

2. She should have a daily bath and enough changes of bed linen to keep her clean.

3. She should have sufficient nourishment of the proper kind furnished continuously. As a general statement one might say, at least one quart of milk daily-often more,one or two fresh eggs, and one or two cups of beef tea or soup.

4. She should have the appliances requisite for comfort and treatment; bed-pan or douche-pan, or ice-cap, or hot-water bag, or surgical dressings, etc., etc.

5. There should be some one to give her food and medicine by day, and, if the illness is critical, by night also.

6. Beside her own laundry the family laundry must be seen to. If there is no one else some one must be paid to do the washing and occasional scrubbing.

Beside the nursing, there will be watching and friendly advice needed for the rest of the family, the children encouraged to keep tidy and help in the house, and the comfort of the husband, if the wife is sick, arranged for in little ways.

The management of contagion is a difficult subject. Speaking academically, all contagions ought to be isolated. Practically this is impossible in the homes of the poor. In working with such cases you will not find it possible to rise much above the standard set by your board of health, whatever that may be. The towns are few where there is sufficient hospital provision for scarlet fever, owing to its protracted convalescent period. Measles is hardly hardly even considered,

Severe

and chicken-pox still less. cases of scarlet fever should, if possible, be sent to the hospital. All cases of diphtheria had better be sent there; although with the use of anti-toxin, which some cities provide free for the poor through boards of health, this contagion is no longer so terrifying. We feel, in our work, that typhoid is more of a menace than a mild scarlet fever or even a mild diphtheria. Under the circumstances existing in our crowded tenements, we have rarely known of a case, left at home, where a second case did not develop, and in some instances six and seven members of the family, in periods of time which showed successive infections from the first case; whereas we have innumerable times watched scarlet and diphtheria where no second case developed.

There is also, practically, no such thing as isolation of tuberculosis. And in the case of a gonorrheal or syphilitic member of a family not only would such a thing as isolation be unheard of, but also medical care does not always extend to cautioning and instructing the patient against infectious contact. with others. Yet the former infection, conveyed by towel or handkerchief, may cause the most virulent inflammation of the eyes, with not infrequent loss of sight while the latter may poison a second person through even a slight cut of the finger.

About all that a visitor, or even a nurse,can do in regard to contagions, is to instruct people in the mode of transmission of different diseases, and so enlist their intelligence in the specific mode of disinfection; special attention being given to the following points:

That the germs of phthisis are in the sputa, and that these should be burned, and dishes used by the patient boiled.

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