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SI 'S I t PULMONARY TUBERCULOSIS ITS MODERN PROPHYLAXIS AMI HIE THHATMHNT IN SPECIAL INSTITUTIONS AND AT HOML AI.VAkliNCA PKIXH hSSAY (^F THE COI.I.HGE OF PHYSICIANS OF I'HILADLLt'HIA FOR THK YI-;AR i8f;8 Kl-VlSbD AND ENLARGF.D BY • S. A. KNOPF, M.l). (Pakis and Bi: llk \ uic . N. V.) FIIVMCIAN TO 1IIK LlNli IIPI^AKTME NT OF IIIH NRW VOKK THIIOAT AMI NoSK IIOSI-ITAI. ; POKMKK ASSISTANT PIIVMIIAN to HKOFHSMiR HinTWKIirK, KAIKKSSTKIS SANATUHllM, (iKKMANY ; VU K IHPMIIKNr OK TIIK TRNNMI VANIA SonKlY HOH THK I'K'VKNTION OH Tl BKHI IT.OSIS; FHI.OW Ol' IHH AMKKUAS A( ADKMY AMI OH Hi E NHW Y^'HK AIAIIKMV OH MllllrINK; I Al KEATK OH THK AIAUHMV OP UKKICINK OH I'AKI^, HTt. ■^TH] ■ ■.! JW IL - ^^ lUith E>Ci?cru>tloiis? .1n^ llliunratione nl 1(11' MOST IMI'OKTANT SANATOIUA OK I'.lKi 'IT, Till , I'MIRP STAli;s, AN1> CANADA H .; E .• i .,6 i ).v .;< ,sr.<.;i' r, vv.c. ni;i \i»i;i.i'iiiA P. in.A K I s ro X's son ^v co. loi 2 w A I. NT 1' s rKi.i: r 1899 C0I'VKI(,MT. 1899. BV S. A. K\(M'K. M.D Press or Wm, F. Fk l & Co, I230*34 Sansom St., PHILAUtLPHIA To thf: t>v>(i(cnf6te, Statesmen, an^ pIMlaiUbrorisits and Tin; /i^aiu} Hoblc /iRcn an^ lUotncn insidi: and ol tside of TUL MliDICAI. PROI"ESSI()N WflO LABOR AND IIA\F. LABORED ON BEHALr Ol- Tl'BERCULOL'S INVALIDS. AND WHO HA\E HELRFD TO DEMONSTRATE THAT CoNSl .WPTION IS A PRE- \LNTABI.E AND ClRABLi; IJJSEASE. CONTENTS. PACK Introduction "'■' CHAPTER I. Interesting Data in the History of 'ruberculosis, 17 CHAPTER II. Mortality from Tuberculosis 27 CHAPTER HI. Palliological Proofs < if the Cural)ility of Pulmonary Tuberculosis 3! CHAFFER IV. The Communiral)ility of Puhnonnry Tuberculosis and the Means to combat its Pro- pa};ation l)y Individual Prophylaxis, 35 (<;) Infecti(m by Inhalation. (d) InftHtion liy Ingestion. (pitals, Homes, Camps, and Colonies for Tuberculous Patients 188 CHAPTER X. Climatotherapy, 200 CHAPTER XI. Description of an Ideal Sanatorium for the Treatment of Tuberculous Patients, . 204 ix ( X CONTENTS. CHAl'TKk XII. TAGK ASrolhorapeutics, Rest Cure and Exercises 213 CIIAI'TKR Mil. The Pneumatic Cabinet in the Treatment of I'lilmonary Tul)ercuIosis 218 CHAriKK XIV. ilydrotiierapeiitics in the (leneral Treatment of I'lilmonary Tulterculosis, .... 226 CIIAI'TKR XV. Personal Hygiene and Dress of Tuberculous Patients, 234 CHAPTER XVI. Dietetic Trei .inent, 237 CIIAI'TKR XVII. Symptomatic Treatment, 244 CHAPTKR XVIII. Laryngeal Tuberculosis and Intercurrent Diseases, ...... 268 CHAPTER XIX. Educational Treatment, Prognosis, Marriage, and Cliildbiith, 277 CHAPTKR XX. Tuberculin, t)ther Culture Products, Serums, etc., in the Treatment of Pulmonary Tuberculosis, 286 CHAPTKR XXI. Consumptives in Health Resorts; .Sports, etc. , 290 CHAPTKR XXII. The Treatment of Consumptives in Special Hospitals 294 CHAPTKR XXIII. The Treatment of .Anilnilant Tubereulous ratlents in Private and l)i>pensary Pr-ictice 297 CHAITKR XXIV. Treatment of Consumptives nl their Home-s, , 302 t:iIAPTKR XXV. Special Institutions for the C'onsumptive Poor; Care by the Authorities, and the .Social Probl-m of Tuberculosis, .... 307 CII.U'TKR XXVI. Clinical Evidences of the Curability of Tuberculosis hy the Hygienic and Dietetic Treatment. Conclusions, 328 LIST OF ILLUSTRATIONS. PIG. I. 2. 3. 5- 6. 7- 8. to. II. 12. «.?• M- '5- i6. 17- i8. iq. 20. 21. 22. 23- 24. 25- 26. 27- 28. 29. 30- 31- 32. 33- 34- 35- 36. 3/- 38- 39- 40. 41- I'Al.K Dr. Hermann Brehmer, 24 Dial Showing Ki'lalive Morlality from Various Diseases, ,?o 4. Dr. Knopf's Elevated SpillooTi for Hospital and .Sanatorium Use. Figure 3, plan ; figure 4, elevation . . 38 Elevated Spittoon with Stand, 39 Dr. I'redoelil's Spittoon for Factories and Workshops, 4I Spit tenll.'istlichen," 42 Dr. Knopf's Pocket Sputum Flask. «. Closed. /'. Taken Apart for Cleaning, 43 Prof. Fraenkel's Moutli Mask, 44 First and Second Respiratory Exercises, 83 Third Respiratory Exercise, 84 Exercise for Patients in the I laliit of Stooping 84 Falkenstein Sanatorium ((leiieral View) 92 X'eranda at Falkenstein, 93 Main Building of the Sanatorium at Ru|>p('rtshain, 95 .Main Huilding of Dr. lirehmer's Sinatoriuin, Cloerbersdorf 97 Winter-garilen of Dr. lirehmer's Sanatorium 99 Sanatorium of Dr. Roenipirr, lol Liegehalle of Dr. Roempler's .San.itorium, 102 General View, I.iegchalle, and Dr. Weicker's Canip-lied at the Pueckler Sanatorium, '03 Villas of Dr. Weicker's Krankenheim 104 Hohenhonnef Sanatorium, I06 Plan of Hohenhonnef Sanatorium 107 Sanatorium at Reiholdsgii'ni '09 Rest Cure in the Wood-, at Reiboldsgriin HO Oderherg Sanatorium, ''5 Rest Cure (lallery of the Canigou Sanat.orium, 117 Maritime Hospital at lierck sur-Mcr 1 19 Dr. Turban's Sanatorium, Davosplatz, 122 A Kiosk at the I.eysin Sanatorium 125 Sanatorium of Tonsaasen 126 Alland Sanatorium, 1 29 Royal Hospital for Consumption and Diseases of the Chest at Ventnor, ... 131 Ho.spital for Consumptives, I!rompt-.)n (London), 133 .\dirondack Cottage Sanitarium, Saranac Lake, X. V. , 140 Main Huilding of the Adirondack Cottage Sanitarium 141 Some Cottages of the Adirondack Cottage Sanitariinn. (Smniner View), . 143 Some Cottages of the .Adirondack Cottage Sanitarium. (Winter View), . . 144 xi xii LIST OF ILLUSTKATIONS. no, PAliK 42. (IroiiiKl rinii of McAliiin CniwiiiK rnoin nt till' l.(>ital for Consumptivrs, 165 53. .Sharon Sanitarium, 166 54. Massachux'tts Stati' I lospilal for ConMimptives, 16S 55. CIcnrral View of the I'ri'f Home for Consumptives in the City of lloston, . . 170 56. I'lan of the I'lee I lomc for Consumptives in the City of lioston, 172 57. .Vshi'ville Sanal( ri.nn, 174 58. Main lluildinn of (he Sanatorimn Hyjjeia at Cilronille 175 59. CottancH of the Sanatorium Hygeia at Citronelle, 176 60. " 'I'lic Home" at Denver, Colorado, 178 61. MusUoka Cotla^i- Sanatorium 183 62. A Cottage iif Muskoka Cottage Sanatorium, 184 63. I.aurentian Sanatorium 186 64. Perspective \'ie\v of an Ideal Sanatorium for Consumptives. I,ar|»c Pavilion System, /v/^ctv;/ 204 and 205 65. Plan of the Ideal Sanatorium 206 66. Plan of the First Story of One of the Pavilions, 208 67. Corner of Veranda, with .Adjustahle Chair for Kest Cure 2Io 68. Usual .\ttilude in an Ordinary t'liair, 2l6 69. Prof. Usedom's l!realhin(; chair, 216 70. Pnennialic Cabinet 220 71. Tuhe with Nose-mask, 222 72. Dr. llaruch's Douche .Apparatus 227 73. Di.ifjram of (Water ) Cooling Apparatus 229 74. Vestsuspei\r mnii tn caiisp all parn^lUc (llsense* to liliapiteni from tlie worlil." — A. I'itslriir. In tin's age of rapid printing and in view of the vast and exten- sive literature daily produced on nearly all subjects in medicine, one should pause and think, and offer good reasons for writing another medical book. Tuberculosis pulmonum is no new disease, and countless are the books and monographs written on its thera- peutics. Thus, in offering to the Knglis.i-speaking medical world, and especially to the medical profession of the United States, to which I have the honor to belong, a new book on the treatment and prevention of pulmonary tuberculosis, I must give weighty reasons for doing so. First, I maj' say that I had been encouraged to write this work by a number of my colleagues of the United States and l-'ngiano, who had honored me by reading my French thesis, which procured me the final degree at the faculty of medicine of the University of Paris, in June, 1895. It was entitled " Les Sanatoria: Traitement et Prophylaxie de la Phtisie Pulmonaire." Another encourage- ment to write down in book form the newer ideas and experiences of what I like to call modern phthisio-therapy I found in the interest which was manifested in my occasional addresses before American medical bodies, and the very kind reception which was accorded to the communications on this subject by the medical press of this country. But, aside from these encouragements, I felt that there was a need in the United States of spreading the ideas and principles of the modern management of pulmonary tuberculosis — ideas of which I witnessed the best fruits during my stay abroad, especially in Germany and in England. That the College of Physicians of Philadelphia honored my work with the Alvarenga prize for the year 1898 is, perhaps, the best evidence that I had not been mistaken in thinking that the appearance of a book on the .sanitation, hygiene, hospitalization, xiii XIV INTRODUCTION. I and treatment of tuberculous patients of all classes of society mi<;ht find a just recognition in this country, and help to show that consumption is, indeed, a preventable and curable disease. I have arranged the Alvarenga prize essay in chapters, more suitable for publication in book form, and reinserted what I had necessarily left out in regard to personal experiments and works previously published.' I have also added a short historical chap- ter containing some interesting data in the history of tuberculosis. But the most considerable addition to this essay, and one which, I trust, will increase the interest in the book, is the description and illustration of some of the most important sanatoria, special hospitals, homes, etc., for the exclusive treatment of consumptives. My object in presenting this Ijook to the English-speaking medical world is to give the latest thought of the leading Euro- pean and American hygienists, sanitarians, and physicians on the subject in question, in addition to the results of my own studies and researches in the field of phthisio-therapeutics. These have been gained by years of active practice and actual living among tuberculous patients in hospitals, sanatoria, and American and European health resorts. The desire to study this disease more thoroughly, with its treat- ment and prevention, dates back to my early medical career in my former home in Los Angeles, Cai. There, where thousands of consumptives from all over the United States flock in, winter after winter, many of them hopelessly advanced in their disease, others with insufficient means to ei'able them to be idle long enough to get well, all believing that the glorious climate of Southern Cali- fornia alone would suffice to restore them to health, I was much impressed with the urgent need of a more timely and systematic treatment independent of climate. The perusal of the best Amer- ican and foreign literature on the subject gave me the first idea of the feasibility of such a method. But I believe I have especially enriched my experience in regard to the difference between sanatorium and health-resort treatment by an extensive trip, in wliicli I visited, in both continents, some thirty sanatoria, special hospitals, and numerous lieatth resorts con- secrated exclusively to the treatment of pulmonary tuberculosis, ' As is customary in an essay desliiied to cuiiipelc lur a pii/.c, any lufiUiDii of |)re- vioiis works whereby the iileiility of tlie author might he revealed must be carefully avoided. INTRODUCTION. XV I am lastingly indebted, however, to my distinguished teacher, Herr Geheimrath Dr. Dettweiler, of the Sanatorium Falkenstein, who appointed me his assistant at the conclusion of my studies in Paris. During my service in his institution I believe to have had rare opportunities to study the treatment and management of tuberculous patients in closed establishments. On my return to the United States I began a series of e.xperiments with Marmor- eck's antistreptococcic serum in the mixed infection of pulmonary tuberculosis. Professor Hermann M. Biggs, of New York, very kindly placed at my disposal the necessary laboratory and clinical facilities to carry out these experiments, and I desire to express here my gratitude to him for the many courtesies extended to me. I shall speak of these expeiiments under the heading of Symptom- atic Treatment. Since my appointment as Physician to the Lung Department of the New York Throat and Nose Ho.spital, I have endeavored to study how best to manage and treat our dispensary cases. I consider this subject most important, and have devoted a chapter to it. As to the results of the treatment of consumption in its various stages by what is commonly known as culture products, tubercu- liiies, etc., I will state what I have seen and learned from the many attempts in this direction, and will give my reasons for preferring the hygienic and dietetic method in either a closed establishment or under careful medical supervision at home. Under the chapter of Acrotherapeutirs I will describe my modified method of the use of the pneumatic cabinet, and under Dietetic Treatment I will sum- mari/.c my reCLnt experiments with tropon. During my visits to the sanatoria of Europe and the United States I have been everywhere so cordially received that I find it a pleasant dutv to thank all these gentlemen (directors and their assistants) once more for their helpfuhiess in making my I'oyni^e (i'iliidc so profitable. To compile the statistics on the pathologi- cal and clinical evidences of the curability of tuberculosis pulmo- num T addressed several hundred letters of inquiry to the leading medical authorities of this country and of luirope. Many honored me by replying in full to my questions, and to all of these I wish to express my gratitude. In chapter ix I give a list of sanatoria, special hospitals, homes, camps, and colonies existing in various parts of the world devoted to the treatment and care of consumptive patients. I do not claim XVI INTRODUCTION. that this list is complete. Throughout the civilized world there is now a movement in favor of such institutions. In Germany and Austria these enterprises, best calculated to combat the spread of consumption among the poorer classes, are especially active and enjoy the support of royal personages and of the general govern- ment. Hardly a month passes that some German city does not form the project of creating a sanatorium for its consumptive poor. For information concerning the work done in Austria, England, France, Germany, Italy, etc., since my last visit to those countries and in the countries I could not visit, I am particularly indebted to Professor von Schrotter, of Vienna ; Dr. F. R. Walters, of London ; Dr. L. H. Petit, of Paris ; Dr. Georg Liebe, of Loslau, Germany ; Dr. Massalongo, of Verona, Italy ; Dr. Klaus Han.sen, of Bergen, Norway; Dr. Charles Saugman, of Horsens, Denmark ; Madame Paolovvskoja, M.D., of St, Petersburg, Russia; Dr. Sand- fort Jackson, of Brisbane, Australia. Lastly, I desire to express my thanks to the many State and city health officers of the United States, who so promptly an- swered my inquiries about the provision for consumptives in their re.spective States and cities, and their laws and regulations con- cerning bovine tuberculosis. Notwithstanding the care I believe to have cxerci.sed in writing this work, it will be far from perfect. There will be errors by omission, and probably also some by conmiission ;• for these I ask the indulgence of the reader. The book does not claim the title of a te.\t-book ; my earnest and only desire in publishing it is to endeavor to aid the sanitarian and hygienist in their labors to combat the spread of tuberculosis. I would show to the statesman where his duty lies in regard to a disease, which is as much a social as an individual physical affliction, and I hope to indicate to the philanthro^jist how he may best aid the tuberculous poor and render the greatest service to the community at large. Finally, if the present work will aid some of my fellow-physicians in the man- agement and treatment of that complex disease known as pulmo- nary tuberculosis, or phthisis pulmonalis, and if through my con- freres, the general and family physicians, the public will learn at last that consumption is, indeed, the most preventable and curable of diseases, I shall feel that my labors in the field of modern phthisio- therapy have not been in vain. i6 West Ninkty I'inii Strkk.t, Nkw York, PULMONARY TUBERCULOSIS ERRATA. f)n page 64 (tenth line from below), instead of " vigorous measures'" read " rigorous measures." On page 247, where it reads " for two suppositories, to be applied within twenty-four hours," read " for four suppositories, to l)e applied within forty eight hours.'' On page 252, where it reads " Synip. linionis, 3J»" it should read " Syrup, limonis Sj" And instead of " Acjua', q. s. ad .^Jiv," it should re.id " Aipifc, q. s. ad ,^iv. " On page 262 (fourth line) it should read "exacerbations'" instead of "exas- perations."' On page 272 (thirteenth line), instead of "stage of ulceration" it should read "stage of resoiulion." On page 289 (eighth line), instead of "exasperation" it should read " exacerbation." ' "''"'"; '/I' '•? "/»,V'/'-' "f/'"-fi'"'/ i'/iijc ;()fr«i( (" if the patient [consumptive] is treated from the beginning, he will get well''), Hippocrates, vol. vu, p. 77. From Littre's I'rench translation. - I'rancis Adam's translation of Hippocrates; quoted from Lawrence V. Flick's " The Contagiousness of rhthisis," Philadelphia, 18S8. ' Aretivus, chap. 111. " I)e raorborum diuturnorutn et acutorum causis, signis et curatione." 17 XVI INTRODUCTION. tliat this list is complete. Throughout the civilized world there is now a movement in favor of such institutions. In Germany and Austria these enterp'-ises, best calculated to combat the spread of consumption among the poorer classes, are especially active and enjoy the support of royal personages and of the general govern- ment. Hardly a month passes that some German city does not form the project of creating a sanatorium for its consumptive poor. For information concerning the work done in Austria, England, n nary tuberculosis, or piunisis pumionaiis, anu ii inrougn uiy con- freres, the general and family physicians, the public will learn at last that consumption is, indeed, the iiiost preventable and curable of diseases, I shall feel that my labors in the field of modern phthisio- therapy have not been in vain. i6 West Ninetv-kiktii Street, New York, PULMONARY TUBERCULOSIS CHAPTER I. INTERESTING DATA IN THE HISTORY OF TUBERCULOSIS. In this chapter it is not intended to give a complete history of pulmonary tuberculosis, — a disease known to the medical writers of all ages, — but only to put in relief some of the interesting data in connection with the various views that have been expressed on the contagious nature of this disease and the methods of treatment instituted. Hippocrates, the father of medicine, who lived from 460 to 377 B. c, gave us the first ideas in regard to judicious exercise and the rest cure when he told us (vol. vii, 1 49) to have the patient walk if h', jls benefited thereby ; if not, to rest as much as possible. The hereditary tendency he mentions in his aphorisms (sect, iv, S). He also believed in the curability of the disease,^ but we see nowhere any mention of its contagious nature. Isocrates, who lived about the fifth century before Christ, and who shortly preceded or was a contemporary of Hippocrates, taught that consumption was contagious, but he apparently had few disciples.- Aretaius,^ supposed to have lived about the year 250 n. c, has ' OiTof !/v ff i'ip,xi}(: fteiiuTTFi'O/j i'>/;)f ;/'i'frii( (" if the patient [consumptive] is treated from tiie beginning, he will get well"), Hippocr.ites, vol. vil, p. 77. From Litlrc's I'rencli trniislation. '' Francis Adam's trimslation of lli[)pocrates; quoted from Lawrence F. Flick's " The Contagiousness of Phthisis," I'hiladelpliia, 1S88. ' Aretxus, chap. in. " De rnorboruni diuturnorum et acutorum causis, signis et curatione." 17 i8 PULMONARY TUBERCULOSIS. * ,! given us excellent indications concerning the management of phthisical patients. He prescribed the sea-coast as a residence, and recommended sea voyages and e.xercises followed by rest and friction of the skin. Milk diet he considered of great importance in the treatment of phthisis. Celsus (30 B. C.-50 A. D.), the Latin Hippocrates, recommended a life in the country for the weaker tuberculous patients. For the more robust ones he prescribed sea voyages. Pliny ^ the elder (73-23 b. c), though his views in medicine were rather empirical, ascribed a most beneficial action to the sun and to the air of pine forests in the treatment of phthisis, Galen 2 (131-200 a. d.) used to send his patients to higher altitudes, believing that the drier air of the mountains would heal the ulceration of the lungs. Impure air he considered an impor- tant etiological factor. He was probably, next to Isocrates, the first to think of the contagious nature of pulmonary tuberculosis. (" Poriculosum prastera est consuescere cum his qui tabe ten- entur.") We must now look to the Arabic school of the tenth century for further light. Avicenna^ (980-1037 A. d.), the most celebrated Arabic physician of that time, believed in the contagious nature of phthisis. He chose mountain climates for his consumptive patients, and he and his pupils recorded the first authentic cures of the disease.** From the eleventh to the sixteenth century little of importance happei.id in the history of medicine. But with the renaissance medical science also arose from its slumbers. Jacobus Sylvius ^ (1478-1555), whose real name was Dubois, gave the first exact description of the tubercle, and seems to have had an idea of the close union of scrofula and tuberculosis. Falloppio ( 1 523-1 562) was evidently a firm believer in climate as a factor in the treatment of phthisis pulmonalis. He was elec- 1 Littrt, " L'hisioire de Pline," 1848. ' Boissfau, " liistorique de la cont.igion de la plitisie pulmonaire." Dans le recueil de iti£moires de medecine, chirurgie et pharmacie militaires. 3 .ser. xxil, niai 1869. ' .\vicenna was born in Persia and liis real name was Abou-Iba-Sina-Avicenna. " Arabuni medicorum principes canon nicdicincu " (Hoisseau). * Manasse, " Die Heilung der Lungentul)erkulose," Berlin. 5 Predoehl, " Die Gescliichte der Tuberkulose," 1888. INTERESTING DATA IN THE HISTORY OF TUBERCULOSIS. 19 tive in the choice of localities, and was guided in this by the temperament and constitution of the patient. Montano, who lived at the same period (1550), was a strong par- tizan of the theory of contagion. According to him, one could contract pulmonary tuberculosis by simply walking witli naked feet over the expectorations of a patient. Lazare Riviere, of Montpellier( 1589-165 5), was also a strong but a more scientific believer in the contagious nature of tuberculosis. He maintained that the transmission of the disease through co- habitation was much more frequently the cause of its development than the hereditary influence. Van Helmont (1577-1644) believed in mountain and warmer climes for the phthisical invalid, and had the courage to recom- mend wine as an antipyretic. Willis, of London (1622-1675), considered the Riviera as espe- cially conducive to the reestablishment of tuberculous invalids, and was in the habit of sending the majority of his patients across the Channel to the southern portion of France during the winter. Baglivi (1669-1707) deplored the inefficiency of medicinal remedies, and has left us a long description of the different regions particularly favorable for consumptives. The celebrated Sydenham, of Westminster, London (1624-1689), must have believed in vigorous exercise, for he maintained with certainty to have saved several phthisical patients through horse- back riding.^ Friedrich Hoffmann (1660-1742) believed in moderately warm and moist atmosphere as best suited to consumptives. Morgagni (1682-1771) was, perhaps, next to Montano, the great- est believer in the -.contagiousness of tuberculosis pulmonum. He absolutely refused to perform an autopsy on individuals who had died of consumption. 2 Boerhaave (1668- 1738), while not speaking in any of his writings of the contagious nature of phthisis, nevertheless made it a rule to send his patients away from the locality where they had contracted the disease. Van Swieten (i 700-1 772), Boerhaave's most celebrated pupil. ' Dupri de Lisle, " Trail6 de maladies de la Poitrine connus sous le noni de Phtisie Pulmonaire," Paris, 1769. ^ Opera omnia physio-medica, vol. ill, de affeclione phthisici sive tabe. 20 PULMONARY TU13EKCULOSIS. '<{ followed the teachings of his master in regard to therapeutics, but was a convinced contagionist. Dupre de Lisle, in his book which appeared in 1769, speaks favorably of horseback riding as a therapeutic means in consump- tion, but insists that this exercise should be regulated by the physician, and he recommends country life in addition for this class of patients. In the library of the Surgeon-General of the United States Army' is to be found a work, dated London, 1747, entitled " A letter from a physician in the Highlands to his friends in London." The author of this work remains, however, unknown. There we find for the first time the idea expressed that the hygienic and dietetic treatment is the most important factor, and that climate and medicines are only to be considered as niore or less precious adjuvants. He quotes cases, of incontestable proof, of patients having been cured in their home climate by judicious diet, careful living, and moderate exercise, without the aid of any medication. The contagious nature of tuberculosis must have been a popular belief toward the latter part of the eighteenth century. Jeannet de Longrois, in his" Traite de la pulmonic," "tells us of an incident at Nancy, where the municipal authorities had caused the furniture and bedding of a woman who had died of consumption (femme pulmonique) to be burned. The woman had contracted the dis- ease from another one with whom she had often shared the same bed. In Naples, a royal decree, dated September 20, 1782, ordered the isolation of consumptives and the disinfection of their apartments, personal effects, furniture, books, etc., by the aid of vinegar, brandy or lemon-juice, sea-water, or fumigation. Any violation of this law was punished, if the individual was an ordinary mortal, with three years in the galleys. If he happened to be a nobleman, he was sent for the same time to a fortress, and had to pay three hundred ducats. The physician who failed to notify the authorities of the existence of a tuberculous patient was fined three hundred ducats for the first offense. A repetition of the neglect would banish him from the country for ten years. Any one aiding a consumptive to escape was fined and imprisoned for six months. Portal (1742-1832) wrote that in Spain and Portugal the parents ■ Index Catalogue, vol. viil, p. 70. » Paris, 1 781. INTERESTING DATA IN THE HISTORY OF TUUERCULOSIS. 21 of a consumptive were obliged to notify the authorities when the patient had arrived at the last period of the disease. This was done for the purpose of securing the disinfection of the personal effects of the patient. A similar regulation prevailed at that time in Languedoc' Toward the end of the eighteenth and at the commencement of the nineteenth century much discussion concerning the etiology, pathology, and treatment of tuberculosis was carried on in the various centres of medical learning, without bringing forth any new facts concerning this complex disea.se. Brou.ssais ( 1 772-1 838) ■ applied his general theory of inflamma- tion also to the lungs, and bled his patients, not only in the first but even in the more advanced stages of the disea.se. In his chap- ter " Traitement du deuxieme degre de rinflammation " he says : " J'ai saigne dans ce degre de phlegmasieet les malades sont morts, j'ai epargne leur .sang et je n'ai pas ete plus heureux ; j'ai cependant obtenu plus de guerisons avec la saignee que sans le secours de ce moyen." Thomas Reid, of London, in his work entitled " An Essay on the Nature and Cure of Phthisis Pulmonalis," which appeared in London in 1785, draws again the line of distinction between tuber- culosis and scrofulosis. He considers contagion a rare incident, and only due to cohabitation. lie recommends vegetable diet and milk as essential in the treatment of tuberculosis. At times he thought bleeding beneficial, but warns against its excessive use by saying that of all diseases human flesh is heir to, in none has bleed- ing been so frequently resorted to as in phthisis, and he thought that the old saying " the lancet has killed more people than the lance " was particularly applicable in this case. Reid believed in the curability of tuberculosis of the lungs on the same ground that he believed in the curability of diseases of other viscera. A most singular opinion was expressed by Cullen, of Edinburgh (1700-1790), in regard to the contagious nature of tuberculosis. He claimed that a warm climate was essential before contagion could take place. Hufland ■' (1781-1827) believed in hereditary influence f .id a ' .Straus, " I.a (uberculose et son bacille," Paris, 1S95. - Hroiissais, " llistoire de i)hlep;masie chroniques," 1826. ' Hutlaiul, " Ueber die Xaliir, Erkeniitniss, uiid lieilart der Scropliel-Krankheit," Berlin, 1S19. 1 1 \i K ■if 22 PULMONARY TUBERCULOSIS. predisposition to the disease, but he disbelieved in the possibility of contagion /iT .ft'. Me and his contemporary, the distinguished Schonlein (1793- 1864) were, however, strong advocates of climatic treatment.' Schonlein particularly thought to have observed immunity from this disease among the people who had lived their entire life in mountainous regions. One of the most interesting figures in medicine at the beginning of this century, and whose works are of particular interest to phthisio-therapeutists, was doubtlessly Rene Theophile Hyacinthe Laennec (1781-1826). In pathology he established the unity of all tuberculous diseases, and in clinical work he taught us how to auscultate the diseased chest. He believed in the curability of the disease, but it is difficult to say whether or not he believed tuber- culosis to be contagious. The fact remains that he died of the ultimate results brought about by an inoculation during an autopsy on a tuberculous subject. Therapeutically, he ascribed to ocean air the best effects in phthisis. He was so convinced of this that during the latter stage of his disease he had the sea air produced artificially in his bedroom. At the end of the last century (1791) May endeavored to demonstrate that the dietetic treatment was all that was necessary for a successful issue in the treatment of phthisis pulmonalis. Curchot and Carriere placed their faith in buttermilk and in the grape cure. One of the next most important events in the history of tuber- culosis was Villemin's communication to the Academy of Medicine of Paris on December 5, 1865, wherein he demonstrated the inocula- bility of tuberculosis and the necessity of classifying this affection under virulent diseases. These experiments have since been veri- fied by many observers, foremost among them Cornet, Cohnheim, Tappeiner, of Germany; Grancher, Cornil, Straus, Verneuil, Chauveau, and Herard, of Franct ; Williams, Clarke, and Wilson Fox, of England ; Welsh, Biggs, Loomis, Prudden, Hodenpyl, and Klebs, of the United States. On the 24th of March, 1882, Kocb announced to the world his memorable discovery of the bacillus tuberculosis — a discovery which shed a new light on tuberculosis as a disease due to a dis- ■ J. L. SchSnlein's " Allgemeine und speciclle I'atbologie unci Tlierapie. " INTEKESTINO DATA IN THE HISTORY OF TUIIERCULOSIS. 23 tinct micro-organism.' Of the history of Koch's next most im- portant communication, concerning the tubercuhne, made on tlie 24th of August, l8go, before the International Medical Congress in Berlin, we will speak under the respective chapter, treating of culture products. In concluding this historical sketch I only desire to add the short, but nevertheless interesting, history of sanatoria for con- sumptives. Special hospitals for scrofulous and tuberculous dis- eases were first founded in England. The oldest of all, "The Royal Sea-bathing Infirmary for Scrofula," in Kent County, is still existing. It was founded in 179 1. It is for the poor only, and admits all forms of tuberculosis except laryngeal and pulmonary. It has now 220 beds. The next oldest hospital for tuberculosis, and the first exclusively devoted to diseases of the lungs, is the " Royal Hospital for Diseases of the Chest," on City Road, in London, which was founded in 1814. It now accommodates eighty patients. " Brompton Hospital for Consumptives," the most im- portant of the English institutions, was established in i84i,and has now 321 beds. Since then special hospitals have multiplied in England in greater proportion than in any other country. Sanatoria, on the contrary, are still relatively rare in England, and Germany takes the lead in this class of institutions. Perhaps the earliest effort in sanatorium treatment was inaugu- rated by Dr. George Bodington, of Sutton Coldfield, Warwickshire, England.- In him we must recognize a predecessor of Brehmer and Dettvveiler, for in his " Essay on the Cure of Pulmonary Con- sumption on Principles Natural, Rational, and Successful " he advocates a generous diet consisting of fresh meats, eggs, farina- ceous food, beef-tea, milk, etc., and insists upon fresh air day and night. Concerning the foundation of the first sanatorium for con- sumptives, in 1839, which very nearly approaches the conception of the German " Heilanstalt " of to-day, we will quote his own words : " I have taken for the purpose a house in every respect adapted, and near to my own residence, for the reception of patients of this class. . . . It is presumed that the advantages to be derived from ' Robert Koch, "Die Aetiologie iler Tuberkulose," " Berliner klin. Wochenschrift," No. 15, 1882. ^ " Dr. CJeorge Bodington (1840)," by A. Tucker Wise, M.D. (" New York Med. Journal," vol. l..\ix, No. 2). 24 PULMONARY TUDKKCULOSIS, systematic arrarifjements with rejjarii to exercise, diet, and genera) treatment, with the watchfulness daily, nay, almost liourly, over a patient of a medical superintendent, {jreat advantages may be obtained by the consumptive patient treated in tliis way." The founder of the first sanatorium in Germany for the exclusive treatment of tuberculosis, and the best-known promulgator of modern phthisio-therapy, was Hermann Urehmer, of Gorbersdorf. His tliesis for the final degree, published in 1856, is characteristic of his life's work : " Tuberculosis primis instadiis semper curabilis." Hut in spite of his efforts he could not get the autliorization to I'Ui. I.— Illl. llKK.MASN ItKKHMKR. open an establishment for the exclusive treatment of tuberculous patients. His democratic ideas were not favorably looked upon by the Prussian government, and only through the powerful influ- ence of his distinguished friends, Humboldt and Schonlein, he received at last, in 1859, the authorization to open his sanatorium. Ikehmer's work and example has born good fruits. He died December 22, 1889. Dr. lirehmer was a striking figure: impos- ing, energetic, with a beautiful head on broad shoulders, and a patriarchal beard. He knew how to inspire his patients with implicit confidence. The photograph which I reproduce here is a splendid likeness of this great physician, lirehmer was most INTEKESTINr, DATA IN TIIK HISTORY OF TUBKKCULOSIS. 25 fortunate in his enterprise, but he was not privileged to enjoy the satisfaction of seeing sanatoria erected all over the world, where his precepts for the treatment of consumption would he eagerly followed. His most distinguished pupil and co-worker, Geheim- rath Dr. Dettweiler, has somewhat modified lirehmer's treatment, by instituting more particularly the rest cure. He is still at the head of the celebrated institution at I'alkcnstciii. Dr. Dettweiler is also consulting piiysician for the first German sanatorium for the consumptive poor at Ruppertshain, which was founded in 1S92. As pioneers in .urotherapy and in the rational treatment of pul- monary tuberculosis, two persons shouUl not be forgotten — Bennet, of Menton, an English physician, himself a consumptive, tried on his own person the effects of a permanent outdoor life, under the guidance of that ingenious and world-famed nurse, Florence Night- ingale. Iknnet published his treatment of pulmonary phthisis by hygiene, climate, and medicine in Paris, 1874; a book which is still considered a mo.st valuable guide in the treatment of pulmonary tuberculosis. The history of sanatoria for the poor and for those of moderate m_ans is still the history of the day. Only in recent years have they begun to multiply in various countries. To the United States belongs the credit of having erected the first sanatorium for con- sumptives among the poorer classes. Some fifteen years ago Dr. E. L. Trudeau, of Saranac Lake, made a personal appeal for con- tributions in order to erect a cottage sanatorium in the Adirondack Mountains. In 1884 a small cottage and the wing of the intended main building were erected. Each year the institution grew, so that it now has some eighteen separate cottages, and can accom- modate nearly one hundred patients. It owes its prosperity mainly to the personal efforts of its founder and his friend, the late Pro- fessor Alfred Loomis, of New York, and to the generosity of the public. . As of historical interest in modern phthisio-therapy we must mention the inauguration of the first l^i-annual Congress for the Study of Tuberculosis in Paris, in 1888, under the presidency of Professor Chauveau. Lastly, I desire to note two literary events connected with our subject: In 1893 appeared the first number of that excellent journal, " La Revue de la Tuberculose," under the direction of the late Professos Verneuil, with Jiouchard, Chauveau, Brouardel, Charcot, Cornil, A. Fournier, J. Grancher, Lanne- BHOHiiHi t,l fii 26 PULMONARY TUBERCULOSIS. ■ T' lonffne, Nc.ard, Potain, Richet, I. Straus, Tarnier, and L. H. Petit as co-editors. On the 1st of January, 1897, appeared in Berlin, under the direction of Dr. Gotthold Pannwitz, the first issue of that interesting little journal called the " Heilstatten Korrespondenz.' It is the organ of the German Central Committee for the Foundation of Sanatoria for the Consumptive Poor, and contains all the latest news appertaining to the subject. Lastly, on February 15, 1898, the first number of " La Tuberculose Infantile " appeared. It is a bright, interesting bi-monthly journal, devoted to tuberculous diseases of childhood ; edited under the direction of Drs. Leon Derecq and Georges Petit, of Paris. CHAPTER II. MORTALITY FROM PULMONARY TUBERCULOSIS. ' Miyiarov 5e Kai. ;^aAen-iilTaTo»' Kal irAeiVou? iKTfLve to tftdivuSti.^' " The greatest and niORt dangerous disease, and the one that proved fatal to the greatest number, was con- sumption."— (Hippocrates, " Epidemics," iii, Sec. 3, 13, Adam's translation.) We see from the above quotation that even at the times ot Hippocrates the mortaUty from pulmonary tuberculosis was already alarmingly great. To-day it is generally conceded that one-seventh of all deaths are due to consumption, and that one- sixth of all mankind is tuberculous. The following statistical table is the latest I could obtain. It gives the mortality from pulmonary tuberculosis for each thousand individuals living. It appeared in the " Miinchener med. Wochen- schrift " of January 7, 1896, and seems to be most carefully com- piled : Cities. Population. 1894. Francf.: Le Havre, • Rouen 1 16,000 111,000 2,424,000 86,000 431,000 105,000 122,000 I'S.coo 70, OX) 252,000 131,000 406,000 148,000 83,000 65,000 161,000 361,000 8i,ooo 50.3 450 41.6 33-7 33.6 32.6 30.1 m 25-S 23s 21.8 17.7 16.5 52.4 39-3 34-9 33.S Paris Nan<:) Lyon Keims, Nantes, Roubaix, Lille Bordeaux, SaintEtienne, Marseille Toulouse, Alger Gr.RMANV : WUrzburg Nuremberg, Breslau, . . Augsburg 27 I ^i 28 PULMONARY TUBERCULOSIS. Cities. Germany — Con tin ued. Munich, .... Cologne, .... Frankfort, . . . Elberfeld, . . . Dresden, .... Altona, .... Leipzig, . . (iiirlitz, .... Chemnitz, . . Herlin, Hamburg, . . . Liibeck, .... In Other Countries liudapest, Vienna, .... St. Petersburg, Moscow, .... Warsaw, .... New York, . . . Philadelphia, . . (llasgow, , . . Naples, .... Buenos-.Vyres, Manchester, . . London Chicago, .... Population. 393.000 309,000 201,000 138,000 316,000 149,000 404,000 67,000 150,000 1,703,000 604,000 69,000 552,000 1,465,000 954,000 753,000 500,000 1,925,000 1,115 .000 686,000 535,000 580,000 522,000 5,300,000 1,600,000 1894. 30.8 28.2 27.2 26.6 26.0 24.7 24.0 24-3 22.7 22.3 21.1 16.1 49-3 45-4 44-3 42.9 25-7 24.1 23.7 22.6 21. 1 20.7 19.6 17-3 134 For the United States it seems to me of interest to give the statistics of each State, as reproduced in Polk's " Medical and Surgical Regi.ster for 1898": Stat I Alabama, .... Alaska.* Arizona Arkansas, .... California, .... Colorado, .... Connecticut, . . Delaware, . . . District of Columbia, Florida, Georgia, Llalio, Illinois, . ' dian Territory,* Total Ni'Mbkr DF.ATH-RATE Dbaths from OF Dkaths from FROM CONSUMP- Consumption pi- R Consimption TID.N IM-.R 1000 OF looo of Total DiRr.NG 1890. Population. Dkaths. 2163 1-43 103.50 68 1. 14 I1S.67 1209 1.07 8401 28K() 2.39 163.19 4X9 1. 18 89.68 1743 2.34 120.46 476 2.83 153-20 827 359 138.87 377 0. 96 90.9s 2155 1. 17 101.77 36 0.43 46. 69 5698 1.49 107.26 * No reliable mortality statlsticB are obtainable. MORTALITY FROM PULMONARY TUBERCULOSIS. 29 1894. State. 30.8 28.2 27.2 26.6 26.0 24.7 24.0 243 22.7 22-3 21. 1 16. I 49-3 45-4 44-3 42.9 25-7 24.1 23-7 22.6 21. 1 20.7 19.6 17-3 134 to give the Medical and Dkaths from iinsimftion i'kr 1000 OI- TOTAI. Deaths. 103.50 I1S.67 84 01 89.68 120.46 153-20 138.87 90-95 101.77 46. 69 107.26 Indiana, . , . . Iowa Kansas, . . . . Kentucky, . . . Louisiana, . . . Maine, . . . . Maryland, . . . Massachusetts, . Miciiigan, . . . Minnesota, . . . Mississippi, , . Missouri, . . . Montana, . . . Nebraska, . . . Nevada, . . . New Hampshire, New Jersey, . . New York, . . North Carolina, North Dakota, . Ohio Oklahoma, . . . Oregon, . . . . Pennsylvania, Rhode Island, . South Carolina, . South Dakota, . Tennessee, . . . Texas, . . . . Utah Vermont, . . . Virjjinia, . . . . Washington, . . West Virginia, . Wisconsin, . . . Wyoming, . Total Ni'MBER Death-rate Deaths from uF Ukaths from FRO.M CONSI'MP- CONSIMFTION PER Co.nsl'.mption TION PER 1000 OF 1000 OK Total Dt'Ri.N'; 1890. POPL'LATION. Deaths. 3504 1.60 144.91 1832 0.96 104.56 1368 0.96 i'3-83 353S 1.90 148. IS ISI6 1-35 92.70 1477 2.23 147-05 23»S 2.22 128.61 5981 2.67 132.58 2747 '•31 109.81 1532 1.17 98. 92 1433 MI 96.18 3559 1-32 109.72 55 0.42 54.34 604 0.57 71-52 35 0.77 80.65 729 1-93 103.05 3388 2-34 112.65 14.854 2.47 120.65 2212 1-37 112.00 167 0.91 9732 6393 1-74 128.26 21 0.34 59.66 305 0.97 118.45 7689 1.46 104-57 921 2.67 121.84 2112 1-83 136.30 208 0.63 76.89 3637 2.06 152.47 2059 0.92 77-93 62 0.30 29.26 601 1. 09 121.84 3050 1.84 131.28 278 0.79 103.15 "43 1.50 138-13 2015 1. 19 107.97 18 0.30 43-48 Concerning the relative mortality from the various diseases, I give here Professor Fletcher VV. Heues' interesting dial, as it appeared in Cuzner's article in " The Journal of the American Medical Association," of December 17, 1898. This dial shows the terrible mortality from diseases of the respiratory organs, and especially from pulmonary consumption. We will learn in chapter vii, on the Care of Consumptives by the Authorities, how much the mortality has already been decreased in these latter years in some of the cities of Europe, thanks to the creation of special hospitals and sanatoria for the poorer clas.ses, and also in a few cities in the United States by the inauguration of r !i! 30 PULMONARY TUBEKCULOSIS. a rigorous prophylaxis against the spread of tuberculosis. How- ever, we shall also see how much is yet to be done in the line of 1 ^'^ eoo I'lG. 2. prophylaxis and in the creation of special institutions in order to combat the spread of this disease more effectually everywhere. : y n CHAPTER III. PATHOLOGICAL PROOFS OF THE CURABILITY OF PULMONARY TUBERCULOSIS. The curability of pulmonary tuberculosis in the first and second stage is yet much contested, even by medical men. Among the laity the belief that, the disease once declared to be present, all hope has to be abandoned, is still very prevalent. To convince the patient of the contrary, to instil in him the hope of recovery, to encourage him in his persistent effort to carry out all the details which tend to improve his condition, should constitute an impor- tant part of the educational treatment of all consumptives. Doubt- ing physicians should go into the dissecting-room and witness the coroner's post-mortem examinations. They will see many a cicatrized lung lesion in persons who have died from entirely different diseases or from accidents. As early as 1838 Carswell ' wrote : " Pathological anatomy has perhaps never given more decisive proofs of the curability of a disease than it has given for pulmonary consumption." These words from one of the foremost pathologists of his time may be recalled to doubters as an evidence of how wrong they are in their pessimistic conception of a disease which is eminently curable. By personal inquiry, through letters addressed to the leading pathologists of the world, and by looking up the literature on the subject, I have myself compiled some statistics giving the pathological proofs of the curability of pul- monary tuberculosis, from which I append the table on next page. Besides those mentioned in the table, Andral, Meckel, Roki- tanski, Ulsperger, Virchow, and Werdmiiller" have reported cases of healed tuberculous lesions in persons who had died of other than tuberculous diseases. Laennec^ believed in the curability of pulmonary tuberculosi.s. Curveilhier, in his " Traite d'Ana- ' Carswell, " Pathological .Xnalomy," London, 1838. ' P. Mnnasse's statistics in his " lleilun<; tier I.uiigentuberkulose." • Laennec, "Traite tie I'auscultation imjiliate." Kdilion ile la Faculti;, 1S79. 31 32 PULMONARY TUBERCULOSIS. 1(1 1 !l Reportro by. Nl'.MBER OF Autopsies. Number ok Cases WMKKE Autopsy Kevkai.eo Healed Pulmonary Tuberculous Lesions. lioudet, of Paris, Heaux, of Paris liennet, of Menton, Uaudet, of Paris Marsini, of Basel, Bollinger, of Munich, ... 135 1 66 73 III 400 16,562 701 670 763 189 '31 1.943 445 103 116 157 28 10 89 69 789 78 75 71 92 29 SO 17 177 42 25 51 percent. 27 " " 39 " " 10 " " Heitler, of Vienna, ... Chiari, of Prague, Flint, of New York. Loomis,' of New Vork, Letulle, of Paris F. P. Weber, of l^ndon Ormerotli, of London, .... ... Vilbert, of Paris, Fowler, of London, Martin, of London, Jos. Coats, of Glasgow, . . Rogee, of Paris, Standacher, Thomas Harris, of London, Furl>ringer, of Berlin, Renvers, of Berlin, . . Bugge, of Christiania , . Osier, of lialtinjore 30 " " 27 '• " 7-5 " " 4 " " 30 " " Walker, of Chicago H. M. Biggs, of New York, ' Loomis, H. ['., " A Study of the Processes which Result in the .\rrisl or Cure of Phthisis." " Medical Record," J.in. 9. 1892. tomie generale," vol. iv, page 538, declares tuberculosis a de- cidedly curable disease, and so does Charcot,' in his "Traite de Medecine," by saying: "Phthisis is susceptible to be cured completely and definitely even at the period of cavities." Gran- cher, in his " Lemons cliniqii<.5 sur les Maladies de I'Appareil respiratoire," 1880, page 245, says : " We affirm the curability of the tubercle; we affirm that, instead of being a miserable neoplasm incapable of organization, the tubercle tends naturally to fibrous formation." Jaccoud" even maintains that pulmonary phthisis is curable in all its stages. Herard and Cornil ' are of the same opinion. Professor l^ouchard,of Paris, concluded his lectures on phthisis in the year 1888 by the following comforting words : ' Charcot, " 'I'raiti de Mddecine de Charcot at Bouchard"; aiticle, Phtisie pulmon- aire. 2 Jaccoud, " Curabilite de la Phtisie pulnionaire," l8S8. ^ Herard, Cornil et ilanot, " La Phtisie pulinonaire," iSSS. m Cine of Plilhisis." e, I'htisie pulmon- PROOFS OF THE CURABILITY OF PULMONARY TUBERCULOSIS. 33 " This disease, which has such a strong hold on humanity, is curable in the largest number of cases." Of the striking and interesting answers I received to my letters, or to personal in- quiries, I desire yet to cite the following: Dr. Brouardel, Dean and Professor of Legal Medicine at the Faculty of Medicine of Paris, said to me : "There is hardly any autopsy performed at the morgue, of persons having died an unnatural death, where healed tuberculous lesions, cicatrized and calcified, are not found; especially if the individual has lived more than ten years in Paris." Professor Fritz Strassmann, of Berlin, expressed himself as follows: " I have very often found old foci of pulmonary tuberculosis, cicatrized and cal- cified, in individuals who had died by accident." Prof. James Goodhart, Physician of Guy's Hospital of London, wrote me: "I am able to say that there is nothing more common than to find in those dead from other causes evidences of old and healed phthisis or calcareous changes in the various glands ; moreover, in most cases of tubercular disease there is similar evidence that a former disease of this kind has healed. I am, therefore, accustomed to say that there is no disease that gives stronger evidence of healing tendencies than phthisis." In connection with the preceding state- ment, Hermann Weber's remarkable case of a twice-healed tuber- culosis may be cited.' This case was first diagnosed in 1867 as pulmonary tuberculosis. A hzemophthisis was the cause of the patient consulting Dr. Weber. The patient was completely cured after several months of judicious hygienic, dietetic, and climatic treatment. In 1873, after a year's residence in Paris and London, he was again seized with a ha^mophthisis. While in the first attack the left side was involved and the right side was free, this time it was the right side which presented the dullness, with crepitant rhonchus down to the fourth rib, the condition in which the left side had been in 1867. The left side at the time of the second attack had remained free, showing only a slight dullness. Again outdoor life and judicious hygiene and diet cured the patient. In 1881 Dr. Weber saw him again, the patient being ill with well- developed typhoid fever of a moderate type, without any lung complication. He had almost recovered, when, at the end of the fourth week of the disease, he committed, against strict advice, the ' Weber, " Hygienische uml klimatische liehandlung (k-r clironisclien Lungen- schwindsucht." 3 mmu m 34 PULMONARY TUUKRCULOSIS. imprudence of eating a rather large quantity of grapes, and died of a perforation of the lower part of the ileum. At the post mortem examination there were cretaceous patches in the apices of both lungs, and also in the lower lobe of the right lung. Dr. Whittacker, of Cincinnati, said, in answer to my inquiry : " It is a great exception to find upon the post mortem table a pair of lungs totally free from some evidence of existing or preexisting tuberculosis." Dr. Nicholas, Physician-in-Chief of the Hospital of Neuchatel, in Switzerland, very kindly responded to my letter by saying: "It has happened to me repeatedly to find at autopsies cicatricial tissue, with and without calcareous foci, in the apices of the lungs; but owing to a lack of special notes I am unable to give you the exact proportions." While we must admit that at times these foci represent only the tuberculosis which has become latent, whenever the fibrinous or calcareous transformation of the tubercles is complete these latter are no longer virulent. Kurbow ' was able to demonstrate by inoculation that out of one hundred cases of seemingly latent tuberculosis, in twenty-seven the tubercles had entirely lost their infectious qualities. Dejerine,^ who made similar investigations, examined a very large number of such old localized calcareous* foci, and in not one instance could he discover the presence of the tubei le bacillus. Ot the clinical evidences of the curability of pulmonary tuber- culosis, and the results obtained in special sanatoria, I will .speak in the concluding chapter. ' Kurbow, "Arch, fiirklin. Mediciii," 1889, vol. xi.lv, fas. 5-6. ' D^jerine, " Recherche du bacillc de Koch," " Conii)l. reiisis n . ' _ ' ^ / \ . •' healll. 11.- invalids, I have seen these patients, in all stages of the disease, s"ri»- promenading and expectorating everywhere, and I became con- vinced that they were thus disseminating their disease among the permanent inhabitants of that region. I addressed the proper authorities in these resorts for information, and I will reproduce here the answers of two of them. The chief health officer of Nice, Dr. Ballestre, wrote: "II e.st de notoricte publiqiie que Nice, et surtout Menton, ont vii augmenter dans une i)roportion enorme le nombre de leurs tiiberculeu.x depuis que les phtisiques ont frequente ces stations." (" It is a well-known fact that Nice, and especially Menton, have seen the numberof their consiimj)tives increased in an enormous proportion since phthisical patients have frequented these resorts.") The Secretary of the New Mexico Territorial Board of Health, Dr. F. H. Atkins, wrote me as follows: " Like other communities much resorted to by consumjitives, we are year after year discover- \x\g cases of phthisis occurring in New Mexico among people born here, or quite recently come here and healthy, and in many of them there has been a definite exposure to the infection of the tubercle bacillus." To stop the spread of tuberculosis by the careless or ignorant consumptive we must begin by convincing him of the wrong he is doing to himself and others by the manner in which he disposes of his infectious expectoration. The danger of his becoming continually reinfected must be particularly impressed upon him. Such a [)atient should be taught never to expectorate except in a proper receptacle. The habit of expectorating in a handker- chief should be considered as dangerous as expectorating on the ground, for the frequent unfolding of a handkerchief containing the dried sputum is a most common way of disseminating the bacilli, and, besides, not infrequently the patient reinfects thus his upper air-passages. The frequent coexistence of pharyngeal and laryngeal tuberculosis with relatively little advanced pulmonary lesions may well be explained by this mode of secondary infection. In all places where there are likely to be tuberculous patients, able to be about, whether in private residences, workshops, offices, hospitals, or sanatoria, there should be the proper kind of spittoons, and a sufficient number of them, properly placed and kept. Cus- W i 38 PULMONAKY TUHEKCULOSIS. I DaiiKer pidors placed on the ground should be done away with, for wliilc a from ciis- r ■ t c \ • • t • • pidors fair number of male patients may possess a certain df'xterity in placot oil . r,. .. r t the gromui. disposing of their sputum, I have yet to find a woman who knows how to hit the spittoon. Where much expectoration is going on, I'lr,. 4. KiG. 4'. FlCS. 3 AND 4.— SlMTIOOS, El.KVATKD TMRKK I'KKT OR TMHKK FKKT SlX I.NCIIKS IROM IHK Fl.DOR, AND INCLOSKI) IN IlIK WaI.I.. I'"igs. 3 and 3', plan ; 4 and 4', elevation. ^ and 4 represent the door closeil ; 3' and 4', llie door open. A. Frame. B. Cover. C. Spittoon. P. Uoor. S. Hinyed support. L. Linoleum cover. one usually finds the brims of the cuspidors that are placed on the floor covered with dried sputa, and even the piece of oilcloth placed underneath as a precautionary measure often shows signs of the inexperienced spitter. To obviate these difficulties, and still COMMUNICABILITY OK PULMONAKY TUBKRCULOSIS. 39 ICllKS FROM TIIK make the presence of numerous cuspidors in eitlier private dwell- injj, hospital, or sanatorium as little objectionable as possible, I have devised an arrangement of elevated spittoons, visible only when in use. In the walls of parlors, halls, galleries, etc., at appropriate distances, arc constructed small niches or cupboards 3 or 3 1/2 feet from the floor. They are larjje enough to hold a spittoon eight inches high and about the .same diameter. Not to expose the persons intrusted with cleaning these vessels to the |)()ssible danger of inoculation by breakage of porcelain, I prefer metal spittoons, lilue enameled iron seems to be the most prac- tical of all. The dark-blue color makes the contents less visible. The cuspidor is supported by a metal ring attached to the door of the cupboard. The patient desir- ing to e.xpectoratc opens the little door, thus bringing the spittoon within his reach, and closes it again when he gets through. An autonuttically closing extra cover makes it impossible for flies or other insects to sojourn in the interior. The drawing will more fully explain the construction and the worlring of this arrangement. In the grounds surrounding the hos- pital or sanatorium the niches may be rejjlaced by boxes mounted on stands (see Fig. 5) or attached to the trunks of trees. The cuspidor of metal, elevated and covered, has additional advan- tages over the usual uncovered vessel of porcelain or earthenware. Animals, such as cats, dogs, etc., will not be able to reach the contents of the cuspidor ; and there is less danger of its bursting when placed outdoors at freezing temperature if covered and inclosed in a box. In the grounds of in.stitutions where porcelain vessels have been placed it has happened that the frost cracked the spittoons and caused their contents to be spread over the ground. Now, it is well 5— Ki.KVA ii;i> Stand ior Simttdon. 40 PULMONARY TUBERCULOSIS. [i I > n m Flies may transmit bacilli. known that the tubercle bacillus does not die at the freezing tem- perature, and henre there is danger in the use of porcelain vessels. Galtier,' and later Catieac and Malet,' have exposed the tuber- culoas expectoration to repeated freezing and thawing, and a tem- perature of — 8° C. did not destroy the virulence of these tuber- culous products. For factory and workshop use, Piedoehl's^ enameled iron spit- toon, of which I also give a drav/ing (Fig. 6), seems to answer all practical purposes, especially if its cover can be made to close more tightly, .so that flies cannot enter. This is a rather important item in the prophyla;;:3 of tuberculosis. Spillmann and Haushalter,^ of Nancy, have demonstrated by extensive experiments that the fly may become the propagator of tuberculosis. The abdominal cavities of flies caught m the rooms of consumptives were found to contain the liviuLj bacilli, so also did the fly-specks scraped from the walls and windows of hospital wards and rooms where consumptives habitually sojourned. The same experiments were repeated and verified by Hofifmann '. Now, the danger from these infected insects is twofold. They die and crumble to dust which contains the bacilli, and the micro-organisms may thus enter the system through the respiratory tract. Or the fly which may have partaken of the tuberculous expectoiation deposits its excrements at the next opportunity upon some article of food, whence the bacilli con- tained in the deposit find their way into the alimentary tract of man or beast. Predoehl's cuspidor — which is about nine i' ches high, eight inches at its largest, and three inches ?t its smallest diameter — can be suspended at any height, and can be very easily cleaned and disinfected. A third kind of spittoon is the small mug, wliich should also be of some unbreakable material, — enameled iron, tin, or aluminum, — and, of course, with a tightly closing cover. On account of its 1 Galtier, Congrts |X)ur 111 tuberculose a Paris, 1 8.S8. ''Straus, " Lit 'i'uberculose et son I5,icille," I'aris, 1S95. 3 Predoclil, " Der Spucknapf," " Miiiicliciier med. VVocliensclir. ," Oct. 22, 1895. * Spillmann et IlL.iislialter, " I )issiimiiiiition ilu liacilie dc la t'.iberculosc par les inouclies," '• C. R. de I'Acadeniie dt'i Sciences," iS86, vol. iv, p. 352. ' E. HofTin.-tnn," Ueber die Verbreilung der 'I'uherkulose Uurch unsere .Stjbenfliegen," 1888. COMMUNICABILITY OF PULMONARY TUBERCULOSIS. 41 lightness, I prefer the last-mentioned metal. I give here a design of the form which seems to me most convenient (Fig. 7). Another k-ind of spittoon of practical use, at home or in institu- tions, is the Seabury and Johnson spitting-cup, made of imperme- able pasteboard, to fit in a metallic frame with handle and cover. I I'U,. 6. — Br. I'KKDOKHI.'S Sl'ITTDON KOR Factories and Workshops. \-u. -Si'IT-Cl I' FOR I'SI: ON THK \liKANT)A AND AT THK BP.DSIDH. ould also be iluminum, — count of its let. 22, 1895. tierculose par les re Stjbenfliegen," a. Fig. S. Skakiky AM) Johnson's Sim itini;-iii'. a. I-'ranie. d. l*\>l(ie(l cardboaril. When the cup is filled, the pasteboard is taken out and burned, with its contents. These are the cuspidors for patients in bed or for such who are taking the rest cure on the veranda. Patients who arc too weak tc Miake use of this cup should have at their bedside a number of moist rags, which should be burned immediately after use or, at least, before tiiey have had time to dry. m m\ I! I : I: I r I! 42 PULMONARY TUBERCULOSIS. Precnutioii against reiiifL'ction and the expu'sioM of p irticlcs (if spultmi. We now come to the fourth kind of spittoons — the pocket flask, which, to my mind, when properly and faithfully used by the pulmonary invalid, will prove one of the most important factors in the prevention of tuberculosis. It should be carried by the tuber- culous individual all the time, and used whenever he can not conveniently get at the stationary cuspidors. One of the most ingenious pocket spittoons invented is Dr. Dettweiler's " Husten- flaschchen," of which I will also give an illustration (Fig. 10). It is a flask of blue glass, about four inches long and six inches in its largest circumference, provided with a hermetically closing top and bottom, and so constructed that it can easily be cleaned. The lid flies open at a slight pressure on the spring, and after use is closed by pushing the top down again. This otherwise excellent flask has a few dis- advantages, which I have sought to over- come by the construction of an aluminum pocket flask. This is, of course, unbreak- able, which can not be said of a glass flask, where the danger of inoculation in case it should break in the pocket must not be forgotten. As can be seen from the drawing (Fig. 11), it is, like Dettweiler's, constructed so that its contents cannot be spilled by tip- ping over; but instead of being of three pieces it is of but two, can easily be cleaned, and boiling will not injure it. Instead of six ounces (which is the weight of the glass flask) it weighs but two ounces. Its length is four inches and its nearly uniform diameter is but 1^4 inches. Thus the aluniinum flask is less bulky, can be manipulated with more ease, and will attract less attention. It can be easily hidden in the folds of a handkerchief when used. This is an important point, for consumptives are nauirally sensitive, and are ever anxious not to attract attention to their infirnn'ty. Tliere is one precaution to be observed in connection with the use of the pocket flask and the cuspidor in general. I always tell my tuberculous patients never to use the same handkerchief for wiping the nose that they use to wipe their mouths after having expectorated. They should have two handkerchiefs with them, Fig. 10.— Or. DKrrup.ii.KRs " III STKNIM.ASCIICIIHN." COMMUNICABILITY OF PULMONARY TUBERCULOSIS. 43 and always hold one before their mouth during an attack of cough- ing or sneezing, to guard against the expulsion of small particles of sputum. Fliigge and Latschenko ' have demonstr^s^ed the need of such precaution through careful and extensive experiments. They requested some consumptives to cough (but not to expec- •■-^late) in a large glass box. The patients had to put on new I •- -^"T coats and rubber shoes, to make the detaching of particles jt dried sputum, which might have been on their clothes, impos- sible. Sterilized glass plates, somewhat moistened, had been pre- viously placed in the upper portion of the big box. Animals inoculated with the substance scraped off these plates were ren- dered tuberculous. 1 II. CloHet!. *• I'akoii apart for cleaiiiiij;. Fig. II.— Ur. Knopi-'s Tockkt Sputim I'i.ask. In special institutions — sanatoria and hospitals — one can, of course, carry out prophylactic measures to guard against the expul- sion ■ t" particles of sputum which wouUl be much less practicable for /-V uts outside of such establishments. Professor R. Fraenkel, for ex-iuple, has inaugurated, at the Berlin " Charite," this innova- tion : All the tuberculous inmates must wear masks (Fig. 12) to catch the germs they expel in speaking and coughing when they are in the common room, and only remove them while eating or expectorating.- The patients soon become accustomed to the ' Flllgge, " Oeutsclie med. V/ochensclirift," 1897, No. 42. -I!. Fraenkel, " /.ur I'rophylaxii' der 1 uherkulose," " Iterl. kliii. Woclienschrifl," l8<)9. No. 2. • -J '-if Jlfc 1' CleaniiiB and disin- fecting: cuspidors. 44 PULMONARY TUBERCULOSIS. Ot ■< — mask, as by impregnating the gauze, which is held in place by the metallic frame, with some medicinal substance they suppose it is to be worn for theii iv nersonal benefit, instead of for the pro- tection of others. Bar • •' frequently found on the gauze. It is, of course, .self-understo. that the gauze, lint, or cotton removed from these respiratory masks should be burned immediately, and the masks disinfected at regular intervals. A patient should, if possible, have two pocket flasks, .so as never to be without while one is being cleaned. In hospitals and sanatoria the same rule should hold good for the fixed cuspidors. In such institutions the person who attends to the cleaning ofthe.se vessels should, during his work, be provided with rubber gloves, so as to remove all possible danger of inoculation through an abrasion of which he might not be aware. The most thorough meth- od of cleaning any cuspidor filled with tuberculous spu- tum is certainly the one re- commended by Professor Grancher, of Paris,' consist- ing in placing the spittoons — contents and all — in boiling water, where they are left for five or ten minutes; by the addition of some bicarbonate of soda the boiling-point will be raised to 102° or 103° C, which will destroy the tubercle bacilli most certainly. The next best, and perhaps the most convenient method, is to mix the tuberculous e.xpectoration freely with a five per cent, solution of carbolic acid. After this in order of efficacy comes the bichloride solution of i to lOOO. This should always be u.sed in combination with tartaric acid, citric acid, or some other preparation that will prevent the coagulation of albumen. The strength of the solution of corrosive sublimate should be i to 500. According to the experiments of Yersin,* it took thirty seconds to \-\i.. 12.— I'Roi-. FKAKNKia.'s Moriii Mask. (!4 n.'lural size.) a. Metal ling. b. Supporter, c. Saddle, d. lilastic band. e. KiuHS for fasienliiK. ' Granclier, "Maladies de I'appareil respiratoire," I'aris, 1X90. '■ Yersin, " De raction de ciui'iciiies niiliseptique.s et de la cliaieur sur le liacille do la tubercirlose," ".\niiales de I'lnstiliit I'astevir," 1888, p, 60. 'Hi COMMUNICABILITY OF PULMONARY TUBERCULOSIS. 45 kill the tuberculous germs immersed in a five per cent, solution of carbolic acid, while it took ten minutes before all the germs were killed when immersed in a bichloride solution of i to looo. Every stationary cuspidor, and also the hand-cup in the sick-room or on the little table next to the steamer-chair where the patient takes his rest cure, should be filled every morning to about one-fifth with a five per cent, carbolic acid solution. Of late, wood vinegar (acidum pyrolignosum) has proved to be an excellent disinfectant for tuberculous secretions. It kills the bacilli after six hours, and lakes also from the expectorated matter its unpleasant aspect.^ To encourage the use of the pocket flask, one must make its manipulation, and especially the process of cleaning, as simple as possible. Thus the directions which accompany the aluminum pocket flask above referred to are as follows : To empty the flask, unscrew the top and pour the contents into the water-closet ; or fold a newspaper into several layers, pour the contents on to this, and throw the whole at once into the fire, being careful not to spill any.- Rinse the flask in hot water and wash the hands imme- diately afterward. Some consumptive individuals will not use the pocket flask, in spite of all persuasion, for the simple reason that they do not wish to attract attention to their malady. For these there is but one thing to do — to tell them to use squares of cheap linen handker- chiefs, or Japanese paper handkerchiefs specially manufactured for that purpose,'^ which can be burned after use. But I should insist that they place in their pockets a removable lining of rubber or other impermeable substance which can be thoroughly cleaned. This additional pocket could be fastened to the inside of the ordi- nary pocket by clamps, and thus be of no inconvenience to the patient. Of course, all invalids using handkerchiefs as receptacles for expectorations take their chances of infecting their hands, and should be enjoined never to touch any food without having thor- oughly washed them. 1 15: m f il ' " Zeitschrift filr Krankenpflege," .\x, No. ')• ' ^ For the prailiial suggestion of using newspa[ier for tliis purpose I am indebted to I'rof. Piudden, of Columbia I'niversity. ' Weise, " Ilnndixercbiefs for Consumptives," " Lancet," Nov. 14, l8yl. r le bacille de la I 1 1 il > 'i 1 ,1 1 ; 1 il 46 PULMONARY TUBERCULOSIS. INFECTION BY INGESTION, The saliva of consiimptives frequently contains the tubercle bacilli. Petit,' Freudenthal," and many others have reported their clinical experience in this respect, which shows that there is real danger in kissing tuberculous patients on the mouth. The napkins used by consumptives should be boiled after each meal. If, for economic reasons, a freshly washed napkin can not always be had, Japanese paper napkins, which are burned after use, may be sub- stituted. Knives, forks, spoons, glasses, etc., should be thoroughly boiled or rterilized after each use. How important it is to tell the patient about all these things, and explain to him the reasons, may best be illustrated by the following anecdote : I was called in con- sultation to see a phthisical lady, and on the way there the family physician told me how particular he had been to warn his patient of the contagious nature of her disease. On our arrival we found the young mother with a baby a few months old in her arms. She was preparing the food for her infant, which sacred duty she would intrust to no one else. She had one .spoon for herself and baby, with which she tasted the food to judge of its palatability and tem- perature. She then told me that since the good doctor had told her that her disease was contagious she had never once kissed her darling child. To the mind of this unfortunate mother it was the kiss alone, the direct contact, that was capable of transmitting the disease, and she restrained herself from caressing her child. But, unconsciously, she was conveying the bacillus into the very food of her infant. Consumptive men should either wear no beard at all or keep their mustaches and beards closely cut, so that they may be easily kept clean and not become the cause of infection or reinfection. It is of great importance to tell the patients never, out of false modesty or for any other reason, to swallow their expectoration. There is always danger of an intestinal infection. Among the in- sane tuberculous patients, secondary intestinal tuberculosis is ot most frequent occurrence.' There seems to reside a certain danger ' L. H. Petit, " Sur quelques modes pen connus de contngion de la tuberculose par la voie IniLcale," " Keviie y rarlli- woiins. INFECTION I^Y INOCULATION. Consumptives who attend to the cleaning of their spittoons themselves must be especially prudent. If they have anywhere a cutaneous abrasion, they must be careful not to soil it with saliva or expectoration. The habit of putting an injured finger in the mouth has not infrequently caused local tuberculosis in consump- tives, the result of an auto-inoculation.' Surgeons and nurses should be particularly careful when attending surgical cases of tuberculosis. I have had occasion to observe such an inoculation in the service of a colleague of mine. The unfortunate nurse came well-nigh losing his whole hand from dressing a tuberculous wound. The seat of entrance of the tuberculous infection was only a slight abrasion of the skin which had passed unobserved. Pathologists handling fresh tuberculous specimens, physicians performing autopsies, and students dissecting tuberculous subjects, are also greatly exposed to the danger of becoming inoculated with tuberculosis. The " piquure anatomique " has, alas! too often develop'^'d iiiLo a serious tuberculous infection. To incise freely with an aseptic instrument at the seat of inoculation and apply a careful dressing of bichloride of i to 3000 seems the best imme- ake in case such accident 5tep IPP ' K. Ullinaiin, " Cutaneous Tulierculosis by Auto-infection," " New York L.incet," A]iril, 1S9S. 'M:' !'i 52 PUI-MONAKY TUIIKKCULOMS. 1 . -Hi t if- Infection from wc't- iiurse to child, anil vice versa, Vaccina- tion. Infection tlirougli sexual rela tiOMS. Infection frdin wet-nurse to child, and vice versa, is possible. Happily the cases where a tuberculous mother nurses a child are now exceedingly rare ; thus one sees this mode of inoculation seldoni, but against the other we should always be on guard. 1 would have no hesitation to give the child of a consum])tive mother to a healthy wet-nurse, provided a most thorough exami- nation of the infant revealed no sign or sympton^i of tuberculous infection ; but, if tliere is the sliglitcst doubt, a wet-nurse should not be exposed to the probability of becoming infected by the child. Weber's case, cited in his Croonian lectures of 1885, gives a very striking example of the possibility of a tuberculous child commu- nicating the disease to a healthy wet-nurse who had no hereditary predisposition. The possibility of transmitting the tuberculous disease to a child through vaccination can not be denied,' especially when one con- siders that the vaccine is now almo.st exclusively obtained from young bovine animals. Although Villain's statistics show a com- parative rarity of tuberculosis in calves between the ages of four to six months, it seems to me good practice to follow Brouardel's suggestion - that, in order to obtain absolute security, the best thing would be to slaughter the animals immediately after they have served as vaccinifers, to keep the vaccine obtained and not to use it until the examination of the slaughtered animals had shown that there was no trace of tuberculosis in their organs. That a tuberculous infection can take place through sexual rela- tions has been again and again demonstrated. All phthisio-thera- peutists have occasionally met with such cases. I only need to refer to the works of Reclus,^ Schuchardt,' Carrera,'' and Petit." I'^ducation in private by the family physicians, and in some cases, 1 Surmont, II., Article " Vaccine," " 'I'raite de Midecine et de Tlicrai)." Hrouardel, Gilbert, et Girondc, vol. i, 1895, p. 207. 2 I$rouardel, Article " Vaccina," "Twcnlicth Century Practice." 3 Reclus, P., "Clin. chir. do I'HOtel Dieu," Paris, 1888 (514-527). ♦ Schuchanlt, K., " Die UebertragungderTuberkulose auf dem Wege des geschlecht- lichen Verkehrs." "Arch, fiir klin. Medicin," lierlin, 1892, xi.iv. ° Carrera y Miro, " Conlagio tulierculosD por h. via genital." (" (jac. nied. catal.," Harcelona, 1888 XI, p. 385). * Petit, L. II., " Tuberculosa et rap|X)rl.s ak ore" " Revue de la Tuberculosa," vol. II, p. 234. COMMUNICAHILITY OF PULMONAKV TUHKRCULOSIS. 53 perhaps, the sanitary '^olice intervention, can only do the necessary prophylactic work. Of less frequent causes of propagating tuberculosis, but which, in the light of modern sanitary science, can and should be pre- vented, I will cite first the ritual act of circumcision, practised according to Jewish rites. This operation has, in numerous in-";"^.{!",^ stances, been the cause of transmitting to an iimocent, healthy f|J,,'','|,',[.'j"f' child the disease in question. The tuberculous inoculation mani-'""" fests itself first as a local disease of the genital organs, from whencf, in a great number of cases, it becomes generalized. Of the earlier cases reported, I will mention the one of Lindemaiu. : "Two chiklren who were circumci/ed by a man who was in the last stage of consumption, and who, after the circumcision, su-ked the pre- puce, according to the Jewish rites, both became infected with ulcers on the prepuce and swelling of the genital glands. One recovered; the other's infection continued, the child developing Pott's disease and dying finally, after a few years' suffering, from pulmonary phthisis." Since then the surgical literature of all countries, where Israelites practise this rite, occasionally contains notes of cases of tubercu- lous infection through this modus ■>t>cianiU. Professor A. Jacobi, of New York, had the courtesy t«, tell me that he remembers having seen as many as tweWe cast, of tuberculosis following ritual circumcision. Drs. Ware and ?»loschkowitz, of the same city, have also very kindly reported to me several recent cases of the same kind. Dr. Willi Meyer, in a very able paper, read before the Scientific Union of German Physicians of New York, on March 25, 1887,- reporting one of his own observations of such tuberculous infection, calls attention to the manifold dangers to which a child is exposed throuj^h the performance of this rite, and comes, with Professor Maas,' to the conclusion that it should be the duty of every physician to protest against ritual circumcision. It is well known that syphilis and diphtheria have also been transmitted through this suction process, and, again, that through lack of skill ■■M ' I-iiKlemaiiii, " Deutsche med. Wochensclirift." No. 30, 188,5. * Meyer, " Kin Fall von Impf-Tuberkulose in Folge ritueller Circumcision." " \. V. Med. Presse," Jiini, 1887. " Maas, Konig's '• I.elirbuch der spec. Cliirurgie," 4. .Aull., 11, p. 588. ^iii; M \ 54 PULMONARY TUBERCULOSIS. Mow this rite may be l-'erformed with c>.'Ri • parative safety. Tattooing. in after-treatment .secondary hemorrhage, erysipelas, and gangrene ' have ensued. Too uiany a young life has thus been needlessly sacrificed. The operation of circumcision, when skilfully and rapidly performed, is in itself trifling, but the sucking of the prepuce afterward makes it dangerous. Since it will be difficult to stop this practice by a simple protest on the part of physicians, and as the law cannot interfere with the free exercise of a religious rite, I should suggest as a remedy that only such persons should be allowed to perform circumcision as have shown the necessary skill before a medical board of examiners, and that every time they are called upon to perform the rite they should submit themselves to a medical examination. Only when bearing a certificate from a regular physician, stating the absolute freedom from specific dis- eases, should they be allowed to perform ritual circumcision. As another reliable prophylactic measure against the possibility of inoculating the child, when the parents insist upon tiie orthodox method of circumcision, is the suction by the aid of a glass tube, as practised in France and Germany. I will also mention the possibility of inoculating tuber- culosis by the process known as tattooing. Messrs. Collins and Murray reported no less than three cases in the " British Medical Journal " of June i, 1895. They were three boys of the age often, thirteen, and fifteen, respectively, all inoculated by the same person, and all three died from general tuberculosis. Not to allow such useless and dangerous practice would seem the only prophylactic remedy. Before closing with the subject of the communicability of pul- monary tuberculosis, I desire to return to the recent experiments of Fliigge and his pupils.- While by no means disproving the conclusions of Cornet and his followers, in regard to the danger of dried tuberculous sputum as a means of propagating the disease, these experiments have nevertheless added a good deal to our knowledge of the methods of tuberculous infection. We have already referred to Fliigge's work in speaking of the danger which ' I'rotliers, A., "Gangrene of the I'enis After Ritiinl Circumcisioii," " Medical Record," Jan. 30, 1897, 2 " Zeitsclirifl fiir llyg. iind Infectionskrankh.," 1899, vol, \xx, No. i. n COMMUNICABILITY OF PULMONARY TUBERCULOSIS. 55 may result from the expulsion of particles of sputum containing bacilli during the act of coughing or sneezing, and have recom- mended holding a handkerchief before the mouth and nose at such moments, and, in addition, where it is practical, the use of Fraen- kel's mouth-mask. That an expulsion of particles of infectious sputum is possible, p^^^j^j^ even during the act of speaking, must also be admitted. The very ^|,'|'|^J^p"'"' interesting experiments of Latschenko and Heyniann in the labora-'*'""''""*^" tory of Professor Fliigge have, however, demonstrated that for the infection to take place through the expulsion of particles of sputum a close proximity to the invalid is essential. At a dis- tance of over four feet from the patient this mode of infection is no longer possible. Again, this danger is still more reduced by the fact that not all individuals afflicted with pulmonary tuberculosis have bacilli in their saliva; also the time the physician, nurse, or friend need to be in close proximity to the patient is rarely longer than a few moments. Bearing all these points in mind, we may, after all, say that with a clean, conscientious consumptive, with a faithful nurse, and intel- ligent friends and relatives about him, the danger of his communi- cating his disease to others is very small indeed. m ■i'u I 'it} 4 i ;■!■ I : Compul- sory; regis- tration of tuberculous patients. fessioil. i^ ^ CHAPTER V. PUBLIC PROPHYLAXIS IN REGARD TO TUBERCULOSIS IN MAN. We will now consider the duties of the sanitary authorities and the general government in regard to prophylaxis. We have, I believe, pointed out all that can reasonably be ex- pected from the tuberculous patient and those who surround him, in being instrumental to stop the spread of this disease. What remains must be done by the sanitary authorities, aided by the good-will of the physician, especially the general practitioner. It is he, under whose observation come the greatest number of cases of pulmonary tuberculosis, who is most likely to discover them in the incipient state. Experience has demonstrated that compulsory registration or reporting tuberculous cases finds little favor with the general pro- The controversy which went on between the Board of Health of the City of New York and the medical profession at large of that city is, perhaps, the best proof that the time for such radical measures has not come yet. If we succeed, if not in stamp- ing out, at least in reducing in a marked degree, the mortality from phthisis pulmonalis without resorting to any measures unwelcome to the medical profession and the laity alike, so much the better. But to attain this end a co-operation of the sanitary authorities — government, States, county, or city boards of health and all medi- cal practitioners — is indispensable. It should be made possible for the general practitioner to send any suspected sputum to his respective health board for bacteriological verification. He should be provided with circulars issued by the board to give instructions to the patient, his family, and friends. These circulars will be placed by the medical attenda.it in the hands of such person among the friends of his patients as he can trust to carry out his instructions. If the physician thinlcs it best, he will give the instructions to the patient directly. If this latter be refractory, insane, or too ignorant, S6 PUBLIC PROPHYLAXIS. 57 and his family or friends, from some reason or other, are unable to prevent him from disseminating his disease by promiscuous ex- pectorating, it should become the duty of the physician to report the case to the respective sanitary authorities, who should effect proper restriction, or, if necessary, isolation. The strictest supervision on the part of the board of health in^f^^^Jj',*!"" regard to tuberculosis should be exercised over insane asylums, [,'°"j^,^",''„„ prisons, cloisters, large boarding-schools, and all places where ofj"f"c[fo„. many people are constantly confined to a relatively small space. The statistics from all over the world show that the mortality from pulmonary tuberculosis in these places has been higher than any- where else.' My personal visits to some otherwise well-regulated prisons and similar institutions have convinced me of the need of more serious attention to this matter. A most reconimendable innovation in this respect is the projected convict camp of tuiieicu- lous prisoners of the State of Alabama. In many cities tuberculosis seems to cling to ce n localities and houses owing to the nature of their construction. Tlu dis- ease appears in a veritable endemic form, either from tlic fa( t that careless tuberculous patients have lived for years in these hon < - or from the equally important fact that the soil on which these houses have been built, or the manner in which they have been constructed, is of a nature to retain the tuberculous infection indefinitely. That this is so has been shown by the report of Professor Biggs,- of the Health Board of New York, and the inter- esting works on this subject by Dr. Flick,^ of Philadelphia. When a thorough sanitary overhauling does not suffice to stamp out these centres of infection, the destruction of such dwellings seems the only remedy. The circulars issued by the board of health* in regard to any ciicuiaisor . . • 1 1 1 1 r instriictioii disease, but especially m regard to consumption, should be framed aiKi free in clear, precise, untechnical,and comprehensible language. Theyiion. should call attention to the danger from an unclean, unscrupulous consumptive, and explain wherein this danger lies and how to avoid it. But the circular should explain also that, if proper pre- ' Cornet, " Zeitschrift filr Hygiene," vol. \l, p.irt I, iSSi). ' l^iggs, " Tlic Action of the Health Department in Rehition to Pulmonary Tuber- culosis." A report, 1897. » Flick, " The Contagiousness of Phthisis," 1888. iijl' i Mi :'M .1'; ! I ill 58 PULMONARY TUBERCULOSIS. cautions are taken there is no danger in associating with such a patient. Not to frighten very impressionable natures, the circu- lar should .state that pulmonary tuberculosis is one of the most curable and frequently cured diseases, for this has been amply proved ; and the earlier the patient puts himself under the doctor's care the more chance has he for an early and complete recovery. Such circulars should be freely distributed, and especially in the densely crowded districts of large cities. To the poor a free disinfection by the health authorities should be held out as an inducement to avail themselves of such an oppor- tunity. The disinfection of the rooms occupied by a consumptive should not only take place after his demise, but should also be made ob- ligatory at stated intervals during his life-time. The method indi- cated by Novy and Waite in the "Medical News" of May 21, 1898, seems to me most practical and recommendable: (i) All cracks or openings in the plaster or in the floor, or about the door and windows, should be caulked tight with cotton or with strips of cloth. (2) The linen, quilts, blankets, carpets, etc., should be stretched out on a line in order to expose as much surface to the disinfectant as possible. They should not be thrown into a heap. Books should be suspended by their covers, so that the pages will fall open and be freely exposed. (3) The walls a id the floor of the room, and the articles contained in it, should be thoroughly sprayed with water. If masses of matter or sputum are dried down on the floor, they should be soaked with water and loosened. No vessel of water should, however, be allowed to remain in the room. (4) One hundred and fifty centimetres (five ounce.s) of the commercial forty-per-cent. solution of formalin for each one thousand cubic feet of space should be placed in the distilling apparatus and be distilled as rapidly as possible. The keyholeand spaces ab-nt the door should then be packed with cotton or cloth. (5) Tin room thus treated should remain closed at least ten hours. If there is much leakage of gas into the surrounding rooms, a second or third injection of formaldehyde at intervals of two or three hours should be made. Dispensaries should distribute suitable pocket-spittoons gratui- tously to their very poor tuberculous patients. Those able to pay for them should be treated only under the condition that they provide themselves with such pocket-flasks. 11 PUBLIC PROPHYLAXIS. 59 Each community should have health ordinances to suit its own Health ... Ai i-i- r • r ordinances. conditions. A place which is a favorite resort for pulmonary invalids will require much more stringent rules in regard to boarding-houses and hotels than the average place. To put in public conveyances, halls, theatres, churches, etc., placards making spitting on the floor a punishable offense will prove a good thing everywhere. If it does not deter all the spitters from expectorating wherever they please, it will deter some. In Denver the City Improvement Society has sent out the following note to ail physicians residing in the city : "Realizing that physicians can do more than any one power to prevent the spread of consumption, and to insure sanitary reform in the matter of non-expectoration on the sidewalks, to the physicians of the city we therefore appeal for co-operation, that by instructing their patients not to spit on the sidewalks we may have a cleaner and more healthful city." The city attorney has also prepared a bill, as follows : " Sec- tion I. It shall be unlawful for any person to spit upon the floor or any part of any street-car or elevator within the city of Denver. Section 2. Any person violating the provisions of this ordinance shall, upon conviction, be fined not less than three dollars nor more than five dollars for each offense ; and the conductors of all street-cars and the pilots of all elevators are hereby authorized and empowered to enforce the terms of this ordinance." An excellent method of educating the public in regard to the societies ^ I o lor the pre- necessitv of preventive measures to stop the spread of tuberculosis vention of is the formation of societies for this purpose. They exist now in^'^- nearly all civilized countries, and have done some very good work- already. These societies are composed of laymen and medical men, and their purpose is usually twofold. The medical members deliver public lectures or compose tracts for distribution. The Pennsylvania Society for the Prevention of Tuberculosis, for exam[)le, distributed last year 50,000 tracts entitled " 1 low to Avoid Contracting Tuberculosis," 40,000 tracts entitled " How Persons Suffering from Tuberculosis Can Avoid Giving the Disease to Others," and 10,000 tracts entitled "How Hotel-keepers Can Aid Ml Preventing the Spread of Tuberculosis." This year, a circular, setting forth the " Predisposing Causes of Tuberculosis and How to Avoid or Overcome Them," has been extensively circulated by the same society. ' I 11 i\\ ii It; ii ' i 60 PULMONARY TUBERCULOSIS. . Duties of the school physician III rc'Raril to tuberculo- sis. Lack ot hyKieiie in railway- and street- cars. The second very laudable purpose of some of these societies is the end'^avor to establish sanatoria for the treatment of the tuberculous poor. Of the importance of such institutions as preventive factors in the prophylaxis of tuberculosis we will speak directly. An Association for the Prevention of Consumption and Other Forms of Tuberculosis was founded in London during the summer of 1898, and more recently a similar association was organized in Chicago and one in Durham, England. The object and scope of these associations are similar to those of the Pennsylvania society. The place where the coming generation should receive most of its hygienic education is the public school. There the children should be taught all that is conducive to health, and also how to avoid all that is unsanitary. The intelligent boy or girl will com- prehend, as well as the grown person, why one should not expecto- rate except in a proper receptacle. In our chapter on prophylactic treatment we will speak more fully of the duty of the public school in the prevention of consumption. I wish to state here only that the school physician (and every school should have one), charged with examining the children every morning for contagious diseases, such as scarlatina, variola, diphtheria, and measles, should, on discovering a child developing tuberculosis, insist upon the exclu- sion of this pupil from the public school. Besides being a menace to the other pupils, the child will have no chance of getting well while daily attending .school in a crowded classroom. Quite an important factor in the propagation of tuberculosis has always seemed to me the unhygienic mode of construction and management of railway passenger-cars, and especially of the sleep- ing-cars, which are extensively used in the United States by pul- monary invalids in search of warmer climes. The unsanitary arrangement of these sleeping-cars must be evident to any one who has given the matter attention. Only a few months ago, when going south, I had three traveling companions in the more ad- vanced sta{7"es of pulmonary tuberculosis, one unable to leave his berth during the daytime. They were all male patients, and with them the rest of the male passengers, the conductor, the trainman, and the colored porter enjoyed the privilege of one drinking-glass. The patients coughed and expectorated a good deal, sometimes hitting and sometimes mis.sing the small hole in the flat cuspidor, which contained no liquid whatsoever. One may draw hisconclu- PUBLIC PROPHYLAXIS. 6l sions from this as to the safety of the innocent traveler who enters this car having a slight bronchitis, being in a condition of acci- dentally enfeebled health, or with a natural predisposition to con- sumption. A few days later I returned in the same car, and I am sure it had not been disinfected since I traveled in it south- ward. Now, I am told that it is impossible to hinder a consumptive from entering a Pullman car, and that if there were a law whereby he could be prevented from doing so it would be well-nigh impossible to enforce it. I grant this to be true, but if our wealthy railroad corporations owning lines which habitually carry consumptives to and from health resorts could be induced to run ambulance-cars, especially adapted to the purpose, a good deal of danger now exist- ing would be done away with. If these ambulance-cars would offer to the traveling consumptive only twice the ordinary breathing- space, and if the railroad company would be magnanimous enough to have a trained nurse in charge of each car, the accommodations thus offered would be eagerly sought by all invalids; even an additional price would not deter the average patient from making use of this mode of travel, which would certainly lessen materially the many discomforts from which he has to suffer in the ordinary sleeping-car. Wire mattresses, leather cushions, linen curtains, special cuspidors, and linoleum instead of carpets, with better ventilation generally, could make of such a "Pullman" a model ambulance-car, easily disinfected, and a credit to the respective company. But a regular, thorough cleaning and disinfection of all passenger-cars, even of our street-cars, at stated intervals should be made obligatory. I am happy to learn that Mr. E. A. Jewett, the Assistant General Superintendent of the Pullman Palace- Car Company, has recently issued directions for disinfecting the Pullman cars by formalde- hyde vapor. Equally important seems to me the regular disinfection of all pisinfet- localities in which large gatherings take place, such as theatres, theatres, churches, music-halls, etc. I learn that some of the New Orleans theatres have already distinguished themselves by the happy inno- vation of disinfecting their entire building, after each performance, with formaldehyde gas. This practice is certainly most highly to be recommended, and should become obligatory in all civilized communities. -m '■W iiitriMifiil il 1\ •A\ 62 PULMONARY TUBEKCULOSIS. Street sweepiliK :iii(l tiuiiii.'d dresses. Disposal of the dead. Streets should never be swept without having been previously thoroughly .sprinkled. Professor Schrotter calls the sweeping of unsprinkled streets and its accompanying raising of clouds of dust a crime toward one's fellowmen. But, to my mind, equally dangerous is dame Fashion, when she decrees that our ladies shall wear long or trained street-dresses. To walk and breathe behind a lady dragging her dress over dusty, dirty sidewalks, often dotted with deposits of buccal, bronchial, and pulmonary secretions, sometimes containing the various pathogenic microbes, at others mixed with the juice of the leaves of Nicotiaita tabacnm, must be dangerous to the health of every one. How I pity the poor woman who is afterward obliged to clean these skirts, soiled with an accumulation of filth, dust, and, alas! too often with disease-producing germs! If our ladies will not soon awaken to the danger of this mode of dress, I should certainly favor city ordinances prohibiting the wearing of trailing dresses in public streets. A chapter on prophylaxis of tuberculosis would not be complete without mentioning the danger arising from the present most universal mode of the disposal of the dead. In connection with the disposal of the sputum, I have already referred, on page 50, to the experiments of Lortet and Despeignes, whereby it was demon- strated that earth-worms are capable of ingesting and ejecting the tubercle bacilli without the micro-organisms losi.ig their virulence. Other experimenters, such as Galtier,' of Lyons, showed that the bacillus of tuberculosis resisted putrefaction for several months, Gartner" buried the bacillus for one year, and it retained its infectious property, and Schottlius even claims that it resisted putrefaction for two years. In view of these and numerous other proofs of the danger of burying those who have died from tuber- culous diseases, the Third Congress for the Study of Tuberculosis, held in Paris in 1894, adopted resolutions asking for obligatory disinfection of the bodies of diseased tuberculous individuals. A motion for recommending obligatory cremation of such bodies was not carried. Leaving the religious objection to cremation out of con- sideration, it seems to me that the objection raised from a medico- legal standpoint (inability to discover jioison after cremation) ' Galtier, "Congrfis pour r^tude de la Tuberc," p. 213, Paris, Oct., 1893. ^ Gilrtner, Congress, ileriiti, 18S7. PUBLIC PROPHYLAXIS. 63 can hardly have any weight in a case of death from a chronic tuberculous disease. As one of the means of stamping out tuber- culosis in the human race, I would certainly favor the cremation of all bodies of individuals having died of a tuberculous disease. Thalassic submersion as a means for the disposal of the dead seems also preferable to the methods now most universally in vogue.' We have not yet touched upon the social causes in the propaga- tion of tuberculosis. These are numerous, but we will speak only of those which can be remedied by the sanitary authorities. Dr. Hermann Weber, cf London," in a very able paper read before the Tenth Medical Congress in Berlin, on "The Influence of Climate, Soil, and Social Conditions on the Occurrence and Course of Pul- monary Tuberculosis," speaks of the danger of badly ventilated workrooms and factories, where all sorts of dust is inhaled, unhealthy sleeping-rooms, etc., in the furtherance of this disease. Promiscuous spitting should be especially prohibited, and appro- priate spittoons, such as Predoehl's, should be placed in suflficient numbers in all factories, workshops, etc. A sanitary supervision of factories, workshops, and stores, with a view of securing hygienically constructed and managed places where the workers have to toil, is, of course, essential. In all such indus- tries where the inhalation of organic or metallic dust seems to be inevitable, the workers should be provided with respiratory masks, such as are in use in some of the factories in luirope. The regulation of working-hours, especially for women and children, will also lead to a reduction of the mortality from tuber- culosis. No one is more prone to become consumptive than the overworked individual whose environments are the contrary to what is considered sanitary. Syphilis is not infrequently a predisposing cau.se to pulmonary tuberculosis. To regulate prostitution, and thus diminish the dan- ger of venereal infection, by humane but strict laws, must, of neces- sity, become a portion of the public prophylaxis of consumption. Alcoholism predisposes to pulmonary tuberculosis to a still higher degree. Children of alcoholic parents are ])articularly susceptible ' H. D. l.iihty, " jouinal ,)f Aincricaii Med. Association," Nov. 26, 1898. ^ Weber, II., " Oberden Eiiiiluss derkliniatiscbeii lioden- uiid gesellschaftliclieii \'cv- li;Utnisse niif <:atioii of liiberciilo- sis. 1*1- it J' 64 PULMONARY TUHKRCULOSIS. to tubercular diseases. Legrain, in his excellent work on " De- generescence et Alcoolisme," says that he found tuberculosis pre- vailing 32 times in 215 alcoholic families. To combat alcoholism must be the work of the statesman and sanitarian. With the diminution of the consumption of alcohol there will be a corre- sponding reduction in the mortality from pulmonary tuberculosis. The following table, compiled by [Archibald Ken Chalmers, M.D., D.P.H.,' showing the comparative mortality of individuals, occupied in the various pursuits of life, will be the best guide to the sanitary authorities as to where intervention is most needed: Agriculuirist, Engiavir (Artist class), . . Shopkeeper, Butcher, Commercial Clerk, . . Watchmaker, Sa.liller Shoemaker Draper, Tailor, Hairdresser, Tobacconist, Tobacco Manu- facturer, H&tter Musician, liookhinder, Printer, Phthisis. 106 146 172 195 21S 243 248 256 260 271 276 280 322 325 326 OrHi:K Um- KASKS OI' Rhspirahon. "5 133 17;; 209 172 193 169 181 181 195 213 181 210 200 218 214 UOTII T(>GKTii!:i;, 221 279 350 404 390 427 437 441 466 489 461 511 522 543 540 Pi.K Cknt. or I'HIHISJS K) All. UlS- KASKS Ol' Rkspiration. 48.0 52.3 49.1 483 55-9 S4.8 59-5 58.6 59-0 5f;.2 56.4 60.7 589 61.7 59-9 60.4 Coal-smoke ^" somc cities vigorous measures against the production of nuisance, quantities of coal-smoke would doubtlessly render the atmosphere purer and the diseases of the respiratory organs rarer. In England there exists a Coal-smoke Abatement Society, which has for its object to combat the smoke nuisance and to enforce existing laws against black smoke. They are trying now to have a law passed making it illegal for any house to be built without being fitted with proper smoke-consuming appliances. Damp, badly ventilated, and dark habitations seem to favor the development of tuberculous diseases, and a well-drained spot with ' " The Causation of Tuberculosis and its Prevention by Legislation," " The Prac- titioner," London, June, 1S98. PUnr.IC PROPHYLAXIS. 65 porous soil will always be the best place to build a dwelling, hos- pital, or sanatorium for consumptives. Another urgent need in our large cities, as urgent as sanatoria for the consumptive poor, is model tenement houses. So long as the poor arc housed by hun- dreds in dark, filthy, and badly ventilated buildings, so long will it be impossible to stamp out consumption. Of what great importance it is to our rising generation that only the most sanitary schools and colleges should be built! We should be as anxious to give our children, young men, and young women, during their school life, just as much opportunity of developing a sound, vigorous body as of obtaining culture and knowledge. II i CHAPTKR VI. SANITARY LAWS CONCERNING THE PREVENTION OF BOVINE TUBERCULOSIS. We come now to another important class of preventive measures to combat the spread of tuberculosis in man ; I speak of those directed toward the suppression of tuberculosis in our domestic animals, especially in cattle. The danger from tuberculous meat and milk has been, I fear, underestimated in years past. Many authors have considered, and consider yet, the dissemination of the germs contained in the carelessly deposited sputum of tuberculous patients the only im- portant factor in communicating the disease to others ; and I am willing to admit that I, also, formerly adhered to the same opinion. But I recently undertook to trace, in as many cases as it was possible from the ])ublished history, the etiology as to ante- cedents, environments, and personal and family history, and I was astonished to find in how large a number one was justified to ex- clude the inhalation of bacilli as the etiological factor. A farmer, cowboy, gardener, wood-chopper, or any other individual living in the open air most of the time, residing in an isolated district where consumption is rare, if not unknown, with no family history of tuberculosis, sickens and dies of j)hthisis pulmonalis. Now, while it is true that primary intestinal tuberculosis is of relatively rare occurrence in the adult, we can account for this by the fact that he rarely takes raw or unsterilized milk as his exclusive nourishment, which may be the case with an unfortunate child whose delicate intestinal epithelium, as we ex- plained before, becomes the abiding-place of the tubercle bacillus contained in countless quantities in every meal he gets. In the adult the ingested bacillus seems, in the majority of cases, to pass through the lymphatic system into the circulation of the blood, to find its favorite lodging-place in the badly ventilated apices of the lungs. It is well known that the bactericidal quality of the gastric 66 SANITAKY LAWS TO PREVENT IIOVINK TUIIERCUI.OSIS. 67 secretions is insufficient in refjard to the germ of tuberculosis. The only defense against this mode of invasion seems to lie in the good phagocitic power of the blood of the healthy individual. Now, when we consider that milk, butter, and meat of cattle constitute m s! important ami most universally used articles of food for man, and how relatively recently laws in regard to tuberculosis have been enacted at all, and in how many States such laws do not exist or are but feebly enforced, I think it is not surprising when, in looking into the e.xact etiology of many cases of pulmonary tuber- culosis, we find that a very large number must h?ve been caused by the ingestion and not by the inhalation of the bacillus. After arriving at this conclusion I was much gratified, when on a r' 'cnt visit to Dr. von Ruck's sanatorium in Asheviile, North (.'arnli'ia, to hear his opinion in this matter. Me told me that, to judge from the carefully kept history of many thousand cases from all over the United States, which have come under his observation, the majority of cases of pulmonary tuberculosis, in his opinion, had their origin in the ingestion of tuberculous food of some kind. Dr. V. W. Smith, of the Tuberculosis Committee of the State Board of Health of New York, whose experience in the matter of prophy- lactic measures in regard to tuberculosis has been considerable, seems to be of a similar oi)inion, for he writes me: "The first great step toward the prophylaxis of tuberculosis in man is to stamp out the disease in cattle." Dr. Martin, of the Royal Com- mission of England, says : " The milk from cows with tubercu- lous udders posses.ses a virulence which can only be described as extraordinary." Even the geographical distribution seenis to pointto the fact that^. ,, the bovine race is in a large measure responsible for the prevalence {Jy,'i,'j',',""f" of tuberculosis among men. In a very able paper, read before the [;",^,I[j[;,'Jis. American Health Association, at the twenty-fifth annual meeting, heldat Philadoipliiaon October 26to 29, 1897, Dr. M. P. Ravenel,of the Veterinary Department of the University of Pennsylvania, showed that in northern Norway, Sweden, Lapland, and Finland, where reindeer constitute the bulk of farm animals; about Hudson Bay and in the islands of the Pacific, where no cattle exist; in the Scottish Hebrides, Iceland, and Newfoundland, where there are only few cattle, tuberculosis is far less prevalent in man. Particularly dangerous, on the contrary, seems to be the regions where cattle are housed and the people live in close pro.ximity to them, as, for lii III .■(4;-(,. 68 PULMONAKY TUBEKCULOSIS. I i I example, in Italy. This condition caused Perroncito to call tuber- culosis " the scourge of man and beast." It is estimated that in the State of New York there are at this time no less than 75,ocK) tuberculous cows.' I am not prepared to give other exact .statistics, I think, however, it is usually estimated that at least five per cent, of all milch-cows are tuber- culous. But among some herds of high-bred cattle not infre- quently fifty per cent, are found to be suffering from tuberculosis. Let us, then, in our war against this disease, divide our attention equa.'ly between the bacilli which may be ingested and the bacilli which may be inhaled. Most European governments have realized the importance of concerted action in this matter. England has its Royal Commis- sion to investigate the spread of tuberculosis in domestic animals ; I'Academie Nationale de Medecine of France has its permanent Section on Veterinary Medicine, which has done much in the direction of bovine legislation; Germany has most rigorous laws and regulations in connection with bovine tuberculosis. Here in the United States, owing to our geographical and sutes''"^^ political situation, we have no uniform laws regarding bovine tuberculosis, much less regarding tuberculosis in man. To ascer- tain the true condition of prophylaxis in regard to tuberculosis, I addressed, last year, letters of inquiry to all the secretaries of the State boards of health of all the States and Territories of the Union, and to the health officers of forty of the largest cities, and reported the results of my inquiry to the Section on State Medicine at the Forty-eighth Annual Meeting of the American Medical Ass jc'ation." I quote the following from my report: Alabama. — No laws or regulations concerning tuberculosis in man or beast, and no circulars issued. Arkansas. — No laws, regulations, or circulars concerning tuber- culosis. Dr. Jennings, the executive officer, writes that the State not having made any appropriation, the board is handicapped for want of funds. TubercnlO' sis laws in ' Cassidy and Siiiilli, "Tuberculosis: It is llie Duty of tlie .Slate to Suppress tlie Greatest Destroyer of the Human Race." New York, February, 1897. " Knopf, " The Present Status of Preventative Means against tlie Spread of Tuber- culosis in the Various States of the Union Ciilically Reviewed," " Journal of the Atner. Med. Assoc," Oct. 30, 1897. SANITARY LAWS TO PREVENT BOVINE TUBERCULOSIS. 69 California. — Good bovine laws and regulations; circular issued on consumption. Colorado. — Good bovine laws and regulations, and a special circular, " How to Prevent the Spread of Consumption in Colo- rado." Connecticut. — Good bovine laws enforced by the State Board of Agriculture, and a circular on " Consumption : Its Cause and Means of Prevention." Delaware. — Circular on the prevention of consumption. District of Columbia. — Only one law in regard to tuberculosis, which forbids the sale of milk that may be tuberculous. No cir- culars or public notices. Georgia. — There was formerly a State board of health, but it has been allowed to become ext'nct for lack of appropriation. Idaho. — No State board of health. Provision is made for the appointment of health officers by the various boards of county commissioners, but they are answerable to the local authority only. Illinois. — The board has never passed any laws or resolutions concerning tuberculosis, and no circulars have been issued. Indiana. — No bovine laws yet, but the question is agitated. The board issues two thousand quarterly bulletins free to all county, city, and town health officers, and to others who may subscribe for them. lo'iva. — The board is very active in educating physicians and laity in regard to tuberculosis, and is enforcing its bovine laws with vigor. Kansas. — No laws, regulations, or circulars concerning tuber- culosis in man or beast. The Legislature failed to make any appro- priation and the State veterinary office is abolished. Kentucky. — For want of appropriation the board has undertaken no work in regard to bovine tuberculosis, but a circular on con- sumption has been issued. Louisiana. — Circulars are sent to physicians, and stations for the free examination of sputum have been established, but the attempts of the board to secure legislation in regard to bovine tuberculosis have been thwarted by concert of action on the part of the ignorant and prejudiced Creoles, who have almost entire control of the dairy business. Maine. — The cattle commissioners are authorized to slaughter - 1 ' in I I 70 PULMONARY TUBERCULOSIS. S- tuberculous cattle and reimburse the owners, and the board has issued a circular on consumption. Maryland. — No laws, regulations, or circulars on tuberculosis. Massachusetts. — Five cattle commissioners appointed by the governor are entrusted with the suppression of bovine tubercu- losis. A circular on the best means of preventing consumption is issued. Michigan. — The State Live-stock Commission is intrusted with the work concerning the suppression of bovine tuberculosis. Cir- culars for public instruction are issued. September 30, 1893, resolutions were adopted to include consumption in the official list of diseases dangerous to the public health. Minnesota. — Good bovine laws. I received no report in regard to provisions concerning tuberculosis in man. Mississippi. — No laws, regulations, or circulars concerning tuber- culosis in man or beast. With the reorganization of the board better work is hoped for. Missouri. — No answers to my inquiries, but I learn from the daily paper that the State board recommends public lectures on the question in the more populous centres, and all pupils of the public schools throughout the State be given a course of instruction in the causes of consumption and means by which it may be pre- vented. Montana. — No State board of health. Nebraska. — The board at present is a mere licensing body with- out sanitary powers. Nex^< Hampshire. — No special regulations on the prevention or restriction of tuberculosis, but some papers on the subject have been printed. In 1891 the Legislature enacted a law creating a State Board of Cattle Coiumissioners. Neiv Jersey. — The State Board of Agriculture enforces the bovine laws, and a circular on consumption has been issued. Neiv Mexico. — The territorial board ha.; noticed the increase of phthisis among natives of the Territory and has traced many cases to an exposure to possible infection, New Mexico being a favorite resort for consumptives. Circulars on consumption are profusely distributed, and last year the board passed resolutions encouraging the testing of domestic animals with tubercuiine. Neiv York. — Good bovine laws not very rigidly enforced because the State appropriation is small. Most efficient work was done at SANITARY LAWS lO PREVENT BOVINE TUBERCULOSIS. 71 first by the Tuberculosis Committee of the board, but there was no appropriation last year, in spite of the fact that it has been demon- strated that there are at this time 75,000 tuberculous cows in the State.' Circulars like those of the New York City board have been issued. To New York belongs the credit of having done the pioneer work in educating the public to the dangers of tuberculo- sis. The State board requests all local health officers to i^egister name and address of every person suffering from tuberculosis within their respective jurisdictions. North Carolina. — No laws, regulations, or circulars concerning tuberculosis in man or beast.- NortJi Dakota. — No laws, regulations, or circulars concerning tuberculosis in man or beast. Oliio. — No bovine laws. A circular on the prevention of con- sumption has been issued. Oklahoma. — There is a law prohibiting the sale and use of milk from cows not in proper condition of health. Nothing else is done in regard to the prevention of tuberculosis. Oregon. — No State board. Pennsylvania. — The State Live-stock Sanitary Board is entrusted with full power to suppress bovine tuberculosis. The board of health has passed resolutions that tuberculosis be added to the list of communicable diseases dangerous to the public health. Circu- lars are issued and the Pennsylvania Society for the Prevention of Tuberculosis is in a flourishing condition, although it does not re- ceive any aid or encouragement from the State. Rluhlc Island. — Circulars are freely issued. Sputum is examined free of charge, and $10,000 yearly is expended to enforce bovine regulations. South Carolina. — No bovine laws. Some years ago circulars were [)rinted and distributed, but, no more appropriation for this purpose having been forthcoming, nothing is now done. South Dakota. — There is a law providing for the destruction of ' Cassidy and Smitli, " Tuberculosis : It is tlie Duty of tlie Stale to Suppress the Ciieatest Destroyer of the lliuuan Race." ' Anil to tills State llock, year in and year out, thousands of tuberculous invalids in search of hcjitli. Duriiij^ the discussion nu this subject at tin- meeting of the New Vorl< Academy of Medicine, of May 5, I.S9S, Dr. John II. (jirdncr said tliat a year ago he had e.xperinienled with tubercuHiie among the cattle in the mountains of North Carolina, and had found tlieui tul)eri;ulous almost without exception. 72 PULMONARY TUBERCULOSIS. ) it tuberculous animals and carcasses ; nothing concerning tubercu- losis in man. Provision is hoped for from the next Legislature. Tennessee. — Circulars on the prevention of tuberculosis in man and beast have been issued. There are bovine laws, but owing to want of funds the board has been deterred from formal action up to this time. Texas. — The quarantine department is the highest sanitary authority. Its powers are limited to epidemic diseases. Circulars on tuberculosis have been sent to physicians. There are no bovine laws. Utah. — No board of health or any organization of a similar kind whatsoever. Vermont. — Ko answer, but I learn indirectly that this State kills tuberculous cattle and recompenses the owner. Virginia. — Bovine laws are enforced by the board of control of the experimental station of the Virginia Agricultural and Mechan- ical College at Blacksburg. Circulars on the restriction of con- sumption are issued. West Virginia. — No bovine laws. Circulars on consumption have been issued. Wisconsin. — The board of health and the State veterinarian co- operate in destroying milch-cows that arc tuberculous. Circulars on tuberculosis in man are issued. Wyoming. — No State board of health. During the legislative sessions of 1895 a bill was introduced to create one, but it was not passed. Sanitary regulations are left to the cities, some of which have boards appointed by ordinance. This gives us: Fourteen States which have bovine laws and regulations and in which circulars are issued for public instruction in regard to tuberculosis in man, viz. : California, Colorado, Con- necticut, Iowa, Maine, Massachusetts, Michigan, New Jersey, New Hampshire, New York, Pennsylvania, Rhode Island, Virginia, and Wisconsin ; two which have bovine laws, but where apparently nothing is done to stop the spread of tuberculosis in man, viz. : Minnesota and South Dakota ; one which has bovine laws but can- not enforce them for lack of funds, and where thus far the board has only issued circulars on the prevention of tuberculosis in man and beast, viz.: Tennessee; two (the District of Columbia and Oklahoma Territory) which have a law prohibiting the sale of tuberculous milk, but nothing else concerning tuberculosis in man '*"■**"———- SANITARY LAWS TO PREVENT BOVINE TUBERCULOSIS. 73 or beast; eight which issue circulars of instruction concerning tuberculosis in man, but where nothing is done in regard to bovine tuberculosis, viz. : Delaware, Indiana, Kentucky, Louisiana, New Mexico Territory, Ohio, Texas, and West Virginia; nine where nothing is done to stop the spread of tuberculosis in either man or beast, viz. : Alabama, Arkansas, Illinois, Kansas, Maryland, Mis- sissippi, North Carolina, North Dakota, and South Carolina ; seven which have no boards of health, viz.: Georgia, Idaho, Montana, Nebraska, Oregon, Utah, and Wyoming; five from which I have received no answer, viz. : Florida, Missouri, Nevada, Vermont, and Washington. To the letters addressed to the health officers of forty of our largest cities I have received twenty-nine answers. In one-third of these it was stated that nothing at ail had been done concerning the prophylaxis of tuberculosis. This state of affairs speaks for itself and shows that as a nation we have a most limited protection from tuberculosis in man and beast. Let us consider for a moment the injustice done to States with ""J'' ^"".'■■s J witli good good laws in regard to bovine tuberculosis by those which have no'j"^"^",^^"^ such laws. Where interstate traffic exists it will be well-nigh im i,^,,^. possible for the States with good sanitary laws to suppress bovine tuberculosis within their borders. The following incident, which I have from a reliable source, will show a danger and injustice to which a State with good laws is no doubt frequently exposed : A farmer in a State with no laws to suppress bovine tuberculosis enters into a compact with a friend residing in a neighboring State where the government kills all tuberculous cattle and recompenses the owner; all the worthless cattle which he can procure are driven across the line to the friend. At the next visit of the State veteri- nary surgeon these cattle are found tuberculous, ordered killed, and, considering their real value, handsomely paid for. The farmer and his friend divide the profit. This may be the first dire-t loss in money to the State with good laws, but how mraiy times may not these diseased cows, secretly imported, be the cause of infecting whole herds of valuable cattle ? And yet the citizens of the State with good laws in regard to tuberculous cattle, though imposed upon, are to be envied ; for the State with no such laws is an unsafe place to live in. The following extract from the " lughth Biennial Re- port of the Iowa State Board of Health" will show how tiuc this ■ from those with !i!! -> . f.WI 74 PULMONARY TUBERCULOSIS. 1 i Inspection of cattle. is : " Some time since the State Veterinary Surgeon found a lot of cattle which he condenmed as tuberculous, placing them under quarantine and expecting in a day or two to slaughter them. Upon his return he found that the cattle had been sold to be shipped out of the State for food." The seller claimed that he had fully made known the condition of the cattle to the buyer, and thus the law could not reach him. To effectually combat tuberculosis in cattle and other domestic animals, the federal government is alone capable to do the worlc, and should have in this respect equal juri.sdiction over all the States and Territories. Much excellent educational work has already been done by the Bureau of Animal Industry under the direction of its distinguished chief. Dr. D. E. Salmon. However, the need of concerted action must certainly be felt more in the United States than in other countries. While each country and State may have to frame its bovine laws and regulations in accordance with the demands of its geographi- cal, climatic, and perhaps also its political situation, there are some which should be common to all. From a careful perusal of exten- sive literature on the subject, and an effort to make myself acquainted with the practical workings of the many different laws, regulations, and recommendations concerning the restriction of tuberculosis in cattle, I may suggest a few points which should form part of the rules essential to the prophylactic work instituted by any government in this respect: 1. There should be a central bureau, from whence the work of the sanitary inspectors, especially educated for their duties, may be directed. 2. Tliere should be an inspection of all cattle at regular inter- vals, besides, of course, always upon the demand of the owner. Regarding the manner in which the inspection should be carried on, I have not found in all the literature anything more practical and more thorough than the directions given by Professor Leonard Pearson, the distinguished State Veterinarian of the State of Penn- sylvania, and I take great pleasure in reproducing them /// cxtcuso. " DIRECTIONS FOR INSPECTING HERDS FOR TUBERCULOSIS. " Inspection should he cai.i.d on wliile tlic Iierd is stahloch If it is necessary to stal)le animals tmdcr luuisual conditions ov among imiisnal surroundings tliat make them uneasy and excited, the tuberculine test SANITARY LAWS TO PREVENT liOVINE TUBERCULOSIS. 75 should he postponed until tlie cattle have become accustomed to the conditions they are subjected to, and then begin with a careful physical examination of each animal. This is essential, because in some severe cases of tuberculosis no reaction follows the injection of tuherculine, but experience has shown that these cases can be discovered l)y physical examination. This examination should be complete and include a care- ful examination of the udder, and of the superficial lymphatic glands and anscidtation of the lungs. " Each animal should be numbered or described in such a way that it can be recognized without difficulty. It is well to number the stalls with chalk and transfer these numbers to the temi)erature sheet, so that the temperature of each animal can be recorded in itsapprojjriate place with- out danger of confusion. The following procedure has been used exten- sively and has given excellent results: " (a) Take the temperature of each animal to be tested at least twice, at intervals of three hours, l)efore tuberculine is injected. " (/>) Inject the tuberculine i in the evening, ])referably between the hours of 6 and 9. The injection should be made with a carefully steril- ized hypodermic syringe. The most convenient point for injection is back of the left .scapula. "Prior to the injection the skin should be washed carefully with a five percent, solution of creoline or other antiseptic. " (c) The temperature .should be taken nine hours after the injection, and temperature measurements repeated at regular intervals of two or three hours until the sixteenth hour after the injection. " ((/) When there is no elevation of temperature at this time (sixteen hours after injection) the examination may be discontinued ; but if the temi)erature shows an upward tendency, measurements must be continued until a distinct reaction is recognized, or until the temperature begins to fall. " (e) If a reaction is detected prior to the sixteenth hour, the meas- urements of temperature should be continued until the e.v[)iration of this period. " (/) '{"he thermometers used for this work should be accurate, and if several are used they should be compared before the examination is commenced. " (.i,"-) If there is an imusual change of tem]ierature of the stable, or a sudden change of weather, this fact should l)e recorded on the report blank. "(//) If a cow is in a febrile condition when the initial temperatures are taken, tuberculine should not be used on her, because in this case the temperature curve is irregular and the result of the test imcertain. " (■/) Cows should not be tested within a few days before or after calving, for experience has shown that the result at these times may be misleading. '' ( / ) The tuberculine test is not reconunended for calves under three months old. ; ii«t- ' Average dose ; 0.25 c.c. In diluting for an injection a 10 per cent, solution of tiil)er- culine is made l)y adding 9 parts of a I per cent, solution of ac. carliol. I? I 76 PULMONARV TUIiKKCULOSlS. ijtfi ' " (/:) In old, emaciated animals and in rotests use twice the iisnal dose of tuborciiline. "In reporting upon the examination of thv. herd, the large temjiera- tiire sheets should he fillet! out and returned, togetiier with a more de- tailed record for each animal that i)roves to be tuberculous. This de- tailed report should be made out on the individual report-blanks provided for this pur|iose. "Condemned cattle must be removed from the herd and kejit away from those that are healthy. " In special cases inspectors may be directed to destroy and make |)ost-mortem examinations upon the condemned animals as soon as they are recognized, but this must only be done when directions to this effect are given in the original letter of advice. "In making post-mortems the carcasses should be thoroughly in- spected, and all of the organs mentioned on the blank for reporting this work should be examined." i J, 3. There should be a thorough destruction of all tuberculous meat, etc., and a most thorough disinfection and cleaning of the stables and all utensils which may have come in contact with the tuberculous animals. The owner of the cattle should be instructed in regard to the sanitary arrangements to prevent, as far as pos- sible, a new outbreak of the disease. He should be especially instructed as to the precaution to be taken before introducing new animals into the herd. 4. There should be a just compensatioii for his loss according to the actual value and condition of the animals at the time of appraisement. 5. There should be a careful examination of all imported cattle and the strict exclusion of all tuberculous animals. 6. While several authors caution against the employment of a consumptive to help about cattle or in the dairy, I have failed to discover anything in the literature on the subject calling attention to the fact that the presence of any disease such as diarrhcea in children or adults, persistent cough, bronchitis, pleurisy, local badly healing sores in any one on or about the premises, might lead to the detection of bovine tuberculosis among the cattle of which they had charge, or of which they received milk. I would tluis make it compulsory to notify the nearest sanitary authority of the occurrence of any of the above-named diseases, in addition to typhoid fever, scarlatina, diphtheria, etc., on the premises in the vicinity of where milch-cows are kept. 7. A thorough supervision of all the slaughter-houses, milk- SANITARY LAWS TO PKKVKNT BOVINE TUBERCULOSIS. 17 depots, butcher-shops, and jiIl tlie retail milk-stores is, of course, also one of the vital points to he considered in our strife against tuberculosis in man or beast. Of the many interesting letters which I received in reply to my inquiries there is one from Indiana which gives, concerning the question of how to solve the problem of combating bovine tuber- culosis, such a unique and practical method, without having even resource to the law, that I tliink it my duty to reproduce here this letter in cxtenso. I am sure my distinguished friend, Dr. Hurty, will pardon nie for doing so, since the example set by the wise City board of Indianapolis can only be productive of much good, and is certainly worthy of emulation : " Oii'iCK OF State Board ok Health oe Indiana, "Indianapolis, February 7, 1898. " Dr. S. a. Knoi'K, New York : ^^ Dear Doctor: In reply to your favor of February 3d. The snl)ject in wliich you arc so deeply interested is being agitated in this State, but at the present time there are no special hospitals, either public or private, for coiisuinijtives. In this city, Indianapolis, a good work toward the suppression of tuberculosis is being done without intervention of law. The City 15oard of Health induced one of the iirominent dairymen to write a letter, rcijuesting tliat his herd be tested witii tuberctiline, and also that a sanitary survey be made of his dairy and suggestions be made for sanitary inipvovements, lie pronusing to destroy all cattle wiiieh re- acted to the tuherculihe test, and to make all sanitary improvciiients suggested. For this he was to receive a certificate from the Board of Healtli, simjily stating the facts of the case. This, you see, was a true commercial metiioti. 'I'he work was done, as above indicated, and im- nietliate'y the popular demand arose for tlie milk suiiplied from tuber- culine-ttsted animals, livery dairy supjiiying milk to tiiis city has now been tested and sanitary surveys made, as above. About six jjer cent, of the duiry cattle have been killed, and in every instance it was discovered that tlie tubercuiine test was accurate and al)soiute. This method seems better than the legal method. Some of the i)Oor dairymen have rebelled somewhat against the loss of their animals, but the answer given them is final and cor.iplete — viz., that no matter how poor they are, or what financial injury may be brought to them, still they have no right to fur- nish milk which will probably produce disease and death. I believe, however, it would not be bad policy for the State to pay. say, one-half the value of the cattle slaughtered on account of tuberculosis. This would be a mere matter of jjuIjUc policy to aid in a consummation which is devoutly to be wished. " Communications from citizens and physicians have appeared in our local papers advocating public homes for consumptives. We think, Solving tlie tuberculous milk prob- lem with- out tlie aid of the law. ■m ;> W^ 7« PULMONARY TUnEKCULOSIS. therefore, it will not be long before Indiana will be able to report prog- ress in this direction. "Thanking you, I am veiy truly yours, '•J. N. HuKTV, Seife/(irv." Tuberculosis in hogs is not infrequent, but the cause of the dis- ease can almost always be traced to the infection from tuberculous bovine products. I quote from Pifiard's article in the " New York Medical Record" of April 3, 1897': " Tlie rej)ort of the C"o])enhagen Experiment Station ^ 's that at a Danish creamery, where the centrifuge slime was fed to swiiit. all of these l)roved tuberculous, and warns against the use of slime for this ])urpose witliout its being previously boiled or heated toward tiie temperature of boiling water. The prevalence of tuberculosis among swine in certain parts of (lermany lias been attributed to this system of feeding. " Many other examples pointing in the .same direction might be quoted. The rare instances of tuberculosis in horses, goats, dogs, etc., can doubtlessly always be traced to an infection by tubercu- lous products from either man or cattle. ' Piffard, " On the Tuberculosis Question." ! 1 w chapti;r VII. PREVENTIVE TREATMENT. In the previous cliapters we have spoken of the measures wliich mi^ht be instituted to prevent tlie germ of tuberculosis from enterint^ tlie liunian system throu|^h cither the n-spiratory or the digestive tract, or through inoculation, l^ut even with the most severe laws and regulations the bacillus tuberculosis will not van- ish completely. For a long time to come there will be only too many chances to contract tuberculosis through the carelessness of consumptives, or the unscrupulousness of meat-dealers, farmers, or dairymen, or through the bacilli that, even with the best intentions on the part of the sanitary authorities and their co-workers, are likely to escape detection. What, then, can we do to protect our system against the invasion of this deadly micro-organism ? (^ur bacterio-therapeutists have thus far failed to give us any remedy which we might safely inject as an immunizing agent to prevent the development of tuberculosis. I should rejoice if such a boon would still be in store for mankind. However, we need not despair in the meantime. If the teachings of modern phthisio- therapeutists are followed, even the cliild of tuberculous parent.s may become a strong, health)' man or woman, and the accidental inhalation or ingestion of the tubercle bacilli will not suffice to make a consumptive of him or her. Vor, as we have already stated, it is the weak and enfeebled organism which becomes the easy prey of the bacillus tuberculosis. One in f;iir health, living a regular and hygienic life, has little to fear. The bactericidal quality of his nasal mucous membrane will protect him from harm through the inhalation of the bacilli, while the good phagocitic action of liis blood will protect him from harm through the inges- tion of tuberculous meat or milk, or from the i)acilli which he may have taken in with the dust in the air while speaking or breathing through the mouth. A predisposition to pulmonary tuberculosis may be inherited or acquired, but in either case the means to overcome this peculiar 79 'I :-s! m 8o I'ULMONAKY TUIIEKCULOSIS. ! 1 ■ f t if Descri|ilioii of an iiidi- vidiml |iiv- ilisposeil to CDiisiinip- tioii. sus^cptiljility are the same. Let us exainine, for a moment, an indivicliial predisposed to consumption, ami we will be better able to understand the reasons for the therapeutic measures which I shall describe. If it be a child he will be either undersized or jiresent an almost abnormal hei^dit for his age, with a narrow chest, lie will be a bad cater, irritable, nervous, aniumic, with irregular diges- tive functions, at times constipated, at times suffering from diar- rhoea, prone to all the diseases of childhood, and still mentally rarely behind his more robust companions. He is averse to out- door play, and, owing to his delicate constitution, he is allowed to have his way, and his character is often spoiled. The adult candidate for pulmonary tuberculosis differs from his younger brother but little ; the physique is the same ; the peculiar condition of mind is more pronounced ; while sanguine at times, anxieties, disappointments, especially unfortunate love affairs, and similar sorrows, often suffice to bring about a rapid development of the disease. In sorrow one eats but little, the arterial pressure is low, the muscular weakness and depressed nervous state make the act of breathing incomplete. The beneficial influence of natural and full breathing does not e.xist any more ; the heart is called on to iXo more work and a perpetual palpitation ensues. The circulatory disturbances in the lungs impair the nutrition of this organ, and thus the field for the invasion of the bacillus of tuberculosis is prepared. The decreased power of resistance makes the anremic individual, in addition, especialljr prone to acute inflammations of either the mucous or serous membranes, and catarrhal conditions of the upper respiratory organs become alarmingly frequent and inclined to descend into the deeper air-passages. And why do these people take cold so easily and frequently? Because their vasomotor sys- tem is impaired, and the slightest change of temperature or insig- nificant e.^ijosure of some part of the body usually covered suffices to hinder the peripheral circulation to the extent of producing con- gestions and to impair the process of eliminating used-up sub- stances, whose toxicity increases with the length of time they are retained. It seems evident, then, that the insufficient air-supply to the respiratory organs and the increased susceptibility to the slightest change of temperature are the principal factors in the production of consumptive individuals. Therefore to prevent or improve the iijliOT'illil'liriviVij T FKEVENTIVK TKKATMKNT. 8i cniulition caused by an insufficient air-supply we must resort to acrotlierapeutics, and to arouse tlie vasomotor system to a more ener^'etic action we have in liycirotlicrai)eutics not the only, but, considering its salutary secondary effects, the most valuable thera- peutic ajjent. To prevent pulmonary tuberculosis we must begin with treating the child /'// tt/t/v, continue in the lying-in room, nursery, antl school-room, and teach the young man or woman to keep the treatment up throughout life. A woman who is to give birth to a child should abandon the corset and tight clothing in time to allow a continued, free abdominal and thoracic respiration. Wiser yet if she never liad been addicted to the habit of tight-lacing, for the experiments of Kellogg ' and Mays have demonstrated that the so-called female or costal type of respiration wiiich prevails among civilized women is the result of their restricting and unhygienic mode of dress, and is not due to the influence of gestation or to a natural difference in the anatomo-physiological growth of man or woman. For the mother to live as much as possible in pure, fresh air, to take frequent breathing exercises, to avoid crowded assemblie.-; where the air is vitiated, ami live, in short, as hygienic a life as cir- cumstances will permit, will have a most salutary effect on the child's future health. The new-born child is in need of pure, ''resh air as much as the mother; and the lying-in room and the nursery shoultl always be well ventilated. When the child, in time, is taken for an airing, the thick, almost impermeable veil should be aban- doned. These veils, often tightened around the little face, press against the nose and make it difficult for the child to breathe naturally, and the mother wonders why the baby got into the habit of breathing through the mouth. Frequently, also, mouth-breathing in children, and sometimes in atlults, must be attributed to adenoid vegetation in the retro- pharynx, or to enlarged tonsils. These as well as all other causes of obstruction to a free, natural respiration, such as deviated septum, spores, enlarged turbinated bones, hypertrophied mucous mem- brane, polypus, etc., must be removed if we desire to protect the child or adult from chronic nasal, pharyngeal, and laryngeal catarrhs, so often the forerunners of pulmonary diseases. ' Kellogg, " Experimental Researches Re?.|)ecting the Kehitioii of Dress to Pelvic Diseases of Women," " Transactions of the Micliigaii Stale Med. Society." 6 l'ri)|>hy- lactic ircal- inciit sIkiuIcI tlu' child /// u/t'yu. Moiitli- brcatliiiiK. t1 ',i! («' m i .t ' ( 111 PULMONARY TUBERCULOSIS. I mi !15J: i*,i ,174 H KespiraUiry exercises. Only after the removal of all possible causes of obstructions in the upper air-passages is a natural physiological respiratory func- tion possible, and only under such conditions can we hope for real benefit from breathing exercises. I consider the air-bath and sun-bath for children at the earlier age most beneficial. Let the little ones toddle around naked every day for a short time ; in cold weather in well-warmed rooms, and in summer in the room bathed by the rays of the sun. They will become less susceptible to colds than if always carefully bundled In localities where it is impossible to prevent the constant inha- lation of coal-dust or ether irritating substances, a regular nasal toilet with a milH antiseptic solution, or, perhaps, best of all, plain tepid but previously boiled water, should be instituted for children until they are old enough to blow their noses properly. As soon as the age and intelligence of the child will permit, breathing exercises should be taught to him. He should learn to love them, as the average child likes general gymnastics. The fol- lowing is a description of the exercises I recommend to all children and .dults who breathe faultily, to the an;tmic, the predisposed, and to the chronic tuberculous patient who is able to be about and where a modification is not indicated. These are also a par*- of the gymnastic exercises I should like to see incorporated in the curriculum of all schools, and not only in the selected few. I have prescribed them for years with very satisfactory results, and I can recommend them as practical, efficacious, and easily learned. Presuming'that the upper air-passages are in a normal condition, the patient is taught to stand properly — that is to say, straight, chest out, and head erect — and to breathe always through the nose. He takes a deep inspiration slowly, beginning with the abdominal muscles and then expanding the chest to its fullest capacity. Dur- ing this inspiration he raises his arms from his sides to a horizontal position (Fig. 13). He holds the breath for a moment, and then lowers the arms during the act of expiration, which should be somewhat more rapid. The second exercise is like the first, except that the upward movement of the arms is continued until the hands meet over the head. In the third exercise the patient stretches his arms out as in the position of swimming, the dorsal sui.aces of the hands touching PREVENTIVE TREATMENT. 83 each other. During the inspiration the arms are moved outward and finally meet behind the back. They are brought forward again during the expiration. This exercise can be gr.atly facilitated and made more effective by the patient rising on his toes during the act of inspiration, and descending during the act of expiration. Each respiratory act should be followed immediately by a secondary secomiary forced expiratory effort. This is for the purpose of expelling aspiratory KiG. 13.— First asu Sixond Rlsimkaiorv ExKRCisiiS. much of the supplemental air as possible, and may be effectually aided by supinating the arms and pressing the thorax with them. Considering that the amount of tidal air — that is to say, the vol- ume which is inspired and expired in quiet respiration — is only 500 c.c, the complemental air — the volume which can be inspired after an ordinary respiration — 1500 c.c, and the si'pplemental or reserve air — the amount which can be forcibly expelled after an ordinary respiration — amounts to 1240 to 1800 c.c, one can readily see the !i 84 PULMONAKY TUBERCULOSIS. value of respiratory exercises, and also the utility of this second expiratory effort. Usual scat The fact that in the majority of cases the tuberculous process of ))ninaiy ^ _ ^ ^ lesion. begins at the apices has been t.xp'.c-ined by the supposed bad inspi- ratory function of this part of the lungs. Now, I agree in this respect with Hanau,' and consider the almost universally adopted statement of the deficient inspiratory function of the apices erro- 4/j. / "- i /-■-•■A^^- \^ Fig. 14.— Tiimn Ki;.si'Ikatukv Kxkrcise. Fig, 15.— t.\K.''i' ;; for Patients in the H.Mirr OK Stooping. neous. On the contrary, these portions of the lungs inspire excel- lently well, almost too well, for dust and all sorts of micro-organ- isms enter there mo.st easily and are found in large quantities in careful post-mortem examinations. What is faulty is the expi- ratory function of the apices. A thorough expiration followed ' Ilaiiaii, A., Ziiricli, " Reitnlge ziir Pathologic dor Luiigenkmnkliciten," " Ze it- schrift fiir Ulin. Muilicin," xii, 1S87. PREVENTIVK TREATMEM'. 85 by a forced expiratory effort, as described above, is, to my mind, the only possible way to improve tiiis defect and prevent stagnation and conj^estion, wliich, as is well known, torni excellent media for the development of bacilli. To consumptive!-', those predisposed to tuberculosis, and to children who have the habit of stooping, I teach an additional exercise, as follows (Fig. 15): The patient makes iiis best effort to stand straight; he places his hands on his hips with the tluimbs toward the front and then bends slowly backward as far as lie can during the act of inspiration. He remains in this jxjsition a few seconds while holding the breatii, and rises again, somewliat more rapidly, during the expiration. When the patient is out walking it will, ot course, not always be convenient nor possible to do these exercises with the movement of the arms. The patient should, under such conditions, content himself with raising his shoulders and making a rotatory moxe- ment backward during the act of inspiration, holding tlie breath for a moment and then exhaling during a rotatory movement for- ward, assuming again the normal position. The second respiratory effort can follow this exercise also without attracting any attention. For all classes of patients, candidates for consumption and bad breathers in general, the rules hold good never to take their breath- ing exercises when tired or immediately after a heavy meal, never when uncomfortably or tightly dressed, never to continue them to the extent of becoming tired, never to take them in a bad at- mosphere, and not to take them at their caprice, but according to the directions of the physician. One exercise should be taught at a time, and only after it .s thoroughly mastered should the physician proceed to teach the next one. I have described them in the order of their difficulty. The first, a simple raising of the arms to the horizontal line during the act of inspiration, requires relatively little effort. The second one, in which the arms describe a circle by being raised out- stretched until thej' meet above the head, requires a more prolonged inspiration and necessarily an increased muscular effort. The third, the swimming exercise, in which the hands should meet behind the back, is the most tlifficult. The necessary length of time between learning the exercises will dejjend upon the aptitude, the expansive power, and the general condition of the patient. Some patients can be taught all these exercises within nine or ten days, while with ml Hdi' 86 PULMONARY TUBERCULOSIS. 11 « Rreathing exereisfs at school. others months often must intervene before the next exercise can be commenced. The breathing exercises at school should be under the direction of the school physician or teacher of physical culture. In suu'.mer they should be taken out-of-doors, and on rainy, windy, or too cold days in the school-room, which should be a model of ventilation. To teach the children how to breathe, sit, stand, and walk properly, should be a part of the every-day curriculum. Every school should have its large playground or roof-garden, where, weather and season permitting, the classes should alternately receive their instruction. In rural communities, during iiie warmer season, in- struction in-doors should be the exception, not the rule. Singing and recitation especially should be encouraged out-of-doors. I have found that singing in pure air is an admirable and most useful adjuvant in acrotherapeutics. Barth,' of Koslin, who has made a careful study of the effects of singing on the action of the lungs and heart, on diseases of the heart, on the pulmonary circulation, on the blood, the vocal apparatus, the upper air-passages, the ear, the general health, the development of the chest, on metabolism, and on the activity of the digestive organs, has come to the con- clusion that singing is one of the exercises most conducive to health. Considering the fact that it can be practised anywhere (when the air is pure) or at any time, without apparatus, it should be much more cultivated than it actually is. The German military authorities, which have the reputation for instituting all exercises which tend to invigorate the soldiers, have of late years encour- aged singing during marches of all the troops. Before closing with the subject of school hygiene, I can not help repeating here the very impressive words of Dr. W. W. Hitchcock,- in his article on the gymnasium as a sanitary measure. Referring to the frequent lack of the development of the thorax, particularly noticeable in those predisposed to pulmonary diseases, he said : " There is no doubt that if as much care were bestowed on our young in seeing that this particular part was developed with that care tiiat the brain receives, tuberculosis; would almost disappear." Finally, it can not be impressed too strongly on the minds of I » ' "Aiuliiv fiir L.iryngologje," 5. "Deutsche Mtilicinal Zeitung," Nov. 15, 1S97, 2 Hitclu'dck, W. W.,"Tlie (Jyiiiiiasium from tlie Standpoint of the Suiiitiiriiiii," "I'lansait, of the I'durlli Calif. Saiiit. ( onveiition," 1896 PREVENTIVE TREATMENT. 87 I consumptives, and those predisposed to the disease, tliat they should always seek environments where the air is as pure as pos- sible. Lord Beaconsfield's celebrated words, "The atmosphere ini^rti '■ Beacon s- which we live has more to do with human hapiiiness than all thei'ii''*"' ' ' piMo all. accidents of fortune and all the acts of (government," have, I think, a special meaning for this class of sufferers. Hydrotherapeutics, as a measure to prevent pulmonary tuber- "y'"™- culosis, tends to develop to a more \i , ' ^ striMinlluii system, and should also be instituted at an early aie wooded mountains, which inclose a most beautiful view of the plain. In the foreground lies Cronberg (terminus of the railway to Frankfort), with its castle; and beyond, the broad valley of the 90 IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 9' Main, dotted with towns and villages. A little farther to the east the view even extends to the plains of the Rhine. The institution proper consists of a main buildinfj with two wings joining at an obtuse angle so as to inclose a large terrace, and two annexes, united to the main building by covered prom- enade-galleries, opening toward the south. On the east side, in direct conmuinication with the main building, is the new, elegant dining-hall, and the model kitchen and store-rooms. In the dining-hall, which is 78 feet long, 39 feet wide, and 32 feet high, 200 persons can be comfortably seated. It is well ventilated and in winter is heated by steam. In the main building on the ground-floor are drawing-, music-, and reading-rooms ; the library, with 2000 volumes in iMiglish, I'Vench, and German; the inspector's office, and the post- and telegraph-offices. The terrace inclosed by the wings of the main building has an especially protected situation. Around it exteml covered verandas provided with curtains, so that even the weaker patients may be able to remain in the open air from morning until night, winter and summer. Similar structures and revolving pavilions are situated near the building, and serve the same purpose. In these and the verandas are placed comfortable, cushioned, cane reclining chairs. These chairs enable the patients to carry out with comfort the main part of the treatment — namely, the prolonged sojf)urn in the o[)en air. Through a gallery, 200 feet in length, the eastern annex is reached, which lies immediately on the border of the forest. This building, formerly occupied by the physicians, is now, since the completion of the new structure, exclusiveh- reserved for patients. These rooms are heated bj' hot-water pipes, as in the lower story of the main building. The halls, main stairca.se, and corridors are heated by the Bacon system of steam. To the southwest of the main building, and united to it by a gallery 108 feet long, is the western annex. The basement of this annex contains the bath-rooms and arrangements for the hydro- therapeutic applications, which form part of the treatment. The institution has its own water-supply, derived from springs situated 250 feet above the sanatorium, on the slope of the " Altkonig." The water is excellent, and has a temperature of 50^ to 54° V. On the ground-floor are the waiting- and consulting-rooms and the 1!:* i ■ •, h ll 1i I 11! |i i i-; 92 rUI.MONAKV TUUKRCUI.OSIS. IMPORTANT SANAIORIA AND Sl'FXIAr HOSIMTAI.S. I chemical ami microscopical laboratories. The upper lloors ate occu[)iecl by the physicians and their families. Ikhind these biiiklin'^s, forming; together a semicircle open towaril the valley, are the barns, stables, disiiifectint; apparatus (Bacon system with superheated steam), and the washing'- and dry- ing-rooms. The entire institution is li<^hted by electricity. In 1883, W. II. Lindley, C. Iv, constructed a .system of draina 94 PULMONARV TUBERCULOSIS. the institution was visited by some five hundred pat'^nts, quite as many remaining in winter as in summer. Patients are not permitted to take their meals in iheir rooms unless so ordered by the physician. Friends and servants may take rooms in the village if their constant presence with the patient is not required. The more vigorous patients may also, with the consent of the physician, reside in the village. They lose none of their privileges thereby, nor are they released from their obligations as patients of the sanatorium. The sanatorium was founded in 1874, through the efforts of some Frankfort physicians, with the view of creating in Western Ger- many, in a healthy, mountainous region easy of access, an establish- ment for the treatment of those suffering from disease of the lungs. The capital necessary for the enterprize was principally subscribed by wealthy citizens of Frankfort, under the condition that the share- holders should not receive more than five per cent, interest, and that the surplus should be used first for the necessary improve- ments, and then, as soon as possible, for the founding and maintai i- ing of a sanatorium for poor consumptives. Thus was formed tlje nucleus of the capital needed to create the now so flourishing institution for the consumptive poor at Ruppertshain. Since the retirement of Dr. Dettweiler from the position of directing physician, Dr. Karl Hess has become medical director, with Drs. Besold and Pickert as assistant physicians. Dr. Dett- weiler still remains the consulting physician of the institution. The nearest railway-station to Falkenstein is Cronberg, which is about an hour's distance from Frankfort-on-the-Main. RUPPERTSHAIN SANATORIUM. Ruppertshain is the first institution founded in Germany for the treatment of the poorer classes of consumptives. It owes its e.xistence to the energy of Geheimrath Dr. Dettweiler, his co- laborers, to the generosity of the wealthy patients of Falkenstein, and to the philanthropic citizens of Frankfort-on-the-Main. The .sanatorium of Ruppertshain is situated at a short di.stance from the village of Ruppertshain, in the Taunus Mountains. The grounds on which the buildings are constructed cover about twelve acres, anil are protected on the north and west by high, wooded hills, which open toward the south. All the buildings are con- IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 95 !!'' nil X ) ! m. i : _tJjCZ : 96 PULMONAKY TUBEKCULOSIS. structeil so as to face south or southwest. There is a main building, two pavilions, and two large galleries, sheds, stalls, etc. The main building is three stories high. The ground-floor contains douche-rooms, bath-rooms, machineries, etc. On the next floor are the reception-rooms, music-room, and jiarlors. The rest of the building is taken up by rooms varying in size ; some contain five beds, some three, and some only one. The bedrooms arc light and airy, about ten feet higii, and the walls are painted. The floors are of inlaid wood, and the ceilings whitewashed. There is no special arrangement for ventilation except the iron rule, " Keep window open day and night." The sanatorium is heated by steam ; it has its own water-supply from one of the mountai'i sources. There is a division for men and one for women. The institution is under the direction of my former colleague, Dr. Naliin, of Falken- stein, aided by an assistant, and the nursing is done by a Protestant sisterhood. The sanatorium can accommodate about one hundred patients. Additional buildings, to enlarge this capacity and to give a private residence to the medical director, are projected. While the interior arrangements of the sanatorium at Rupperts- hain are not as elegant and luxurious as in the mother-institution at Falkenstein, everything, though plain, is exceedingly comfortable and practically arranged, .so that the hygienic and dietetic treatment can be most carefully carried out. BREHMER SANATORIUM, IN GOERRERSDORF. We have already mentioned, in our historical chapter, the event of the founding of the first .sanatorium for consumptives, by Dr. Hermann Brehmer, in 1859. This institution, which is considered to-day the largest of its kind in the work!, being able to accom- modate about 250 patients, had a very small beginning. In 1862 a new building was added, and ever since the institution has grown and prospered. Brehmer selected Goerbersdorf for his sanatorium because he believed in the inmuinity of this mountainous region, and because he found it best adapted to carry out his ideas of a .systematic ascending of graded walks in order to strengthen the small ami feeble heart of the consumptive. According to his idea it was the disproportion between heart and lungs — the latter rela- tively large, the former small and with weak muscular action — which was the main etiological factor in the production of pulmonary tuberculosis. IMHOKTANl" SANATOKIA AND Sl'KClAL HOSPITALS. 97 V '\m ! M \§ t!i; ^1 98 PULMONARY TUBERCULOSIS. Goerbersdorf is situated in the southeastern part of Germany, in the province of Silesia, at an altitude of 1840 feet. The natural beauty of Goerbersdorf is certainly remarkable. I visited the place in midsummer and was charmed with its climate, its hills, and splendid woods. At one end of the village, in the midst of a beau- tiful park, stands the Brehmcr Sanatorium, composed of a series of buildings. The main building is a large Gothic structure of brick, which, I confess, did not impress me as particularly well adapted for a sanatorium. The first impression this vast structure makes upon the visitor is that of a fortress or castle, rather than a resi- dence intended for pulmonary iin'alids. The other buildings, as, for example, "Das Ncue Kurliaus," the "White House," "Villa Rosa," etc., are of lighter and more pleasing construction. Be- tween the old and the new " Kurhaus " is a separate construction surmounted by a tower. This wns the late Dr. Brehmer's private residence, and is to-day occupied by Professor Kobcrt, the director of the establishment. The "White House," "Villa Rosa," etc., are located in the midst of the park ; each of these villas contains about twelve rooms. The i)ark and gardens are most beautifully kept, and one can find therein so-called Norwegian and .Swiss challets, shady corners, sun-boxes, a lake containing fish, and an inclosure for deer. On one of the hills, about four hun- dred feet higher, is a little Russian pavilion, called the " Kath- arium," from which one has a most beautiful view over the Giant Mountains. The music-rooms, parlors, rece[)tion-rooms, and bedrooms are elegantly furnished. There is a large library, numerous tlouche- rooms and bath-rooms. Of late there are also galleries for the rest cure. Ik'sides, there is a beautiful winter-garden, of which I give a photograph, where the patients remain when the weather does not permit them to be out-of-doors. Ventilation, heating, and illumination are in accordance with the times. The disinfection of all the apartments is regularly done with formaldehyde, and with the special apparatus designed by Professor Robert. A large, well- kept farm, belonging to the sanatorium, is located at some distance from the institution. There the kefir u.sed in the sanatorium is manufactured. Besides the establishment f )r patients paying the full price, there has existed since 1895 an anne.x to the Brehmer .Sanatorium where patients with moderate means are received. IMPORTANT SANATORIA AND Sl'ECIAL IIOSPITAI-S. 99 r~ ■ a ^7+ -r- .'■ :ii^ti^ " ^^^tmmk IKM ■• J ■.: \ I- 4 \ *««iHUHU[ ^^^^^ 1 ij^^^^^t/M •■ ^^^^ 9Kv '4|^K!P"M I ^^ 1 1 "7 t^ ^^-^ yjmiS^4. ' ■■* — -^n^H ' •4 ^'^v.-^^-'wi-r-r.^^ 1 ^ — • \\ *■ - X < 1 1 .<- ' _'"i ^ ^ t-i 1 1 .'^«VS ^-.m 1^ ., ^"H s^ 1 1 ' ^#flV OVB sa -Jo \ <'f . - . mmt / »i;fl^ff'^ 1 ^£^41 \ '^- ^'■- J '■' L -^ rj^MI . .'^"■a V • ■ ':^ .-:%. <- Cw V "v. . \ ;■■■;. :..'-""-^'^ V . r 1 ' ^ ^--y :,■'>- '^-arM-i^rm^ •' 'i * ^:^ *¥ . . ' r • »*r-.*- . , ■ , r ■ ♦;■• -■ - r 1 * 4 1 J. A as IMPORTANT SANATORIA AND SPECIAL HOSPITALS. Ill '■J Id as villas of smaUer sizes: villa " Thurmhaus," with twenty rooms ; villa " Karlsruhe," with twelve ; villa " Mathildenruhe," which is the residence of the former director, Dr. Driver, and, lastly, the private cottage of Dr. Wolff. At some distance from these buildiny;s are the laundry, the dis- infecting-room, and the stables. The park in which the sanatorium is situated extends over five hundred acres. There is now room for about one hundred patients, but since my last visit to Reibolds- griin Dr. Wolff wrote me that plans were in readiness to erect other and more expensive buildings. The country surrounding Reiboldsgriin offers many interesting places for excursions. The social life in Reiboldsgriin is particu- larly pleasant; Dr. Wolff, himself an accomplished musician, frequently organizes concerts, theatricals, etc. There are several pianos and an organ in the institution. As an anne.x to the sanatorium we must mention Zoebisch, a little colony of friends of patients residing in the sanatorium grounds, with a sprinkling of convalescent patients among them, who, while still under the doctor's care, have graduated from the sanatorium, and do not any longer require the strict supervision. Near the sanatorium there is a natural spring containing iron salts. The water is utilized for the especially anaemic invalids of the sanatorium. The spring enjoyed a reputation even before the erection of the sanatorium. Reiboldsgriin is eight miles from Rautenkranz, a station of the Chemnitz-Adorfer Railway, and twelve miles from Auerbach, a station of the Zwickau-Oelsnitzer Railway. ALBERTSRERG SANATORIUM. A few hours distant from Reiboldsgriin, at Albertsberg, near Auerbach, is located the new sanatorium for the consumptive poor of the kingdom of Saxony. Its erection is largely due to the generosity of the King of Saxony, who endowed the institution, and who seems to take particular interest in the social problem of pulmonary tuberculosis. The institution was inaugurated in Octo- ber, 1897, and can accommodate eighty patients. It resembles, in its exterior and interior arrangements, the sanatoria devoted to the treatment of the richer classes, and, while there is less elegance, the patients are most comfortably situated. The direction of the institution is in the hands of Dr. Gebser, a former assistant at Rei- boldsgriin. i^^ 112 PULMONARY TUBERCULOSIS. DR. HAUFFE'S SANATORIUM AT ST. BLASIEN. Dr. Hauffe's sanatorium, which I visited in July, 1895, when it was still under his direction, has now passed into the hands of Dr. Sanders. St. Blasien is situated at the foot of the Feldberg, one of the mountains of the Black Forest. The valley is called the Valley of the Alb, and has an altitude of 2500 feet above sea-level. The Black Forest is known for its natural beauty, and St. Blasien especially for its mild climate. The air is particularly rich in ozone, and the surrounding pine-forests produce an atmosphere laden with the pleasant, health-giving odor of these trees. The buildings of the sanatorium are situated on a somewhat higher level than St. Blasien, which is itself a health resort much frequented by neuropaths. This proximity to a very noisy and gay health resort, where dancing and sports of all kinds are much in vogue, might be considered an objection for a sanatorium for con- sumptives. Aside from this. Dr. Hauffe's institution offers all the advantages of tiie other closed establishments for the cure of con- sumptives. The sanatorium is composed of a scries of buildings united by a glass gallery and a veranda for the " Liegekur." In addition to this, every story has balconies which serve as places for the feebler patients to take their open-air treatment. The equipment of the bedrooms, parlors, library, etc., is in accordance with the special hygiene to be observed where tuberculous patients congregate. There are no draperies, no carpets (except a few rugs), and the floors of corridors and rooms are covered with lino- leum. There are special arrangements for ventilation by a sort of transom over the windows; all the other hygienic arrangements concerning the sputum, etc., are those in vogue in most of the sanatoria in Germany. The institution is lighted by electricity, and the water-supply is excellent. There are kiosks and benches distributed in a garden and park near by. Under the management of Dr. Hauffe the sanatorium accepted even the most advanced cases ; but Dr. Sanders wrote me recently that he had departed from this policy, and only accepts patients in the earlier stages of the disease who have a reasonable cliance of recovery. He wishes to make the institution a sanatorium — that is to say, a healing institution in the highest sense of the word. The village of St. Blasien is of ancient origin. Its church and cloisters, which date from the eleventh century, are still in good IMPORTANT SANATORIA AND SPECIAL HOSPITALS. "3 preservation. St. Liasien has no railway-station. The nearest one, at Albbriick, on the Hasel-Constance Railway, is at a distance of about twelve miles. Another station is Titisee, ;it a distance of fourteen miles from St. Blasien, on the Freiburg-Neustadt line. DR. OTTO WALTHER'S SANATORIUM. Dr. VValther's institution, which is situated in Nordrach, in the Black Forest, is also known by the name of the " Nordrach Col- ony." It is at an elevation of 1500 feet and commands a beautiful view of the valley, opening; toward the south and southwest. It consists of a series of small buildings situated at considerable distance from each other. There is a central building which con- tains the dining-room and administration-rooms. There are no galleries for the rest cure as in other institutions, but some of the rooms have balconies. In the equipment of the rooms much attention has been paid to hygienic arrangement, even to the furni- ture. Linoleum on the floor, plain walls, iron bedsteads, etc. The " Liegesessel " remain in the rooms, which are constantly well aired. Dr. Walther trains his patients so that they can even stand drafts. He ascribes the majority of colds rather to the enfeebling of an organism by too much exercise than to the sudden changes of temperature. The Nordrach Colony is surrounded by a beautiful forest, which, however, is at a sufficient distance to allow plenty of sunlight for the whole colony. There is a douche- and bath-room with each bedroom. All the buildings are heated by steam, which comes from the central building. The sanatorium has also its own electrical plant, dairy, steam laundry, and also an ice manufactory. The institution is very flourishing and is much visited by Amer- ican and English patients. A lady teacher is attached to the insti- tution to teach the children, who are either patients or have come with their parents. Dr. Walther's sanatorium can accommodate aboi;t forty patients. The nearest railway-station to Nordrach is Gengenbach, on the Black Forest Railroad. ! -'I m\ 114 PULMONARY TUBERCULOSIS. m ODERBERG SANATORIUM. In describing the " Krankenheim " at Goerbersdorf, I mentioned the work done by the State invaUdity insurance companies of Germany in relation to sanatoria for the treatment of tubercu- lous patients. The first insurance company which undertook the creation of its own sanatorium for its tuberculous clients was the " Hanseatische Versicherungsanstalt fiir Invaliditats- und Alters- versicherung " of Liibeck. The company selected a beautiful site in the Harz Mountains near St. Andreasberg, and built the institu- tion on the slope of the Great Oderberg, at an altitude of nearly two thousand feet. The surrounding mountains and woods protect the sanatorium from cold winds. The institution, of which I give an illustration, is most interestingly situated and managed. There is a main building consi.sting of a central portion and two annexes. To the west and communicating with the annex is the machinerj'- room and laundry. To the south, .separated from the main build- ing, is the residence of the physician-in-chief At a distance of about fifty feet to the west of the machine-room are the disin- fecting- and autopsy-rooms. About three hundred feet to the northwest of the main building is a building which is occupied by the employees and their families, and nearly five hundred feet to the west are located the stables. The buildings occupy an area of about eight or nine acres. The principal building, facing south, is a four-story structure. In the basement are the kitchen and the store-rooms. The first story contains consultation-, administration-, and dining-rooms. In the annexes on the first story are the bedrooms for the patient.'^. The second story of the central building is occupied by the general superintendent and the assistant physicians. The east side-wing contains a large parlor and promenade corridor. The rest of the building consists of bedrooms for i)atients. There are, in all, seven rooms with one bed each, fourteen rooms with two beds each, six with three beds each, and fourteen with four beds each. Besides these there are four bedro 9 1 1 it 130 PUI.MONAKV TUIIERCULOSIS. dietetic — so vastly different from tliat employed in the general hospitals. There is a large tract of ground belonging to the sanatorium where the patients can enjoy outdoor life. The .stronger ones are permitted to do light work, such as gardering, etc. The sanatorium thus far can accommodate 350 patients. At the head of the enterprise and the society .'stands the ener- getic and distinguished Professor von Schrotter. The society is now in a most flourishing condition, and is called " Verein zur Errichtung und Erhaltung klimatischer Ileilstiitten." It has now more than one thousand members, among them many of the most aristocratic families of Austria, and His Majesty, the Emperor, as its protector. The medical director of the institution is Dr. Ritter von VVeissmayr, who is aided by .several assistant physicians. The suc- cess of this, the first institution of its kind in the Austrian empire, has, I am glad to .say, been the cause of starting similar niovetnents in other Austrian cities, such as Baden, Briick, etc. '1 Ui ROYAL HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST AT VENTNOR. To make the title of this institution complete, one should add " On the Separate Principle," and " Founded for the Reception of Patients of Both Se.xes from all Parts of the Kingdom." As Patron we should have to mention Her Gracious Majesty the Queen ; and as President, the Right Honorable the Earl of Roseberry, K.G.; and as Treasurer, Frederick Charles Colman, t"sq., J. P.; and as Chairman of the Board of Managers, .Sir Richard li. Webster, G.C.M.G., Q.C., M.P. I visited Ventnor a few years ago in the fall, and could appreci- ate why the noble founders selected the Isle of Wight for a national institution to treat their consumptive poor. Ventnor is situated on the southeastern coast of the Isle of Wight. The climate is particu- larly mild and the atmosphere very pure, and, owing to the vicinity of the ocean, free from pathogenic micro-organisms. The highest temperature recorded during the sunmier was 80° F., and the low- est during the winter 25° F. It was in 1868 that Dr. nill-Has.sal began, with a modest building, the institution which, up to 1895, had treated no less than 12,500 patients. To-day the hospital comprises ten blocks, providing accommo- ti 1 IMPORTANT SANATORIA AND SPECIAL HOSPITALS. '3' 1 ^ ^^H' '1 » c-^' ;• A 'lis 1 1 r 1 1M. ^\ ^' .^-^e .,::■:■. 5&. X I li; II f I '_yj «3: PULMONARY TUHKRCULOSIS. i dation for 134 men and women patients, with a chapel in the centre (connected by a subway). The establislinient is situated in one of the loveliest and most sheltered spots of the Undercliff. The site covers more than twenty acres, and is about three-quarters of a mile distant from Ventnor. The hospital is erected upon the sepa- rate principle — that is to say, each patient has a separate bedroom. The patients are distributed through the various houses, which are well sheltered from unfavorable winds, constructed upon sound, sanitary principles, and surrounded by gardens. The patients enjoy the advantajjes of large sitting-rooms, a lovely landscape and sea-view, plenty of light and sea-air, effective ventilation and good drainage, and a regular temperature — in short, the comforts of a home, with the medical appliances of a hospital, I am sorry to say that I have to use the word "hospital," for such it is in reality, and not a sanatorium. There are no verandas, no reclining chairs where the rest cure, or " Liegekur " of the Ger- mans, can be carried out. I am convinced that if the governors of that splendid institution at Ventnor would admit this innovation, in addition to the existing method of treatment, the results would be even better — excellent as they are. For 1896 Dr. Coghill re- ports a mortality of 4.7 per cent.; very much improved, 18.5 per cent. ; improved, 60.5 per ccrft. The cases eligible for admission are those in an early stage of pulmonary tuberculosis, and which, there- fore, afford a reasonable expectation of marked alleviation or cure. Each person is required to pay J^2.50 per week, in part payment of the cost of maintenance, etc., and (on entrance) a guarantee fee of $5.00 to the general superintendent, which will be returned on leaving the hospital, unless any portion of it shall have been for- feited for damage done. The institution has an annual expenditure of $55,000. The greater portion is raised by voluntary subscription. On my visit I was most cordially received by Dr. Perkins, who was then one of the physicians in charge. Among the examining physicians we note Dr. Hermann Weber, the celebrated clima- tologist ; Dr. Port, Dr. Thorowgood, and Dr. Davies, of London. Besides these there are three visiting and three resident medical officers. IMPORTANT SANATORIA AM) -SJ'KCIAL IIOSIMTALS. m BROMPTON HOSPITAL. Of the several hospitals for the treatment of consumption exist- injj in the city of London, I wisli to describe the most interestinjj, oldest, and larfrest institution of the kind. Hrompton Hospital was founded in 1S41. It is built in the shape of the letter H, the depth of each win^ bein<; 190 feet, and the width of the buildinjj 200 feet. It stands in a square piece of ground covering three acres, and faces the street. On entering the lodge- gate there are three broad drives — one to the central entrance. 1-"k;. .57.— Hcisri I al iok lUssiMrrivKs, Driimi'ton (Ldnikin). which opens into a cheerful hall upon the first floor ; another to the east entrance, which leads to the offices for the transaction of the hospital business; and the third to the west entrance, which is for the use of the inmates and the friends of the in-patients on visiting- days. The grounds are well drained, so that the broad terrace- walks become available for the patients very soon after the heaviest rains. The ground-floor is on a level with the gardens. The west wiiig contains rooms for the physicians, resident medical officer and clinical assistants, and servants' hall. The east wing contains the apartments of the lady superintendent, the linen-room, store-room, M J=M.l 134 PULMONARY TUBERCULOSIS. Hi ; It' secretary's office, board-room, and nurses' sitting-room. The heating of the hospital is effected by hot water constantly circu- lating in -irge pipes extending throughout the building. The ventilation is obtained by means of extracting-shafts, consisting of two lofty towers heated with steam, into which the vitiated air is drawn through large ducts leading from all the wards and corri- dors. There arc also open fireplaces in all the wards, both on account of their cheering appearance and warmth, and their use as ventilating agents. The kitchen is on the north side of the central basement corridor, in a separate building; it is of large size and is fitted with all the modern contrivances. Immediately adjoining is the boiler-house, in which are the two boilers for supplying hot water to the systems of pipes for warming the building. It also contains -i powerful steam-boiler, which generates steam for heat- ini: the extracting-coils in the ventilating towers. This boiler likewv.e supplies steam to heat the water in the kitchen and baths, as also to grind the coffee and to run the dumb-waiter, which takes up the patients' meals hot from the kitchen, as well as other neces- saries ; also to raise an elevator for conveying to and Trom the gal- leries those patients for whom exercise in the grounds is desirable. This is a great comfort for the more feeble, as they are enabled to enjoy the garden and fresh air, which otherwise they would not be able to enter by reason of the fatigue of going up and down the stairs. The second floor is devoted exclusively to female patients, except small rooms for the chaplain and for each cf the two head nurses, and the two requisite pantries, baths, and lavatories. The tempera- ture is the same in the galleries as in the wards ; patients are, therefore, able to read or work in tnese well-lighted, roomy corri- dors without inconvenience or exposuie; or they may walk there when the weather will not permit of their going out; they are also provided with easy couches and seats and movable tables for meals. The gallery of the west wing is named after Her fTajesty, the Patron of the Charity and one of its earliest friends, and is called the " Victoria Gallery. ' The gallery of Ine east wing is called the "Jenny Lind Gallery," in testimony "^o the kindness of Madame Lind-Goldschmidt, who enabled the committee to conmience t' e building of the wing, now filled with grateful patients. The second floor accommodates lOj female patients. The arrangements on the third floor are precisely the same as IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 135 those on the second ; the wards being occupied by male patients, for whom tliere are 107 beds. The west gallery is named after H. R. H. the late Prince Consort, who laid the foundation-stone of the hospital in 1844, and is called the " Albert Gallery." The east gallery is called after the late " Sii Henry Foulis, Bart.," at whose expense the beautiful chapel of the hospital was built. The breadth of the galleries in both floors is ten feet, and their height and that of tlie wards is fourteen feet. The attic-floor has comfortable dormitories for the nurses and servants, and in the tower are the sleeping-apartments of the clinical assistants. During my visit to the hospital, under the kind guidance of Dr. Philip, who was then resident medical officer, I was pleasantly sur- prised by the scrupulous cleanliness of everything, and the par- ticular care which was exercised concerning the disposal of the tuberculous expectoration. As a consequence of the great care in everything that might possibly lead to a contamination, there has never been a case of contracted tuberculosis among nurses or other employees of the hospital. This led Dr. Williams, one of Bromp- ton's most distinguished physicians, to deny the communicability of pulmonary tuberculosis. To my regret there is also in Brompton an absence of arrangements to carry out the rest cure, such as in- augurated b}' Dettweiler of Falkenstein. Brompton can accommodate 321 patients. While the work of the English hospitals for the consumptive poor cannot be too highly estimated, I can but feel that a custom of granting privileges to governors and subscribers in regard to the admission of patients must, of necessity, be a detriment to im- partial charity and impartial selecting of the cases which would be most benefited by a sojourn in the hospital. It is to be hoped that there may be a change in this methofl of recruiting patients, which should' be left entirely to the discretion of the examining phy- sician, aided by a lay committee to investigate the financial situ- ation of the applicant. I [ i ■ ■ , ^ [ 1 f i; 1 i !' J)l 136 PULMONARY TUBERCULOSIS. ilJ THE VICTORIA HOSPITAL FOR CONSUMPTION. THE OUT-DOOR Department and the Craigleith Hospital. Among the many medical institutions which I visited in Scot- land, the one which interested me most was the above-named. It was then only in its infancy, but has since grown steadily, and now gives great promise for the future. For the interesting facts concerning the history of the institution I am indebted to Dr. R. W. Philip, F.R.C.P.Eo., in whose company I visited the institution in the fall of 1894, and to whom great credit is due for his energy and devotion to the enterprise. In 1887 it was proposed that the Local Jubilee Memorial for Edinburgh should take the form of a scheme for the relief of con- sumptives and other sufferers from chronic diseases. Impressed by th(. fitness of the suggestion, a citizen waited on one or two of those who were prominently associated with the loyal movement, to urge the suitability, for the purpose in view, of a hospital de- voted to the treatment of consumptive patients. The result of the deliberations regarding the memorial was as unsubstantial as were the fears expressed regarding the success of the hospital. There was no local memorial, and nothing was done for the tuber- culous poor. OuT-DooK Department. Disappointed at this turn of affairs, the promoters of the hos- pital movement commenced work on their own account. A com- mittee was formed, and three rooms were hired in 13 Bank Street, as the nucleus of an out-door department. Within a kw weeks from its opening, on the 22d of November, 1887, the limited resources were taxed to the uppermost and the waiting-room crowded to overflowing. The ne.xt .step was the acquisition of larger premises at 26 Lauriston Place. These were adapted so as to afford sufficient accommodation for a large out-patient depart- ment, for which they have been in use since. They comprise two large consulting-rooms, one for new and the other for old patients, with dark-room fitted up for laryngoscopical examination, '^ne large and two smaller waiting-rooms, a laboratory for nu'croscopical and bactei logi ipen;- ipply those of the out-patients who require such help, and a dwelling- louse for t! e orncer. IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 137 The out-patient department is worked in the following way : After the patient's name and address have been entered in the books, notes are made of his condition ^n sheets arranged for the purpose, and a graphic report of the physical signs recorded on outline charts. Careful inquiry is pursued along certain lines, with the view of determining the frequency of causal and concomitant con- ditions. The larynx and expectoration are examined in the greater proportion of the cases, with the object of obtaining further evi- dence of tuberculosis. No patient is seen on a subsequent occa- sion, without the record of his condition and of the treatment which has been followed. A register of the patient's weight is made on each visit. If the condition be urgent, more particularly if there be evidence of rapid progress, much pyrexia, haemoptysis, or other serious symptom, the patient is placed on a list for out-door visiting by a qualified medical officer of the institution, the list being restricted to cases of tubercular disease. In order to disseminate knowledge of the proper measures to be adopted in the treatment of tubercular patients, printed instruc- tions of a simple character are issued to all such patients or their friends. Besides the instruction given to the patients by the phy- sicians, and through the printed directions, the dispensary ofificer, who i:i an old soldier, trains many of the younger subjects with deformed chests in suitable dumb-bell and other exercises. Impor- tant service of a beneficent character has been rendered by the institution of a Samaritan committee, in connection with the out- door department. This consists of some twenty ladies, who, in co-operation with the medical officer, undertake the home-visiting of the bedridden cases and the distribution to really necessitous persons of invalid comforts. This department of the work has been of incalculable service. These labors have been assisted not infrequently by the kiini ofTices of nur.ses from the Queen Victoria's Jubilee Institute and other organizations. The attendances at the out-door department have been very large, varying from some thirty to as many as eighty-.seven patients on one afternoon. In addition to this, the list of home-visits paid by the medical officer has amounted to over one hundred and forty per niontii. il >38 PULMONARY TUBERCULOSIS. i II 1 i IIP 1 : -4. 1 r ^ 1 ( i 1 i 1 The Hospital. The svcessive steps in the elaboration of the out-door depart- ment ser\ ' ;>rove in most forcible fashion the necessity for a hospital wht. elected number, at least, from the mass of tuber- cular cases miync be received for more special in-door treatment. The obtaining of this was no easy task. Many conditions had to be fulfilled, and funds were needed. After much consideration and more than one disappointment, the acting committee, who took the matter warmly in hand, were fortunate in obtaining a lease of Craigleith House. This is a fine old property, little more than a mile to the northwest of the west end of Princes Street, easily accessible both by railway and car. The substantially built man- sion-house is charmingly situated in the midst of some seven and a half acres of prettily disposed grounds. It basks in the sun, facing due south, and, without being overshadowed, is sheltered on various sides, more particularly on the east and northeast, by lofty trees. The property is suitably laid out with walks, a high-walled garden, and park, which have proved a great boon to the patients. Entrance was obtained in March, 1894. Various structural alterations were speedily undertaken, so as to adapt it for hospital purposes. These were completed by the beginning of August, when patients were received at once. The Victoria Hospital for Consumption, as at present arranged, comprises: (i) basement-floor, containing kitchen, scullery, larder, pantries, and nurses' hall ; (2) ground-floor, containing two male wards with three beds each, house-physician's sitting-room and bedroom, dispensary, and bath-room and lavatory accommodation for male patients; (3) first floor, containing three large and two smaller female wards available for eight patients, lady superin- tendent's sitting-room and bedroom, and bath-room and lavatory accommodation for female patients ; (4) second floor, containing bedrooms for two nurses and three maid-servants. A large, open courtyard back of the house contains buildings which include an observation ward, wash-house and laundry, lava- tory accommodation for the staff, disinfecting chambers, coal- cellars, etc. Removed from the hospital, more than one hundred yards to the northwest, lie the mortuary and other offices. The porter's lodge is occupied by the gatekeeper and gardener. The house was opened on the 9th of August, 1894, and since IMPORTANT SANATORIA AND SPECIAL HOSPITALS. ■39 that date has had its full complement of patients. The Victoria Hospital was the first consumption hospital in Scotland. Up to the 31st of May, 1895, sixty-two patients have been under treat- ment, and the results have been satisfactory. The climate of Scotland is certainly not one to be considered as ideal for the treatment of tuberculous invalids. The good work done and the excellent results obtained by Dr. Philip and his asso- ciates is the best plea for sanatoria for the consumptive poor of all climes. INSTITUTIONS FOR THE TREATMENT OF TUBER- CULOUS PATIENTS IN THE UNITED STATES AND CANADA. THE ADIRONDACK COTTAGE SANITARIUM. The Adirondack Cottage Sanitarium is located one mile to the north of Saranac Lake, a village situated on the northern part of what is known as the Adirondack Plateau, in New York State. This region has an elevation varying from fifteen hundred to eigh- teen hundred feet above sea-level. It is heavily wooded with pine, spruce, fir, Canada balsam, maple, birch, and beech, and has an almost uniformly sandy soil. The plateau is studded with many beautiful lakes and mountains, the latter varying in elevation from two thousand five hundred feet to five thousand feet above sea-level. The lakes are fed by springs and mountain streams, which render the water exceptionally clear, and, owing to the small amount of dissolved salts, it possesses but little hardness. In the heart of this plateau, with fifty to one hundred miles ot forest in all directions, lies the village. It is located in a sheltered valley one mile from the Lower Saranac Lake, and is built on sandy plains and hill-sides along the Saranac River. It is protected from winds by mountains to the north and northwest, while the long range to the southeast and east of heavily wooded peaks un- questionably influences the climate by breaking the force from that source, besides making scenery of peculiar beauty. The founder of the sanatorium has kindly sent me such a good descrir iptK story 2pr( in full The Adirondack Cottaee Sanitarium was the first institution in « i \u It Ml I 140 PULMONARY TUHERCUI.OSIS. < I It) IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 141 America to attempt to cure incipient pulmonary tuberculosis in persons of moderate means. It had its origin, fifteen years ago, in a desire on the part of its founder, Dr. E. L. Trudeau,to extend the benefits of sanatorium methods and an open-air life, spent under good climatic influences, to working men and women whose lives are constantly sacrificed on account of their pecuniary inability to avail themselves of these means of restoration. " In 1884, by personal appeals, a few thousand dollars were ob- tained, with which one small cottage and the wing of the intended 5 i •im^ s&S^Si^^^^^^^^^ ^'^^^^^HK^^^^l ■Jj- *wl !fi^£l599V^9P^^^^^I^^^^M^^KSS^IK^&v^H^^^^^^^^^^^^^^^^I^^^^^I I i Fig. 39.— Main Blii.ding ok the Adironback Cottagk Sanitarium. main building were erected. Each year the work was developed step by step, and the running expenses met principally through the generous aid of the guests at Paul Smith's, Saranac Inn, and other hotels in the region, who held annual fairs during the summer for the benefit of the institution. Its growth has been steady and uninterrupted, until a small village consisting of twenty-two buildings now stands on the original site where, fifteen years ago, the institution made so humble a beginning. " In order to protect patients against the evils of aggregation the cottage plan has been adopted, in spite of the greater cost of build- 1 , 14: PULMONARY TUBERCULOSIS. )■'& \\i ■: 'I i ing and operating an institution on tliis plan, arid the sanitarium is now composed of a collection of eighteen small cottages and sev- eral otiier structures, grouped about the main or administration building. "The cottages of the Adirondack Cottage Sanitarium are one- story buildings, which accommodate from two to ten persons, but the greater number have a capacity for four or five inmates only, and these have been found the most satisfactory. Each patient has his own room, which opens into a central sitting-room in direct communication with the veranda, on which the out-door plan of treatment is carried out. The partitions between the sleeping- and general sitting-rooms reach but seven feet from the floor, an ar- rangement which gives the patient the benefit of the entire air-space of the cottage, and allows of its being heated by a single fireplace or stove located in the general sitting-room ; but the walls which separate the sleeping-rooms from each other reach to the ceilings, and are of solid construction. Good ventilation is insured by transoms located over the front veranda. " In the main or administration building are to be found the dining-room, kitchen, reception- and general sitting-rooms, super- intendent's and doctor's offices, and rooms for servants and nurses, while the upper floor of the building is devoted to large rooms for a limited number of patients. The library, recreation pavilion, doctor's cottage, chapel, and infirmary are all separate buildings. Should any patient in one of the cottages become rapidly worse or be taken suddenly ill, he is at once removed to the infirmary, where every convenience for his care and proper treatment is at hand. The separation of those who are failing rapidly, or are acutely sick, from the comparatively well, not only furnishes the former with the constant and necessary attention and nursing which they require, but withdraws them from the daily observation of their more for- tunate cottage-mates, and prevents in these the depression of spirits which would otherwise occur from the contact with the very sick. The success of this plan is attested by the general cheerfulness of patients while in the institution, who, contrary to what might be supposed, are very rarely depressed in spirits at their enforced exile. "The efficacy against infection which the im'i^nse air-space allotted to each patient by the plan of construction affords, as well as the protection given by the care taken of the expectoration, is 143 u u < Q z ••5 H < O o ^ i n I I 'I' 111 r. I IV i c o u h O u o u I 144 IMPOUTANT SANATORIA AND SPECIAL HOSPITALS. ■45 shown by the fact that the diistof tlie various buildings which have been occupied by consumptives failed to infect guincaj)i^s when injected subcutaneously in these susceptible little animals, and that during thirteen years not a single employee has been known to have contracted tuberculosis. "The treatment consists in the judicious application of an open- (vi 9 /X L_ F= I r-J Co-r-r/KOEi < u (- O o < a •/. o H < 111 o o S /-J I TAP? I U f-^ N Y V\v.. 42. air life, rest, and proper feeding, with regulation of the patients' habits and mode of life, in a climate which has shown a marked tendency to improve the general nutrition of pulmonary invalids; and the methods do not differ materially from those in use in the well-known foreign sanatoria, except that much more liberty is given the patients, owing to the fact that the great majority of them 10 I' tl 146 PULMONARY TUBERCULOSIS. are in the incipient stage of their disea.se and practically apyretic. A medical examination by one of the examiners of the institution in New York, or by Dr. Trudeau at Saranac Lake, is strictly re- quired, and only patients in the incipient stages of tuberculosis, or suffering from the less acute types of the disease, and who cannot afford to pay the usual prices at the hotels and boarding-houses, are admitted. " The patients pay five dollars a week, and the actual cost of maintenance is about eight dollars ..nd a quarter per patient, the deficiency being made up by annual subscriptions and fairs held a» Paul Smith's and Saranac Inn, and occasionally in the past at oth' hotels in the region. There is a small free-bed fund, the income oi which, as well as any subscriptions received for this purpose, is applied to the free maintenance of deserving patients whose means are exhausted. " Each year any surplus remaining over and above the necessary expenditure, as well as any subscriptions which could be procured for this object, has been put aside as a nucleus for an endowment fund, and about one hundred and thirty thousand dollars of the five hundred thousand necessary for this purpose have already been secured. It is to be hoped that by subscripticiis and bequests the endowment fund will continue to grow, so that the benefits of the institution may be made more generally available, and its permanence ultimately assured for all time." I have visited this interesting institution in winter and in summer. The results obtained in both seasons are equally good ; if there is any difference it is always in favor of the winter. The year-round climate may be briefly described as cool and stimulating. The average mean temperature for Saranac Lake is 41.5° F. ; that of Ne.v York City, for comparison, is 51.5° F. The mean temperature by months (taken from " U. S. Weather Reports " for Saranac Lake) is as follows : Month, . . . • Jnn. Fel). Mar. April May June Mean Temp., . 17° «S-4° 25-7° 40.1° 55-1° 63° Year Month, . . . • Jiiy Aug. Sept. Oct. Nov. Dec. 41.46 Me.in Temp., . 66° 2.3° 56.8° 42.7° 32-7° 32.2° Like all elevated places, the range of temperature during the twenty-four hours may be considerable at times. The average IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 147 mean daily range is 22.5 dej^rees. This insures cool nights in summer, though the midday temperature is never so high as in the southwestern resorts of like elevation and greater dryness. Frequent showers in summer and snowfalls in winter keep the air very pure and free from dust. The institution is and has been since its inception in charge of Dr. K. L. Trudeau, whose services are rendered gratuitously, as are those of Dr. E. G. Janeway, Dr. Walter B. James, and Dr. H. ' P. Loomis, who examine patients for ;ii mission in New Yoik City. There are two resident physicians, Dr. VV. H. Jamieson and Dr. J. Wilder. The late Professor Alfred L. Loomis was also deeply interested in the welfare of this institution. He gave his valuable services without remuneration as medical examiner from the beginning of the in.stitution up to the time of his death. SANITARIUM GABRIELS. As a new institution in the Adirondack's we must mention Sanitarium Gabriels, near Paul Smith's Station, on the N. Y. C & H.R. R. R. The institution, for which Dr. Seward Webb and Mr. Paul Smith generously gave the land, was formally opened on July 26, 1897. The administration building is at walking distance from the depot. The post-office address is Gabriels, N. Y. The buildings stand on Sunrise Mount, which is about two thousand feet above sea-level, almost surrounded by State lands, on which there are thousands of acres of pine, balsam, spruce, etc. The sanatorium is on the cottage plan, in detached buildings. The architect was the lion. I. G. Perry, of Albany. The cottages are of hard wood, so as to permit of a thorough disinfection as often as may be necessary. The " Sun Room " in the new in- firmary building is the gift of ex-Governor Morton, and is called the " Anna L. Morton Room." A special feature of the buildings is the facility for heating and ventilating them. They are heated by indirect radiation from a central plant. The boiler-house is located about eight hundred feet from the main building, as pro- tection against fire and to prevent the patients being disturbed by the dust and noise of the machinery. The pure air from without is forced through a shaft into the buildings, and heated on its way ^a li if 148 PULMONARY TUBERCULOSIS. by radiating pipes. One breathes the same pure atmosphere as whe 1 out-of-doors. The system is so nearly perfect that the air can be changed throughout the buildings every five minutes. The quality and abundance of the water-supply are remarkable in the Adirondacks. The analysis proves the water a perfectly pure spring, and yet as soft a«! r.'in for bathing, etc. The institution is supplied with complete installations for hydrotherapeutic applica- tions, or the regulations 1 desire to copy the following from the lecent announcement: " Only those who are in the first stages of consumption or con- valescing from other pulmonary diseases are admitted as patients. I"ic;. .(.1.— Sanitauum Gahkikls. " Persons from a distance making application should be exam- ined by one of the consulting physicians, and ha/e a written cer- tificate from him. " Medical attendance is free. The charge per week is from seven to twelve dollars, according to location of room. Washing and medicine form an additional charge. Patients requiring attendance in rooms will be charged extra. " The plan of the sanatorium is such that it will reach both rich and poor ; elegant rooms, careful nursing, every comfort and luxury will be afforded the one at a moderate price, and, as the Sisters re- ceive no personal remuneration, the money given for this purpose will be expended on the other. The good and charitable have already IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 149 come forward to assist in this noble work, but much remains to be done. The Sisters have built well and substantially, trusting Provi- dence. Already over sixty thousand dollars have been spent on the institution ; but the bulk of this sum has been expendet". on the drainage and water-supply. About seventy patients can be accom- modated." At my visit last year there was no house-phj'sician yet. But I have since received a letter from the Sister Superior stating that Dr. J. C. Lamb is now the house-physician of the institution. ^OOMIS SANITARIUM FOR CONSUMPTIVES. Liberty, in Sullivan County, in the State of New York, was con- sidered by the late Dr. Alfred L. Looniis as an ideal situation for a sanatorium where tuberculous patients, after a few hours' journey from New York, would find themselves 2200 feet above the sea- level, in an air similar to that of Colorado and the Adirondacks. In the winter of 1894 a meeting of the Woman's Auxiliary of the Hospital Saturday and Sunday v\ssociation took place at the house of Mrs. Richard Irvin, who, having Dr. Loomis's idea in mind, determined to win an interest in it by telling of a young girl who was dying of consumption in an inner tenement, and for whom she had tried in vain to gain admission to a hospital. The urgent need for a hospital for consumptives was so im- pressed upon the audience that at th" close of the meeting a woman present offered $1000 toward the opening of such an insti- tution. From this beginning the work gradually developed. The rent- ing of a small house at 230 West Thirty-eighth Street was soon followed by the purchase of 193 acres of land not far from Liberty, where it was hoped in the near future to build a sanatorium for the treatment of incipient phthisis, on the lines so much desired by Dr. Loomis. Then came the death of this distinguished and beloved physi- cian, and, following it, the noble gift of the sanatorium as a me- morial of him by Mr. J. Pierpont Morgan. The sanatorium was incorporated on January 24, 1896, a.id opened to the public on June 1st. It is situated two miles west of Liberty, and stands on the southern slope of a hill crowned with forests and girt by a caverned ledge. It forms a picture full V M ISO PULMONARY TUBERCULOSIS. li' ' o o J I IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 151 of beauty, sunshine, and refinement. The ample grounds, attract- ively laid out with graveled walks and drives, command an exten- sive and uninterrupted view of the surrounding country for many miles. The Loomis Memorial and Administration Building, built of roughly hewn graystone and timber, designed by Mr. Bruce Price, stands on a plateai' on the highest part of the grounds, '^d Icoks over a rarely beautiful expanse of mountain and vatley. The dimensions are 190 feet by 60 feet. It is three stories high, and contains reception-room, library, dining-room, offices, drug-room, butler's pantry, kitchen, store-room, and laundry on the first floor. The second floor has a solarium, four emergency wards, laboratory, nurses' rooms, baths and closets, sleeping-rooms for house staff, and guest-rooms. On the third floor arc servants' quarters and store-rooms. All the charm of modern decoration and furnishing is shown in the interior, and ever- modern appliance equips the house. Over the mantel in the libiai} a bronze tablet, with palm- and laurel-branch on either side, bears the following inscription ; " This building is erected in loving memor\ < ♦ Alfred L. Loomis, M.D. To be used as a Sanitarium for the treatment of Phtl isis. 1831-1895." Grouped around the main building, within a few hundred yards of it, are a casino and eight cottages. The casino, given '>> Mrs. George Lewis in memory of her husband, is a two-storj luilding of stone and wood, fifty by sixty feet, with a huge fireplace and the attractions of a billiard-table, organ, piano, games, etc., for the amusement of the patients. The sanatorium can accommodate about eighty patients. Each building is heated by its own hot-water plant, and lighted from a central dynamo. There is a reservoir situated above the highest point of the sanatorium, into which water is pumped from a mountain spring, thus insuring a pure water-supply. The staff consists of Dr. Stubbert (the physician-in-charge), and a house-physician. Dr. Walter V. Chappel, of New York, is the laryngologist of the institution. There is a laboratory, furnished with all the necessary appa- ratus for bacteriological and experimental work ; also a powerful " X-ray" apparatus and well-equipped throat-room. The general idea of the sanatorium is that known as the cottage plan : patients are grouped in cottages short distances from the ^m 152 PULMONARY TUBERCULOSIS. main building, and, except in rainy weather, have daily exercise in walking back and forth for meals, and for the amusements at the casino. The object of this sanatorium is to help persons in the incipient stages of phthisis to recover their health, who by reason of limited means are unable to go to more expensive resorts or to travel greater distances. Only those will be admitted who are in the early stages of consumption, and to whom a residence for a number of months in the sanatorium promises either a complete cure or such an improved condition that they can return to their homes and be able to carry on their work. I'Ki. 4,'i.— A CoTi'Ac.i;, I.ooMis Samiarium ai I.iiikkty. As for the financial basis of the institution, Dr. Stubbert said to me, in a recent letter: " It is not a charitable stitution, neither is it a money-making one ; we aim to give the i)atients the very best of everything in the way of buildings, food, nn icai attendance, and comforts of all kinds that can be expected — that is, we plan to give them everything that they could obtain from money-making sana- toria charging $25,00 to $50.00 a week. Our rates are 312.00, $15.00, and $20.00 a week; there are a few beds on which we hope in the future endowments will be placed, whereby each patient will receive from the beneficiary fund $5.00 a week toward his expenses. You will therefore see that the aim of this insti- IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 153 tution is to reach a class of patients, first, who are able to pay their way absolutely ; second, who are of good connection and person- ality, and yet who need a certain amount of aid — in other words, the sanatorium is supposed to receive refined people. To my rnind, this is even a greater charity than that which reaches out to only the poorer elements of our cities." Before patients can be admitted they must be examined by either Dr. H. P. Loomis, Dr. Charles E. Quimby, or Dr. A. A. Smith, of New York ; or by Dr. J. E. Stubbert, at the sanatorium ; or by some other member of the medical board. Liberty is located on the main line of the New York, Ontario I I'li;. ,(6.— A Cottai;k I)kauini;-room at thk I.oomis Sanitaku m. & Western Railway, 1 19 miles from New York, and has an ele- vation of from sixteen hundred to eighteen hundred feet above tide — the greatest elevation reached on this railroad between New York and the Great Lakes. The atmosphere at Liberty is always invigorating; the nights are cool in summer, and the winds make even the hot days bearable. The winters are cold; the ground freezes up in November and remains so until late in the spring. The intense cold is less felt at Liberty than in the lowlands, and the patients, as a rule, enjoy the out-door life at Liberty as much in winter as in summer. The last semi-annual report, dated May i, 1898, which Dr. Stub- bert had the courtesy to send me, shows the following remarkable 1 1 5 r 2^ 1 (■' . •■ ., f' I 154 PULMONARY TUBERCULOSIS. results obtained in the Loomis Sanitarium : " During the past six months i8 per cent, had lost their bacilli. During the first year 13 per cent, of the patients discharged were apparently cured, while during the past six months 23 per cent, of those discharged were apparently cured, and 70 per cent, of those discharged were either cured, had their disease arrested, or were so much improved as to be able to return to their work. Of the patients discharged after a residence of three months or less at the sanatorium 17 per cent, were apparently cured, while of those who remained more than three months 26 per cent, were cured." The treatment in vogue at Liberty is the hygienic and dietetic Fig. 47.— a Bedroom at the Loomis Sanitarium. method, but Dr. Stubbert has also used recently the U. S. Govern- ment serum (of de Schweinitz) in a number of cases, and has noted a fair number of improvements under its administration. Dr. Stubbert believes more in exercise than most European and Amer- ican phthisio-therapeutists. As a rule, he allows all patients whose evening temperature does not reach 100° F. to walk moderately, and if their temperature is not above 99° F. no restrictions at all are placed upon them in this respect, but they are allowed to gradually accustom themselves to pedestrian tours extending over from two to ten miles daily. He assures me, and also states in his recent report, that he has never seen any untoward results from IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 155 this exertion on the part of the patients, and he considers it a mis- take to encourage any such cases to take the rest cure. An interesting innovation has been inaugurated at Liberty by Dr. Stubbert by creating a nurses' training school. The course being two years, they receive a thorough training in the sanitary work of a sanatorium, and are lectured to twice a week by the difterent members of the medical staff. To nurse a consumptive is not always an easy task, and to train nurses in this special art is an idea for which Dr. Stubbert is to be congratulated. The Loomis Sanitarium has also a city branch for consumptives, where the incurable cases are admitted. It is located at 104 and 106 West Forty-ninth Street. Attached to it is also an out-door dispensary. One of the houses is devoted absolutely to charity patients, and the other to those who are able to pay for their board (seven to ten dollars a week). MONTEFIORE HOME COUNTRY SANITARIUM. At Bedford Station, Westchester County, near New York, at an elevation of about four hundred and fifty feet, there has existed, since September, 1897, a little sanatorium which has grown and promises to become an important institution for the treatment of the consumptive poor. It constitutes an annex to the Montefiore Home for Chronic Invalids situated in the city of New York. The institution comprises 130 acres. It gets its water-supply from an artesian well 400 feet deep, and has a storage tank of 32,000 gallons of pure, wholesome water. There is a farm attached to the institution, which supplies eggs, good milk, fresh fruit, and vege- tables. The institution was opened with ten patients, but the need for additional accommodation made itself felt, and a pavilion with twenty-four beds was erected and opened in May, ',8gS. The first annual report shows that 57 patients had been treated, of whom 5 were cured, 8 left in an improved condition, 15 were transferred to the Montefiore Home at One Hundred and Thirty- eighth Street and Grand Boulevard, New York, as their advanced condition of phthisis became detrimental to the surrounding in- cipient cases; 29 cases remained in the .sanatorium at the time the report was finished. The sanatorium had its inception through the generous gifts ot Messrs. Bloomingdale and Schiff, and is exclusively for the con- n ^ 1 i 1 ,lii 156 PULMONARY TUBERCULOSIS. !'^i ( in OS h Z o o S IMPORTANT SANATORIA AND SPECIAL HOSPITALS. 157 surpptive poor, which are selected from the applicants for admission to the Montefiore Home for Chronic Invalids. The house-physi- cian of the institution is Dr. Herbert; the medical director, Dr. J. Fraenkel. It is the plan of the founders to add to the existing buildings some smaller cottages with separate rooms, more suitable for the care of tuberculous invalids than is the original large pavil- ion, which consists only of a large dormitory. I reproduce here a photograph of the latter, showing tlie neatness with which the insti- tution is kept. For the benefit, however, of all those desiring to build sanatoria for consumptives, I must criticize the arrangement whereby twenty-four patients congregate at night in one large hall. To me it seems to be an utter impossibility to assure a good night's repose to these invalids, as among such a large number coughing will be heard mo:e or less all the time, and thus they will disturb each other. o u X THE PASTEUR SANATORIUM. Pasteur Sanatorium is the name given by Dr. Paul Gibier, Direc- tor of the Pasteur Institute of New York, to the sanatorium for the treatment of tuberculous patients at Suffern. In selecting this name Dr. Gibier desired to honor the memory of his celebrated teacher. Suffern is a little village and station on the P>ie Railroad, a short distance (about one hour by rail) from New York City. The sana- torium is situated at the foot of the Ramapo Mountains, in Rock- land County, N. Y., at an elevation of 500 feet above sea-level. The laboratories of the Pasteur Institute and the model farm belonging to Dr. Gibier are also on the same property, which comprises about two hundred and fifty acres. The sanatorium stands on higher ground than the other build- ings, and tlie structure is built according to the best sanitary prin- ciples, and in compliance with the requirements of modern phthisio- therapy. It has a south and southwestern exposure, and is in the immediate vicinity of a grove of pine, chestnut, maple, and oak- trees. There are verandas and balconies for the rest cure in the open air. The principal veranda is twelve feet above the ground, in front of the second story, and can be entirely closed by glass and transformed into a solarium in too cold and windy days. The ground-floor is used for liydiotherapy and for bacteriologi- cal and "X-ray" work. On the main-floor are the diniug-room, II 158 PULMONARY TUnERCULOSIS. lU m IMPORTANT SANATORIA AND SPECIAL HOSPITAI^. >59 parlors, library, billiard-room, music-room, etc. The kitchen, the laundry, the servants' rooms, and the machinery arc in an annex, connected by a corridor. The sanatorium is provided with fresh vegetables and excellent milk from the farm. The cows are tested at regular intervals by a competent veterinary surgeon. The woods surrounding the sanatorium and the Spitzberg Moun- tain near by offer pleasant e.xcursions to the patients. The cottage of the medical director is about one vhousand feet distant from the sanatorium, with which it is connected by telephone. The estab- lishment is heated by hot water and lighted by electricity. A house- physician resides in the sanatorium. The climate at Suffern is similar to that of New York, but the atmosphere is very much purer, and in summer it is less hot. The treatment in the sanatorium is the hygienic and dietetic method as prescribed by T^rehmer, Dettweiler, and their followers. For the time being there is accommodation for about thirty patients, A number of beds, however, are destined by the founder of the sana- torium for the reception and free treatment of poor tuberculous physicians of whatever nationality, school, or religion. The price for room, board, and medical attendance varies, according to the location of the rooms, from twelve to twenty-five dollars a week. An additional pavilion is projected. The accompanying cut gives a general idea of the external appearance of the establishment. SETON HOSPITAL. At Spuyten Duyvil, within the precincts of Greater New York, there was erected, in 1894, a majestic building for the care and treat- ment of the poorer classes of consumptives. The building faces Spuyten Duyvil Parkway, and can be reached within twenty five minutes from the Grand Central Station. It stands on high ground (250 feet above the level of the sea), and from its balconies one has a fine view over the Hudson. The wards of the institution are large, airy, and cheerful. Each has a capacity of twelve beds. There is a system of fans and ventilators, maintaining an even tem- perature in the building. One of the chief attractions of the insti- tution is a large solarium filled with growing-plants, where in cold and stormy weather the patients delight to congregate. The institution is under the charge of the Sisters of Charity, and can accouimodate 160 patients. The patients pay for their 'A m I •mn^ 1 60 PULMONARY TUHKKCUI.OSIS. board only (five dollars a week). With the be The sanatorium is under the direction of Dr. A. J. Richer, of Montreal. The admission of patients is made upon the recom- mendp*^'nn of Dr. H. A. La Fleur, Associate Professor of Medicine at lie ri: College, Montreal. This gentleman is also consulting physic ia'^ to the sanatorium. The therapeutical department is direct. :d by Dr. Robert Wilson, Professor of Materia Medica and Therapeutics at Bishop's College, Montreal. ; i' 1 i •■.■;•> 1 il IMAGE EVALUATION TEST TARGET (MT-3) 1.0 1^128 |2.5 |5o ■^" Hm us 1^ |2.2 1 '-^ 1'-* I.I 1.25 J. »/ . ► < — — V] <^ /2 /: /J /w/ "/ Photograpliic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. MS80 (716) 872-4503 i ■'4**s,_ I J im '^ J ■! m> 1 m If K ' r ' ■ .»L ■ ■ !. wMiu L. X u a: Z O O o Q Z < CO 0. < Q- C/^ C/) t -J a. 3 (^ U LU ca _ H- PL o •< s ■r «a ' = Vwv. f 2 " s j; i 3 « ii 1 E 3 lA 3 U £ j_ o br B >. 3 > 3 X3 M c 0-5 (/! u u M c S lA 3 ,- r 1 3 o ° Si- 1° B u ^ >. o O tfl a.£5 £.09 o : 5 lfc= u.^ o ■s ll c i s . u it ° S ll "3 if (0 — ^^ S ° f T3x ■— a. §■ I U i 3t3 U X Id I ^ o X u z < ou o w K D 0. u 1 ot > « Sg 0- C/) < o < z C/) u. O o u s ! s 3 B E B S c I ? g 1 ■2 5, o 1 3 0< 3 1 8 8 5 « Jin e J4 £ !r. 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My observations in this direction have been confirmed by comparing the results of treatment in .so-called health resorts and in private practice under ordinary conditions with those of the sanatorium treatment. These results, equally good in whatever country the institution exists, are the best plea for their universal establishment. But before entering into the subject of the treatment proper, we must review the subject of climato-therapy and arrive, if possible, at some conclusions as to the value of this or that region in the treatment of tuberculous invalids. There is hardly any subject on which more has been written than on the climato-therapy of pulmonary tuberculosis. There is still a vast diversity of opinion as to the respective merits of what are still sometimes called specific climates for consumptives ; but the number of phthisio-therapeutists who consider even the best and most suitable climate of .secondary importance, and the hygienic and dietetic treatment, preferably in a closed establish- ' Contrary to llie custom of m.iiiy Knglish-spcakiiig people, especially in the United .States, I call these estahlishnifnls SaiKitoria, ami not Suitilariii. 'I'lie former (sana- torium), from siiiiiirf, to heal, gives a belter ec|uivalent to the German " lleilanstalt," the word used by the originator of this system (Hrehmer). .Secondly, the ^vord " sani- tarium," from siiiii/iis, hcallh, is usually employed to designate a place considered simply as especially healthy — a favorite resort for convalescent patients. 200 CLIMATO-THERAPY IN PULMONARY TUBERCULOSIS. 201 ment, or under constant medical supervision in congenial sur- roundings, the all-important factor, is constantly increasing. I do not deny the beneficial influence of certain climatic conditions on the various forms of phthisis; but, with all defe.ence to the opinion of others, I do not believe that there exists any climate with a specific ^'spedfic°' curative quality for any form of pulmonary tuberculosis. Climate can only be considered a more or less valuable adjuvant in the treatment of consumption, but not a specific. A tuberculous patient of the ir- ritable pyrexial type, with much tendency to nasal and bronchial catarrhs, will often do better in a warm climate with little elevation, such as Southern California, Southern Arizona, New Mexico, West- ern Texas, Florida, etc., in the United States ; Jersey and Sidmouth in England ; V a and Hyeres in France; San Remo in Italy, etc. To higher altitudes, such, for example, as Davos and St. Moritz- dorf in Switzerland, or the mountains of Colorado, Montana, Utah, and Wyoming in the United States, may safely be sent early cases with no throat complications, persons with a chest badly developed either by transmission of a phthisical predisposition or fault of development, and all ordinary cases of phthisis. They are most likely to be benefited in such climates. Weber's classification Weber's seems to be the most correct. In his Croonian lectures (1885) heuon. classes the following cases as those for which higher altitudes are unsuitable: (i) Consumptive persons belonging to the erethic type, whether the affection is early or advanced ; (2) phthisis in a very advanced stage; (3) phthisis complicated with extensive emphy- sema; (4) phthisis complicated with albuminuria ; (5) phthisis com- plicated with di :,ease of the heart ; (6) phthisis with ulceration of the larynx ; (7) phthisis with rapid progress and constant pyrexia ; (8) phthisis with great loss of substance ; (9) phthisis with consider- able empyema; (10) phthisis in persons who cannot sleep or eat in high elevations, or who feel constantly cold. As an intermediate altitude of between two and three thousand feet, Fletcher Ingals recommends some portions of Dakota, Ne- braska Minnesota, the Adirondack Mountains, and those of Vir- ginia, North Carolina, and Tennessee, to which I would wish to add the region about Liberty in Sullivan County, N. Y., as especially suitable for phthisical patients in summer. As typical winter climates he mentions Arizona, .Southern California (among the foot-hills as far as possible from the ocean). Southern New Mexico, South Carolina. Georgia, and Texas. ' ' n f, h1-3; 4 202 PULMONARY TUBERCULOSIS. Climatic idiosyn- crasies. Choice between warmer anil colder climates. Besides this selection of climates to suit the respective forms of pulmonary phthisis, there are to be considered what I would like to call climatic idio.syncrasies among tuberculous patients. Of two patients with seemingly the same temperament and at about the same stage of the disease, one feels best and makes most rapid road to recovery in one of the Mediterranean places or Southern Cali- fornia ; while the other, who had also been sent to such places, apparently would have died had he not left there in time and gone to Davos or Colorado, or some other resort of high altitude. I know of patients who got well at the Adirondacks and felt badly at Liberty, and vice versa ; both places are in the State of New York, and their climatic conditions differ very little. Some patients do well in island and coast climates ; others improve greatly on a sea- voyage. While it may be safely said that in the majority of cases any climatic change will do good, too much travel should be dis- couraged. To send a patient away from home in the advanced stage of phthisis has always seemed to me cruel and useless, it nearly always hastens a fatal termination, which is the sadder since it takes place among strangers and away from home. Those desir- ing to benefit by climatic changes should travel to warmer climates in fall and to colder ones in spring ; thus the acclimati/;i.tion of the consumptive individual will be more easily accomplished. As to the choice of a warmer or colder clime for a cure, Fletcher Ingals ' may be right in .saying that patients who feel better in cold weather should be sent to a comparatively cold climate ; those feel- ing better in summer, to warmer regions. But, in spite of excel- lent works in phthisio-climato-therapy, such as Weber's,'' de la Harpe's,^ and Solly's,* our present knowledge of the subject is still limited, and opinions as to the best method of classifying climates as to their respective merits in phthisio-therapy differ vastly. If I should be asked to express an opinion on the subject, I would say the best climate for a consumptive is the one where the atirothera- peutic portion of the hygienic and dietetic treatment, as understood to-day by the modern phthisio-therapeutists, can be carried out most easily and most persistently ; or, in other words, the best cli- -' ' Ingals, " Diseases of the Chest, Throat, and Nasal Cavities." 'Weber, Hermann, " Cliinatherapie.'' ' De la llarpe, " I'ornuilaire des Stations d'lliver et des Stations d'litc." * Solly, " Medical Cliniutology." CLIMATO-THERAPY IN PULMONARY TUBERCULOSIS. 203 mate for a consumptive is the one which permits him to remain out-doors more and longer at a time than anywhere else. But since an ideal climate cannot be obtained everywhere and will not be within the reach of everybody, the best thing to do is to get as near these conditions as possible, and preferably at not too great a dis- tance from home. Places where pure, dry atmosphere and some elevation, with protection from winds, can be had, abound more or less in all countries. I cannot conclude this short review on cHmato-therapv in re- J^fsuits in gard to pulmonary tuberculosis without mentioning a most im-<^''"'»'"." portant fact which has been very little regarded up to this date in our text-books on climatology. I refer to the relative dura- bility of cures obtained in different climes. I know from per- sonal observation of quite a number of cases that cures of pul- monary tuberculosis effected in our home climates, which are, in the average, not considered as especially favorable to this class of sufferers, have been more lasting and more assured than cures obtained in more genial climes away from home. In these obser- vations I do not stand alone, for such men as v. Leyden, Gerhardt, V. Ziemssen, Dettweiler, Naunyn, Frankel,and Walthers' have had the same experience. Of what vast importance these facts are in relation to the social problem of tuberculosis and the treatment of the tuberculous poor, we will see in chapter xxv, where these sub- jects will be dealt with more at length. ' " Tlie Practitioner, " Tuberculosis number, London, 1898, p. 670. 1?.. ^if CHAPTER Xr. DESCRIPTION OF AN IDEAL SANATORIUM FOR THE TREATMENT OF TUBERCULOUS PATIENTS. What locality should be chosen for the establishment of a sana- torium where all classes of consumptives should be received, benefited, and the largest possible number cured? Thoroughly disbelieving in the specific curative quality of any climate, I should place a sanatorium where it can do the most good to the largest number. When we consider the vastly important social and eco- nomical questions which the modern phthisio-therapeutist must take into consideration, I cannot help declaring my firm belief that it is essential to the majority of tuberculous patients to be treated and cured in the same or nearly the same climate where they will have to live and work after their restoration to health. i-ocaiinn. I would, therefore, placc the sanatorium for consumptives within easy reach of a large centre of population, at no greater distance than from three to five hours by rail. It should be in a region known for its relative purity of atmosphere, where there is freedom from all miasmatic and malarial influences, and where the patho- genic microbes are only found in negligible ([uantities. If possible, it should be where the extremes of temperature are not too pro- nounced, and, if the region is a mountainous one, at an altitude of from one thousand to fifteen hundred feet. The site should be a pleasant one, with a southern exposure and protecteu from cold winds by higher mountains or woodlands (pine-woods should be given the preference). The ground, of course, should be dry and porous. Rut that all these conditions are not necessary has been proved in institutions which have neither the advantages of a favor- able climate nor a high altitude. There exists in Scotland an estab- lishment devoted to the treatment of consumption, known as the "Victoria Hospital of Edinburgh " (at Craigleith). When I visited it, in September, 1894, it had only just opened, and up to the 31st of May, 1895, sixty-five patients had been already under treatment, 204 '. ■ M \£ 1 'I li w I ft ],\ ^:^^M^ . M Lo< .jfWrrsf'; ••'*' r r r n r r^r r ^ p TT fp p'Pff 7 I'i p-p "■ in'*rrrrf?rFrrrn t p*r fr rifft I'lii O.I.— l'iKsi'i-;i 1 1\ I- \ II u (II AN luKAi. Sana iiiKiiM '*=^_&.i^ A*'"','**'. V-i-wSS^ ^^*.-, :^ IKU III- .\N I[)KA1. Sana ICIKIIM I(IK C'uNSIMI'I I\ l-.S, — I.AKl.K 1'A\I1.|UN Snsii-m. I, ;t fi- ll W m I .'J J. % AN IDEAL SANATORIUM. 205 with satisfactory results.' What is possible in Scotland with its rigorous climate is possible anywhere else. In the United States I know of two institutions located but a few miles from two of the largest cities, and the results obtained are certainly most remark- able, for there are no special climatic advantages claimed for either of them. Both locations are exposed to the extreme heat as well as to the severe cold so frequently experienced in the Eastern cities of the United States. I refer to Sharon Sanatorium, near Boston, and the Chestnut Hill Hospital for Consumptives, near Philadel- phia. If I had to choose between sending a patient to what is usually considered an ideal specific climate, but where he would live as in an ordinary health resort, or keeping the patient home in a fairly pure atmosphere and applying the hygienic and dietetic treatment under constant medical supervision, I should choose the latter method of treatment, and think the patient had a far better chance of recovery. In a very elaborate work Blumenfeld ^ has eiven the results ofinfluence his daily observations, throughout the year, of the influence of the weather on various meteorological changes exerted on the condition of a large "ves. number of phthisical patients. His conclusions prove, what Dett- weiler has been preaching for the last twenty years, that tempera- ture, atmospheric pressure, and humidity scarcely influence the condition of the consumptive. The only really dangerous thing such patients need to guard against is strong, penetrating wind. Dr. H. Weber* expressed himself, at the Tenth International Med- ical Congress, in the following terms : " Die Behandlung der Schwindsucht ist iiberall moglich wo fiir reine Luft, passende Nahrung und massig graduirte Bewegung gesorgt werden kann." (The treatment of consumption is possible wherever there is pure air, wherever appropriate food can be procured, and wherever moderate graduated exercises can be instituted.) Von Leyden, Kretschmar, Dujardin-Beaumetz, Cantani, and other members of the congress expressed themselves in a similar way. ' riiilip, R. \V., " 'llie Victoria Hospital for Consumption, Edinburgh: Its Rise and Outlook." " Edinb. Hosp. Reports," 1S95. - niiimenfeid, " CIkt den Einlluss mcfeorologischer Vorgilnge auf den Vcrlauf der bacilliiren Lungenscliwindsutlil." ' " Verhandiungen des X. Internal. Congresses," lid. 11, Abtlieilung 5. .1 m\ 206 PULMONARY TUUEKCULOSIS. If . AN IDEAL SANATORIUM, i07 The next question to be considered would be the choice of buildin<^s and their mode of construction. Whicli plan would it be best to adopt — the European system, in which they house as many as seventy-five to one hundred patients under one roof, or the American cottage-system, with no more than from four to eight in each cottage ? To make so large an aggregation as one finds in some of the European institutions seems certainly not a good plan, since the hygienic measures are almost sure to suffer in such a liouse. On the other hand, the cottage system, while it may be the ideal for some diseases, is, on the whole, not the most desirable for a sanatorium for consumptives. The constant medical super- vision — one of the most important features in the sanatorium treatment — can hardly be carried out in a village of twenty or thirty small cottages several hundred feet apart, not to mention the increased expense such a system involves. In visiting the numerous institutions I endeavored, by taking comparative notes, to form a plan of what would seem an ideal sanatorium for the treatment of tuberculous patients in all .stages, and under varied climatic conditions, and adaptable to nearly all localities. I conveyed my ideas to my friend, Mr. John Van Pelt, formerly of the " Ecole des Beaux Arts " of Paris, now Assistant Professor of Architecture at Cornell University in Ithaca, N. Y., with instructions to draw the plans necessary to illustrate my conception of an ideal sanatorium for the treatment of patients suffering from pulmonary tuberculosis. He carried out my ideas most faithfully, and I here show photographs of the general view, the general plan, the detailed plan of the first story of one of the pavilions, and a drawing of the corner of the veranda, with an adjustable chair for the rest cure. As will be seen, I have adopted a plan between the European and the American ; in other words, the large pavilion .system. Three pavilions, each accommodating about twenty patients, are united by galleries one hundred feet long, which serve for promen- ades on rainy days. Behind the central building are situated the winter-garden, dining-room, kitchen, and the administration building, all connected by covered passages. At some little distance ve find, to the right and left, two medium-sized houses, one serving as a residence for the medical .staff, the other as a place where visitors or the friends of the patients, desiring to ii 4\ '"ft** I m 208 PULMONAKY TUBKRCULOSIS. be near them, may reside. At about two liundred and fifty feet from the main building, to the left, is a paviHon for the purpose of I'nviiionfor isolatintr patients. The necessity of such a precaution was shown me when, on visiting one of the sanatoria in Switzerland, I learned that a short time before a case of scarlatina had been discovered among the inmates of the one existing building, and as a consequence everybody who could had fled. Besides, even among the ordinary pulmonary invalids, the occasion for the need of isolation may arise. (In cases of gangrene, temporary insanity, etc , a separate, smaller pavilion will be indispensable.) On the opposite side of the other buildings, at a considerable di.stance, is situated the recre- Fic. 66.— I'l.AN (IF THK First Story ok One ok thk I'avm ions. ation pavilion, constructed so that two sides are always entirely open. The closed sides can be changed according to the direction of the wind. The rest of the buildings are houses for the gardener and stables for the horses, etc. In front of the pavilions, on the south side, is the park, with its turning kiosks, sun-bo.xes, pr^Jated paths, benches, etc. On the first floor of each pavilion are fourteen comfortable, well-lighted, well-ventilated sleeping-rooms for the patients, with two more rooms for the nurses ; also the toilet-rooms, etc. On the ground- floor are the sitting-rooms, library, parlor, consultation-rooms, and 1 AN IDKAr. SANATORIUM. 209 the room necessary for the hydrothcrnpeiitic applications, and als(j several bedrooms for patients. The verandas, eacli 135 feet lonj; and 15 feet wide, extend aion^ the len^'th of tlic pavilions; they are protected by a roof made partly of fjlass, provided with curtains, and arrani^ed to make the prolonj^ed stay of the pul- monary invalid as pleasant as possible; for it is here that he will have to pass the greater part of li. fection of man through beast, he must also necessarily institute""""*!'' ^ ' ■' man. measures to protect the beast from tuberculous infection through man. The necessity of such precaution was strongly impressed upon me when visiting an institution in a State where much is 14 I 1 ■ t It i If i •'%' lif m ">^' 1^1 Sift"; 'mi 2IO PULMONARY TUBERCULOSIS. done in the direction of prophylaxis. This institution receives nearly two hundred patients annually, the majority being con- sumptives. The following is one of the rules conspicuously posted through- out the house: " Patients must at all times, when in the institution I'lu. 6;.— CoKNKR OF Vkkanda. wnii Auji STAiii-K Chair for Ri:st Curk, I or on the verandas, expectorate in the sputa-cups provided. They must never expectorate in the sinks, wash-basins, closets, or on the floor, or in their handkerchiefs." Outside the institution the patients are not restricted ; they may expectorate wherever they please, and I have no doubt they do. I was told that a neighbor- ing farmer, who had some time ago bought five healthy cows, had AN IDEAL SANATORIUM. 211 theiii tested recently, with the result that three were found tuber- culous. It seems thus to me unwise to have the dairy on or too near the premises of a sanatorium for consumptives. There will He occasionally a careless, unconscientious patient in all institutions of this kind who may expectorate on the surroundinj^ grounds, where animals are likely to come in contact with the sputum on the grass. In an institution for the treatment of consumptives there will be, of course, the strictest precautions concerning the tuberculous e.Kpectorations and other secretions. We have described at length in chapter iv (pp. 38-43) the various spittoons which should be in use in such a sanatorium. They should be the elevated spittoons in niches or on stands ; the small, mug-like spittoon, which the patients may use during their rest cure ; and, finally, the pocket- flask. Of all these there should be two sets, so that they are never wanting when one set is being cleaned and disinfected. Each well-regulated sanatorium should have special facilities forManase- ,..-. ,. iri 1*11 111 1 r nient ami disinfecting spoons, knives, and forks, which should be done after discipline _, . . ill a Sana- each meai. At the ralkenstein Sanatorium an especially con- tonum. structed sterilizinp; apparatus is used for this purpose. All table- linen should be steeped In boiling water before being given to the laundry, and the same precaution should be e.xercised with the bed- -ind private linen of the patients. The rooms in an ideal sana- torium for consumptives should be submitted to a thorough dis- infection by formaldehyde gas at regular intervals, and not only after the death or removal of a patient. A simple and thorough method of room disinfection we described on page 58. While it will not be possible to enforce a rule concerning the toi''. .s of ladies in a sanatorium, the wearing of trailing dresses should not be permitted, and the gentlemen of the institution should not be allowed to smoke inside the buildings. The discipline in an ideal sanatorium for the treatment of con- sumptives need not, of necessity, be too severe, but all those rules and regulations enacted in the interest of the patient and his sur- roundings should be religiously obeyed. A patient should not absent himself from the .sanatorium without permission from the doctor. It mny not be amiss, in speaking of an ideal sanatorium, also to say a few words regarding the ideal management. Some of the European institutions are managed in two departments, presided !l- I ili: 212 PULMONARY TUBERCULOSIS. p.. * '^■•1 1 I irfl I over by a medical director and a general superintendent, respect- ively. In some the former, in others the latter would be con- sidered the superior in cases of conflict. While visiting the Euro- pean sanatoria it has been my lot to witness such a conflict between the two heads of a sanatorium, and the lesson I learned therefrom was most valuable. In a sanatorium for the treatment of con- sumptives the medical director should always be the final court of appeal, as well in the general as in the medical affairs of the institution. PI!' CHAPTER XII. AEROTHERAPEUTICS, REST CURE, AND EXERCISES. The main object of actotherapeutics is to oblige the patient to live as much as possible in the open air. A patient arriving at a sanatorium and having a high temperature — for example, above 102° F. — should be left in bed and moved, during the day, toward the open window or on to the balcony. When his temperature goes down he is allowed to begin his rest cure (Liegekur of Dettweiler) on the veranda on a lounge, steamer-chair, or, better yet, on a reclining-chair especially constructed for the purpose, such as I illustrate on page 210. The back of this chair can be given any desired inclination. It is needless to say that a patient, especially one coming from a sick-room in a large city, must only be submitted gradually to the exhilarating influence of a constant sojourn in the open air; but the endurance at which one may arrive in this respect is wonderful. In Falkenstein the patients remain out-of-doors on their chairs from seven to ten hours a day all the year round, in spite of fog, rain, wind, snow, and even with the thermometer at 12° C. below zero, and often no sunshine. Dr. Andvord, of Ton- saasen, Norway, wrote me that l.e leaves his patients on their chairs, wrapped up in furs, from five to nine hours a day at a tem- perature of — 25° C. It is to this prolonged stay in the open air (Dauerluftkur of the Germans) that the marvelous results obtained in these institutions may be attributed. Besides the rest cure in the fresli air, there is moderate exercise on gradated walks in the garden — that is to say, on paths varying in inclination from one foot in three hundred to one in sixty. At night the patient sleeps with his window open, rain or shine, warm or cold ; wide-open in summer, less so in winter. The only excuse for closing the window migiit be a very strong wind or a thick fog. A consumptive, if he wishes to get well, should live every moment of his existence in the purest and freshest air possible. During the rest cure on the reclining-chair 213 Precaution (liiiiiiK the rest cure in tlie opuii uir. i AW m ( '^i ' I .1 I ? ■ h 214 PULMONARY TUBERCULOSIS. the patient is allowed to read or write, and is made as comfortable as possible. The main point to be attained is an almost complete muscular relaxation, in order to economize and store up strength and reduce the fever. When on their chairs on the veranda, patients should always be covered with blankets or lap-robes, in accordance with the season ; furs in winter are indispensable. There is always an attendant attached to the service to see that patients do not become uncovered while asleep. Short naps after Uieals are allowed, but they should not exceed ten minutes or so. Consumptives are so apt to perspire when asleep any length of time, and especially when warmly dressed, that this might be the cause of their catching a severe cold. The patients watch over each other alternately to see that they do not sleep too long. Patients are warned, when taking their rest cure, never to let the sun shine directly on their heads. Congestion, headache, and other troubles often follow if this precaution is neglected. The good results which are obtained by the rest cure in the open air are, indeed, at times wonderful; and still, with all due reverence for the great originator of the " Liegekur," the distinguished phthisio-therapeutist, Dettweiler, it is not without danger as it is practised in many European sanatoria. To have a patient lie on his back for three or four hours at a time without rising, and repeating this two or three times during the day, seems to me dangerous, for it facilitates hypostatic congestion of the lungs. I know of several cases where this condition has been brought about by thus remain- ing too long in the recumbent position. There is another reason why I do not favor this remaining undisturbed for hours on the re- clining-chair. The local temperature of the back, being in constant contact with the warm cushions, will cause this part to become more sensitive to temperature changes than it had been, perhaps, ever before ; and it seems to me easy to explain thereby why patients in institutions where the cure is practised as just described always complain of cold backs. It is for this reason that I think respiratory exercises should be The patient If ^ipHKiit po-this tires him too much he may, however, simply change his reclining position for the straight sitting position, raise his arms ani^ go through the first and second respiratory exercises a few ti.iies. Should even the raising of the arms tire him, he may go Value of aUeriiating . , . the "Liege- made to alternate with the rest cure out-doors. kur" with , , , . , 1 tr 1 11 respiratory should risc evcry hour, or half-hour, to take these exercises. exercises 111 iiprigl sitioti AEROTHERAPEUTICS, REST CURE, AND EXERCISES. '• I through the exercise by simply moving his shoulder-jomts upward and backward, which is the exercise prescribed for pulmonar}* in- valids when the raising of the arms is not practicable (p. 85), My experience has taught me that these exercises are of value in nearly all cases except in acute inflammatory processes, m fretjuent active pulmonary haemorrhages, and whenever there is a con- stant temperature of 100° or more. I have described in full, and endeavored to illustrate, my system of breathing exercises in a preceding chapter on Preventive Treatment (pp. 82-S6J, As I stated there, they are alike beneficial for the predisposed and for the patient with developed pulmonary tuberculosis. For the latter a more strict medical supervision and a more careful! gradation is, of course, necessary. It is true that whenever there are old pleuritic adhesions these e.xtra respiratory efforts may cause mo- ments of pain ; the patient must, however, bear in mind that these pains are not lasting and are in reality salutary, being caused by the loosening of the fibrinous bands. By these breathing exercises the respiratory muscles become developed, the process of haema- tosis more complete, and the increased respiratory function helps to dissolve the mucus and makes cough and expectoration more easy. More advanced and very weak patients must content them- selves with deep but quiet respirations without movement of the arms. Placing a pillow under the back of these patients so as to realize somewhat Sylvester's position, employed when artificial respiration is necessary, will be found a valuable adjuvant- It is interesting and pleasing to note how patients who have been bad breathers for years learn to love these exercises, so that it seems to them they can no longer live without going through with their regular performance at stated intervals. There are in the market numerous apparatus invented for the purpose of performing certain alleged especially beneficial respir- atory movements. I have experienced with several of them myself and had them tried by patients. These trials resulted in having abandoned all these mechanical devices, finding that the simpler the exercises and the less exertion there is re^juired, the more readily will the patient carry out the instructions concerning them, and the more efficacious will they prove in the end. The only instrument which seems to me of real value in stimu- j.^p^^on^.g lating the desire to take deep inspiration is Professor Alifred von cha!r.'""^" Usedom's " Athmungs-Stuhl," or breathing-chair. The dcscrip- n'* !i 2l6 PULMONARY TUBERCULOSIS. tion of this chair appeared for the first time in the " Aerztliche Politechnik " of May, 1898. The arrangement of the chair seemed to me so ingenious that I had one constructed for a patient who was in the habit of sitting and standing in a bent-over position (Fig. 68\ and who needed a great deal of reminding to take his respi.dtory exercises. The result of making him sit on the breath- ing-chair, instead of an ordinary one, has been most gratifying. The main characteristic of the chair is the movable back, suspended by a cord at about the height of the middle of the back (Fig. 69). iG. 68.— Usual .'\TTlTunF in an ORniSARV Chair Fig. (>9.— Pr()i\ Iskdom's Brkathing-Chair, This cord must be arranged loo.se enough to yield to forward and backward movements. During inspiration the upper portion of the back will be pushed backward, the lower portion forward. During the act of expiration the reverse process will take place. Since the two acts are automatic and regular, the lungs of the patient receive thus an energetic stimulus to deep respiratory movements. I should advise a number of such chairs as necessary to a complete equipment of a sanatorium. In fact, considering that the majority of chairs now in use have backs which rather AEROTHERAPEUTICS, REST CURE, AND EXERCISES. 217 tend to make one sit in a bent-over position, I would recommend this sort of chair for more universal use, especially in schools, colleges, offices, etc. They would, no doubt, constitute one of the factors in the prevention of pulmonary diseases, and serve in a measure to overcome the so-called " habitus phthisicus," so characteristic of many consumptives. Much has been written on the question of exercise in the open walking air for pulmonary invalids. Brehmer was much in favor of it and as much as possible of it in order to strengthen the heart, and some of our American phthisio-therapeutists are of the same opinion. Dettweiler and his pupils, on the contrary, are opposed to it, ex- cept under restriction and the most careful supervision. The rest cure on the reclining-chairs, as above described, is even now ad- mitted in the sanatorium created by Brehmer. It seems to me that the wisest course to pursue would be to consider each in- dividual case, and prescribe or forbid exercises according to the condition and the strength of the patient. We have already spoken of gradated walks of various inclina- tions to test the patient's strength in regard to his climbing powers. The duration of a promenade should be graduated with equal care. One should commence with a walk of a few minutes until a walk of an hour or an hour and a half can be taken without producing fatigue. Wherever it is practicable these excursions should begin up-hill, so that the return is easy. After his promenade the patient's temperature should be taken. If it exceeds the normal it is an indication that the patient has overtaxed his powers. Whether complete rest or simply shorter walks are then indicated will be decided by the variation of the temperature before and after exercise. When the temperature of the patient only rises slightly in the evening (99°-99jj° F.), short walks in the morning, while in the apyretic state, may be permitted. A lasting tem- perature of 100° F. or over is an absolute contra-indication to exercise. Tachycardia should also be considered as such. If there is, however, a chronic tachycardiac condition, absolute rest might not be the best policy. But these patients, more than any others, should be warned against the slightest overexertion. Breathing exercises and walks may be combined, the patient taking three to five of the exercises above described, with or without moving the arms, in every 150 to 200 steps. M i''j. Descrip- tion. CHAPTER XIII. THE PNEUMATIC CABINET IN THE TREATMENT OF PULMONARY TUBERCULOSIS. In the modern therapeutics of pulmonary diseases the pneumatic cabinet takes its place in importance immediately after general aerotherapeutics. To the physicians who have used it persistently and studied its effects, it certainly has rendered valuable services. Still, I am aware that it is relatively little known, and thus it may, perhaps, not be amiss to describe its construction somewhat in detail. The pneumatic cabinet has the form of a tall safe, somewhat larger at the bottom than at the top. Its door and apertures close hermetically. It is large enough for a patient to sit comfortably inside. The fr at is composed, in part, of a large plate of glass through which the operator, manipulating the lever, watches the patient. By a system of valves, bellows, and lever, compres.sed or rarefied air can be produced. An opening through the frontal glass plate serves for communication with the outside air, which the patient inhales through a rubber tube. The amount of in- coming air can be regulated by the stop-cock of a faucet. The degree of rarefication or compression is indicated by a manometer in communication with the inside atmosphere of the cabinet. I append a drawing of the pneumatic cabinet in my possession, which is the model now used by nearly all phthisio-therapeutists who employ this instrument. The principle of the cabinet in the treatment of pulmonary tuberculosis is to diminish the weight of the atmospheric pressure, which at the sea-level, under normal conditions, is about fifteen pounds to the square inch. With the aid of the cabinet it can be reduced nearly to fourteen pounds to the square inch. The action of the pneumatic cabinet has been described by 218 THE PNEUMATIC CABINET IN PULMONARY TUBERCULOSIS. 2\g many authors, such as Bowditch/ Fox,^ Houghton,' Hudson,^ acHoh Jensen," Ketchum,' Westbrook,^ Williams,* and others. In perusing cahintt. the extensive literature on the subject I found Piatt's' exposition one of the clearest. His experience concords with mine in almost every detail. He describes the action of the pneumatic cabinet as follows : " Such portion of the thoracic cavity as is not occupied by tissue — muscular, glandular, the parenchyma of the lung, etc. — consists of air-space and blood-space, and it is obvious that the increase in one of these will tend to the diminution of the other. The respiration of air at the normal tension while the body is immersed in a rarefied atmosphere is, in effect, the same as the introduction of a compressed atmosphere into the air-space of the lungs ; it will increase the air-space and tend to diminish the blood- space, driving a certain portion of the blood from the lungs into the general circulation, which is subjected to a diminished pressure. The pulmonary congestion is diminished in exactly the same way as the congestion of an inflamed joint or of an ulcer by bandaging. Or, to put it in another way, the blood is sucked or drawn out from the lungs into the general circulation, as it is sucked into the space beneath a cupping-glass. "This I believe to be the main action of the cabinet, the re- duction of pulmonary congestion, and the theory is practically verified by our experience with regard to blood-spitting and bron- chial hivniorrhage. Time and again, patients have come into the office complaining of the sputa being blood-streaked, and, almost ' V. \'. liowditch, " Boston Med. and Surg. Jour.," July l6, 1885 ; and " Journal of the Anitr. Med. Association," Aug. I, 1885. 2 .Sidney A. Fox, " A Report of Sixty-nine Cases of I.ung Disease Treated with the rneumatic Cabinet," "New York Med. Jour.," June 26, 1886. ' A. F. Houghton, "Journal of the Amer. Med. Association," Xov. 7, 1S85. * E. Darvin Hudson, Jr., " Present Status of the Pneumatic Treatment of Respira- tory Diseases," " Med. Record," Jan. 9, 1886. ' Dr. Jensen, same journal and date as r->r. Houghton's article. 'Jos. Ketchum, Fsq., "The Physics of Pneumatic Differentiation," "Med. Record," Jan. 9, 18S6. ' Henj. F. \Vestbrook, "Pneumatic Differentiation," "New York Med. Jour.," Jan. 26, 1S86. * H. F. Williams, " Antiseptic Treatment of Pulmonary Diseases by Means of Pneumatic Differentiation," "Med. Record," Jan. 17, 1885 ; "Pneumatic Differentia- tion," "New York Med. Jour.," July 16, 1885. ' Isaac Hull Piatt, " On the Practical Application of the Pneumatic Cabinet," " New York Med. Jour.," June 26, 1886. mi i> li ■ lilt I j 2 20 PULMONARY TUBKKCULOSIS. without a siiif^le exception, the use of the cabinet has relieved the symptom in tlie course of a few minutes. " In addition to the effect it has u])on the pulmonary congestion, it undout)tedly acts beneficially in other ways. The thoracic gym- nastics afforded by e.>cpiration against increased resistance will probably be of benefit to the weak-chesteil. The increased Kk;. 70,— Pnkl'Math; Caiunkt. oxygenation of the blood will, doubtless, improve the nutritive processes. Then the spray, if proper medicaments are used, may be expected to act beneficially upon the accompanying bronchitis." Quimby,' who is, perhaps, the best authority on the subject of cabinet treatment in pulmonary tuberculosis, — for he has used the cabinet longer and more persistently than any other phthisio- ' Quimby, C. E., " The Pneumntic Cabinet in the Treatment of Puhuonary Phthisis," " Internal. Med. Magazine" for January, 189J. , 'HI THK I'NKUMATIC CAlilNKT IN rUI.MONAKV TUIiKKCULOSIS. 221 ve ay 5. of he io- theiapeiitist I know of, — gives as the conclusion of a most remark- able paper on this subject, rend before the American Climato- logical Association in Richfield Springs, N. Y., June 24, i) Allaying (c ) Restoring (t/) Diminishing (e ) Preventing ( /■) Minimizing 5. Stretches and absorbs Thus, Restoring I 3. Tissue and vascular compression from (a) Inllammatory exudate. (/' ) Necrotic products. 4. Alveolar and tubular obstruction, causing (a ) Collapsed alveoli. (/') Local tissue irritation. (r) Deficient oxygenation. ( ■' C. SYSTt.MIC. Ci. Diminishes and retards l!y (<;) Removing (/' ) Increasing 6. Systemic malnutrition from (a) Respiratory olistructions. (i) Weak circulation. KKLATIONS OF THE PNEUMATIC CABINET TO THE CON.STRUCTIVE FORCES OF PULMONARY PHTHISIS. T H E C A li I N E r A. Specific. 1. Increa.ses nutrition of 2. Makes dynamic I''avors and moderates 1. Tubercular granulations. 2. The potential value of toxine (?). Local. 3. Productive depend- By (<; ) Traumatic increase of (fi ) Removing obstruction to (c) Augmenting (d) Increasing Stimulates By {(I ) Incre.nsing (fi) Restoring normal C. SV! Stimulates By ((?) Improving (fi ) Doubling inllammntion, ing on (<; ) I.ocal irritation. (/') Freedom of circulation. ((■) Nutritive vascular supply. (d) Lymphatic absorption. Local tissue vitality, depending on (ti) Circulation. (/') Anator'ical conditions. Genp.al glandular activity from (<;) Circulation. (i) Respiratory eapacitv. ^1 i jf'i n* I 4»' " 9i — feij m Itt k> ■':■ ' ■ 22: PULMONAKV TUBERCULOSIS. When I first began to investigate the pneumatic cabinet treat- ment, I saw it used as I believe it is now still used by the majority of physicians. The patient enters the cabinet completely dressed, he inserts the tube into his mouth, and the operator manipulates the lever from five to ten minutes, retaining the manometer at the height of about an inch. The good effect of this treatment, it seemed to me, could be lieightened by some modifications whicli suggested themselves to me in the course of my own experience with the cabinet. I have refrained from publishing these modifications, for the simple reason that I wished to see their utility verified by larger experience. Now, after having used the cabinet treatment with my modifications in quite a large number of cases in liospital and private practice, and in most instances for many months at a time, I feel more prepared to publish the system I have adopted in connection with the use of the cabinet in pulmonary tuberculosis. Fig. 71.— Tube with Nosb-.mask. Author's With the exception of the very weakest and highly febrile cases, tiimoftiie nearly all tuberculous patients can take the pneumatic cabinet treatment, treatment. Before admitting my patients into the cabinet I tt ach them how to breathe. They must first take a course of respiratory exerci.ses, such as I described in chapter vii, and only after they have learned to use their respiratory muscles to the best advantage do I begin the treatment, with short seances at first. Any mechanical obstruction to proper breathing has, of course, been looked after previous to the commencement of the respiratory exercises. Any intercurrent acute coryza must be attended to before putting the patient in the cabinet. Besides the general treatment, these coryzas should be treated locally by either the application to the nares of a one or two per cent, solution of cocaine, or by cleansing with and spraying of liquid albolene, benzoinol, alphasol, or other mild antiseptic solution. I insist upon proper breathing through the nose, and the conditions neces.sary thereto, for the reason that I have abandoned the custom of having the patient put the rubber ; TlIK I'NEUMATIC CAllINET IN I'ULMONAKV TUMKKCUI.OSIS. 223 breathin^^-tiibe in his mouth. To this end I liad nosc-niasks con- structed, which, owing to the malleability of their posterior portion, can be molded to lit the form of any nose. The patient either holds the mask, pressing it to the face, or it is fastened by a strong elastic band encircling the head. A little cotton or a thin cloth placed between tlie nasal bones and the malleable portion of the mask will prevent the possibility of the outside air entering the cabinet. The anterior portion of the mask is attached to the ordinary rubber tube, which, in turn, is fastened to the cabinet end of the faucet. The accompanying drawing will illustrate both. I have found this system of natural breathing superior to mouth- breathing, and many of my hospital patients who had been also treated by my predecessors, but with the mouth-tube, have again and again assured me that they not only liked the nose-breathing better, but that they felt better after it than when they breathed through the mouth. They felt that they got just as mucli air into their lungs as with the old .system. I mention this to answer the objections which were made by some of my colleagues at the hos- pital, who claimed that the patient does not receive enough air through the nose-mask. After having placed my patient in the cabinet, I open widely the window of the room in which the cabinet stands. I do this in office as well as in hospital practice, be it summer or winter, rain or shine, to assure my patient the purest and freshest air obtainable. Since the patient breathes through the nose, the possibility of catching cold is removed, thougii the outside tem- perature may even be severely cold. In very ana;mic individuals I occasionally combine ozone inhalations with the cabinet treatment. My second modification in the pneumatic treatment consists in having the patient enter stripped to the waist, and the trousers or skirts loosened, that not only a free thoracic but also a free abdom- inal breathing may be possible. My reasons for exposing the cutaneous surface of the thorax to dinjct contact with the rare- fied air are threefold : 1. There is no outside restriction whatsoever to fullest expansion of the lungs — a thing which is not possible for a woman wearing a tightly laced corset and numerous skirts tight around the waist. Even a man will breathe easier with trousers loosened and sus- penders removed, 2. The cupping effect, if I may call thus the action of the cabinet which relieves over one-half pound of atmospheric !,:. 224 PULMONARY TUBERCULOSIS. i 1 pressure per square inch, is heightened by removing several inter- vening layers of clothing. 3. It does the cutaneoi 5 surface good to get a chance to breathe directly, as it acts also as a respiratory organ ; in other words, the skin of the Jiest, made especially sensitive in nearly all con- sumptives through exaggerated warm dressing, will become less sensitive by systematic exposure to the air. To prevent the patient from taking cold the window is closed before he is allowed to leave the cabinet ; and if he should feel very warm, or if he should perspire, as patients soiiietimes do, a large Turkish towel is thrown around his shoulders, wherewith he produces vigorous friction over chest and back before dressing. To make the use of the cabinet as comfortable for the patient and at the same time as effectual as possible, I have added two minor modifications in its use. I had a stand constructed with a seniicircular board top, which, placed in the cabinet in front of the chair, enables the patient to rest his arm when holding the nose- mask. This stand can be fixed at any desirable height. The other minor modification consists of a little cap made of two layers of metallic gauze, placed over the external opening of the stop-cock communicating with the tube. Between the two layers absorbent cotton can be placed in order to filter the air which enters the tube when the patient inhales. The cotton can also be impregnated with whatever medicinal substance the physician thinks most appropriate. I give the essence of peppermint the preference for such purposes, for it has a soothinir^ cooling influence on the irri- tated membranes. Like all respiratory exercises, the pneumatic-cabinet treatment should be begun carefully and gradually. I usually commence with a seance of two minutes, increasing the duration from day to cay up to six or eight minutes. A.t first the seances should be given once every day. As the patient's respiratory function becomes more perfect and the disease tends toward recovery, the sittings need not be quite as frequent. Longer seances than eight min- utes are seldom indicated. About one inch of elevativjn, shown by the manometer, suffices to reduce the atmospheric pressure a little more than half a pound to the square inch. This reduction is all that is needed to produce the desired effect. My patients, with rare exception, look forward to their seance with pleasurable anticipation, especially when there is a tendency THE PNEUMATIC CABINET IN PULMONARY TUBERCULOSIS. 225 to dyspnoea. I have entered the cabinet myself, my assistant working the lever, in order to experience the sensation so vividly described by some of my patients. I cannot say that at first the feeling of being inclosed in such a small space, with only a tube to breathe through, is a pleasant one. The first movements of the pump produce an almost painful sensation in the ears, but, by and by, with the exhaustion of the air, and by swallowing a few times, this ceases and there comes a feeling of freedom. The respiratory muscles seem to expand to a much greater degree; the fresh, cool air, entering through the nose, arrives in the lungs sufficiently warmed not to be harmful, penetrating habitually unused portions of lun'^-substativ-es. There comes, and remains for hours afterward, a feeling of exhilaration analogous to that experienced on mountain-tops. On the actici of the cabinet on the various pathological conditions in pulmonary tuberculosis, I have cited the experiences of Piatt and Quimby ; as stated above, I may repeat that they coincide in nearly every respect with mine, and I can recommend the j'ldicious use of this method of aiirotherapy most earnestly. I thmk that the few modifications which I liave instituted in connection with the employment of the cabinet will tend to increase its usefulness. 11 M ''1 ft '^:',r ' i1^ St ■•»i ;h i n i ' f ^ i i If Exercise during llie application of cold walcr. CHAPTER XIV. HYUROTHERAPEUTICS IN THE GENERAL TREATMENT OF PULMONARY TUBERCULOSIS. After aci'otherapy, hydrotherapy conies next in importance in t^'" treatment of pulmonary tuberculosis. Of the tonic effects of cold water, and its stimulation of the general system, we have already spoken in the chapter on Preventive Treatment. The general education of the cutaneous and nervous systems of a patient whose uody i^as not been accustomed to the extensive application of cold water is especially imperative in the case of a consumptive. How this should be done has been described in detail on page 87. Presuming, then, that the patient has gone througl: the usual preparatory course of dry friction, friction with alcohol, with water, etc., we come to the douche. So as not to produce too great a shock, I begin by directing a gentle stream toward the feet, then rapidly upward as far as the hips ; then I apply the spray uniformly all over the body, and direct also a small jet with a little more force over the apices. Apparatus for this kind of douche can easily be constructed in a .•5ar. Bell. G. GaiiKe. '/'. Tlierinoniotcr. A'. Rain doiiclic. Cr. Cir- cular douche. Cy. Cold jet douche. ///. Hi)l-iet douche. //. Hot water for Scotch douche. C. Cold w!>tcr for Scotch -lialh. 67. Steam douche. hi'.iiself, in his excellent book on the " Principles and Practice of Hydrotherapy " ' : "A waiting-room and a number of dressina-rooms havinfr been iiarueh's ° t> b douclie- provided, a room containing two or more cots for packs is set aside, '"om and ' ° ' . apparatus. and another for massage. A space twelve feet or more square is utilized for a douche-room. This should be constructed with marble walls and be supplieil with ample light and heat. Above ^f ro- ' I'liblisliod l>v Win. Wood vS; Co., Ni'W \'oili. 228 PULMONARY TUBERCULOSIS. i a water-proof floor, which slants suflficiently to carry water into a pipe leading to the sewer, a level, slatted floor should be laid in sections, to facilitate remo\ 'i^'* cleansing, in such a manner that all the water used upon the f ''^ may readily flow through the interstices between the slats u^ . the water-proof floor beneath. Upon the upper extremity of this floor a circular douche may be secured. Adjoining this a large bath-tub and sitzbath-tub may be placed, the latter having sufficient space to admit an attendant behind it. The douche-table should be so constructed that its supply of hot, cold, and ice water is sufficient for all requirements. " The douche-table is a box four feet long, three feet high, and two feet wide, covered with marble. Inclosed within the box is a combination of pipes connected with the hot and cold water-supplies and steam-supply on the one hand, and with the hose and other ter- minal arrangements on the other. The hot and cold water-supplies are controlled by stop-cocks by the usual contrivance, the terminal rods and levers of which issue through openings in the upper flat portion or slab of the douche-table, as may be seen in the dia- gram. The attendant, standing behind the table, is protected against receiving the water recoiling from the patient, and is per- fectly free to regulate the outflow according to the prescription ordered in each case. An outflow pipe, controlled by the stop- cocks, Pa.nd R, regulates the pressure of the water, which is plainly indicated upon the gauge. This enables the attendant to arrange any pressure required, either before the douche is administered or while it is flowing upon the body, the range being from ten to thirty-five pounds. A thermometer, T, is so arranged that its bulb, encased in an open-work metal tube, lies within the mixer, whose outlet pip* leads to the hose; and its upper portion, cased in metal also, shows through a magnifying glass-tube cover the temperature of the water flowing upon the patient. A ' second ' clock, C, furnishes information regarding duration, while the clasp, CI, holds the prescription out of reach of the spray. The apparatus is put into operation as follows : " The attendant places the prescription in the clasp after care- fully scanning it, and opens the stop-cocks which close the nozzle. He now opens the hot- and cold-water faucets, and, watching the thermometer, obtains the temperature required while the water is flowing. This may be done with the greatest ease after some practice. He now opens tlie pressure regulator until the gauge mm HYDROTHERAPEUTICS IN PULMONARY TUBERCCtOSIS. 229 I '^ CO ^\_ _i A 1 tm ^ s t. « (0 "B ^ C >• 8 t 1 3 a •f » ( if ■1 "5*" ,a u 1 \ f ii 1 1 ! i 1 230 PULMONARY TUBERCULOSIS. registers the pressure prescribed. The attendant having examined the thermometer again, and holding the faucet-handle in the left hand, while the right holds to one side the hose from which the stream of water is issuing, requests the patient to place himself six feet in front of the douche-table. Again looking at the thermom- eter to insure the exact temperature prescribed, he now directs the stream upon the patient's back ; other parts are treated successively as ordered by the physician. If a circular douche is ordered, the water is also turned on before the patient enters it. This is impor- tant, not only because shock is thus prevented, but timidity of the patient is overcome. " The circular douche used here differs, as the diagram shows, from the usual needle-bath, in not being supplied with semicircular, perforated pipes. I found the effect greatly enhanced and much trouble from stoppage avoided by the substitution of eight roses, three inches in diameter. Each rose contains fifty fine openings in the plate, which, being screwed on to the connecting-tube, may thus be easily freed from accumulating sand and dirt. Moreover, the three upper roses are, by a device of Mr. Frank Richter, made movable. By simply turning these roses downward, an adult of any height may be treated without having the face sprinkled or the ears filled with water. " The douche-table contains pipes the outlets of which are con- trolled by lever faucets, which also open and close the perinaeal douche, the hip-bath, and the full bath. The temperature of these may thus be controlled by the attendant by simply watching the thermometer of the douche-table. "There should also be a steam douche, supplied with low-pres- sure steam from tlic; engine-room, which may be made to issue from the hose by opening the faucet St. " The douche-room is twelve feet long and eight feet wide, its walls being covered with marble eight feet high. The floor of this compartment is slanting and covered with copper ; the edges of the latter are secured by being turned up two inches behind the lower edge of the marble wall. Beams cut slanting on the lower side to fit the water-tight floor, and straigiit on the upper side, are laid horizontally, so as to support a slatted floor, through which all the water flows upon the copper beneath and thence to the sewer. "The water-supply comes from a reservoir (under the roof), to which it is pumped by a stean engine. The hot water is furnished I HYDROTHERAPEUTICS IN PULMONARY TUBERCULOSIS. >3I from a drum which is heated by steam coils. Both cold and hot water flow through appropriate pipes to the douche-table, and ice- water, which is required in summer, is furnished by a cooling apparatus construct'.-d as follows : In the basement is situated a box, seven by five feet and four feet high, which has double walls four inches apart. A manhole, 2^^ feet square on top, admits of ice being thrown in. The box is lined with copper, so as to be water-tight. At the bottom two boards, two inches thick and one foot deep, are placed from one side to the other. These have three semicircular notches, fitting three galvanized-iron cylinders, for which they form a support. " The cylinders contain thirty gallons each and are connected with each other by inch pipes. The first cylinder receives the water-supply from a two-inch main. The water entering this cyl- inder passes to the second, thence at the opposite end to the third, from which it issues into an inch pipe leading to the douche-table in the room above. " Six inches above the level of the cylinders an inch opening exists, which is connected with the sewer. A separate pipe, sup- plied with a stop-cock, should also lead from the main directly into the box, for the purpose of filling the latter with water as high as the outlet above the level of the cylinders. " The box is elevated about one foot from the floor, and an out- flow pipe with stop-cock should be securely connected with the latter and lead to the sewer, for the purpose of emptying the box when necessary. The apparatus is prepared as follows: The stop- cock of the pipe A, leading from the main, is opened for the pur- pose of filling the cylinders; the stop-cock C at the bottom of the box being closed, the stop-cock B is opened and water is allowed to flow into the copper-lined box until the cylinders are covered with water six inches deep. Now half a ton of ice is put upon the cylinders. It will be observed that the lower portion of the ice-supply lies in six inches of water, which covers the cylin- ders. Thus the latter are not only covered by ice, but surrounded by ice-water. As the ice melts, the overflow of water issues through the opening A' to the stop-cock I), which is always left open. " The necessity for this ice-water supply will be evident when it is borne in mind that in midsummer, when the temperature of the water may range from 70° to 80° F., a prescription for a 1 ,:. n 232 PULMONAKY TUBERCULOSIS. I Improvised douche- arrange- ment. Time, tem- perature and dura- tion o( douclie. douche of 50° to 60° F. could not be filled without such a supply. It is necessary only to open the ordinary cold-water sup- ply-cock, as is needed, to reduce the former to the temperature prescribed." In cases where the visit to the douche-rcom is either incon- venient or not safe, I resort to the following simple method : A wooden chair is placed in a large, circular, English bath-tub, and the patient sits astride the chair, holding the back with his hands and bending his head slightly forward. Then two, four, or more pitchers of cold or tempered water are rapidly poured over the shoulders. In cases where the reaction is feeble the patient is quickly put back into his warm bed, even if not thoroughly dry. The best time to take the hydrotherapeutic application is in the morning, half an hour or so after a very light breakfast. Patients accustomed to heavy breakfasts should take such after their douche and morning walk, but should take a glass of milk with a slice of buttered toast before leaving their room. A morning walk should, if possible, always precede the douche. This is for the purpose of creating what French hydrotherapeutists call a preaction. Every douche or affusion should also be followed by a short walk or a return to bed, according to the indication of the case. The cold douche should never last longer than twenty to twenty- five seconds, and one should always begin gradually, not giving more than five seconds at first. The temperature may vary from 60° to 40° F. Only in exceptional cases would one need a more precise'graduation of the temperature. The complicated procedure of the dripping sheet seems to entail too great a strain on the patient, and I do not favor it in phthisio-therapeutics. Wet-packs, on the contrary, over the thorax, seem to exert a soothing influence whenever there are pleuritic or intercostal pains, or that vague and undetermined feeling of discomfort in the chest. Lateral douches, not too strong, directed toward the seat of old pleuritic adhesions, often aid considerably in the resorption of the fibrinous bands and a consequent free chest-expansion. In patients above fifty, it must be remembered that the usual reaction after a cold douche is slow to come, and in such cases it is best not to use the water too cold. A chilly sensation, con- tinuing even after thorough drying and friction, should in all HYDROTHERAPEUTICS IN PULMONARY TUBERCULOSIS. 233 cases be a warning and a guide regarding temperature and duration of the douche. There are idiosyncrasies which must also be con- sidered with some patients in regard to the application of a cold douche. Of the other uses of cold water in pulmonary tuberculosis we will speak under symptomatic treatment. m IIP § \T-!t e.l •M ! /--rsssetftts- CHAP'IKR XV. PERSONAL HYGIENE AND DRESS OF THE TUBERCULOUS PATIENT. The care of the skin is an essential part in phthisio-therapy. As a rule, a tuberculous patient should take his hygienic baths regu- larly once or twice a week. It should be of short duration, not too warm, and followed by a rapid sponging off with cold water. The best time to take the hygienic bath is in the evening, before retiring. A pulmonary invalid should never take his bath without there being some one within call, in case he requires any assistance. When the skin is especially dry, nothing will be better than an occasional massage with vaseline or some other oily, not irritating substance. Whether a consumptive uses a pocket-flask, squares of muslin, or a paper spittoon for the purpose of expectorating therein, it is well to repeat here that he should be enjoined to wash his hands always most thoroughly before touching food. Of the harmful effects of swallowing the expectoration, we have already spoken when treating of infection by ingestion (chap. iv). General Consumptives should dress sensibly, comfortably, and according ceniltig" to the season. They should avoid heaping successive layers of both sexes, clothing upon themselves, especially in the line of so-called chest- protectors. These latter, or the numerous woolen undershirts, often worn by the pulmonary invalid, have been :ii many cases the very cause of contracting repeated colds by having rendered the individual too sensitive. Consumptives should have warm outer garments for winter, but not so heavy as to hamper their move- ments. For under-garments, Jiiger's or similar sanitary wocl suits, the lighter or heavier grade, according to the season or the climate, are to be recommended. The shrinking of these garments can be prevented by well-prepared soapsuds and the use of proper stretchers during drying. To overcome the unpleasant pressure caused by the suspenders, to which the consumptive is more sensi- tive than others, this article of dress might be replaced by a sort 234 PERSONAL IIYGIENK AND DHKSS. 235 : of vest, of light, elastic material, to which the trousers are attached, thus distributing the pressure over a larger surface. Instead of four or six there are eight to ten attachments (see illustration). Whenever and wherever conventionalism does not reign supreme, the starched linen should be replaced by the light, woolen, negligee shirt. It permits better ventilation and freer respiratory move- ments. Men with a good head of hair need not fear to go Hcadwear uncovered at tirnes, but all, even those with thin hair or bald'"'^""" heads, should not wear too heavy hats or caps, and should always have them well ventilated. In the chapter on Infection by Ingestion, we stated already that to wear no beard and no mustache would be the most hygienic practice on the part of the consumptive; but since it is very hard to enforce rules, the carrying out of which would change the appearance of a person often to a con- siderable degree, it is best to simply advise the tuberculous invalid to keep his beard and mustache as short as possible, and to wash the same with warm water regularly a few times dur- ing the day. As a matter of personal hygiene for pulmonary invalids, I should again suggest not to make use of tobacco in any form whatever. For the women I would recommend the Lady Habberton or Jenness Miller system of dress reform. Je",""s ^ ■' -^ _ Miller It may not be amiss to give a short description of the system -Ys'_,*='"°f here, for, while it may enjoy a certain popularity among sani-^°"'"'- tarians, I cannot say that the majority of ladies seem to be very familiar with this reform. " Dame Fashion " has, no doubt, a great deal to do with the seemingly total ignorance of this most healthful mode of dress among otherwise well-informed ladies. According to the fundamental rules for dress reform as advocated by Lady Habberton, Mrs. Miller, and others, the garments are arrangeil so that they follow the symmetrical lines of the female form, and in all possible cases are made of one piece. Each limb is properly clothed in its turn. Legs, arms, and neck are comfortably and closely protected, while the body is wrapped a little tighter. The under-garment is made all in one piece, and with no bands KiG. 74.— XliST-SLSPENDHRS. ^1 '■ IT* li],) , V ' I 'I'l' r '1;: Footwear. 236 PULMONARY TUBERCULOSIS. around the waist. If a corset must be worn it should be corded or stifiened with a few whalebones and never tightly laced, which, with the weij^ht of the heavy .skirts fastened tightly around the waist in the usual manner, renders all abdominal breathing im- possible. As has been already stated in our chapter on prophy- lactic treatment, abdominal breathing is as natural to women as it is to men and animals. Next to this under-garment, or union suit, a so-called " chenii- lette " is worn, made on the same principle as the , nder-garment, but of looser and lighter material. The third in order is the so- called " leglette," a divided skirt and waist attached, which gives the wearer great comfort and freedom of motion. It can be made of almost any material. And now as to the outside dresses : They are made as nearly as possible in the styles in vogue, but never with trains, and in them all are preserved the physiological feat- ures of the female form. In the complete toilet all garments are so arranged that their whole weight is supported by the shoulders, and no pressure whatever brought to bear upon any of the vital organs in either thoracic or abdominal cavity. I have frequently seen ladies dressed according to this sensible mode, and I can assure the doubting reader that they looked to me and to others more becomingly dressed and more graceful than those arrayed in the very latest fashion, whose waists have been reduced by tight-lacing, changing their appearance, perhaps, from the figure of a Venus to something resembling two cones placed with their summits in apposition. Phthisical patients should keep their feet warm and dry, and should never wear tight shoes. Rubber shoes when it is wet, fur- lined ones when it is cold, and hot-water bags or bottles at their feet when lying on their chairs in winter, should be recommended to attain this end. i ; I !i I il ("IIAPTKR XVI. DIHTHTIC TREATMHNT OF PULMONARY TUBERCULOSIS. To nourish the patient, to feed liini well with ,-;oo(J food, or rather overfeed him so that he assimilates more than he expends, forms an important part of the treatment of phtl'lsis. The patient should have an abundance of proteids, carbohydrates, and fats, but in proper proportion ; thus the menu for a tuberculous invalid should be much varied. He should never have a diet exclu- sively of meat, nor of vegetables ; a mixed diet, with some eclecti- cism as to the more digestible substances, should be the rule. Meat, milk, fats, eggs, vegetables, bread (cereals), fruits, especially grapes, should all contribute to the diet of the patient. Consumptives, as a rule, have small appetites, and it requires sometimes no little art to make them eat. The one important truth that they should be made to understand is that their digestive powers are far greater than their appetite indicates. Leaving ex- ceptional cases aside, such as absolute anorexia, hyperacidity, or lack of gastric secretion, of which we will speak later, one usually succeeds in making the patients eat by persistent persuasion, and by offering them a variety of food arranged as appetizingly as pos- sible. The meaij given the patients in the leading European sanatoria are about as follows : In the morning — half-past seven to half-past eight o'clock — they have bread and butter and honey, with cocoa, coffee, or chocolate, and two or three glasses of milk taken slowly in small swallows. At ten o'clock they have bread and butter, cold meats, fruit, etc. At one o'clock the dinner — soup, fish, three kinds of meat, vegetables, salad, preserves, dessert, and fresh fruit, with one or two glasses of wine. At four o'clock they have a glass of milk, with bread and butter. At half-past seven there are thick soup, meat and potatoes or rice, cold meat, bread and butter, salad, and cooked fruit, with again one or two glasses of wine. At nine o'clock they take a glass of milk with two or three teaspoonfuls of cogijac. ■^17 '}■: ■ I : it-- 1' ^ ■■,•)!• i eS >k! 4m n i 238 PULMONARY TUBERCULOSIS. if Average regime. To eat a great deal of butter and cream is especially to be recommended to pulmonary invalids, and milk should be allowed at any time without restriction. However, some patients, in their eagerness to get fat, overdo in this respect. When crinking numerous glasses of milk between meals interferes with the proper appetite at meal-times, the number of glasses should be reduced accordingly. Again, neither milk nor cream agree well with some consumptives. To make the latter more digestible, one may add to each wineglassful one-half or one teaspoonful of cognac, kirsch, or rum, with or without hot water. Milk may be tendered more digestible by adding to each tumblerful about six grains of bicar- bonate of soda and five grains of common salt, dissolved in two tablespoonfuls of hot water. The pulmonary invalid must be treated and fed in accordance with what he was accustomed to before being taken sick, for meal- times and number of meals differ among most nationalities. For average cases I would suggest the following regimen, to be adhered to as nearly as possible during the cour.se of the disease : As soon as the patient awakes in the morning, while yet in bed, a glass of hot milk, half milk and tea, or half coffee and milk, with a slice of milk-toast, should be given him. After a little while he will rise to prepare for his douche, friction, or massage, whatever the physician's prescription may call for. After this it will probably be nine o'clock, and the patient may take his ordinary breakfast. He should have egg", :nd may have his choice as to the way they may be prepared or .served — soft-boiled, poached, raw, etc., or in form of egg-nog, with sherry or whiskey. If he is accustomed to a meat breakfast, he should have broiled steak, chops, poultry, sweet- bread, etc., or raw chopped beef. Bread a day old, — preferably whole-wheat bread or French rolls, but not hot, — with plenty of butter or honey, either milk, cocoa, coffee with milk, but not too strong, or a cup of bouillon, should also form part )f the meal. Whether the patient likes to have his mush (cereals) for breakfast or supper, may be left to his choice ; some fruit should always precede his eggs or meat in the morning. If fish is served in the morning it should be either broiled, boiled, or baked. The patient should take the heartiest meal between the hours of twelve and two o'clock (four hours after his breakfast). liroths or soups should be the first course. Oysters and clams are most easily digested raw. Any kind of fresh fish may be served again at I I i DIETETIC TREATMENT OF PULMONARY TUBERCULOSIS. !39 of or ost at dinner, and in any form except fried ; and there will be, of course, roast meat of some kind, rare roast beef, mutton, poultry, etc. Of vegetables, spinach is particularly to be recommended on account of the large proportion of digestible and assimilable iron. Next to this in nutritive power come lentils, peas, beans, cauliflower, potatoes. Fresh vegetables should be given whenever it is possi- ble to have them. Lettuce and other salads, preferably prepared with lemon-juice instead of with vinegar, are permitted. Light puddings, fruits, and nuts may constitute the dessert. At about four or five o'clock some milk with toast may be taken, or, if the patient cares for it, he should have a cheese or meat sand- wich. At this time the milk may be replaced by bouillon or chocolate. The supper should not be quite as voluminous as the dinner. Cold or warm meats, rice with milk or gruel, with jellies, fruits, etc. At bed-time again a glass of milk or some milk-toast. It is, of course, impossible to lay down an absolute rule of what to allow and what not to allow. One must consider the patient's likes and dislikes; there are idiosyncrasies for certain dishes as well as for certain medicines. I have learned to allow my patients occasionally such things as ham, smoked tongue, and even pickled or salt herring, sardines, and sardelles, and I have not yet found any occasion to regret this practice, for they seem at times to stimulate the appetite. The kitchen should be the phthisio-therapeutist's pharmacy. In a sanatorium the menu should be submitted to the medical director previous to its preparation. I will give a few receipts for particu- larly useful dishes which I have seen served, or eaten myself, dur- ing my voycTigL' d' etude in sanatoria, and have since tried with my private patients with most satisfactory results. First, I desire to describe an excellent method of preparing the raw beef, or the so- called raw Hamburg steak, for which receipt I am indebted to my distinguished teacher. Professor Grancher, of Paris : With a knife, not too sharp, scrape the surface of the meatprciM (rump-steak). Put the fine scrapings thus obtained in a stone or beef.'' glass mortar and grind them. Then spread the mass on a sieve and press it gently with a spoon. What passes through is a meat- pulp without fibres or gristle, perfectly digestible and very nutri- tive. (I have found, however, that for all ordinary cases the scraped meat suffices without being ground.) '- W m riiiK law -■'^m "If h ll MucilaRii: oils soup. Beef essence. 240 PULMONARY TUBERCULOSIS. The supply of meat-pulp for the day may be made in the morn- ing, but it must be kept in a cold place, as it taints easily. It is better, when possible, however, to make it fresh just before it is to be eaten. The patient may take the pulp in any way he pleases. It can be eaten plain with pepper and salt, mixed with milk, with warm bouillon, with mashed vegetables, or with sweets. The latter method will make it tempting for children. It can be rolled into balls easy to swallow, or made into sandwiches with a few anchovies or a little anchovy-paste, pickled herring, or some other relish, according to the patient's taste. The yolk of a raw egg added increases the nutritive quality of the meat-pulp. Thus it will be seen that the ways in which the raw meat may be taken are so numerous that it can be made palatable to almost any patient. To make a good mucilaginous soup, take five pounds of veal- bones and ten quarts of water or weak bouillon. Bring it to a boil and then skim. Add two pounds of barley and a little salt, cook slowly for five or six hours, and then strain off the liquid. A cup- ful should be taken mixed with the yolk of an egg. If the soup is too thick, dilute it with a little bouillon. To prepare a good milk-jelly, boil two quarts of milk with a half pound of sugar for five or ten minutes. When the milk is cold add one ounce of gelatine dissolved in a cup of water, the juice of three or four lemons, and three glasses of good Bordeaux wine. It is often very convenient to have a bottle of beef-essence on hand. The following is an easy method to prepare it : Put two pounds of round-steak, cut in small pieces, into ajar without water. Place the jar, covered closely, on a trivet in a kettle of cold water. Heat gradually, and keep it not quite at the boiling-point for two hours, or till the meat is white. Strain, pressing the meat to obtain all the juice ; season with salt. Or place the jar in a mod- erate oven for three hours. The liquid thus obtained contains all the nutritive parts of the meat. It may be kept in the refrigerator, and a small portion heated (not boiled) as wanted. Or it may be made into beef-tea by diluting with boiling water. The essence can also be given ice cold to febrile patients. All bouillons and soups taken regularly at the principal meal stimulate the appetite and aid the digestion by stimulating the gastric secretions. A patient who has fever should eat when his temperature is lowest, and only the most easily digested substances. All pul- DIETETIC TREATMENT OF PULMONARY TUBERCULOSIS. 24 1 monary invalids should be taught to take their meals at regular intervals, eat slowly, and chew their food well. Everything should be resorted to to make the patients eat, for in this lies the secret of the success of the treatment. The patient should be weighed and carefully examined every month or two weeks, according to his condition, and thus the progress of the cure can be controlled. The good condition of the teeth i:;, of course, essential, and a well-Carcof conducted sanatorium should not be without its dental chair, and should receive the regular visits of an experienced dentist. The physician should teach his consumptives that it will in- crease their appetites to brush their teeth and rinse their mouths after each meal. This is seemingly a trifle, but I have found that it has helped me much in my dealings with the bad eaters among my patients. Of all preparations I give the following tioth-wash the preference : K . Essence of peppermint, . Vl\^x Oil of wintergieen, rt\_ xv Thymol yr. xv Benzoic .acid, 3 'U Tr. of eucalyptus, s ij Alcohol, ^5 XV. M. SlG. — One-half teaspoonful to be diluted in a tumblerful of water. This leaves a pleasant freshness in the mouth. Opinions in regard to giving alcohol to consumptives differ very aicoI.oi largely, and it is extremely difficult to lay down any rule on this subject. My own experience has taught me that it is indispen- sable in some cases, but it should be given preferably in the diluted form of wine or beer, or good cognac in small quantities mixed with milk. It should rarely be given as an antipyretic remedy. When prescribed in the form of cognac or whiskey, it should be dealt out carefully like powerful and dangerous medicine. This is another advantage of treating the patients in a sanato- rium where they are seen several times a day. The effect of the alco- ■ hoi or any other medicine can be watched. The physician of a sana- torium, seeing his patient almost constantly, will soon be able to judge whether the improvement the patient may confess to feel after taking the alcohol is physiological or pathological (intoxication). Of the many food-substances which have been recommended Tropon. recently as especially valuable in the dietetic treatment of tuber- culosis, I have used most extensively and with most satisfactory results the new product, tropon. 16 i: I I ,ftH( I M ^ 24: PULMONARY TUBERCULOSIS. \¥i '.■-- Ill At the Ninth International Congress for Hygiene and Demog- raphy, held in Madrid in April, 1898, Professor Finkler, of Bonn, made his first communication ontropon, under the title of albumen nutriment.' Tropon is a tasteless and odorless, albuminous preparation in the form of a yellowish-brown powder, obtained through a com- plicated chemical process from animal and vegetable substances. Among animals, fish, and among vegetables, the lupines, which or- dinarily are not suitable for the preparation of food for men, have been largely used. Tropon is supposed to represent over ninety per cent, of pure albumen. The clinical experiments made by Pro- fessor Finkler and his pupils with this substance as an adjuvant to food were surprising. The most interesting feature was that tropon was excellently well borne by patients suffering from an impaired digestion. Tropon seems to be particularly valuable on account of its small bulk and its substituting completely the albumen in other foods. That such a substance should be of value in the treatment of consumptives seemed evident. Through the cour- tesy of Professor Finkler I received a quantum of tropon several months ago, with which I began my experiments in feeding tuber- culous patients. The results were so encouraging that I wrote for an additional supply. I selected patients with whom I had had un- usual difficulty in increasing their weight, with some among them on account of their aversion to fats. To sinnmarize the results obtained, I may say that with from one to two ounces per day the average gain in twenty days was about one pound and a half, in- cluding one case with negative results. I must, however, add that these patients were mostly ambulant. In Weicker's sanaUnium in Goerbersdorf, where patients in all stages of the disease are ad- mitted, from out of eighteen cases fifteen responded to the treatment, gaining in the average 2^ pounds in four weeks. The 1 lativcly better results obtained in the sanatorium must be ascribed to a better supervision and a more regular administration of ti ■ tropon than is possible with ambulant patients. Tropon has smce been extensively used with satisfactory results in the clinics of von Ley- den and Senator in Berlin; Schmelinsky and Klein in Hamburg. It can be administered with mush, thick soup, cocoa, chocolate. ' " Kiweissnahning und N'ahrungseiweiss," " Deutsche med. Wocliensclirift," i8().S, No. 17. DIETETIC TREATMENT OF PULMONARY TUBERCULOSIS. ^43 milk, mashed potatoes, rice, sago, tapioca, etc. It must be borne in mind that tropon is not soluble in water, and consequent!}' falls to the bottom in clear liquids, coffee, and thin soups, and when taken with such it must be constantly stirred. It can be ad- vantageously taken with the yolk of an egg and some sugar. For those of my ambulant patients who have not the conveniences of home life, I prescribe the tropon to be taken by the aid of a wafer (a teaspoonful at a time). Considering that tropon is really an able substitute for the albu- men in other foods, that it rarely causes digestive disturbances, that it can be taken for a long period of time without aversion, and that it is excessively cheap, we may look upon this new product as a most valuable adjuvant in the dietetic treatment of phthisical patients. Ik- J 1 . I. .*- • ■*. J. K ^ff»'^ i CHAPTKR XVII. SYMPTOMATIC TREATMENT OF CULOSIS. PULMONARY TUBER- Malmitri- tioii mill anorexia. The hygienic and dietetic treatment in the closed establishment, combined with careful aiiro- ard hydro-therapy, has been described in the preceding pages. This treatment is applicable to the average case of pulmonary tuberculosis, but there are cases in which this alone will not suffice. There are patients who present a disease with one or several symptoms more pronounced, and which will not yield to the hygienic and dietetic measures alone, or to the routine aero- or hydro-therapeutic treatment ; for these we must- institute a judicious symptomatic treatment. A very much impaired nutrition, with a lack of assimilative power, should not be treated by forced alimentation, but by rest, at first in bed and later on the veranda ; regular massage ; frequent administration of small quantities of food, consisting of very easily digested substances, such as scraped or finely chopped raw beef, toast (fresh bread should never be given when there is any digestive trouble), milk pure or with egg in the form of egg-nog (two-thirds of a glass of milk, the yolks of one or two fresh eggs, one or two teaspoonfuls of good cognac or »\'hiskey, and enough sugar to suit the taste), bouillons, soups, etc. The yolks of fresh eggs I recommend to all weak consumptives. Taken raw, beaten with a little sugar or .salt, several times a day, they seem to act by their nuclein as valuable material in the reproduction of new tissue-cells. The yolks of fresh eggs will often be retained when the stomach apparently tolerates nothing else. At times the anorexia consists of a simple aversion to warm meat ; in such cases no "rging will help, and the best thing to do is to replace warm dishes by cold meats appetizingly served. Some patients may be able to take a meal in the open air when, seemingly, they cannot do so in the dining-room. Though this form of anorexia is evidently of purely psychic origin, it is well to be indulgent in this respect, for nothing should be left undone to 244 SYMPTOMATIC TREATMENT OF PULMONAKV TUBERCULOSIS. 245 make the pulmonary invalid eat. As has been said already, the salvation of the patient lies in good nutrition. Where there is anorexia, the cause of which cannot be determined, it will be necessary to change the menu often. Have the patient eat little at the time until he and his physician have discovered something which may serve as a stand-by in the dietetic treatment of the disease. To build up the system cod-liver oil may be given when- j,,,^, ,|^,g^ ever the stomach can support it. A good method for its adminis-"''- tration is that of Ericemoret, which is to mix it as follows : B . Cod-liver oil, 12 fluidounces Syrup of tolu, 6 fluidounces Tincture of tolu, 12 drops Oil of cloves, 2 drops. At the moment of administration the mixture is to be well shaken, and a tablespoonful taken two or three times daily. Taken thus, the taste of the aromatic syrup only remains after the ingestion of the oil. In younger subjects and children, cod-liver oil seems to have a particularly gratifying action. The various malt preparations, as maltzyme, malt-extract, and maltine, may be given with benefit in either the pure state or com- bined with cod-liver oil or hypophosphites. Next in efficacy come the arsenical preparations, the strychnias, the irons (ferratine is especially well borne by phthisical invalids), and the phosphates. Iodoform has given much satisfaction in the hands of many phthisio-therapeutists such as Flick, ^ Daremberg,'^ Ransom, ^ de Renzi."* It has been recommended for nearly all degrees of phthisis, and given as inhalation in the form of one part of iodo- form to ten parts of ether (twenty minims of the mixture for each inhalation with respirator-inj-aler). It is administered as p lis, according to the following formula: li. Iodoform, gr. iss loHnfoim. Codeix, gr- ') Ext. cascane, gr. J4. M. et ft. pil. j. ' Flick, " A Further Report 011 the Treatment of Tuberculosis by Iodoform Inunc- tions," " The Medical News," March 2, 1S92. - Daremberg, " Traitement de la Phtisie I'ulmonaire," Paris, 1S93. ' Ransom, "The Treatment of Phthisis," London, 1896. * De Renzi, Naples, " The Lancet," December, 1897. 1M' !■;•;' n I r.M m h-\ b i ■'. , 1 if^t jji m ^ f»^ k M'^' i Si.' f. ^' 'li : 246 PULMONARY TUBERCULOSIS. ^i i Creosote, Kuniacol, etc. Flick gives iodoform as an inunction. De Renzi's method of its administration is especially recommendable. If the patient is suffering from diarrhoea he gives the following prescription : R . Iodoform, gr. xxx Tannin, ... gf- '"• M. and divide into forty cachets. From two to four cachets daily. If there is a tendency toward constipation, Professor de Renzi replaces the tannin by naphthalin. The various modern preparations of creosote and guaiacol seem in most cases, when given in small doses, to exert a favorable in- fluence on the general condition of the patient. I prefer to give the creosote in milk, beginning with two or three drops thrice daily, gradually ini, ~''".g to about twenty- five drops per day. The moment there is the slightest digestive disturbance I stop the creosote ; and if I then find that the patient does as well without as with it, I do not recommence its administration again. In order to protect the consumptive invalid as far as possible from his greatest foe, dyspepsia, I follow this rule with all medicinal reme- dies, new or old. The creosotal (creosote-carbonate) is seemingly more easily borne than the creosote It has been strongly recommended by von Leyden, of Berliii, and at the last Congress for the Study of Tuberculosis in Paris Dr. S.de Planzoles submitted a very favorable report on its use in nearly all stages of pulmonary tuberculosis. The creosotal contains ninety per cent, of its weight of pure creosote. It can be taken pure or as an emulsion with the yolk of an egg, with milk, or with cod-liver oil. For an adult fifty to sixty minims may be given two or three times daily ; this should, however, be considered a maximum dose. It is best in all cases to begin with small doses, as, for example, five to ten drops per diem ; then gradually increase and return again to smaller doses. According to Stubbert's report,^ of 1898, ichthyol prepared as enteric pills, two grains each (three to fifteen per day), has been used with considerable success at the Liberty Sanitarium. Guaiacol has also found favor with some phthisio-therapeutists as a valuable remedy in tuberculosis. It has the advantage over * " Sanitarium Treatment of Pulmonary Tuberculosis," "St. Louis Med. Gazette," December, 1898. SYMPTOMATIC TREATMENT OF PULMONARY TUHERCULOSIS. 247 creosote that h " Prcsse Midicale," 1899, No. 13. - Drozda, " Cirundziige einer rationellen Phthisiothera) ie," XII. Intcrnationaler Congress. ■■' " Gazette hebdomadaire de niedecine el chirurgie," July 17, 1S98. !, i.f- ■ ^ is kill M 248 PULMONARY TUBERCULOSIS. given, daily, for thirty or forty days, each morning, a nutritive mixture composed thus: U • Yolks of eggs, 4 or 5 ill number Tepsin 15 grains Hot tiiill<, 12^ ounces ; the whole being well beaten up for five minutes and flavored, according to taste, with a little vanilla. Ten minutes later a slice of bread and butter, well salted to the extent of at least half a teaspoonful of kitchen-salt, is given. When the patients are very wasted, there should be administered, in addi- tion, nutrient enemata composed as follows: B . Yolks of eggs, 4 in nuinber Liquid peptone, 375 grains Chloritle of sodium, 75 grains Hot concentrated bouillon, 1 200-1500 grains. This enema, well beaten up, should be slowly introduced by means of an irrigator. Each enema should be preceded by an evacu- ating enema. The patient also takes, daily, from ninety to one hundred and eighty grains of tribasic phosphate of calcium and from thirty to sixty grains of phosphate of sodium, as in the following formula : K . Tribasic phosphate of calcium, 30 grains Phosphate of sodium, 7j^ grains; in each powder. From three to six daily. After each meal there is given, in half a glass of water, from two to four teaspoonfuls of hydro-chlorophosphate of calcium in ten per cent, solution. All the drugs enumerated should be administered first in smaller doses, increasing gradually for forty days ; toward the end of this tiine it is necessary to diminish the doses, to continue with smaller doses for six months, and to recommence later with intermissions as may be deemed necessary, guided by the tolerance of the patient. Further, there is prescribed daily, for thirty or forty days, two hundred and twenty-five grains of common salt mixed with food already salted in the ordinary culinary preparation. It is neces- sary for the patients to take, indefinitely, from ninety to one hundred and twenty grains of salt daily. SYMPTOMATIC TREATMENT OF PULMONARY TUBERCULOSIS. >49 Resides this treatment Dimitropol administers, daily, eighteen ounces of meat, a quart of mili<, three eggs prepared to the patient's taste, fish and fresh vegetables in habitual quantity. Wherever there is a great difficulty in nourishing the patient, it seems to me that this treatment is well worth trying. Of course, a patient submitted to the ingestion of such large quantities of salt should be closely watched ; for, doubtlessly, there will be individuals who cannot take half the quantity of salt prescribed without intestinal disturbances. The old idea of ingestion of the fresh blood of bullocks as an biooU anti-phthisical remedy has been recently revived by Dr. Whit-*^"^ taker.^ He, however, recommends it administered in form of enemata. To each quart of blood he adds half an ounce of bicar- bonate of sodium and sugar of milk and one grain of common salt. Two pints of a m' :ture consisting of equal parts of water and blood are thrown high up in the rectum. Dr. Whittaker has found marked increase in weight and gain in nutrition to follow the repeated use of such blood-enemata in tuberculosis. As a general tonic the following composition has given me much satisfaction : B , Tiiict. nucis vomicre, . 3 ij Tinct. cinchonas, Tinct. calumlnv, aa _^j Tinct. gentiana;, q. s. ad ^^iv. M. SlG. — One teaspoonful in a little water before each meal. i } ! A milk diet often helps to bridge over a period of anorexia ; but some people can not or will not take milk. Raw eggs stirred into substantial soups may be made to take its place. Koumiss miiu, (fermented mares' or cows' milk) is also a most valuable substitute tic. whenever there is an aversion to milk in its natural state. In absolute anorexia one must endeavor to find out the cause by an analysis of the gastric juice, and direct the medication accordingly. A good preparation for excessive acidity of the stomach is five grains each of bismuth, bicarbonate of sodium, salol, or benzo- naphthol, to be taken before meals. Not infrequently, however, this hyperacidity seems to be of a purely nervous origin, and persuasion and suggestion or electricity will prove the best remedies. In undetermined troubles, to wash out the stomach a * "Practitioner" ; "Canada Lancet," January, 1899. ij^: m ^ll I t: !5o PULMONARY TUBERCULOSIS. meat- powder. Dilatation of the stomach. DiarrhiL'a. few times often gives relief. At times, however, it may b .come necessary, in order to convince the patient of his digestive power or not to let him starve, to resort to Debove's method of tube- feeding.' His poudre aliinentairc, or meat-powder, is prepared in the following manner : Beef is taken and all the fat possible removed, and also the tendons. It is hashed rather coa:"seiy and spread on plates, to be dried in an oven at a temperature '>f 194° F. When the meat has dried hard, it is ground in a moilar at d then strained through a fine-silk sieve. The powder thus oL'^a ned is impalpable and will keep indefinitely if preserved from dampness. It represents four times the weight of fresh meat. The best vehicle for the introduction of meat-powder is bouillon, to which may be added the whites and the yolks of two eggs, previously beaten. Other digestive troubles may often be successfully treated by simple and careful dieting and the judicious administration of pepsin or pancreatine preparations. Dilatation of the stomach, for example, often yieldsrapidly tothedry dietso highly recommended by Bouchard, of Paris. Acute attacks of diarrhoea, if not due to tuberculous intestinal lesions, are best treated by first cleansing the intestinal canal and then giving the patient appropriate food, such as cocoa, toast, eggs,' rice, mucilaginous soup, and Bordeaux wine with arrowroot. If the diarrhoea is due to tuberculous intestinal lesions, the case is more difficult. Mere diet does not suffice to stop it, and even large doses of opium and bismuth have no lasting effect. Hot claret with cinnamon, also tannic or gallic acid in large doses, sometimes give more lasting relief. As a medicinal remedy for chronic diarrhcL'a in tuberculosis. Dr. de Renzi's combination of tannin and iodoform, as cited above when speaking of iodoform, should be recalled. Phthisical patients suffering from frequent diarrhoea should keep the abdomen warmly covered. They should avoid such articles of food as cabbage, salads, sweetmeats, or substances which their experience has taught them tend to increase the frequency of stools. They should adhere .strictly to the anti-diarrhcuic diet just described for acute attacks. In the severer forms of diarrhoea, absolute rest in bed must be insisted upon. It should be impressed upon the patient that his bowels must -1 ' Diibove, .M., " Kecherches sur rAlimentation arlilicielle, la Suralimentation," etc. Communication faite a la Socl6t6 med. des HOpitaux. Stance du 14 Avril, I.SSz. !«! SYMPTOMATIC TREATMENT OF PUI.MONAKV TUHERCULOSIS. 25 I move freely once every liay. Any tendency to constipation hecnnsiipa should at once report to the physician. Great effort during the act of defecation maybrin<^ about a severe h;cnioptysis or cause the development of hemorrhoids. Carlsbad salt and the California cas- cara sagrada are favorite remedies in the Euro[)ean sanatoria when prunes and other fruits are of no avail. For the more obstinate forms of constipation in fairly .strong patients the judicious adminis- tration of hydrargyrum chloridum mite — as, for example, ten grains in fractional doses of one grain every hour, with the sugar of milk- as vehicle — renders often valuable services. Not to weaken the patient unnecessarily I have him stop the calomel powders the m ment he has had a free evacuation, which in many cases is tifected by the fifth or sixth dose. I do not favor too frequent enemata : they tend to lessen the contractile power of the large intestines. At times a glycerine suppository will do the work of an evacuating enema. If the constipation takes a chronic char- acter, abdominal massage is usually resorted to with good results. The application of the wet-pack over the abdominal cavity for a few hours, followed by a gentle friction with alcohol, also rarely fails to help. Painful coughs seem best relieved by small, repeated doses ofcouKh. codeine in solution, but the dry cough, which is often the result of habit, and where there is really nothing to expectorate, should be suppressed by discipline. Dettweiler tells his patients that to cough in public without cause is scratching the throat because it tickles, and that it is as ill-mannered as scratching one's head in public when it itches. Sips of cold water, orange-juice, or milk, small pieces of ice or tablets of Iceland moss (cetraria), will help to overcome tickling sensations in the throat until the patient has fully become master of the cough. Holding the breath for a few seconds will often help also. It is really wonderful how much it is possible to accomplish in this respect by discipline. In Falken- stein I have dined for weeks with a hundred and more consump- tives in one large dining-hall, and it was a rare occurrence to hear a single cough during the dinner-hour. To relieve the not infrequent morning attacks of coughing, a glass of hot water with some lemon-juice, with but little or no sugar, or with five to ten drops of the ammoniated spirit of anise (liquor ammonii anisatus), often suffices. Occasionally, it becomes absolutely necessary to give expectorants regularly to relieve a A' I iM m H 1 J ! ?. \'i 11 ) I Mi TO L, -i t ■ iiu; i f 1 1 ' ^ l^t ir^t.J Bronclior- rlicca. 252 PULMONARY TUBERCULOSIS. distressing cough and the tenacious expectoration. Tlie following prescription has rendered me good service in most such cases : li . Codeinw, gr. vj-viij Acidi sulphurici (iiluti f^iss Glycerini, Aqua" laurocerasi aft f 5J Syr. pmni virginiana; f^ij Syr. tolutani, ... q. s. ad f^vj. M. SiG. — A teaspoonful whenever the cough becomes distressing; more than six t'^aspoonfuls should, as a rule, not be taken in twenty-four hours. At times I change this prescription for Murrell's cough-mixture, which is also very good. It is as follows : R . Co- t i :5 ■ ' i t'i !< Illl ffm ■£ 1 ¥\ .^ - V If' II t t 254 PULMONARY TUBERCULOSIS. cantharides should be employed. Whenever a strong revulsion is indicated, and the patient's fear of the hot iron can be overcome, I give ignipuncture the preference, it being the cleaner and safer " revulsive." After its application I sprinkle over the respective region some inert powder as a protective. To prevent night-sweats the patient should take a glass of cold milk with a little cognac before retiring; he should never retire hungry, and should always have some light lunch on a table near his bed, so that he may eat something if he wakes in the night feeling faint. Again, if the patient is in the habit of waking up at a certain hour in the morning bathed in perspiration, he should be waked two hours earlier and given egg-nog or another light lunch. Sometimes it will be necessary to give him a sponging off with water and vinegar, or water and lemon-juice, and the admin- istration of atropine, agaricine, etc., also may be indicated. But once, when all remedies had failed, I resorted to the following hydrotherapeutic procedure, which worked so well that I no' • "osfs'^'" prescribe it in most cases of severe hyperhidrosis, before, experi- menting much with medicinal agents : Several thicknesses of rather coarse linen, folded in the form of a shawl, or, better yet, three different cloths, — one narrow one for each apex like a broad shoulder-strap, and another wider one to wrap around the chest, — are soaked in water at a temperature of about 55° F., wrung out and then closely applied over the apices and around the thorax. A thick flannel band, somewhat wider than the com- press, is wrapped over this, and the whole is fastened in place and remains thus all night. The 1 itient usually feels no discomfort, sleeps well, and sweats but slightly, if at all. In the morning the compress is removed and the chest and shoulders are rubbed thoroughly dry. If the consumptive is relatively strong and experieii' c has demonstrated to the attending physician that an occasional sweat-bath does not exhaust the patient too much, and, on the contrary, lowers his temperature and improves his general condition, this method of combating a hyperhidrosis is perfectly justified. Through the sweat-bath the excretory action of the skin is considerably increased and a larger quantity of toxine thus more rapidly eliminated. Pulmonary hemorrhage is one of the most important symptoms to be considered in the treatment of consumption. We cannot here enter into the pathological significance of the various types SYMPTOMATIC TREATMENT OF PULMONARY TUBERCULOSIS. ^55 and degrees of hemoptysis, from almost imperceptible bloody expectoration to a profuse flow of bright-red or dark-colored blood, at times from mouth and nose at once. When called to see a patient with a considerable hemorrhage, it is not always easy to say whether it is due to a congestive or an ulcerative process, and I really do not think that the treatment can differ very much. In profuse bleeding, absolute rest is the all-important indication. The patient is not allowed to talk and should be placed in a semi- recumbent position. He should be enjoined to refrain from an attempt to hold back the flow of b'ood. Suffocation or ensuing pneumonia is to be feared when such attempts are made. All persons not needed in the room should leave, and everything should be kept as quiet as possible. The physician will have at his disposal four important remedies, — viz., morphine, ergotine, atropine, and hydrastis canadensis, — all of which he may need before being able to obtain a stoppage of the flow of blood. Starke' and Solly recommend the hypodermic injection of large doses of atropine (J^ of a grain) in all serious cases, partic- ularly in those in which ergot has proved a failure. Nitro- glycerine in one-half-drop doses of one per cent, alcoholic solution every half-hour has, in the hands of Dr. Flick, of Philadelphia, rendered excellent services as a hemostatic in hemoptysis.- In the meantime the patient is given small pieces of ice or small sips of ice-water. To give the assurance that a pulmonary hemorrhage is in itself not by any means a symptom necessarily dangerous to life, and still less excluding the possibility of a good recovery, will have the best effect on the usually much alarmed patient. Right here I wish to say that I think Wolff's ' policy, to tell all patients, even if they never had a hemorrhage, of the possibility of this occurrence, will have, as far as mental agitation and excite- ment are concerned, a most prophylactic effect. Especially will this be so when the warning is accompanied by the assurance that pulmonary hemorrhages are one of the phases rarely absent in the development of the disease, and are symptoms which, while needing careful attention, are not more dangerous than many Hemop- tysis. SugKestive Ireatment of pulino- naiy lieiu- onliaHe. i^\ ' Starke, " Phthisis," " Dietetic and Ilygienir Ga/ette," March, 1899. 2 " Philadelphia Med. Journal," Ftb. 19, 1898. "• Woltr, " Die modenie Behandlung der I,ungensehwindsucht," Wicsi.aden, 1894. 1 1 ll ? 256 PULMONARY TUBERCULOSIS. % I Ul [lit , 1? rli 1 ' || 1 if/ I 'M i ll m: 1 t Lij;atioii of litiibs. others. After the injection of morphine or ergotine or atropine or the administration of hydrastis canadensis, bags of morseled ice may be placed over the pv-^-toral region of the apices. But since ice may not always be had when it is most urgently needed, and the weight ot the bag becomes sometimes oppressive to the patient, the following method of applying cold water when in presence of hemorrhage of the lung is, I think, well worth remembering. It was, I believe, first instituted by Winternitz. One procures the water as cold as possible and soaks in it a part of a sheet or a piece of rather coarse linen. When rung out so that it does not drip, the cloth is folded in the shap" of a triangle, placed clo.sely over the patient's chest, and is pressed into the supraclavicular spaces. The apex of the triangle reaches over the pit of the stomach and the base touches the neck. Whenever the compress becomes warm it can be rapidly changed without disturbing the patient's position. The cooler and more frequent the application, the more rapid is the action of the vaso-constrictors. When the shock from the hemorrhage has been very severe a hypodermic injection of ether, digitaline, or caffeine is well indicated. I should also suggest in cases of severe shock, as a result of a pro- fused hemoptysis, Kemp's new method ' of recto-irrigation with hot salt solutions (one teaspoonful of chloride of sodium to a quart of water at a temperature of 100° to 120° F.) by the aid of his double catheter. The warmth thus conveyed to the body, and, in audition, the absorption of the saline solution, will help to bring about a favorable reaction. The irrigation can be kept up for an hour or more without the patient being inconvenienced. Brannan- recommends aconite as a direct cardiac sedative. According to the experiments of Andrew^ it produces a fall in the pressure in the pulmonary artery. Of the physical means to control pulmonary hemorrhages I desire yet to mention the sometimes very useful ligation of lower and upper limbs to prevent, in a measure, the blood from returning to the lungs. During my visits to the European sanatoria I saw some very elaborate and expensive instruments djvised for that ' Kemp, " Intestin-.'i Hydrotherapy," " Tr-insiut. of N. V. Academy raniian, J. \V. "The 'I'leiUii.tiit of rulinoiiaiy llcmorrliage," " X. \'. Med. Journal," vdI. i , p. 21IS. ' Andrew, llarvciati lectures; " Hritisli Med. JDurnal,'' 1890, vdI. 11, p. 942. t SYMPTOMATIC TREATMENT OF PULMONARY TUBERCULOSIS. 257 purpose (Assalinische Schriallen), but any flannel band, mufHer. or large handkerchief will answer the purpose just as well. These lijrations of arms or legs are made as near the trunk as possible, and just tight enough to hinder the return of the venous flow, but not to compress the arterial pulse. Every half-hour or so the bands should be loosened, provided a too painful compression of some nerves or a threatening anjemia of the brain does not demand an earlier removal of the ligatures. Under ordinary circumstances these constricting bands can be renewed after short intenals and as often as the condition of the patient may indicate. A hot-water bag should, at the same time, be placed at the feet. After the stoppage of an acute hemorrhage, the administration After- '^^ " " treatment. of astringents, such as the fluid extract of ergot, or, better yet. gal- lic acid in ten-grain doses, and of iced drinks, must, of c'^ F. or a trifle over, with streptococci in the si)utum, a first injection of 10 c.c. reduced the tenijierature from 1° to i ^°, A second of 10 c.c. broujjht it down to nearly normal. A third, fourth, fifth, and si.xth of 5 c.c. each, given first every twenty-four hours, then at longer intervals, helped to maintain the normal, or nearly normal, temperature, and a general better feeling was experienced by the patient. Dr. I'.iiward J. Bermingham, who used some of the same serum, which was sent to me at various times from Paris, kindly reported to me four cases. All were typical cases of mi.xed infection, .vith streptococci as the main companion of the tubercle bacilli. In case I, 10 c.c. of Marmoreck's serum reduced the temperature from I03j<^ to ioij/°; this had to be repeated three times at intervals of three weeks. Case 2 : the temperature rose daih' to 103° ; after one injection of 10 c.c. of Marmoreck's serum the temperature did not go above 101° daily for four months. The disease then progressed rapidly and the patient died in three weeks. Case 3: the tempera- ture rose daily to 103° or 105°; injections of 10 c.c. and 15 c.c. of the serum were given without effect; 20 c.c. brought down the temperature to 102°, where it remained for six months, when patient left the city. Case 4: the temperature rose daily to 103° ; one injec- tion of 10 c.c. brought the temperature down to 99 'i°, where it remained for six months ; it rose again to its former height and a new injection reduced it to 100° and has not risen since — a period of seven months. Stubbert, who experimented exten.sively at the Liberty Sanato- rium with Marmoreck's antistreptococcic serum, reports 10 cases in the "St. Louis Medical Gazette "of December, 1898. Of these, 6 improved and streptococci were no longer found after the injec- tions ; 2 improved, but the streptococci returned, and in 2 cases the antistreptococcic injections had no effect whatsoever, though in I three and in the other eight injections of 10 c.c. were given. Dr. Weaver, of Chicago, reported .still better results.' Among other cases he cites one, in the " Journal of the American Medical Association " of September 5, 1896, with a temperature of 105° F., m St w !■ < if ' Wenver, \V. II., " -Vntistreptococcic Serum in the Treatment of Consumption." ■♦ ■ I I ii li ,f! ' 1! '. Chills. Exticme state or weakness. Dyspiicca. Enipliy- senia. 264 PULMONAKY TUBEKCULOSI.S. which he broujijht down to nearly normal with a .single dose and maintained it there by repeating the injection every .second day. However, I think it will require much more experimentation to fix the real value of this serum. Its action seems to depend not only upon the make of serum u.sed,' but also upon the variety of strep- tococci' in the system and the deie Krnnkheiieii der oberc-n I.iiftwege," Berlin, lS()4. 268 Jl >} I LARYNGEAL TUBERCULOSIS AND INTERCURRENT DISEASES. 369 Acrotherapy, of course, must not be neglected in such cases. Breathing e.xercises should be instituted in this disease as well as in pulmonary tuberculosis. They should be taken jutiiciously, according to the strength of the patient. The milder the air these patients breathe, the better they will feel. My modification of the pneumatic-cabinet treatment, described on page 222, will permit the sufferer from laryngeal tuberculosis to enjoy the benefit of this valuable adjuvant in aCrotherapeutics just as well as the sufferer from pulmonary consumption. ]?y breathing through the nose with the aid of the adjustable mask instead of through the mouth- tube, the air is warmed sufficiently to cause no irritation whatso- ever, and the increased air-supply thus entering the respiratory organs has its beneficial effect. As a urative measure the lactic-acid application, varying in Lactic strength from ten to seventy-five per cent., has thus far been most universally used. The most frequent way of applying this acid is directly upon the tubercles or ulcerated surfaces. It may, how- ever, be also injected under the mucous membrane. At times, surgical interference is inevitable, and every large institution de- <:;i„.gjca] voted to the treatment of tuberculous patients should not be' without its competent laryngologist. The removal of tuberculous growth in the larynx by means of curettage seems to be indicated in a certain number of cases. Gleitsmann,' in his excellent report to the Section on Laryngology and Rhinology of the Twelfth International Medical Congress at Moscow, has promulgated the following indications and contra- indications of the curette in laryngeal tuberculosis: Indications : 1. In cases of primary tuberculous affections without pulmonary complications. 2. In cases with circumscribed ulcerations and infiltrations of , im.'asures. th( lary nx. 3. In cases with dense, hard infiltrations of the arytenoid region of the posterior wall, also of the ventricular bands and tubercu- ous tumors o f th e eu\ii lottis P 4. In the incipient stage of pulmonary disease with but little fever and no hectic symptoms. 5. In advanced pulmonary disease with distressing dysphagia ' Gleitsmann, I, \V., "Medical Kecord," Dec. 4, iSqy. 270 PULMONARY TUBERCULOSIS. J 1 , ' 'X I m ■t .¥ Obesily in luberciilous patients. Bronchitis. resulting from infiltration of the arytenoids, as the quickest means of giving relief. Contra-indications : 1. Advanced pulmonary disease and hectic. 2. Di.sseminated tuberculosis of the larynx, 3. Extensive infiltrations producing severe stenosis when trache- otomy is indicated or laryngotomy can be taken into considera- tion. Gleitsmann, as well as Heryng, does not advise the operation in timid, distrustful patients lacking the necessary nerve-power, and both prefer to operate on the patient in a hospital, where he is under absolute control and the after-treatment can be carried out more satisfactorily. For the operation of curettage various instruments have been devised, such as Krause's curettes, Gougenheim's" emporte piece," and Hcryng's rotary double curette. The last one mentioned is given the preference by Gleitsmann because it enables the operator to remove a greater amount of tissue. Occasionally we meet a consumptive with more adipose tissue than is good for him, and in such cases a fatty degeneration of the heart is to be feared. Extreme dyspnoea and feeble heart-action are frequently the alarming symptoms. To attempt to reduce their fat by such diet as^prescribed by Ebstein, Harvey, or Schweninger would be dangerous. The dieting must be done much more gradu- ally, and, while it is essential to relieve the heart from its too fatty environment, such patients should not lose more than about two pounds in the course of one month. Moderate exercise and mas- sage will aid in replacing the adipose tissue by muscular tissue. Bronchitis must be treated first prophylactically by the aiiro- and hydro-therapeutic measures described in the chapter on prophy- lactic treatment. The inhalation of impure, dusty, or irritating atmosphere is productive of bronchitis, especially in consumptives whose point of least resistance lies in the respirator)' tract. An unobstructed nasal breathing is one of t!ie essential conditions to avoid bronchial catarrhs. The use of opium is certainly a valuable remedy to abort an attack of bronchitis. Charbonneau says a full dose of Dover's powder will frequently abort an attack. Osier is of the same opinion, saying tliat no remedj- can take its place. h^iigli'^h ' 1 "Therapeulic Hints," "Medical Record, " Jan. ; 4, 1899. LARYNGEAL TUIiEKCULOSIS AND INTERCUKRENT DISEASES. 271 i i I explains the tlierapeutic action of opium in such cases when given in full doses as follows : " Reactioi' of irritability, congestion, or inflammatory activity. Alteration in the character and limitation of the amount of the secretion. Increase in the general comfort by relief of pain and soreness, and removal of cough and inci- dental insomnia." Counter-irritants, as mustard plasters or dry cupping, are good local remedies. The inhalation of thymol (one grain to one ounce of liquid aibolene) or other antiseptic or balsamic preparations is also useful. As antipyretic in an acute bronchitis 1 give quinine the preference. If the cold-pack — that is, cold-water compresse.: — is applied, it should be done as described on page 254 for excessive hyiJerhi- drosis. Care should be taken in removing the compresses, so as not to have the patient take a new cold. It is prudent to remove the wet-pack under the bed-cover, and rub the chest drx- with a somewhat rough towel, and follow this by a vigorous friction with alcohol. As a cough-mixture I use one of those given on page 252. Of course, any other expectorant may answer as well. Pleurisy may manifest itself in a consumptive as a concomitant Pituris>. or an intercurrent disease. The acute forms, arising as a new complication, must, of course, be treated by rest in bed. If there is a large exudate, absolute quiet before as well as after thoracen- tesis must be 'isisted upon. If there is but a small amount of liquid in the chest, dry cupping and mustard applications often suffice to aid absorption. Judiciously directed respiratory exercises are also of value, especially in the subacute and chronic form if there is no intense pain. To relieve the sometimes acute suflfering from intercostal or pleuritic pains, cold applications are indicated; if they are not well borne warm poultices may be substituted. Of medicinal substances opiates are at times indispensable. Diuretics, such as potassium acetate, digitalis, scilhi,', etc., may be indicated. The patient's strength mu.'t he kept up by tonics. Of the value of lateral douches and the respiratory exercises, to aid the absorp- tion of fibrinous adhesion, the residual of long-standing pleuritic inflammation, wc have already spoken in the respective chapters. li the pleuritic exudate becomes purulent (empyema*, tne case belongs to the domain of surgery. In the s[)eedy and thorough evacuation of the pus lies the mil}' hope for the recover)- of the patient. m^' SI 1. If F'M 272 PULMONARV TUBERCULOSIS. m !V ' ffi lb Pneumonia. Pneumonia, which in consumptives is usually of the lobular kind, must, when arising in the course of pulmonary phthisis, be treated as in any other patient. Rest in bed, careful antipyretic medication (quinine or lukewarm-water baths), and, above ail, remedies to keep up the proper heart-action — digitalis, alcohol, etc. — are essential. Professor A. Jacobi counsels to give, from the very onset, two drops every four hours of the fluid extract of digitalis (Squibb's), thus strengthening the heart, and by its cumulative effect putting the heart in a condition of defense at the most critical stage of the dis- ease. Counter-irritation over the whole of the chest renders also great service. The administration of ammonium carbonate and ammonium iodide will aid materially in the removal of the in- flammatory products during the stage of ulceration. Professor E. G. Janeway's method of putting the pneumonia patient on a milk diet has rendered me excellent services on various occasions. In all cases the diet should be in liquid form, not too concen- trated, and water should be given freely. For severe pains, care- fully administered doses of morphia (hypodermically over the seat of pain) are the best analgesic. Pneumothorax, during the course of pulmonary tuberculosis, is most frequently the result of some sudden physical overexertion or traumatism, such as jumping, running, rapid mounting, loud singing, or a sudden blow against the chest. Again, a violent coughing spell may be the cause. It is most important to prevent such accidents. However, patients cannot always control their coughs, and a pneumothorax may occasionally develop in a con- sumptive without any apparent traumatic origin. As in pneu- monia, rest in bed is es.sential. Liquid diet and stimulants of all kinds are strongly indicated. Leyden,' of Berlin, favors " gavage " in such cases. Locally, the cold-water compresses or ice-bags often give relief. Pulmonary gangrene, which is one of the distressing inter- current troubles that may appear during the course of pulmonary tuberculosis-, should be treated vigorously by tonics (digitalis, caffeine, alcohol, etc.). Jaccoud recommends to give the patient from eight to ten grains of salicylic acid a day. As antiseptic inhalation a few teaspoonfuls of the essence of turpentine poured into hot water is to be recommended (Trou-sseau). Thevaporofa Pneunio thorax. I'liliiKinary gangrene. ■ I.eyden, "I'ber rneiiniothorax tulierculosis," schrift,' 1S88. ] )eiitsche niedizinisclie Woclien- LARYNGEAL TUBERCULOSIS AND INTERCURRENT DISEASES. -/ .1 five per cent, solution of carbolic acid can also be used for the same purpose. If there are .several foci, medicinal treatment is all that is possible ; but if the gangrene is circumscribed and this treat- ment is ineffectual, pneumotomy and draina<;e are indicated. The part of the lung involved has been resected in some cases with satisfactory results. Pulmonary phthisis complicated by diabetes or diabetes com- uiaiiutcs. plicated by pulmonary tuberculosis, of course, needs special atten- tion. Von Noorden, who is to-day considered the greatest authority on diabetes, having studied the subject perhaps more thoroughly than anybody else, summarizes in the "Twentieth Century Prac- tice of Medicine " ' by saying, " This complication should not cause any relaxation in the carrying out of the suitable dietetic principles (of diabetes), but rather demands greater strictness and especially the greatest possible increase in the amount of fatty food, with the addition of considerable quantities of alcohol. It is advisable that the patients should reside in places where the climate is mild, rather than in those lying in high elevations, where the air is raw, and treatment in a sanatorium is preferable to a stay in one's own home or in a hotel. Certain hydrotherapeutic measures of a mild character may be cautiously instituted ; diabetics with phthisis are indinduals demanding the greatest protection against injurious influence?. ' My only objection to this excellent sum- mary would be that too considerable quantities of alcv)hol are not always well oorne by these patieimts. Whenever I give alcohol, I prefer to atnninister it at meal-tiines, in the form of light vt'liite wines. The main point, in such cases, is to.-trive to maintain the strength of the patient by a judicious suraiinient-jtion with ihe exclussion of sugar, swet'meaits, pastry, preserves, swxet j<'llies, macarcmi, peas, beans, etc. A small an «unt f bread and pota- toes should be occasionally allovcd. While pityriasis versicolor > tinea versicolor, pityriasis of I'.ich- I'ityHasis. stedt) can hardly, in the light of nmdem research, be considered .symptomatic of pulmonar\ phthisi* it is, nevertheless, met with frequently enough in [phthisical prr cnts to .nerit some consKlera- tion here. It is most usually foun^. >.n patients whose skin has not received proper hygiene. The disc.ise is due to a vegetable para- site (microsporon furfur); the eruption is superficial, of yellowish or it' Tweiilicili reiiiiiry I'laclice," vol. n, " I)i.-ilietes Mcllilus.'' I8 ft 274 PULMONARY TUBERCULOSIS. Miliary tubLTCll losis. reddish color, and the itching sensation is most intense when the patient gets overheated. It is usnally located over the sternum ; sometimes, however, scattered over the front of the cliest and the back. The edges of the patches are rounded and somewhat elevated. The treatment consists in first removing these patches by warm baths with soap, preferably sapo viridis, and then applying the antiparasitic remeiiy. As an antiparasitic the pure ichthyol has given me much satisfaction in such cases. After having bathed the affected parts as above described I apply a good coat of the ichthyol overnight, removing it in the morning by the aid of a weak solu- tion of bichloride (i : 5000 to i : 10,000). Other applications, such as salicylic, carbol, or resorcin salves, will also rarely fail to destroy the parasite. One precaution must be insi.sted upon, otherwise the trouble is sure ^o recur: that is, the thorough boiling and disinfect- ing of the patient's underwear. Acute miliary tuberculosis can, in the present state of our knowl- edge, be treated only .symptomatically. A remedy which I have seen do excellent service, and under which I observed a few appar- ent recoveries, is tannic acid, administered in large doses of from ten to fifteen grains three or four times daily. At times, in a patient suffering from pulmonary tuberculosis, even in the earlier stages, there will be found manifestations of joint-tiiber- local tubcrculosis in the joints, testicles, etc. I do not intend here to treat the subject from a surgical point of view, but only to indi- cate the newer methods of treatment applicable to the earlier stages of joint tuberculosis. Bier's method of treatment by local venous Iiypera;mia' I saw applied for the first time two years ago in the service of Dr. Torek, at the New York Post-Graduate Clinic, with most satisfactory results in several cases of tuberculosis of wrist- and knee-joints. This method consists of ligating the member ab treatment lies, as has already been stated, in the constant medica supervisi. n and the pos-ibility of keeping tli> [)atient busy all day with something which ha his cure for its definite object, — at this hour his I'ueals, at that his rest cure, at this his respiratory exerci.ses, at that his walk, at another his douche, etc., etc. The first matter in regard to the education of a pat. -nt is, of course, the instruction concerning the care f the e.xpector.ition, of which we have spoken in detail in the preceding pages. Next in im- portance comes teaching him how to avoid taking cold. The most frou tion suitable mode of dress for consumptives lias been briefly mentioned i''kin on pages 235 and z;^- The precautions to be taken during respir- atory e.xercises have also been touched upon. Consumptives should be particulai !y > 'eful not to face the wind when taking these e.xercises, and, of cour.-iv, always keep their mouths closed. When taking the rest cure on reclining-chairs out on the veranda, they should avoic! much conversing on cold or windy days. The same rule holds good when out walking. In a sanatorium graded walks, such as described on page 213, and the distribution of num- bered benches will make the method of carefully testing one's strength from day to day especially interesting. The consumptive should never start out with a determination that lie must reach a certain spot. Overexertion is to be feared. The pulmonary invalid must, more than any other, be careful not to get in ^77 ' '19 ^ J! olds. ■»sr.». IMAGE EVALUATION TEST TARGET {MT-3) .^' ^,V 4^ I V] ^;j ^c^ ^/^J^ ^>/ '^> /^ ^'^^^V^ ^ 1.0 I.I ^■2.8 12.5 ■so 1^ I Ui ^ |2.2 •^ 140 12.0 Photographic Sciences Corporation I 11.25 11.4 11.6 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 ^ V ^o^ ^-% '^ ^l 1 ,j 1 Childbirlh and mirs- iiig. tion in an overindulgence in sexual pleasures, which a tuberculous invalid should exercise only at the rarest intervals. Some tuberculous women suffer, at the time of their monthly period, from pulmonary congestion and h.-cmoptysis. To these, absolute rest, beginning three or four days before and lasting throughout the period, should be the rule, Daremberg recom- mends, in addition, a mustard plaster over the lower abdomen, and gives some bromide with digitalis to quiet the pulmonary condition. As a rule, the tuberculous patient should not marry ; but I have no hesitation to give my consent to marriage when the patient has been cured, or, since some authorities do not accept this word in the ad integrum sense, if he has remained in good health for two successive years. He should, however, be im- pressed with the importance of his living a quiet, regular life, free from excesses of any kind. There are times, however, v/hen we must deviate from the iron rule not to allow a tuberculous patient to marry. If we are in the pre.sence of a young, highly impres- sionable woman in the first stages of pulmonary tuberculosis, who is engaged to be married, it would be cruel and unwi.se to put a stop to the union : the con.sequent sorrow brought upon this young woman would simply mean hastening a fatal termination of her disease, while, as a happily married woman, she has a fair chance of getting well. This is one of the few instances in the practice of medicine where it becomes the duty of the physi- cian to tell the husband that, if his wife becomes pregnant before her complete recovery, it means danger to her and to the child, and the husband should be instructed to that effect. When, nevertheless, a tuberculous woman has become pregnant, should we interfere with a view of saving the woman's life? To judge from what I have seen in the large maternity hospitals of the Old and the New World, and from my own personal experience, such procedures are, in the light of our present knowledge, no longer jus- tified. Tarnier, Hergot, Gaulard,' and others have, in accidental or brought-about abortions, seen the mother's tuberculous disease take, nevertheless, the rapid course so frequently observed after an appar- ent improvement in ca.ses which go to full term. During my visit a-' i M, ■ 1 1 ■!'• 1 1 lit i ' " Presse miidicaie," Dec. S, 1894. MARRIAGE AND CHILDBIRTH. 283 to the various sanatoria, I inquired into the results obtained by the hygienic and dietetic treatment in these institutions with preg- nant tuberculous women. Dettweiler, Meissen, Wolff, Roempler, Turban, and Trudeau, had observed cases where the patients did remarkably well for years after, as also did their children. Sabourin, Achtermann, and Weicker, on the other hand, had only observed an apparently much improved state before the birth of the child, followed by a rapid decline after confinement. To sum- marize this important question we would say: Prevent conception in a tuberculous woman ; if conception has taken place, institute hygienic and dietetic treatment, preferably in a sanatorium near the home of the patient. But, as Trudeau says, it is essential that the treatment be continued for a long time afterward ; and I should like to add that a repetition of pregnancy must be prevented. Never bring about abortion, for it does not save the life of the tuberculous mother. It goes without saying that a tuberculous mother should not nurse her child. A child whose father or mother is, or has been, phthisical should be, from its very earliest age, surrounded by the best hygiene. Especial care should be given to its nutrition. A healthy wet-nurse would, of cour.se, be the best guaranty for the child's normal development. If the procuring of a healthy foster- mother is impossible, sterilized cow's-milk, carefully diluted with boiled water, etc., must constitute the child's food. All the precautionary measures that have been fully described in our chapter on Preventive Treatment should, if possible, be instituted. All offspring of tuberculous parents should choose out-door occupations by which to earn their livelihood, and live and work in places where they are as little as possible exposed to the inhalation of dust and other irritating substances. The cured or ameliorated patient, upon his return home, should lead a very regular life. He should avoid crowded assemblies and violent physical exercises ; in short, use his experience and training in the sanatorium as a guide to keep well or to complete his cure. To those who doubt, the physician should hold out living exam- ples of cured tuberculous patients, which are so numerous that I do not think I exaggerate when I say that a few can be found among the patients of every general practitioner. Pulmonary tuberculosis is, indeed, one of the most curable of all diseases, but the treatment requires more attention on the part of the physician, perhaps, than Tiihcrcu- loiis otl- spring and cured patients. 'D , if iMi 'H^ Duration of cure. 1 ; Training of pliysi- cia;i and nurses. I 'If ■''•' f m 384 PULMONARV TUBERCULOSIS. any other, for, as the preceding pages have shown, besides the great prevailing symptoms, many little ailments and causes of new disturbances ari.se. It is rarely wise to deceive a tuberculous patient as to the prob- able duration for his cure. Some will be able to resume their daily occupation within three months, others not before three years. It will not only depend upon the extent of the lesions produced by the tuberculous process and upon the manner in which the system responds to the treatment; but also in a measure upon the degree of hope and confidence with which the physician can inspire his patient. In looking after the patient's condition, from the most alarming symptom endangering life to the slightest cause of dis- comfort, and in the endeavor to remove or ameliorate them all, lies the .secret of success. It may not be inappropriate, at the close of the chapter on Edu- cational Treatment, to say a few words about the education of the physician. Modern phthisio-therapeutics, as carried out in well- equipped sanatoria, must be practically studied. The custom, recently instituted by Professor Curschmann, of Leipsic, and Pen- zoldt, of Erlangen,' of making excursions with their students to neighboring sanatoria as a practical demonstration of their lectures on phthisio-therapeutics, seems to me well worth imitating. There is much to be seen in such institutions which will be of value to the young practitioner. A few years ago Weber, of London, esti- mated that there is only room in special institutions for about one tuberculous patient in a thousand. Since then the sanatoria have multiplied, but there still remains a large percentage of tuberculous patients to be treated by the family physician ; therefore, the more thorough his training in the management of so universal and com- plex a disease as pulmonary tuberculosis, the more will be accom- plished in the line of prevention and cure. Chronic pulmonary consumption is not an ea.sy disease to treat. It requires not only a thorough knowledge of the etiology, path- ology, and therapy, and a familiarity with all the symptoms of the disease, but also a great deal of devotion and patience, combined with great strength of character. The peculiar psychological state of nearly all phthisical patients, we repeat once more, makes it neces- • Penzoldt und Stintzing, " Hancllnich der Therapie der Erkrankungen der Atmungs- und Kreislaufsorgane," Jena, 1898. TRAINING OF PHYSICIANS AND NURSES. 28s new sary for the true phthisio-therapeutist, not only to be to his patient a devoted physician, but also his best and most confidential friend. Nurses who undertake to help the physician in his care of the consumptive invalid should be physically strong and of a cheerful disposition, and especially prepared for this kind of work. A nurses' training school might advantageously be attached to some of the larger sanatoria. There exists already one at the Loomis Sanitarium at Liberty, which does excellent work in preparing young women for the special duties required as nurses to patients afflicted with tuberculous diseases. -m'\ m ! 1 ; ;, } li 1^ firf- ■fj CHAriKR XX. UT in m TUBERCULIN, OTHER CULTURE PRODUCTS, SERUMS, ETC., IN THE TREATMENT OH PULMONARY TUBERCULOSIS. We will now say a few words in relation to culture products. Foremost, of course, .stands the tuberculin, of which the first men- tion to the medical world was made by Robert Koch at the Inter- national Medical Congress in rSgo. The results obtained with Koch's first tuberculin, when employed for a curative purpose, have been almost universally at least deeply disappointing, if not disas- trous. Its diagnostic value cannot be disputed, and in the lower animals it has given, as such, definite and useful results. The wis- dom of its use for diagno.stic purposes in the human race I, for one, dare to question. Five, or even ten, milligrams of tuberculin may in nine hundred and ninety-nine cases do nothing but reveal a latent tuberculosis ; buf in the thousandth case it may cause an unexpected generalization with a fatal result. When one has witnessed such a generalization his desire to use tuberculin for diagnostic purpo.ses in the human race is diminished. A drug or any other substance which, when introduced into the system, is capable of bringing about a sudden rise of temperature, some- times as much as four degrees above the normal, and which, tlirough the circulation, will reach the tuberculous deposits, if such are present, irritating these latent tubercles into an active process of inflammation, must be considered a dangerous thing. Ambler,' of Asheville, in an article upon the early diagnosis of pulmonary tuberculosis, asks whether any physician would be willing to risk the consequences of such a method of diagnosing a disease; and, addressing physicians directly, he says : " Do you believe you would carry out such a procedure in your own person under such possibilities? If you would not, you have no right to use it upon your patients." 'Ambler, "The Karly Diagnosiii of Pulmonary Tuberculosis," Journal," I'eb. 12, 1898. 286 N. V. Mod. TUHEKCULINS AND OTIIEK CULTUKE rROOUCTS. :S7 If 1 find myself in the presence of a case of suspected pulmonary tuberculosis, and repeated careful auscultations of the patient's chest, and a number of bacteriological examinations, and even an examination by the X-rays cannot confirm the suspicion, I institute the educational, hygienic, and dietetic treatment for a few months, certain that it will do an enfeebled organism a great deal of good. It may prevent a very latent tuberculosis from ever developing or fortify a predisposed individual against the invasion of the tubercle bacilli. In some sanatoria (Adirondacks, Dr. Trudeau ; Davos, Dr. Turban) and in some special hospitals small doses of tuberculin, much smaller than formerly recommended by Koch, are continu- ally used as a curative means, and good success reported, especially in the early cases. But may we not ascribe these good results just as much to the hygienic, dietetic, and symptomatic treatment so rigorously adhered to in these institutions, where sucii good results were obtained before tuberculin was ever used ? There are also numerous general practitioners, and among them such men as VVhittaker,' of Cincinnati; Spengler,- of Davos; Barton,'' of New York, who still believe in the curative power of this culture- product. But do not these distinguished practitioners also in their private practice, as well as in hospital practice, insist upon the very best hygiene and diet for their tuberculous patients? Specialists in cutaneous diseases have reported cases in which tuberculin has favorably modified the growth of lupus, and others where the injections did not stop the growth. What has just been said of Koch's first tuberculin as a curative agent we may say of all its modifications. The tuberculocidin and its child, the antiphthisin of Klebs ; the tuberculinum purifi- catum of von Ruck, Whitman's purified tuberculin, Hirschfelder's o.xytuberculin, Koch's new tuberculin R (though the latter has already been withdrawn from the market by its manufacturers), etc. — all, in the hands of some e.xperimenters, have produced satis- factory results. I do not wish to speak of their respective merits, but from what I have seen, heard, and read, I may summarize I I! ' Wliittaker, " General Impressions from Six Years' L'se of tlie Old Tuberculin," " Journal Amer. Metl. Assoc," Nov. 6, 1897. ' .Spengler, " Deutsche med. Woclienschrlft," No. 36, l8()7. ^ I!;ulon, " The Scientific Irealnient of I'uberculosis," " Medical Record," Septem- ber, 1897. 388 PULMONARY TUBERCULOSIS. i m^ m their reported curative effects by saying of them collectively: Whenever a new culture-product is discovered, and through experiments on the guinea-pigs is shown to have a specific anti- tuberculous action, it is usually recommended with the following restrictions : Not to be applied in advanced cases. Not to be applied in mixed infections. Not to use it as exclusive remedy, but always in connection with the best of hygiene and the best of diet. Not to neglect the symptomatic treatment. And the results of the treatment read about as follows: A large percentage of incipient cases were cured. A small percentage of advanced cases were benefited. A still smaller percentage remained indifferent to the treatment. A very small percentage died. Cannot any one, private practitioner or sanatorium physician, report just as good and even better results whenever the hygienic, dietetic, symptomatic, and educational treatment has been carried out conscientiously without the aid of any specific or antibacillary remedies ? Of the serum of Maragliano, Paquin, and others, we can only say the same, though I am glad to acknowledge that I have not yet seen any real ill effect from their employment in tuberculosis. I cannot say this of tuberculin. Of Brunei's "sue pulmonaire"' (lung-juice), we know as yet too little to express an opinion. His claims are based on Brown- Sequard's theory of the utilization of organic extracts as thera- peutic agents. Lastly, we desire to allude to the treatment by inhalation of " formalina," recently instituted by Professor Cervello, of Palermo. P'ormalina is said to be a powerful antiseptic gas, expensive and difficult to obtain. No opportunity has been offered yet to try the remedy in this country; but the good results reported by Pro- fessor Cervello justify mentioning this new therapeutical agent in phthisis. Whether or not other bacterio-thera:K;i'f) its will offer us that long-hoped-for remedy which will cure tubciculosis with a degree ' Urunet, F., " Lo Sue I'ulmonaire (Effets physlologioufis et thirapeiuiques)," Bor- deaux, Imprimerie Y. (adorct. u TUllEKCULINS AND OTIIICK CULTUKE I'KOUUCTS. 289 of certainty, so that the name spe:-ific may be justified, I am not prepared to say. But it seems to me difficult to believe that we will ever have a serum or tuberculin which, in a few weeks, even with numerous injections, will be able to produce enoufjh fibrous connective tissue to strangle countless tubercles which it took years to form, or to create enough phagocytic blood-corpuscles to swallow myriads of bacilli. v^Ve may employ serotherapy in acute exasperation, due to an association of microbes, but to heal a tuberculous lesion we must produce new tissue, new and better blood. How this may best be done I have endeavored to outline in the preceding pages. Even should the future give us a bacte- ricidal substance strong enough to annihilate, without hurting the patient, all the tubercle bacilli which may have invaded him, to build up his m-ich weakened system, to protect him from inter- current diseases and possible relapses, the hygienic and dietetic treatment in sanatoria or under good medical supervision, and in a fairly good climate, where the extremes of temperature are not too pronounced and the air free from pathogenic organisms or irritat- ing substances, will still remain the only rational method. I I H i 19 mW M m CHAPTER XXI. CONSUMPTIVRS IN HEALTH RESORTS, SPORTS, ETC. We have outlined in the preceding chapters what constitutes a careful treatment of tuberculous patients in a closed establishment under the constant supervision of the medical attendant. Can the same conditions be realized in an open health resort ? In some instances, yes ; in the majority of cases, however, I have no hesi- tation to answer emphatically, " no." In our American resorts, such as Southern California, Florida, etc., the tuberculous invalid is perhaps less bent on pleasure than the consumptive visitor to the European health resorts, but he is more inclined to business. How often (in Southern California) have I observed the newly arrived guest, after a few weeks' sojourn, plunge himself into business, especially exciting real estate and other speculations ! In health resorts, no matter how beautiful the climate, if the patients are at liberty to do as they please, I affirm that all attempts at an effective cure are an illusion. In the great health resorts of the Riviera I have seen any number of consumptives promenading in the close, dusty air of the casinos gambling, smoking, expecto- rating everywhere. At the fad/e dlibte they usually eat little, or that which is not good for them. Now and then they consult a phy- sician, whose directions they carry out only so far as does not incommode them. Sometimes they do not even go to see a doctor, but have some of the countless prescriptions filled of which they have brought a supply from home. After a while, feeling no better, they leave, disgusted with the climate that has done them no good, and blame the physician who sent them there. In the next resort the same thing is repeated, or they go to the mountains for a change. In some cases, by the change of climate and out-door life, they really get better. They will then feel them- selves privileged to make long excursions, climb mountains, or (in winter) skate, ride toboggans, or race on snowshoes. How danger- ous such sports are for the phthisical patient, even if on the road to recovery, is well known. 290 .^dBWWi CONSUMPTIVES IN HEALTH RESORTS, SPORTS, ETC. 291 Especially bad for pulmonary invalids have alw ays seemed to me the sports which demand frequent stooping down, such as croquet, bowling, etc. Bicycling is now quite frequently indulged in in health resorts by tuberculous patients in the earlier stages, and especially by those as yet only predisposed. Many physi- cians recommend it as the best means of preventing the outbreak of tuberculosis in the predisposed individual. Now, while fully realizing its valuable therapeutic effects in many other diseases, I consider the bicycle ill-adapted either to the cure or the prevention of pulmonary tuberculosis. There are two great dangers connected with the use of the bicycle for any one whose lungs are already affected or in danger of becoming so. One is the tendency to overdo, the other the danger of taking cold. The excess of mus- cular exertion results in an unhealthful waste of tissue which, in the tuberculous individual, is replaced with more difficulty than in others. Bouchard, of Paris, has repeatedly demonstrated that an excess of waste-products renders [an individual more liable to succumb to infectious diseases, especially tuberculosis. Persons predisposed to this disease often have a rather feeble heart-action, and such are, of course, in great danger if they put too much strain upon the heart. Mendelsohn ' cites several cases of sudden death from this cause. The bent-over attitude is especially injurious to pulmonary invalids. Any one who has practised cycling himself must acknowledge how easily and imperceptibly one overtaxes his powers, and how almost unawares one gets in a profuse perspira- tion. One is then liable to become quickly chilled when stopping to rest or cool off, or if obliged to stop to fix something about the wheel. Herein lies the second danger to persons who have reason to be especially careful to avoid nasal and bronchial catarrhs, which, in the consumptive or the predisposed, have such an unfor- tunate tendency to descend into the deeper air-passages. Lastly, the nervous strain which all novices undergo while learning to ride I cannot help considering injurious to a relatively weakened or weak constitution. If cycling must be done, I consider the tricycle or four-wheeled vehicle propelled by some easily managed motor, as recommended by Gihon," the' safer machine for the pulmonary invalid. ' Mendelsohn, *' Deutsche med. Wochenschrift," April 30 and June 18, 1896. * Gihon, "The liicycle in its Sanitary Aspect," "New York Medical Record, " Oct 3, l8c)(). IM I In m Hi il m ^;il .1: m 292 PULMONARY TUBERCULOSIS. m ■ni I 1,' As I stated abovt, I think a strict supervision of the phthisical patient is almost impossible in an open health resort. Unless the patient is exceptionally situated and very prudent, he has little chance to be benefited in such a place. If, on the other hand, the patient is a convalescent, and has been taught how he should live, with a view to getting well, by his physician or in the sanatorium, the health resort may well offer him an opportunity to complete his cure. Fremy,^ considers these open health resorts also good places for the scrofulous and the predisposed to consumption ; but it seems to me essential that any one, even if only predisposed to tubercu- losis, should always subject himself to the guidance of a physician in an open resort as well as at home. Many an intercurrent trouble may thereby be avoided. That in open health resorts, in spite of endeavors on the part of the municipal authorities, one is not free from the danger of con- tracting a tuberculous disease, and that there is much chance of reinfection, I have shown by the reports kindly sent to me by Drs. Ballestre and Atkins, and which I reproduced on page 37. If we compare these reports with those from Goerbersdorf and Fal- kenstein (see page 311), which show not only the absolute freedom from danger, but the real sanitary advantages, we will see how much safer and better places are the latter to go to to be cured from a pulmonary disease. I am sorry to say that in some of our resorts here in the United States similar conditions prevail to those of Europe. Recent personal inquiries in some of the boarding places in the Adirondacks, where consumptives congregate, outside of the jurisdiction of the sanatoria, revealed to me the fact that these places constitute not infrequently veritable centres of infec- tion. In some States, much frequented by tuberculous patients, there exists a popular feeling that with the influx of pulmonary invalids there is a danger of consumption becoming " endemic." In California, for example, an attempt has been made to restrict the immigration of consumptives into that State by legislative procedures. This Draconian endeavor to settle the question of prophylaxis of tuberculosis did not have any success, and justly so. Education, judiciously and strictly enforced laws, and the multiple creation of sanatoria, especially for the poorer classes, will achieve more good and do no harm. > Fr^my, Communication au Congris de la Tuberculose, Paris, 1888. u CONSUMPTIVES IN HEALTH RESORTS, SPORTS, ETC. 293 In the interest of all it is to be hoped that the sanitary authori- ties of all so-called health resorts for consumptives will soon succeed in enforcing such laws as will make of these places what their name implies — resorts for health-seeking people, where there will be no danger of reinfection or chance of contracting a new disease. Then the convakscent or incipient tuberculous patient may go to these resorts, place himself under the care of an experi- enced phthisio-therapeutist (and there are many in most of these places in Europe, as well as in the United States), and complete his cure under the guidance of his new medical adviser. (I n „ 'til m ! " I 'i CHAPTER XXII. THE TREATMENT OF CONSUMPTIVES IN SPECIAL HOSPITALS. The special hospital serves its most useful purpose by gathering in and caring for advanced cases, or receiving others from which the most suitable for sanatorium treatment could be selected. The treatment />erse in a special hospital for consumptives need not, and, of course, should not, differ materially from that instituted in a sanatorium, which has been dealt with in detail in the preceding pages. But, since the special hospital is situated in or near a city, in it much that can be had with ease in the country sanatorium can only be obtained with difficulty. The first requisite for the special hospital is a location as quiet as possible. The building should be erected on high, porous ground, and, of course, in accordance with the modern conception of hygiene and sanitation. While many of the patients will per- haps be in bed most of the time, there should, nevertheless, be plenty of verandas and balconies, wide enough to hold beds or couches, which can be placed on them on warm days with t^'-'r inmates. In a city hospital for consumptives it will be well-nigh impossible to have a separate room for each patient, but too large wards also have their disadvantage. Large rooms for from four to six patients, with a number of single ones for special cases, seem the best arrangement for such an institution. The temper- ature throughout the hospital should rarely be higher than 65° F., and, as much as possible, uniform throughout the establishment. In winter as well as in summer the atmosphere of the rooms must be frequently renewed by opening the windows, or by ventilators. It seems to me that, what has been recently instituted by Unter- berger'in the Military Hospital of Zarskoje Sselo, near St. Peters- burg, would be an excellent addition to the equipment of a special hospital. Pine-trees, planted in tubs of wet sand, are placed ' Unterlierger, " Ueber .Scrophulose, Tuberkulose und Phthisic und die Behandlung in Ilaus-Sanatorien," St. Petersburg, 1897. 294 '^noimaaoatBtsoKx THE TREATMENT OF CONSUMPTIVES IN SPECIAL HOSPITALS. 295 throufjhout the hospital, more numerously in the bedrooms and sitting-rooms. Toward evening, when the odor of the pine grows weak, the trees are sprayed with the following solution : K. 01. piiii silv. (Scotch fir), 10. o 01. terebinlliin. pur., 30.0 Aq. font., 300.0 Through this combination the air becomes more impregnated with ozone, and for a consumptive to live and take frequent respir- atory exercises in such an atmosphere is certainly beneficial.' One or more pneumatic cabinets should also belong to the equipment of an institution destined to treat pulmonary diseases. In the special hospital, where the majority of tuberculous patients are in the advanced stages, and where they will probably remain until they die, special precautions nui.st be taken in view of the sometimes utter helplessness of these patients. All that has been said concerning the expectorations and other secretions in chapter iv applies to special hospitals as well as to the sanatorium. Frankel's mask, as a protection against the expulsion of bacilli, should be worn, whenever practicable, in the wards (see page 44). As additional precaution in a city hospital for consumptives I would suggest, besides the disinfection of the patient's clothing and the supplying of others in the meantime (a practice now in vogue in all well-regulated hospitals), a special, hygiene for the protection against reinfection and the possible transmission of their disease to the hospital attendants. It should be the duty of the nur.se in charge to make the rounds at stated intervals among the patients assigned to her or his care, not only for the purpose of looking after their wants, but to see that they have not, owing to their feebleness or carelessness, expectorated where the sputum may constitute a danger. No person should be employed in the city special hospital for consumptives without being of a strong con- stitution and free from hereditary predisposition to tuberculous dis- eases. A careful physical examination by the chief of the respec- tive service should determine whether or not the applicant may be I i 1. '■■' m * Richet and Ilericourt haA three iloj's, previously inoculated with tuberculosis, inhale turpentine vafKus for an hour every four or five days, with tlie result that two were still alive, nine months later, while the control animals all died in about thirty-live days. Ilenoctjue thinks there is a decided therapeutic value in the ozone generated in turpen- tine vapors. — Paris See. de Biologic, Nov. 12, 189S. 'ii. ; t _ 296 PULMONARY TUBERCULOSIS. admitted to nurse tuberculous patients. Should any of the nurses feel ill they should report at once to the physician. If their illness is of a serious character and not tuberculous, they should, of course, be treated somewhere else, since where there are many consump- tives in the last stages there may remain, in spite of all precau- tions, some danger of infection. When suffering from colds the nurses should not be allowed to attend to their service. I still re- member with gratitude that, in my early student days in Paris, Professor Debove made it a rule not to allow any student with a coryza or bronchitis to enter the tuberculous wards, the atmos- phere of which he knew, in those days, to be laden with micro- organisms of all kinds, and especially with the tubercle bacilli. Physicians and nurses, before entering upon their rounds and duties among the patients of a special hospital for consumptives, should put on long linen coats, and should wash their hands before and after leaving the wards. CHAPTER XXIII. THE TREATMENT OF AMBULANT TUBERCULOUS PATIENTS IN PRIVATE AND DISPENSARY PRACTICE. There cannot be much difference in the treatment and manage- ment of the tuberculous patient able to come to the physician's office or to the dispensary. The instructions given to one are applicable to the other. The dispensary situated in the city, attached to the reception hospital or existing independently of it, is a most important institution for helping to solve the problem of dealing with the consumptive poor who are not sick enough to enter a special hospital or sanatorium. In the Lung Depart- ment of the New York Throat and Nose Hospital I had the satisfaction to see how much good can be accomplished by a well- regulated dispensary service devoted exclusively to the treatment of these unfortunates. I emphasize the word frenti/ient, and I mean thereby not only administering medicine, but teaching them the hygienic and dietetic principles which their cases demand. Since it is often impossible for the ambulant tuberculous patient to present himself daily at the office or at the dispensary, as many of this class of patients are able or obliged to work, it is well to provide them with printed instructions. These should be written in as comprehensible and untechnical language as possible, and should not be too difficult for a patient with little or no means to carry out. It may, perhaps, not be amiss to reproduce here the instruction card which I compiled for my private practice and also for my out-door service at the New York Throat and Nose Hos- pital (Lung Department) : « 1 Ih I i' m n 297 ' it' ■ 298 PULMONARY TUBERCULOSIS. Envelope for Dispensary Use. s m 1 . y^tfi |M 1 ' rf IV ^ f |;1 P 1' |i.j;ir| ;. 1: ! ;. % I - .. NEW YORK THROAT AND NOSE HOSPITAL. JVo. OUT-DOOR DEPARTMENT. Sen'ice of Dr. Instructions for Mr. 1. Read the inclosed instruction-leaflet carefully. 2. Keep it clean by replacing it in the envelope. 3. Bring the leaflet when you call at the dispensary. Date, Number of Patient., . . . . . . Instructions for M . Gknkral Advice. Be hopeful and cheerful, for your disease can be cured. Avoid anxieties and worry as far as possible. The best occupation for a sick person is to labor to get well. Have at least nine hours' sleep in the twenty-four, and retire early. If you have to work during the week, and you feel as if you do not get a sufficient amount of rest, remain in bed all Sunday morning and get thoroughly rested. Live as much as you can in the open air. Do not be afraid of cold weather; only on very windy days remain in-doors. Remain in the sunshine as much as possible, bul; always protect your head ; the best place to take a sun-bath is a spot sheltered from the wind (in front of the open window, when there is no garden, seranda, or flat housetop). Extend yourself on a comfortable lounge, witl^your head in the shade and the body bathed by the rays of the sun ; remain there as long as you feel comfortable. Take your breathing exercises as you have been directed ; always breathe through the nose. Take your walking exercises regularly, as ])rescribed. Never walk until you are tired, and avoid getting into perspiration. mmti TREATMENT OF AMBULANT TUBERCULOUS PATIENTS. 299 Avoid draughts, dust, and dampness, and all places where the air is bad, such as theatres, concerts, crowded meeting-places, etc. Keep at least one window always open in your bedroom. Night air is as good and in cities even better than day air. Never sleep nor stay in a hot room. Have your own sleeping-r jm if possible, but always have your own bed, which should be freely aired during the day-time. In cold weather you may have a fire in the room, but keep the window wide enough open not to have the room warmer than 60° to 65° F. As a rule, do not leave the house until one hour after sunrise. Dress yourself comfortably, but not so heavily as to hinder your move- ments ; discard chest-protectors, for they only tend to make you take cold more easily. ^Vear a suit of good woolen under-garments, also wear woolen socks ; keep your feet dry and warm. Never go without rubbers in rainy weather. Always expectorate in a spittoon filled partially with water, into which you have put one part of carbolic acid to twenty parts of water (five per cent, solution). ^Vhen you cannot conveniently get at the stationary spittoon, use your pocket-flask. You should never be without one. Never swallow your expectoration ; never use the same handkerchief to wipe your nose which you use to wipe your mouth after having expectorated. Always cover your mouth with the latter while coughing or sneezing. Never kiss any one on the mouth. ! • , 1 Directions Concerning Food, Drink, Stimulants, etc. Live on a mixed diet — that is to say, meat, fish, vegetables (especially spinach, lentils, etc.), fresh and cooked fruit, plenty of fresh milk, fresh eggs; all sorts of easily digested fats (not i^ork), especially butter. Thick, nourishing soups should be taken with the principal meals. Raw, cho])ped beef is especially to be reconmiended. Whole- wheat bread, being more nourishing than white bread, is to be preferred. Eat slowly, chew your food well, take the milk in small swallows ; take but little licpiid during and shortly after meals. Keep your teeth in a good condition by brushing them after each meal. Never take any alcoholic beverages i^wine, beer, or liquor) without special consent and direction c the physician. Too much sweets (sugar, pies, pastry, etc.) should also be avoided, as well as all kinds of fried food. Do not use tobacco in any form ; smoking of cigarettes is particularly injurious. rl a 5 .1 300 PULMONARY TUIIEKCULOSIS, Special Diep. DiKFxTiONS Concerning Baths and the Use of Cold Water. Take one short warm bath once a week, followed by a rapid s])onging with cooler water and a vigorous rubbing with a rough towel. Special Directions for the Use of Coi.d Water. I !i Special Directions for Hreathinc; Exercises. Take exercise No. . . . Repeat . . . times. Every . . . hour. These exercises are to be taken near the open window or out-diiors. Special Medical Advice. Any intercurrent trouble, such as indigestion, diarrhcea, consti])ation, increased cough, pain, reddi.sh expectoration, or hemorrhage, should be at once reported to the physician. Do not, however, be alarmed if you have a hemorrhage, as it is but one of the phases of the disease, and does not lessen the chances of recovery. A careful and obedient patient has ten times as much chance of getting well as a careless or disobedient one. M.D., AtUniiing- Physician. Concert. ing the care of the expectoration, I have learned that with the ambulaat patients the simpler the instructions, the greater is the likelihood of their being carried out. The following is a copy of the leaflet which accompanies the aluminum pocket-flask designed by me and illustrated on page 43 : " All expectoration — that is to say, spittle — contains germs. Some of these, especially when there is bronchial or lung trouble, are dangerous; thus it is best to be careful and gather the expec- toration, of whatever nature, and destroy it before harm can be TREATMENT OF AMBULANT TUBERCULOUS PATIENTS. 30 » done by it. To this end pocket .sputum-flasks have been devised. They are destinetl, in all cases of bronchial and lunj,' affections, to receive the expectoration or spittle, which, if not carefully jjathered and destroyed, may become the cause of spreading disease to others. This method of disposing of the sputum also protects the patient him.self from taking the .same germs into his system again, either by inhaling dust containing particles of the dried sputum or by infecting himself locally through sores. It is not .safe to use a handkerchief to spit into, since in this way an infection of the nose is possible. The pocket-flask has an hermetically closing cover, and can safely be carried in the pocket. It can be easily hidden in the folds of a handkerchief, and thus its use will not attract any attention." Instruction for Use and Cleaning tiik Pockkt-flask, To open, take the flask in the right hand and press the thumb against the side of the projecting front s])ring. To close, press the cover down with the inde.x finger. To empty the flask, unscrew the top and pour the contents into the water-closet ; or fold a newsjiapcr into several layers, pour the con- tents on to this, and throw the whole at once into the fire, being careful not to s\n\\ any. Rinse the flask in hot water and wash the hands immediately afterward. In case the washers wear out, rei)lace them by new ones. The pneumatic-cabinet treatment, such as described on page 220, is of especial value in office and dispensary practice. Besides its beneficial effects on the patient's general condition, which he will realize after a few seances, the psychical influence which such treat- ment produces on the consumptive's mind is of incalculable value in the treatment of the average dispensary patient. He sees and feels that something especial is done for him. He rapidly gains confidence in his physician, and his hopes for recovery increase. Whenever possible, the ambulant tuberculous patient should be seen at least twice weekly. li CHAI'IKR XXIV. TREATMENT OF CONSUMPTIVES AT THEIR HOME. The great majority of tuberculous patients cannot, for various reasons, be treated in either sanatorium, special hospital, or health resort; and for these their home will be the only place to seek rest and relief, and become, if possible, restored to health. To be brief, I may say that the best thing to do under such circumstances would be to imitate, as nearly as is practicable, the treatment out- lined for the sanatorium patient. This will be possible if the patient is willing and socially so situated as to have at his com- mand all the comforts and surroundings which the hygienic and dietetic treatment necessitates. Hut such patients are relatively few. The majority of consumptives are poor or have c.ily mod- erate means. For the absolutely poor the municipal sanatoriimi or special hospital is the only place. For those of moderate means I will endeavor to offer a few suggestions which will make an imitation of the sanatorium treatment possible — a*, least, in a measure. The largest, pleasantest, sunniest, best-ventilated room should be given up to the patient. Drafts should be avoided as far as pos- sible, but this precaution must not be carried to extreme so as to make the patient afraid of a breath of fresh air. If the bed- room is too small to make it possible to place the bed to avoid the direct draft from the open window, a substantial screen should be u.sed as a protection. The carpet, heavy curtains, and super- fluous furniture should be removed, without, however, leaving the room cheerless. Small rugs and curtains that can be washed may be retained. All the hygienic rules laid down in our chapter on Prophylaxis, concerning precautions with the e.xpectorations and other secretions, as well as not raising dust, should be religiously adhered to in the private home. During the day the lounge or reclining-chair should be moved near the open window, if there is no porch or balcony. In summer, or on not too cold or windy days in winter, the patient may be placed, warmly wrapped, on his 302 i\ ES? TREATMENT OF CONSUMl'TIVES AT HOME. 303 chair on the flat roof, protecting his head from the sun by an umbrella or a small, improvised tent. If there is a yard or };arden, a small platform of boards may be arranged for the cliair in a spot sheltered from the wind. A plain steamer-chair, padded with a quilt or blanket, will answer the purpose just as well as a costly reclining-chair. Another good and simple method of carrying out the " Liegekur," or rest cure, in the open air is the one =.__ f/' ; !f Fig. 75. — Rkst Curb at Homb. suggested by Daremberg.' A large beach-chair of wicker-work, such as is seen in our fashionable sea-side resorts, is procured. After the seat has been removed the inner walls are lined with padding. A leclining-chair is placed with its back in the interior, and the whole arranged so that the patient is protected from the wind and sun. There tlie patient installs himself for the day, with ' Daremberg, " Traitement de la Phtisie Pulmonaire," vol. u. >f 304 PULMONARY TUBERCULOSIS. ft.:! . t [■ his books or writing-materials at his side, placed on a little tabie, on which his meals may also be served. The accompanying illus- tration (Fig. 75) will show how easily such an arrangement can be effected. Being light, the whole can be shifted whenever th wind changes and according to the position of the sun, so that the invalid's body may be bathed by the rays of the sun, while the head remains in the shade. Rest cure, breathing exercises, and the amount of walking the patient may be allowed to do, should be regulated each day by the attending physician. In our chapter on Preventive Treatment we have already spoken ' f the often excessively dry atmosphere in many of our HUMIDIFIER I FLOOR REOISTER WATDO TANK 3 SHEETS OF OTTON FELT. Fig. 76. American dwellings, and ascribed to this condition the frequent occurrence of nasopharyngeal catarrhs. In the room mostly jc- cupied by the pulmonary invalid there will be, perhaps, no need of any arrangement to combat a too great aridity, since the patient is suppo-sed to keep the window open most of the time. But in the other rooms where he may have occasion to remain for a time, and in the interest of the health of his friends and relatives as well, the use of a humidifier will make the atmosphere less arid, and a lower temperature will suffice to rentier the rooms comfortable. A more humid atmosphere will especially benefit the patient if he is inclined to laryngeal trouble. • The humidifier of which I give an illustration (Fig. 76) is the invention of Dr. Henry J. Barnes, of Boston, Mass. It consists of aassm ■IUH>».'.J— aiiUJJ' TREATMENT OF CONSUMPTIVES AT HOME, 305 an outer case covering a wall or floor register, with a tank for water, over which are suspended strips of cotton felt aggregating about twelve square feet of evaporating surface. These are con- stantly wet through capillary attraction, and impart to the air flow- ing between them from one to twelve quarts of water in twenty- four hours, depending on the percentage of moisture in the air en- tering the case. To further illustrate the usefulness of the humidi- fier, I will quote from Dr. Barnes' paper, read before the American Public Health Association,' the following interesting passage: " During sixteen days of last February I obtained in my ofiice with this device a mean of 53 per cent, relative humidity, with ex- tremes of 67° and 40° in a mean temperature of 65.3°, through the evaporation of from 2 quarts to 2 gallons of water a day, the average being 4 v< quarts. During this period the outside mean temperature was 32° and relative humidity 73^ per cent., with extremes of 92° and 50°. " I found 65" perfectly comfortable, whereas, without the artificial supply of moisture, I required from 70° to 71° temperature. " I could have obtained a higher mean relative humidity by adding more strips to the humidifier, thus increasing the area of the evaporating surface ; but this would be attended with an exces- sive deposit of moisture on the window-panes, either in the form of vapor or frost. Where single window-sashes are in use, the dew- point — or the saturation of the cold air near the windows, which causes the deposit of dew — takes place more abundantly than where double sashes are employed, as a consequence of the cool air being unable to hold in solution the volume of watery vapor that exists in the warmer air of other parts of the room. At zero tempera- ture dew begins to be deposited when the air contains but .564 grains of water in a cubic foot ; at 70° temperature it takes nearly sixteen times as much in a cubic foot to cause a deposit. This deposit of moisture on windows serves as a valuable guide in de- termining the number of sheets, or the area of evaporating surface, necessary to maintain a jjroper relative humidity in any particular room where artificial hydration is employed. When the required area of evaporating surface is once known, the apparatus works automatically. If the o-'tside air supplying the furnace is com- paratively warm and moist, but little water is extracted from the i '■'\-\ ■': 1- * ; ll, 1 Hi ^H n ' i ' - 'tl ' " riie Arid Alriiosiilu'ic of ( )ur Houses in Winter," 1898. 30 3o6 PULMONARY TUBERCULOSIS, l!#l! sheets in its passage to the room ; if cold and dry, it takes water from the sheets with great rapidity." How a hydrotherapeutic arrangement can easily be improvised at home with the aid of an English bath-tub, a wooden chair, and a pitcher ur watering-pot, has already been described (page 232). The friend, relative, or nurse intrusted with the care of the patient should always sleep in another bed, and, if possible, in an adjoining room. He or she alone should be responsible to the physician. All interference of well-meaning but often ill-advised friends should be strictly forbidden. Only the food and such deli- cacies as are ordered by the physician should enter the room. Short, pleasant visits, especially of congenial persons, will do the patient good; but all persons for whom he has a dislike, or who excite him, should be kept away as much as possible. If the patient is too weak to leave the bed, cuch an arrangement with pine-*^rees as has been described in the chapter on Special Hospitals on page 295, will be a pleasant and useful addition to the sick-room. If, on the other h^.nd, the patient is in the incipient state, convalescent, or strong enough to go to the physician's office, the pneumatic-cabinet treatment should, if possible, be applied daily. As in sanatoria, so at home the pulmonary invalid should spend most of his time trying to get well. To keep him in good cheer will be the task of his companions and friends, but to see that he carries out with greatest regularity all that is required of him in regard to treatment and prevention will also become one of their important duties. Carelessness with the expectoration should never be tolerated under any circumstances ; neither should the patient be allowed to indulge in anything forbidden by the physician, as, un- less the latter has absolute control of all that concerns the hygienic, dietetic, and symptomatic treatment, a cure in a private home cannot be hoped for. In many cases an instruction-leaf for each day, left in the hands of the nurse, will assure a better care of the patient. The treatment of tuberculosis in a private home by the family physician can and should be prophylactic in the broadest sense of the word. It is the family physician who will see the incipient cases first; it is he who will know or discover the predisposition to tuberculosis of any member of the family. Through a wise and judicious treatment, instituted in time, the family physician will thus cure an incipient tuberculosis, and prevent a predisposed person from acquiring the disea.se. M>v iRm es water provised lair, and ige 232). of the sible, in le to the -advised uch deli- e room. 1 do the ;, or who ngenient n Special on to the incipient n's office, ied daily. Lild spend od cheer e that he 3f him in e of their luld never patient be in, as, un- hygienic, lie cannot li day, left le patient, he family t sense of incipient josition to wise and iician will edisposed i' CHAPTER XXV. SPECIAL INSTITUTIONS FOR THE CONSUMPTIVE POOR ; CARE OF CONSUMPTIVES BY THE AUTHORITIES; THE SOCIAL PROBLEM OF TUBERCULOSIS. We now come to the subject of special institutions, such as hospitals, sanatoria, dispensaries, etc., for the exclusive treatment of the consumptive poor. To my mind, the multiple creation of such institutions will solve, more than anything else, the difficult problem of how to reduce the mortality from tuberculosis and prevent its spread in general. How true this is has been shown in no other country as well as in England. It is there that the idea of special hospitals and sanatoria for the consumptive poor originated. The Royal Hospital for Diseases of the Chest and the Brompton Hcspital of London were the first institutions of this kind which opened their doors to the tuberculous patient without means. While the marvelous reduction of the mortality from tuberculosis in England must be in part ascribed to the generally improved sanitary condition of the country, I claim that a good deal is due to the workings of these and similar institutions now for many years in operation in England. I am indebted to Dr. Tatham, the statis- tical superintendent in the Registrar-General's office, for the fol- lowing interesting statistics showing the reduction of mortality from phthisis pulmonalis: The death-rate per million of the population of England and Wales from pulmonary tuberculosis — 111 1S70 was " 1S75 " " 1880 " " 1S85 " " l8i)0 " 2410 2202 1869 1770 1682 In 1S93 was 1468 " 1S94 " I3«S " 1S95 " '39S " lSi)6 " 1307 If the relatively few institutions of this kind have been instru- mental in doing so much good, what might not be accomplished by multiplying these special hospitals and sanatoria for consump- 307 i i 111 308 PULMONARY TUBERCULOSIS. A visit to a tenement hunie. Average life of an honest laborer who is tnbercu- lous. tives all over the world ! That there is a great and urgent need of such establishments, especially in and near the large centres of population, no one who has any experience with the consumptive poor of any large city will dare to deny ; and that the majority of general hospitals are ill-adapted to the treatment of tuberculous patients is also too well known to need repeating here. The description of the life of a poor consumptive before and after his admission into the general hospital will constitute the best plea for sanatoria for the poor. Let us begin by a visit to the districts in whose narrow streets, crowded with humanity, most of the poor tuberculous patients live. We make our way into a house through the little world in rags playing on the sidewalk. The hallways are dark, and the odor indicative of crowded and unclean rooms greets us. We ascend one or many flights of stairs, in the rear or in the front — it makes little difference. There lives Mr. So-and-So with his wife and several children. They occupy two rooms, rarely three; but only one receives direct light and air. And in these few rooms live, cook, eat, sleep, and often work from eight to ten human beings. We inquire after the patient, and find him lying on a couch or bed in a dark bedroom. We examine him and find him suffering from pulmonary tuberculosis in the last stages. On examining the other members of the family we find one or two of them already " touched " by the deadly germ. How easy it is for this infection to take place in close and unclean quarters occupied by ignorant or careless people has been already fully described. Of the natural defense against tuberculosis, which is inherent in all robust and healthy individuals, little can be expected among the inhabitants of these tenement districts ; for, alas ! they are mostly underfed, and their unhygienic surroundings are ill-adapted to increase their power of resistance to disease. Let us take, for individual illustration, the case of an honest laborer who has the misfortune to become tuberculous and finally phthisical. Me will at the onset seek the advice of his family physician. Presuming that a correct diagnosis has been made, the physician is likely to prescribe, with the usual remedies just then in vogue, also a few weeks of rest. This, under the most favorable circumstances, means a consumption of a part of the asK THE CONSUMPTIVE POOR IN GENERAL HOSPITALS. 309 rarely savings. After a while, tiie patient, seemingly improved, resumes his former occupation ; but the improvement is not lasting. He is again and again obliged to take a rest. The intervals between the periods of work become longer and longer. Instead of the physician, the nearest dispensary is visited, for there has been too great a drain already on the little capital put aside during better days. At last, unable to work at all, he stays at home until forced to seek admission to one of the public hospitals. A large number of general hospitals, supported by private Sojoum in chanty, absolutely reiuse all patients surfermg from tuberculosis, hospiwi. and it is but natural that the attending physicians of the general municipal hospitals, if not obliged to accept tuberculous cases, should also avoid crowding their wards with such patients, espe- cially if there is a likelihood of a very prolonged stay. Thus the consumptive often obtains admission with difficulty. Finally admitted, he is placed in one of the general wards. His neighbor to the right may have typhoid fever; the one to the left, a pleurisy afrigore ; opposite him may be a rheumatic or a fellow-consump- tive. If the physician-in-charge is in favor of medication, the patient will receive the latest remedies well spoken of in the treat- ment of tuberculosis. If the doctor is skeptical as to the value of medication in this disease, the patient may or may not receive the special diet, and the rest is left to nature. In the morning, before the arrival of the visiting physician, the poor consumptive inhales the dust, and with it countless numbers of pathogenic microbes, raised by the attendant sweeping the ward with an ordinary broom instead of wiping the floor with a moist mop. If the patient has not yet his mixed infection he will soon get it. Instead of pass- ing most of his time in the open air, the consumptive in our gen- eral hospitals is almost totally deprived of this essential factor in the treatment of his disease. Should he, day or night, ask to have a window open, his rheumatic neighbor would very strenuously object, for he could not stand the draught. Respiratory exercises are but rarely recommended, for the physician knows they are useless in the ordinary hospital atmosphere. At meal-times the consumptive patient eats but little. The frequent anorexia he can- not overcome, and even the special diet does not tempt him. The acrotherapeutic and hydrotherapeutic measures, so largely and beneficially resorted to in sanatoria to overcome the loss of appe- tite, cannot be carried out in a general hospital. At night the sn ' i '!! ■■ . 3IO Danger to patients sufl'eriiig from acute diseases. 11 Sanatoria as educa- tors. PULMONARY TUnERCULOSIS. patient sleeps but little. He is either kept awake by his own cough or that of his neighbor. The stuffy night atmosphere of the ward furthers still more his hyperhidrosis. Thus he passes weeks, sometimes months, until a fatal termination ends his suffer- ings ; for these patients rarely enter the hospital in time even to hope for a lasting amelioration. During this time the family, deprived of its natural supporter, is most likely to have become a public charge. How does the presence of the consumptive in the general hos- pitals affect the other patients suffering from acute diseases? Leaving aside the depressing mental effect upon these patients, v-t know that it is next to impossible to have such thorough hygienic and prophylactic measures in a general hospital as are characteristic of the sanatorium. Is not the patient with his pleurisy a frigorc in great danger of having his acute infection transformed into a chronic tuberculous one ? And the typhoid fever patient, with his greatly reduced power of resistance, may not he also become the prey of the bacillus tuberculosis ever present in our general hospitals ? The medical and sanitary advantages which would be obtained by the creation of municipal sanatoria for consumptives are evi- dent, but these are not all. The patient with incipient phthisis, after a few months' practical training in the sanatorium, will have learned how to take care of his expectoration, to avoid auto- infection or the communication of his disease to others. He will have learned how to avoid the causes which may aggravate his condition, and acquired such hygienic habits as to have the best chance to become and remain entirely well. But sanatoria do not serve only as educators of individuals, but as educators of communities as well. In the villages where the two largest German sanatoria are situated, Goerbersdorf and Falkenstein,- the mortality from tuberculosis has actually decreased among the village people, being now one-third less than before the establishment of these in.stitutions. This, no doubt, is due to the example set by the inmates of the sanatoria, and it is also the best proof that well-conducted .sanatoria for consumptives are not 1 Roempler, " Beitrage zur Lehre von der chronischeii Lungenschwindsuclit." 2 Nahm, " Miinchener nied. Wochenschrift," No. 40, 1895. > ■o-i799, 14 1800-1809, 5 1810-1819, 9 1820-1829, 9 1830-1S39 8 1840-1849 6 1850-1859 7 1860-1869, 4 1870-1S79 5 1880-1889 5 Statistics proving tliat sana- toria arc no ilanutr to the neiKli- borhooil. These statistics become still more valuable when one considers that the population of Goerbersdorf has doubled in the last twenty- five years. Recently, Dr. Nahm has compiled the statistics of the village of Falkenstein. Here also the mortality from pulmonary tubercu- losis has been reduced from 18.9 per cent, before the establishment of the sanatorium to 1 1.9 per cent, after it was opened. I will give the statistics of Falkenstein in full as they were published by Dr. Nahm : iJEArilS FROM rilrlllsIS I'lI.MDNAl.IS. Before the Establishment of the Sanatorutiii. 1856-1858, . . . .17.2 per 100 I859-I86I, . • 7-7 " 1 862- 1 864, . . -2.6 " 1 865-1 S67, . . . . 14.0 " IS68-I870, . . . 16.7 '• 187I-IS73, . . . 21.0 " 1874-1876, , . • ■ 33-3 " After the Kstahlishment of the Sanatorium. 1877-1879 17.0 per too 1880-1882 14.6 " 1883-18S5 6.0 " 1S86-1SSS, .... 5.0 " 1889-1891, . 1892-1894, . • 139 . ivi Recalling the dreadful mortality from tuberculosis in general and military hospitals, among the Sisters of Charity and the ordi- nary nurses, as reported by Debove, Bergeret, Lombard, Cornet, Laveran, and Kirchner," induced me to inquire, when visiting the European sanatoria, whether any of the nurses or attendants there had ever contracted tuberculosis. I was told of one case (in Reiboldsgriin). A seemingly well young lady had entered the sanatorium as nur.se and died of consumption a year later. Careful 1 Knopf, "Are Sanatdria fcir Consumptives a Danger to the Neighborhood?" "X. Y. Med. Record," Oct. 3, l8y6; " Revue de la Tuberculose," Paris, vol. ill, p|). 313-319. ' Straus, " La tuberculosa et sou liacille," p. 453. t-\ ^^:l 312 PULMONARY TUBERCULOSIS. •'' pi 4< ' . ^iii ^i PI i Expense in American research revealed afterward that a near member of her family had died previously from tuberculosis. During his many years of service at the Brompton Hospital, London, Dr. Williams had not seen more than three or four cases among nurses or doctors where it seemed evident that pulmonary phthisis had been contracted there. The scrupulous neatness, the excellent hygienic condition, and the thorough precautions against infection from the expectoration make it almost impossible to contract the disease in this excellent institution. At Saranac Lake, the great American sanatorium, none of the twenty to twenty-five attendants have ever developed tuberculosis. The daily expenses of a well-equipped special hospital or sana- torium are little if any higher than those of a general hospital, and the results obtained there are certainly much better than anywhere else with this class of patients. From the statistics which I obtained I may be allowed to quote sanatoria, tjjg following figures to Substantiate what I have said in regard to expense in general hospitals, special hospitals, and sanatoria, and the results obtained in these respective institutions. The daily expense at the Adirondack Sanitarium for Consump- tives at Saranac Lake, reported by Dr. Trudeau, is $i.oo to Si. 25. Patients pay, however, only $5.00 per week, and the difference is made up by public contributions. The daily expense, reported by Dr. Stubbert, of the Loomis Sanitarium at Liberty, N. Y., which has a most modern equipment, is S1.43. Some patients pay $5.00, others from $10.00 to 520.00^ according to the location of the rooms. Like the Adirondack Sanitarium, it is also largely supported by private subscriptions. The daily expense at the sanatorium for the consumptive poor at Ruppertshain, reported by Dr. Dettweiler, is $0.61. The daily expense, estimated by P. .Straus, for the Municipal Sanatorium for Consumptives at Angicourt, France (in construc- tion), will be $0.82. Regarding special hospitals for consumptives, I was enabled to obtain from two institutions, appertaining to the two largest cities of the United States, the following figures : At St. Joseph Hospital for Consumptives of New York the average cost per patient, reported by Dr. Cauldwell.is about fifty cents; and at the Chestnut Hill (Philadelphia) Hospital for the Consumptive Poor the average daily expense, reported by Dr. Bacon, is about forty cents. EXPENSE IN GENERAL HOSPITALS. 313 ily had The following figures relate to general hospitals : against Country. Rbportkd bv HOSPITAI,. i < u si- >t/l >d < 39* < ^a Austria,*. . . ■ Prof, von Schrotler. Vienna General Hos- pital. AA'li 35 days. J0.35 Baden f I / Prof. Biiumler. Dr. F. Parks Weber. Freihurg Medical Clinic. Guy's Hospital, Lon- don, J0!« '94* * ' 1. 00 0.92 1 Middlesex Hospital, ., ., •75 \ London. ] St. George's Hospital, . . 1.5a England, . 1 The Author, London. St. Mary's Hospital, London. St. Thomas' Hospital, London. London Hospital, London. All hospitals in Paris ^^ •• 1.25 1-57 1. 17 0.66 France, . . J under the charge of i the Assistance Piib- I lique. f Prof, Rosenstein. Leyden General Hos- ., .. The Holland, . . { f Prof. Massaloiigo. pital. Verona Major Hospi- greater part. 34.03^ Italy { Dr. Ernest de Verdi. tal. Milan Hospitals. ° •• 0.38 1 I Prof. Fiirbrinser. Berlin General Hospi- l-2-f. 433!' 47-5^ 30 0.65 Prussia, . . Prof. Mosler. tals. Greifswald Medical 25ri 'i-rl^ days. Clinic. ( 1 Prof. Eiohhorst. Ziirich Medical Clinic. \.(f!- 37.5f' 35.49:< • • Switzerland, Prof. Ininicrniann. Biivger-Hospital, Basel. 5ori 36^ days. 0.70 Dr. Nicolas. Neuchfttel Hospital. 20. K 49,6^0 ( Dr.J. N.Walker. Cook Countv Hospi- tal, Chicago, III. 55.5f« 20.4^ •• • • \ Dr. Brainerd. Los Angeles County, , , 50< 14,S 1. 00 1 Hospital, Cal. days. United States ' The Author. (1 ^ Alithe New York City hospitals under the direction of the Cominissioii of Char- ities. ■■ ■■ 1.16 .,:. 5 f^i>' i '1 The results obtained in sanatoria for the tuberculous poor, or inKesuUsob- those institutions where the patients pay only a certain proportion sanatorii'i for their maintenance, are virtually the same as those obtained insmnptive paying institutions, the statistics of which will be found in the concluding chapter. The Loomis Sanitarium at Liljerty, N. Y., reiiorts 25 per cent, of cures and 50 per cent, of ameliorations ; 70 per cent, for early cases. I- Il ! 314 PULMONARV TUllERCULOSIS. The Adiroiulack (.'ottage Sanitarimn for Consumptives at Saranac Lake, N. Y., reports 20 to 25 per cent, cures and 30 to 35 per cent, ameliorations. 'I'he Sharon Sanitarium near Boston, Mass., reports 25 i)er cent, of arrested cases and a nincli larger i)ercentage of improvenu-nts. The Hahla Sanatorimn fci the Poor, Finland, reports 36.7 percent, of cures and 33 ])ercent. ameliorations. The Falkenstein Sanatorium for the Poor, now at Ruppertshain, Ger- many, reports 13 per cent, absolute cures and 77 per cent, ameliorations. While in the three above-mentioned American sanatoria, as a rule, only patients with incipient phthisis are admitted, at the Chestnut Hill Hospital for the Consumptive Poor, in Philadelphia, patients even in the very advanced stages are received. Still the institution could report the following results : Disch.irged as cured, 8 \ht cent. Improved, ^'-'1 percent. Unimproved, 6^, ner cent. Died 17'^ percent., and the average daily expense was only between thirty and forty cents. It may not be unintere.sting to add to the above statistics the results obtained in public sanatoria devoted exclusively to the treatment of scrofulous and tuberculous children. It seems that in the young the sanatoriimi treatment, especially in institutions situated on the sea-shore, is particularly successful. Here are the statistics of five institutions, four situated in France and one in Denmark. Sir't-- Location. Reported by MORTAI.- ITV. Curbs. Improvhd. AVKRACK Stay. Ormesson, . . . . Dr. (aoul. 8.2% 34 '/r 30 '/, 7 inc Villiers, (* Vaquicr. 8.8/. 25-5 '/' 34-4 '/' Forges-les-Bains, . . n Dnnienge. . . 50 '/'■ 25 '/' 12 Arcaclion (. I.ales .^ > r y > for the con- Schrottcr ' for Austria ; Grancher,'* Letulle,® and Petit ^ for France ; uniptive ) > ) I Weber,'' Lindsey,'-* and Walters '" for England ; Hansen " for Nor- way; Saugmann '" for Denmark; and in the United States we ' Dettweiler, " Mitthellungeii iiber die erste Volksheilstatte fiir unbemii., 'n; ■j^n- kranke in Falkensteiii iin Tiunus," " Deutsclie meil. Wocliensclirift," iJi 2. . ., \ - Von 1-cyden, " Lber die gegenwiUtige Behandluiig Ttiberkuloser und die st . \\. un Fiirsorge fiir dieselben," XII. Internationaler Congress, Moscow, August 25, 1897. ' Liclje, Cieorg, " Die Hekiiinpfung dor Tiiberkulose," " Deutsche Vierteljalir^sclirift fiir oiTentliclie Ges uidheitspllege," 1898. * Von SchriUter, " Cber den gegenwiirtigen Stand der Frage der Errichtung eigener IleilslStten fiir die Tuberkulose, " " Allgein. Wiener Med.-Zeitung," 1892. ° " Rapport par M. le Prof. Grancher, Seance de I'Academie do Medecine de Paris," du 3 Mai, 1S9S. " Leiulle, " I.es Tul)erculeiix dans les Ilopitaux de Paris," " Presse "^T'dicale," 1S94, p. 215. ' Petit, L. H., " Allocution du Secretaire," IV. Congris de la I'u ^ . 1 se, 1898. ' Weber, Ilennann, " Croonian Lectures on ttie I lygienic and t'liinaii : i rcalinent of Chronic Pulinonary Phthisis," London, 18X5. ° Lii.dscy, " I'rolilcin of the Consuni|.tive Poor." Inaugural address. "The Lancet," London, Dec. 4, 1897. 10 Wallers, "Sanatoria for Consumptive PiUient-.," "The Practitioner," London, June, 1S98. "Hansen, Klaiis, " Forslag lil offentlige Foranstallninger mod Tuberkulosen," Chrisliania, 1895. " Saugniann, Chr.," Sanatorier for lirystsyge," Copenhagen, 1897. mtmrnm ases, will the weak, atter will, If they hances of increased, nstitution sanatoria ities must on of pro- omen, and n of such nany ; von 3r France ; ' for Nor- Statcs we L, 'ii; Jili- 2 . ' . '. 1 die St . 1.1: w 25, 1897. rteljal'r«sclirift htung eigcner 2. ine de Paris," ■dicale," 1S94, se, 189S. c 1 realinent of 'riie l.nncet," ler," London, 'uberkiilosen," SANATORIA FOR THE CONSUMPTIVE POOR. ;3i have in Bowditch,' Hamilton,- Biggs and Prudden,' Lee,' Tru- deau,-' Flick," Hinsdale,^ Otis,' Shrady," Rose,'" Brush," Gibier,'" and others,'^ strong advocates for the establishment of State and municipal .sanatoria for the care and treatment of the consumptive poor. The crowned heads and princes of Europe, such as the Czar of Russia, the Emperor and the Empress of Germany, the Emperor of Austria, the King of Saxony, the King of Sweden, the young Queen of Holland, the Prince of Wales, and others, have placed the sanatoria for the consumptive poor under their high pro- tection, and have opened their private purses most liberally for their support. The nobility and the aristocracy in finance, art, and literature have been eager to imitate the admirable example .set by their sovereigns, and the latter, too, have given freely toward the erection and maintenance of such institutions. Thus, in the countries just mentioned a number of establishments now flourish, ' Bowditch, " Ticatiiient of I'htliisis in S.-inatoria near our Homes," Annual Meet- inji of the Mass. Med. Society," June, 1S96. ' 1 lamilton, " The I'revenliun of 1 iil)erculusi>," " Journal of the Anier. Med. Assoc. , June 12, i8()7. " Biggs and Prudden, Communicatiim to ihe lion. C. ('•. Wilson, President of the Hoa>(l of Health," Jan. II, 1S97, " .\. V. Med. Journal," Jan. 27, 1S97. ■* Lee, lienjamiii, " Present .Attitude of Sanitarians and Hoards of Health Toward Pulmonary Consumption." Paper read before the Section of State Medicine of the .Anur. Med Assoc, June 3, 1897. '^ Trudeau, "Sanatoria for the Treatment of Incipient Tuberculosis," "Medical Record," Pel). 13, 1897. " Klick, "Special Hospitals for the Treatment of Tuberculosis," "Times and Register," March 15, 1890. ' Hinsdale, " Recent Measures for the Pieventioii and Treatment of Tuberculosis," " The Medical News," August, 1S94. " Otis, " The .Sanatorium or Closed Treatment of I'hthisis," "X. V. Med. journal,'' June 13, 1896. • Shrady, " Medical Record,' vol. I.ll, p. 632. '" Rose, " Gaillard's Medical Journal," New York 18S5, vol. l..\. ''Brush, Geo. W., "An Act to F.stablish a State Hospital for the Treatment of liicipient Pidmonary Tuberculosis." Hill before the Legislature of the State of New ^■ork, 1898. '■'Uibier, Paul, "Proposed Hospital for Physicians Affected with Tuberculosis," March, 1897. ' ■' Mannheiiner, " N. Y. med. Monatsschrift, " May, 1897 ; Kennedy, J. 1'., " Iowa Health Hullelin," April, 189S. 21 (■---■ 322 PULMONARY TUBEKCULOSJS. 1^5 Ui which are doing a world of good by curing the curable tuber- culous cases and taking care of the hopeless ones, thus diminish- ing countless centres of infection. If a government is in earnest in its endeavor to combat tuber- culosis effectually, besides its regularly enforced laws against bovine tuberculosis, its thorough hygienic and prophylactic measures against tuberculosis in man through sanitary regulations and public instruction, it must take upon itself the care and treat- ment of the curable and incurable cases of tuberculous patients among the poor and among those of limited means. I mean here, by limited means, a financial condition which does not permit a tuberculous patient to enter a private sanatorium or to have at home such medical, hygienic, and dietetic care as will assure him the best possible chance of recovery. A point next to be considered would be how to recruit the patients and how to discriminate between the proper and improper cases, and thus avoid increasing the dreadful and degrading abuse of medical charity, from which physicians, and especially the general practitioners, suffer so much in these days. Just as there exists in nearly all States or municipalities a com- mission or a number of special examiners for the purpose of deter- mining who is the proper subject for State care in an asylum for the insane, so should there exist a commission for the determina- tion of admission to a municipal or State institution for consump- tives. Such a commission, composed of a certain number of general practitioners and health officers, should be aided in its work by the charity organizations. ICach and every case should be investi- gated by a combined committee of physicians and laymen for the following purposes : 1. To ilctermine the applicant's condition by a medical exami- nation. 2. To visit his homo if he has been found tuberculous, and to institute such hygienic measures as seem necessary (distribution of pocket-spittoons, disinfectants, etc.). 3. To examine the other members of the famih' in order to find out if any of them have also contracted the disease, and, if so, to counsel proper treatnient. 4. To report in full to the sanitary authorities concerning the condition of the patient's dwelling. Its renovation or even PLAN TO SOLVK TIIK TUHERCULOSIS PROBLEM. 323 destnictioii may become imperative when it is evident that tuber- culosi.s has become " endemic " tiiere, owing to the condition of the seil or to other sanitary defects. 5. To determine the financial condition, whether the patient is or is not able to pay, and whether or not by his being taken to an institution the family will become destitute. If the latter should be the case it would become the duty of the municipality to pro- vide for the family. In many cases, a letter of inquiry, sent to the former medical attendant of the patient, would materially aid the work of the investigation committee. Any individual should have the right to present himself for examination, and every physician should be at liberty to recom- mend any person for examination to the board of his precinct or district. The institutions needed to carry out this plan would be : institution ' _ ' _ iieeileil to 1 . A centrally located reception hospital and dispensary. The dis- eireciuaiiy pen.sarv should treat the ambulant tuberculous patients, whose ad- '"''>''>'"■ ir J I • losis III mission into the sanatorium is impracticable or has to be delayed for'"^"- want of room. These dispensaries should also serve the patient discharged from the sanatorium as a place to seek counsel, and thus aid in his continued improvement or guard against approach- ing relapses. 2. One or several city sanatoria, located in the outskirts, and, if possible, in a somewhat elevated region, where the atmosphere is known to be pure. Mere ail patients should pass through a pre- paratory sojourn before being sent to the mountain sanatorium. The more advanced cases would all be retained here. 3. One or several mountain sanatoria at no greater distance from the city than three or five hours by rail, at an altitude, if possible, of between one thousand and two thousand feet, on porous ground with southern exposure, and as nearly as possible protected against the coldest winds, preferably surrounded by a pine forest. A farm in the vicinity, where the thoroughly convalescent pa- tients can do light work, might make the institution in a measure self-supporting. To this place the selected incipient and the im- proved cases from the city sanatorium should be sent to com- plete their cure. To the mountain sanatorium there should also be attached a department for children suffering frt)m pulmonary tuberculosis. 4. Several sea-side sanatoria for the treatment of children li \ 51',. ! I »•! 1 ■If .!. 324 PULMONARY TUBERCULOSIS. Stale insurance at^aitist tubercu- losis. Ill afflicted with tuberculous diseases of the joints and other tuber- culous (scrofulous) manifestations. 5. A maternity sanatorium. Of the requirements of such an institution I have already spoken. By this plan it will be seen that I am in favor of treating tuber- culous patients near their homes, and in the same or nearly the same climate as that in which they will have to live and work after their restoration to health. My reasons for advocating such prin- ciples are founded on the experience of all modern phthisio- therapeutists, who have demonstrated that the hygienic and dietetic treatment in closed establishments is feasible and successful in nearly all climates. Only by adhering to these principles can we expect to cope suc- cessfully with tuberculosis — this disease of all climes, but which is most prevalent in large centres of population, where civilization has seemingly attained the highest standard. As stated above, these institutions should be open not only to the poor, but also to those in moderate circumstances who can pay part of the expense. For this latter class of patients, many of whom for reasons of a noble feeling of independence hesitate to accept public aid, I have often wondered if a plan, something simi- lar to the State Invalidity Insurance Companies of Germany, could not be inaugurated in this country. There, the moment an indi- vidual enters upon the career of an ordinary laborer or servant, he is obliged to be insured against sickness, accidents, and old age. If he develops tuberculosis he is immediately .sent to one of the many sanatoria of that country. The government authorities, who are at the head of these State insurance companies, have long since learned that, through a timely treatment in a sanatorium, the tuber- culous individual is most speedily and lastingly cured, and conse- quently with the least expense. Dr. Weicker, of Goerbersdorf, to whose institution a great many of such patients are sent by the government, writes me that the percentage of cures among these is higher than among the private patients. His latest statistics give a percentage of 80 established cures with only an average of 76^/ days of sojourn in the sanatorium. This marvelous result is to be explained by tlie fact that the government insurance ofificials send their patients to the sana- torium at much earlier periods than the private physician is likeh- to do. tuber- ich an STATE INSURANCK AGAINST CONSUMPTION. 325 Thirty-seven of these government insurance companies have, according to their published figures for 1S97, collectively assisted 44cSo consumptives, of whom 4432 were sent to subsidized sana- toria. Nearly all these State insurance companies contribute to the funds of such establishments; some have found it to their advantage to erect special sanatoria of their own. For the year 1897 these State insurance societies of Germany invested altogether 1.300,000 marks in sanatoria for consumptives; and for 1898a fund of between three and four million has been destined for that pur- pose.' How would it be if one of our most thickly populated States, after having created a number of sanatoria, would try the experi ment of a State tuberculosis insurance company ? How many families, even of the classes in fair circumstances, but in which tuberculosis is dreaded on account of the disease having been the cause of the death of some of their members, would not gladly avail themselves of this opportunity — especially since the existing life-insurance companies refuse apjilicants with a family history of tuberculosis? This opportunity offered by the State would mean giving to their children the certainty of being afforded the best possible chance of recovery, should they be taken down with the family disease. No matter at what age, so long as the individual remained insured, there would be the State sanatorium to receive and treat him. A payment of, for example, fifty cents a month from the birth of the child would give to the State insurance com- pany after fifteen years, with the accrued interest, a capital of nearly one hundred and fifty dollars. By paying the aggregate amount up to the date of application, any predisposed individual might be insured at any time, and such an institution be called into life at once. As has been stated, the greatest chance of a predisposed in- dividual being taken sick is between the age of puberty and thirty. The chances of the disease beconni.g healed without ever having been discovered are between twenty and twenty-five per cent. That is to say, that out of every hundred autopsies made on people having died accidentally, or of diseases other than tuberculosis, twenty to twenty-five show evidences of healed tuber- culous lesions (cicatrization or calcareous formation). The chances f 1 1 ■ ■; ! : ! S! ' " IleilstilUen Korrespondeiu," 1898. 326 PULMONARY TUI3EKCUL0SIS. Work for l>hilaii- lliropists. of this disease beini ( Saiiatuiiiini, Cures. (ioriuariy, HreliiiiLT " Acblcrmaiin. 7-5i!< tsi 50.55'< 7, Croerbt'rsilt)rf Snnatci iiiin, Germany, Kocniplei " Koempler. rsi 25-27'- s7'-r 22. ScliomherK, (ifiinanx' " Baudacli. Sz.iyi 13- Malchow b. Berlin, Germany, " Renter. '43^ AoH I , 1 will adtl that the sanatoria at Ruppe^rtshain, Malchow, Chest- nut Hill, and Ilalila are for the poor. In the Adirondack Sani- tariinn, Loomis, Sharon, Muskoka, and at Ventnor the patients pay part of the expense. At the Adirondacks, Rnppertshain, and Muskoka sanatoria they do not, as a rule, admit advanced cases. At the Chestnut Hill Hospital for Consumptives (Philadelphia) all cases, no matter how far advanced, are received. To distinguish between the terms absolute and relative cure, I will give Dett- weiler's definition. He calls absolutely cured the re-establishment of the normal functions of all the organs and the complete dis- 1 Deaulavon, " Contributions a retiule du traitement de la tuberculose inilinonaire," etc., " Thdse de Paris," 1896. 2 Holie, "Die liek.iinpfung und Ileilung der I.ungenschwindsnrht," etc., Miiii- clien, 1897. (Iff 330 PUI.MONAKY TUUKRCULOSIS. appearance of the bacillus. He culls a person relatively cured when his general well-beinj; has reapjicared in spite of regular coughinjj spells with some expectoration in the morninj^r. We may ask how long tiiese reported cures have lasted. Among 99 patients discharged from Falkenstein as cured 72 were alive and well at the time the inquiry was made, when the patients !iad left the sanatorium from tliree to nine years. In 15 cases a relapse had occurred, but 12 of these had im- proved again; 12 had died.' Dr. von Ruck, of Asheville, re- ported to me that he had written to 605 of his f ner patients who had left the sanatorium from one to three y Sefore ; 457 re- sponded, directly or through friends. Of the , felt absolutely cured; 70 felt relatively cured ; 258 felt still improved; 62 got worse or had died. Dr. E. R. Baldwin, of Saranac Lake, reported at a recent meet- ing of the American Climatological Association,- that at the Adiron(]ack Cottage Sanitarium they were in constant correspond- ence with 115 patients who had been discharged in the last ten or twelve years ; and while a few had relapsed slightly, the majority of them were well and at their homes. The results of all the curative treatments speak in favor of the hygienic and dietetic treatment under strict medical supervision; and, regarding prophylaxis, no measures have yet proved of any value except good sanitary laws, rigorously enforced, regarding the prevention of tuberculosis in man and beast, and the creation of sanatoria and special hospitals for the treatment, especially of the consumptive poor. In the preceding chapter, on the Social Problem pf Tuberculosis, I believe to have sufficiently demonstrated that in the end the commonwealth would be the financial gainer, even if the large stiff of physicians necessary for such institutions would receive a just retribution for their labors, which are most arduous in establishments where the constant medical supervision consti- tutes one of the most essential parts of the treatment. When the worthy but poor consumptive is taken in time to an insti- tution where liis chances of recovery are still good, he will not ' Deltwcilcr, " liericht iiber 72 scit 3-9 Jaliren in FalUensteiii vijllig geheilte I'allc von T.ungenschwiiulsuclit," l88t). 2 "New Yi'iU Medical Record," vol. I.\', No. I9. / I CONSUMPTION A SOCIAL DISEASK. 331 cured if^nilar 62 got Ii.ivc a chance to infect tlie otiier members of tlie family, and he is h'kely to return, after a relatively short sojourn, restored to lu-alth and liy^ienically educated, ready to betomc a^ain the bread- winner of his family. Now, as aheady shown, tlie maintenance of this i)atient in a municipal sanatorium for from three to six months or even longer, during the earlier sta^e of the liisease, will cost the commonwealth no more than if he had been taken to the general hospital for perhaps the same period of time, but in a much farther advanced and more hopeless state of his disease. Even the family will be C' onomically benefited by the removal of the consumptive to whose care much time and expense had to be devoted. How often does it not hapi)en that, owing to the chronic sickness of one member of the family, another or sometimes two are hampered in their wage-earning capacity? As has been shown on page 312, the daily expense of a patient in a plainly but well-equipped sanatorium for consumptives is little, if any, higher than the cost per day of a patient in a general hospital. If the family were absolutely destitute, the other mem- bers would have to be supported by the municipality, whether the head of the family were in a sanatorium or general hospital. But since, when treated in time and in a special institution, he has from twenty-five to thirty-five per cent, more chances of getting well, the likelihood of the community being obliged to support a widow and several orphans has thus also been reduced by nearly one- third. Consumption is a social disease, and society must help the medical profession to cure it, not only in the rich, but also in the poor and poorest classes. The plan on which the second German .sanatorium for consumptives was built shoidd serve practical philanthropists as a model enterprise worthy of emulation. Some twenty-odd years ago a few wealthy citizens of the city of Frank- fort-on-the-Main united with some of the leading physicians of that city to open a sanatorium for the wealthier class of consumptives. They pledged themselves to accept no more than five per cent, on the invested capital, the annual surplus, after repairs and improvements had been made, to go toward the erection of a sanatorium for the poor. Thanks to this and some additional donations there is to-day, at Ruppertshain, near Falkenstein, one of the most nourishing sanatoria for the poor. But, I repeat, we not only need sanatoria supported by private L li m^ 332 PULMONARY TUBERCULOSIS. beneficence, but also such as ar° in part or entirely maintained by tile State or commonwealth, where the poor or those able to pay a moderate price can receive the best care modern phthisio-therapy can bestow upon them. In the issue of October 30, 1897, the venerable editor of the " Medical Record," Dr. Shrady,^ referring to the papers on tuber- culosis read at the recent International Medical Congress at Moscow, recommends the establishment of special institutions in the United States for the treatment of pulmonary tuberculosis. This method of treatment, the discussion at the Congress showed, had met with so large a measure of success abroad. Concluding his excellent 'editorial, Dr. Shrady says: "The rational method of treating tuberculosis is, without doubt, for the sufferer to live under those conditions which fulfill, in the highest possible degree, the laws of hygiene and diet." What has been said on the subject of the treatment in these pages will show how thoroughly I am con- vinced of the truth of this statement. If we wage a vigorous war on all that is unsanitary in our cities, towns, and villages ; if we endeavor to raise the coming generation to be a strong people, able to resist the invasion of the pathogenic micro-organism which may escape the watchful eye of the sani- tarian ; if we can, by the creation c^ s.inatoria for all classes, rich and poor, and by carrying out the hygienic, dietetic, educational, and symptomatic treatment for all consumptives outside of such institutions, cure the curable and make harmless the incurable tuberculous patients, the problem of dealing with the most widely spread of all diseases will have been solved. What is needed to attain this end is the united working of the statesman, philanthropist, sanitarian, physician, and the good-will of an intelligent people ; for, as the immortal Pasteur has said, "It is tJi t/ic ptnver of 111(111 to cause all parasitic diseases to disappear from the world." ' " \ew York Meilicnl Record," vol. i u, p. 6^2. tained by e to pay a io-tlierapy tor of the on tuber- ij^ress at tntions in Derculosis. s showed, oncliiding method of live under iegree, the subject of I am con- our cities, Igeneration pathogenic \( the sani- lasses, rich ducational, ie of such incurable ost widely ing cf the good-will IS said, "/( ppear from ?f H INDEX A. Acid, I'yroligncous, 45 AdiroiulacU Cottage Sanitarinin, 159 Advocates of sanatoria for tlu; consumptive poor, 320 AerotliLrapy in laryngeal tuberculosis, 269 in sanatoria, 2I_^ in tlie treatment of fever, 259 rest cure and exercise, 213 After-treatment of hemoptysis, 257 Air l)atlis for children, 82 Alabama, OS Albertsberj;, Sanatorium of. III Alcohol in the dietetic trealnunt, 241 preilispo>ing 10 tuberculoNis, 6; Alland, Sanatorium of, 12S Altitudes, 1 li^h, 20t Intermediate, 201 Ordinary, 205 Ambler, Dr., on the use of tuberculin, 268 An\bulant patients, Instructions for, 29S Andral, Dr., on the cura'nility of pulmo- nary tuijerculosis, 31 Andvord, I )r. , on the rest cure at low tem- peratures, 213 Anorexia, 244 Antipyretics, 261 Antistreptococcic serum, 262 Arabic school on the conlagiousnei-s ar d curability of pulmonary tuberculosis. 18 Aretaus on the management of phthisical patients, 18 Arkansas, 68 Arid air of private dwellings, 88 Arnozan, I'rofessor, on revuUion, 253 AroMi, .Sanatorium ol, 1 23 Artificial pine forests, 2<)4, 306 Asheville Sanatorium, 174 Atkins, Dr., on the spread of tuberculosis in health resorts, 37 Atropine in pulmonary hemorrhage. 255 Auto-infection, ('utane di>infectanl, 44 Bicycle, 201 Bier's treatment of joint tuberculosis, 274 •i I 333 334 liiggs, Prof. Hcrm. M. INDEX. Hi: ifc'.su^s- 1 \:f\ IP' i! lis f on patliological proofs of the curability o f ])u 1 mo nary tul>erculosi^, report sliowing tlic (lecre;ihe in llie (leath- ratc from tu- bercular dis- eases in New York Ci ty, 317 Ulootl enetnata, 249 Hlooil-letting in phthisis puhnonalis, 21 lilumenfeld, J)r. Felix, on meteorological inlluence in phthisical patients, 205 liodington's. Dr. < ieorgc, early efforts in sanatorium treatment, 2^ Uoerhar.ve on change of localities for jihthisical patients, 19 Bolliiiger, Professor, on pathological proofs of the curability of pulmonary tubercu- losis, 32 Koston Free Home for Consumptives, 169 Houcliaril, Professor, on the curability of pulmonary tuberculosis, 33 Houdet on pathological proofs of the cura- bility of pulmonary tuberculosis, 32 Bovine tuberculosis, 66 J5owditch, Dr. Vincent V., 01^ the need of sanatoria near our homes, 320 I'rcathing-chair, Usedom's, 2l6 Breathing exercises, description of, 82 in sl, .S6 of pregnant women, Si Brehmer, Dr. Hermann, 24 Hrehmer's Sanaloriiun, 96 Bromplon Hospital, 133 Broncliilis, 270 Broncliorrhcea, 252 lirnoklyn Home for Consumptives, 181 Brouanlcl, Prof. , on infection through vac- cination, 52 on |)athological proofs of the curability of pnl- ni'inary lulKiculo>is, M Broussais' theory of inllainmalioii, 21 Brush, Dr., on the need of State inslilu- tions for the consumptive poor, 321 Bugge, Dr. , on the pathological proofs of the curability of pidmonary tuberculo.-is. Buildings for special hospilals, 294 Bureau of .Xninial Industry, /4 C. Cadeac, Dr., on the virulence of tubercu- lous products. 40 Calcareous foci, Dejerine's investigation of old, 34 Calcareous transformation of tubercles, 34 California, 69 Canigou, .Sanatorium of, 1 16 Carbolic acid as disinfectant, 44 Care of room, bed-linen, etc., 47 of teeth, 241 Carrera, Dr., on tuberculous infection through sexual relation, 32 Carswell, Dr., on jiathological ])roofs of the curability of pulmonary tuberculosis, 31 Catarrhs, Susceptibility to, 80 Cattle, F^xamination of imported, 76 Cauldwell s. Dr. Charles M., report of St. Joseph Hospital, 312 Causes, Social, [jredisposing to tuberculosis, 63 Cels\is on the .selection of climate for consumptives, 18 Central bureau. Work of a, to combat bovine tuberculosis, 74 Cervcllo's treatment by " formalina," 288 Charcot, Professor, on the curability of tuberculosis, 32 Chauveau, Professor, on the infectiousness of tuberculosis, 22 Chestnut Hdl Hospital for Diseases of the I.ungs, 162 Ciliary, Professor, on ])athological proofs of the curability of pulmonary tuberculosis, 32 Childbirth, 282 ( liildren, Tuberculous, in public schools, 60 t hills, 264 Chloride of sodium and intense minerali.:a- tion, 247 Cigars, Hacilli in, 47 Circulars for public instruction, 57 of the Pcniisylvania Society for the Prevention of Tuberculosis, .... 59 Circumcision, Danger of tuberculosis from iilnal, 53 Ritual — how it may be per- formed with safety, 54 t'itric acid to prevent coagulalimi, 44 Clarke, Dr., on the inoculability of lud- monary tuberculosis, 22 Cli'.wiing of spittoons, 44 Climate, Choice cil warm and colil, 202 Weber's classification of, 201 Climatic idiosymrasies, 202 Climate) therapy in the treatmiiit of pul- moiniry tuberculosis, 2co Coal-smoke nuisance, 64 Coals. Dr , on pathological proofs of the curability of pulmonary tuberculosis, J2 Cod-liver oil, 245 Cohnhcim on the inoculability of pul monarv tuberculosis, 22 inrection INDEX. 335 Collins and Murray's case of tuberculosis through tattoojjig, 54 Colorado, 69 Coinmunicahility of pulinouary tuberculo- sis 35 . Communion cup, ("oinmon, cause of the propagation of tlisea.scs, 48 Compensation for destroyed tuberculous tattle, 76 Conclusions, 328 Connectici.i, 69 Constipation, 25 1 Consumptives in health n-sorts, 290 Contagious nature of tuberculosis, I'opular belief in the, 20 Cornet, Dr., on the danger of careless and promiscuous expectorating, 36 on the inoculability of pul- monary tuberculosis, 22 Cornil, Professor, on the cuialiilily of pul- monary tuberculol-. 32 on the inoculability of pulmonar^ Mibcreulu sis, 22 Cough, 251 Counter-irritants, 253 Craigleith Hospital, 136 Creosolal, 246 Creosote, 246 Cullen's, of F.dinhurgh, singular o])inion on the contagious nature of lujjerculosis, 21 Culture products, 2cSt) (Juraliilily of |)ulmonary tuberculosis, Path- ological procifsof the, 31-34 Curchot and ( arriere on buttermilk and grapes as diet, 22 Cure, Duration of, obtained in home eli males, 20? Cure.' con- sumptive poor, 320 on the rest cure, 25 on the duration of cures obtained in sanatoria, 330 Dettvvi iler's " Hustenflaschchen," 42 Diabetes, 273 Dianhiea, 250 Diet in laryngeal tuberculo-is, 26S I iietelic treatment of fever, 2t)0 ol |julmonary tuberculo- N 237 Dilalaiion ;.! the stoui.u h, 250 Directions fo? inspeclini; hei Is, Prof. Pear- son's, 74 Discipline, 2/'; Discovery, K' ^, of the bacillus tuber- culosis, 35 Diseases, Phthj^jo gencsic, 88 Di^ nfectant, liiehlnride of mercury as, for tubercuWius secretions, 44 Carb'ilic i as. for tubercu- lous I el ions, 44 Viixx. . iiicgar as, fortuliercu- Iiui>. secretions, 45 Disinfection free to the poor, 58 of railway cars, The need of regular, 60 of spoons, knives, etc., 21 1 of stools in intC'tinal tuber- culosis, 51 of theatres, churches, inu^ic halls, etc., 61 with formaldehyde, 58 Dispensary patients, 297 Disposnl of the tuberculou> dead. <>2 Dissemination iif bacilli through sputum. Distribution, (ieographical, ot bovine In berculosis, Gy District of Columbia, 6i) Domestic pels, Tuberculosis in, 50 i'l :m^n 336 INDEX. Iff, ^i0^ i Oouclie appaialiis, Improvised, 2J2 Douche rouiii, AiT.\ii{;emeiu of, 226 DiOhS for liolli sexes, lieiieral rules coii- cerniiif,', 234 Dress reform, jeniiess-Miller system of, 255 Dresses, Loiij; trailing, a danger to tlie |mblic health, 62 Dry tuberculous sputum a propagator of disease, 36 Dupre de Lisle on horseback riding in consumption, 20 Duration of cure obtained in home cli- mates, 206 of cure obtained in sanatoria, 330 Dyspna-a, 264 B. Earthworm a propagator of tuberculosis, 51 Eaters, Horn l)aanitarium, I47 Galen on the contagious nature of tubercu- losis and its treatment by high altitudes, 18 Galtier's, Dr., experiments of freezing and thawing tuberculous sputum, 40 Cjeneral hospital. Sojourn in, 309 medicinal treatment of fever, 261 Georgia, 69 Geihardt, Professor, on the ul- monary, 255 Herard, Dr., on the inoculubility of pulmo- nary tul)erculosis, 22 on the curability of pulmo- nary tuberculosis, 32 Hinsdale, Dr., on ihe need of special institutions for the consumptive poor, 321 Hippocrates on the curability of tubercu- losis through rest and exercise, 17 History of tuberculosis, Interesting data in the, 17 Hitchcock, Dr. W. W., on the lack of (ihysical development in children, 86 Hodenpyl, Dr., on the action of dead bacteria, 47 Hoffa's treatment of local tuberculous pro- cesses, 275 Hoffmann, Dr. Friedrich, on moist atmos- phere, 19 Hoheiihonnef, Sanatorium of, 105 Holy water may transmit disease, |8 Home climate, 203 Home, The, at Denver, 177 Homes, Treatment of consumptives at their, 302 Hufland on the hereditary influence of tuberculosis, 21 Humidifier of Dr. liarnes, 304 Hurty, Dr. J. N., oti the tuberculous-milk problem, 77 llydrotherapeuticsin the general treatment of pulmonary tuber- culosis, 226 to strengthen a predis- posed individual, 87 Hydrotherapy in the treatment of fever, 259 Hygeia,The, 175 Hygiene in laryngeal tuberculosis, 286 of room, 47 Personal, and dress, 234 Hyperhidrosis, 254 I. Ichthyol, 246 Idaho, 69 Ideal sanatoriimi. Description of an, 204 Illinois, 69 Immigration of tuberculous patients. Legis- lative restriction of, 292 Impermeal)le pocket lining, 45 Imported cattle, Examination of, 76 Indiana, 69 Individual predisposed to tuberculosis. Description of an, 80 Infection by ingestion of bacilli, 46 by inhalation of bacilli, 35 by inoculation of bacilli, 51 from the hands in pulmonary phthisis, 47 from wet-nurse to child, and Tiff vcrs<7, 52 through sexual relations, 52 Tuberculous, of animals through man, 209 through tattooing, 54 through vaccina- tion, 52 Infectious property of bacilli retained after burial, 62 Influence of the weather on consumptives, lilumenfeld on the, 205 Ingals on choice of warm or cold climates, 201 Ingestion of bacilli, 46 Inhalation of bacilli, 35 Injustice to States with good bovine laws, 73 Inoculation, Infection by, 51 Insomnia, 266 Inspection of cattle, 74 Instruction, Circulars for public, 57 Institutions, Special, for the consumptive (lOOr, 320 Supervision of public, 57 Instruction for ambulant patients, 298 Insurance, Slate, against tuberculosis, 324 Intense mineralization, Chloride of sodium and, 247 Intercostal neuralgia, 253 'I m I 338 INDEX. Intercurrent diseases, 268 Intestinal tuberculosis in adults, 250 in children, 49 Iodoform, 245 Iowa, 69 Isocrates on the contagiousness of tubercu- losis, 17 Isolation, Pavilion for, 208 Value of, 317 J- Jiiccoud, I'rof., on the curability of tuber- culosis, 32 Jacobi, Prof A., on tuberculous infection through ritual cir- cumcision, 53 on the administration of digitalis in pneumo- nia, 272 Janeway, Prof K. G., on milk diet in ])neumonia, 272 Joint-tuberculosis, 274 K. Kansas, 69 Kennedy, Dr. J. F. ,on the need of special institutions for the consumptive poor, 321 Kentucky, 69 Kissing, Danger in, on the mouth, 46, 50 Klebs, Prof. Edwin, on the inoculability of tuberculosis, 22 Knopf's aluminum spittoon for use at the bedside, 41 elevated s|)ittoon, 38 pocket spuluni (lask, 43 table showing clinical proofs of pulmi ary tuberculosis, 329 table showing pathological proofs of the curability of pulmonary tuberculosis, 32 Koch, Robert, on the infectiousness of tuberculous expectoration, 36 Koch's, Robert, discovery of the bacillus tuberculosis, 22 Koumiss, 242 " Krankenheiin," Weicker's, 102 K rueger, Dr., on the infectiousness of dust, 36 Kurbow's experiments with latent tuber- cles, 34 L. Lactic acid in laryngeal tuberculosis, 269 Laennec on the curability of tuberculosis, on the unity of tuberculous dis- eases, 22 Laryngeal tuberculosis and intercurrent diseases, 268 Latent tuberculosis, 34 Latschenko on the possible tran<' mission of tuberculosis while speaking, 55 Laurentian Sanatorium, 185 Laws, Sanitary, in the United States, 66 I.ee, Dr. lienjamin, on the need of special institutions for the consumptive poor, 321 Lesions, Seat of primary, 84 Letterfrom a physician in the Highlands, 20 from Dr. Hallestre, Nice, 37 from Dr. V. II. .Atkins, 37 from Dr. J. .\. Ilurty, 77 Letulle, Dr., on the need of special hospi- tal for consumptives, 320 on the pathological proofs of the curability of pulmonary tuberculosis, 32 l.eyden. Prof. K. von, on gavage in pneumothorax, 272 on the duration of cures in home climates, 203 on the feasibility of the treatment of consumptives in all climates, 205 on the need of special institutions for the consumptive poor, 320 I.eysin, Sanatorium of, 124 Liebe, Dr. (ieorg, on the need of special institutions for the consumptive poor, 320 Life, Average, of the tuberculous laborer, 308 Ligation of limbs, 256 Lindemann on ritual circumcision, 53 Lindsey, Dr , on the need of special insti- tutions for the consumptive poor, 320 List of sanatoria, special hospitals, homes, etc., 188 Ixjcation for an ideal sanatorium, 205 for a special hospital, 294 I-ongrois on the history of contagion, 20 Loomis, Prof II. P., on the palhological proofs of the curability of pul- monary tuberculosis, 32 Sanitarium, 149 Louisiana, 69 Lupus, Tuberculin in, 2S7 Lusk, Prof \V. T., on intervention after tuberculous conception, 318 M. Maas, Prof., on ritual circumcision, 53 Maine, 69 Millet, Dr. , on the freeing and thawing of tuberculous subsU ncc; , 40 Malnutrition, 244 Management nf an ialiioK>gical ility of pul- .32 ;ntion after sion, 53 id thawing iriuni, 211 le need of onsumptive INDEX. 339 Mnrcini, Dr., on the pathological proofs of the curability of pulmonary tul)erculosis, 32 Maritime Hospital of Berck-surMer, 118 Marriage relations, 281 Martin, Dr., on the ))athological proofs of the curability of pulmonary tuberculosis, 32 on the virulence of tubercu- lous udders, 67 Maryland, 70 Massachusetts, 70 State Hospital for Consump- tives, 167 Massage, 264 Maternity sanatoria, 318 May on the dietetic treatment in phthisis, 22 Meat, Destruction of tulierculous, 76 'rul)erculous, 48 Meat-powder, Debove's, 250 Meckel on the pathological proofs of the curability of ))ulnionary tuberculosis, 31 Medicinal, Bacterio-, treatment of fever, 262 Cieneral,treatment of fever, 261 Mendelsohn, Dr., on the danger of bi- cycling in pulmonary tuberculosis, 291 Menton, Sanitary condition in, 37 Metal flasks. Advantages of, 43 Meyer, Dr. Willy, on tuberculous infection following ritual circumcision, 53 Michigan, 70 Mid wives. Tuberculous, 49 Miliary tuberculosis, 274 Milk as diet, 238, 249 problem. Tuberculous, solved with- out the aid of the law, 77 Tuberculous, 48, 67 Miller, )enness-, system of dress reform, 23s Minnesota, 70 Mississippi, 70 Missouri, 70 Moist rags for patients too weak to use spittoons, 41 Montan.), 70 Montano, Dr., on the theory of contagion, 19 Montc.lore Country .Sanitarium, 155 Monthly period, 282 Morgagni, Dr. ,on the theory of contagion. Mortality from pulmonary tulierculosis. Dial showing the relative, 30 from pulmonary tuberculosis, Hippocrates on the, 27 from pulmonary tuberculosis in Kngland and Wales, 307 from pulmonary tuberculosis in tlie United States, 28 from pulmonary tuberculosis in the villages of (ioerbersdorf and Falkenstein, 31 1 Mortality from pulmonary tuberculosis. Statistics on the, 27 Table showing comparative, in the various pursuits of life, 64 Moschkowilz's, Dr., case of tuberculous infection through ritual circumci.sion, 53 Mouth breathing, 81 Mouth-mask, Prof. Fraenkel's, 44 Municipal prophylaxis, 316 Murrell, Dr., on the infectiousness 01' tu- berculous sputum, 36 Muskoka Cottage .Sanatorium, 182 N. Nahm's, Dr., statistics on the mortality of tuberculosis in the village of Falken- stein, 311 Naples, Royal decree of, 20 Naunym, I'rof. , on the durability of cures in home climates, 203 Nebraska, 70 Necro-tuberculosis, 47 .Vervousness, Kxtreme, 264 Nervous system, Education of the, to the application of cold water, 87, 226 Neuralgia, Intercostal, 253 Nevada, 73 New Hamp.shire, 70 New Jersey, 70 New Mexico, 70 New York, 70 Nice, Sanitary condition of, 37 Nicholas, Dr., on the cural)ility of pul- monary tubercidosis, 34 Nightingale, Florence, on outdoor life, 25 Noorden, I'rof. von, on the treatment of phthisis complicated by diabetes, 273 Nordrach colony, 1 13 North Carolina, 71 North Dakota, 71 Nose-mask, Dr. Knopfs, in the cabinet treatment, 222 Nurses, Training of, 285 O'jesity in tuberculous patients, 270 Oderberg, Sanatorium of, 1 14 Ofl'spring, Tuberculous, 283 Ohio, 71 Oklahoma, 71 Oregon, 71 ()rnieroth, I'rof, on pathological proofs of the curability of pulmonary tuberculosis, 32 Osier, I'rof., on pathological proofs of the curability of pulmonary tuberculosis, 32 Otis, Dr. E. O., on the need of special sanatoria for consumptives, 321 . 340 INDEX. Kli" P. Packs, Wef, 232 Tains, Pleuritic, during respiratory exer- cises, 215 Pasteur Sanatorium, 157 Pasteur's maxim, 332 Pathological proofs of the curability of pul- monary tuberculosis, 31-34 Patients, Cured, 283 for whom health resorts are suited, 291 Pavilion for isolation, 208 system. Large, for an ideal sana- torium, 207 Pearson's, Prof. , direction for inspecting herds, 74 Pennsylvania, 71 Society for the Prevention of Tuberculosis, 59 Personal hygiene and dress, 234 Petit, Dr. I.. II., on the infectiousness of the saliva of consump- tives, 46 on the need of special in- stitutions for consump- tives, 320 Pliilanthropists, WorV for, 326 Phthisio-genesic diseases, 88 Phthisic-therapeutists, Education of, 284 Physical means to comlvat fever, 259 " Picquiire analomique," 51 Pine forests. Artificial, 294, 306 Pityriasis versicolor, 273 Pleurisy, 271 Pleuritic pains, 215 Pliny the Elder on the airof pine-forests in phthisis, 18 Pneumatic cabinet. Action of the, 219 IJescription of the, 218 treatment, Dr. Knopfs modification of the, 222 treatment in laryngeal tuberculosis, 269 treatment in emphy- sema, 265 Pneumonia, 272 Pneumothorax 272 Pneumotomy in inilmonary gangrene, 273 Pocket sputum flask. Dr. Knopfs, 43 I'ortal on the history of contagion in tuber- culosis, 21 JVecaution during the rest cure in the open air, 215 I'recautions against taking cold, 277 with patient's wardrobe, 295 Preventive treatment, 79 Proedohl's spittoon, 41 Prognosis, 280 I'ropagation of tuberculosis through spu- tum, 36 Prophylactic trer.tment of fever, 259 Prophylaxis, Individual, 35 Public, in regard to tubercu- losis in man, 56 I'roverb, Persian, 88 Prudden, Prof. , on the action of dead bac- teria, 47 on the need of special in- stitutions for the con- sumptive poor, 321 Pueckler's Sanatorium, 102 Pulmonary gangrene, 272 tulierculosis. Pathological proofs of the curability of, 31 Q. Quimby on the eflects of the pneumatic- cabinet treatment, 221 Railway cars. The need of regular disin- fection o(, 60 kanson on the use of iodoform in phthisis, 245 Ravenel, Dr. M. P., on the geographical distribution of bovine tuberculosis, 67 Raw beef. Preparation of, 239 Reclus, Dr. , on infection through sexual relation, 52 Regimen, Average, 238 Reilioldsgriln, .Sanatorium of, 109 Reid, Thomas, on blood-letting in phthisis, 21 on the ventilation of the House of Lords, 88 Reinfection of upper air-passages, 42 Renvers, Prof. , on pathological proofs of the curability of pulmonary tuberculosis, 32 Reporting, Compulsory, of tuberculous cases, 56 Respiration, Artificial mouth-to-mouth, 49 Respiratory exercises, 82 Rest cure, 213 arrangement at home, 303 in fever, 259 Restriction, Legislative, of immigration of tuberculous patients, 292 Resulls, Average, obtained by culture prod- ucts and other specific remedies, 288 obtained by municipal prophylaxis. 216 in general hospitals, 313 in home climates, 203 in hospitals for tuliercu- lous and .scrofulous children, 314 III?-— li ■J t i INDEX. 341 Results obtained in sanatoria for consump- tive poor, 314, 329 ^ in sanatoria for paying patients, 239 Respiratory exercises in ciironic hemopty- sis, 257 in emphysema, 265 in laryngeal tubercu- losis, 269 in the curative treat- ment, 215 in the |)reventive treatment, 82 " Revue de la Tuberculose," 25 Revulsion in the treatment of pulmonary tuberculosis, 253 Rhode Island, 71 Riviere, I.azare, on the contagious nature of tuberculosis, 19 Koempler's sanatorium, loo Rogee, Dr., on the curability of pulmonary tuberculosis, 32 Rokitanski on the curability of pulmonary tuberculosis, 31 Room, Hygiene of, 47, 302 Rose, Dr., on the need of special institu- tions for the consumptive poor, 321 Royal Hospital for Diseases of the Chest at Ventnor, 130 Sea-bathing Infirmary for Scrofula, 23 Ruck, Ur. Karl von, on the duration of cure obtained in sanatoria, 330 on the etiology of tuberculosis, 67 Ruppert.shain, Sanatorium of. 94 Rush Hospital for Consumption, 164 S. Sanatoria as educators, 310 for consun'.piives no danger to the neip' borhood, 311 for school children, 319 for the consumptive poor, 307 forthe consump'ive poor, Results obtained in, 314 Visits to, 90 Sanatorium, Definition of, 200 Sanitary conditions in Menton, 37 New Mexico, 37 Nice, 37 laws in the United States, 06 Saugm.mn, Dr. Chr., on the need of sana- toria for the consumptive poor, 320 Schmidt, Prof., or. laryngeal tuberculosis, 268 Schonlein on climatic treatment, 22 School children, Sanix'orin for, 319 School of " Prophylaktiker," Dr. Turban's, physician's duties, 60 Scliools, 'i'uberculous children in ])ublic, 60,319 Schrotter, Prof, von, on the need of special institutions for the consumptive poor, 320 on street sweeping, 62 •Schuchardt, Dr. K., on tuberculous infec- tion through sexual relations, 52 Serums, 238 Seton Hospital, 159 .Sexual relations, Infection through, 52 Sharon Sanitarium, 165 Shrady, Dr. G. I"., on the Ir.atment of tuberculous patients in sanatoria, 332 Singing and aerotherapeutics, 86 Site for an ideal sanatorium, 204 Smith, Dr. F. \V., on bovine tuberculosis, 67 Society, Pennsylvania, for the Prevention of Tuberculosis, 59 Soil for an ideal sanatorium, 204 Solly, Dr., on the use of atropine in hem- optysis, 255 .Soups, Mucilaginous, 240 South Carolina, 71 South Dakota, 7 1 Special hospitals. Treatment of toiisuniii- tives in, 294 in.stit'.itijns for the consumptive poor, 307 .Spilhnann, Dr., on the dissemination of bacilli through (lies, 40 Spittiiig-cui), Seabury and Johnson's, 41 Spittoon, Dr. Knopf's elevated, 38 for factory and workshop, of Dr. ' Proedohi, 41 .Sports, 290 Sputum, Expulsion of, 43, 55 flask, Dr. Knopf's pocket, 43 Standacher, Dr., on pathological proofs of the curability of pulmonary tuberculosis, 32 Starke, Dr. G. H. E., on atropine in hem- optysis, 255 State insurance aj^ainsl tuberculosis, 324 .Slutistic.-., Knopf's, on clinical proofs of the curability of pulmo- nary tuberculosis, 329 on pathological proofs of the curaliilily of pulmonary tubercu- losis, 32 on the mortality from pulmonary tuberculosis, 27 showing decrease in the death- rate in villages with sanatoria, 3" St. Joseph Hospital, New York, 160, 317 342 INDEX. Slrassninnn, Prof., on tlip curability of jml- nioiinry tiii)C'rculosis, j^ Straus, I'rof. I., on tlie inoculabilily of piil- iiKiimry liilierculosis, _}6 oil tilt; trnnsiiiission of tli lierciilosis tiiroii^li tlu' parrot, 50 Street sweeping, I'rof. von Scli rotter on, 62 Sluliljert, Dr. J. E., on nntistreptocociic serum, 20J on the use of iclilliyol in pulnioimry tu- herculosis, 246 Submersion, Thalassic, 65 Suggestive treatment of pulmonary hem- orrhage, 255 Sun-ballis for cliildren, 82 Supervision of faetories, worksliops, stores, etc., 63 of pulilic instituti'.ns, 57 Surgical measures in laryngeal tuberculo- sis, 269 Susceptibility to catarrhs, 80 Sweat-baths in hyperhidrosis, 254 Sydenham on horseback-riding in phthisis, 19 Sylvius, jacobus, on scrofula and tubercu- losis, 18 Symptomatic treatment of laryngeal tuber- culosis, 268 of pulmonary tu- berculosis, 244 Syphilis predisposing to tuberculosis, 65 Table showing comparative mortality in various pursuits of life, 65 Tappeiner, Dr., on the inoculability of tuberculosis, 36 'I'arnier, I'rof, on intervention in tul>ercu- lous conception, 318 Tatham's statistics on the mortality from pulmonary tuberculosis in Kngland and Wales, 307 Tattooing, Tuberculous infection through, 54 Teeth, Care of the, 241 Temperature an indication for exercise, 217 Taking of, 258 Tenement houses, The need of model, 65 Visit to, 308 Tennessee, 72 Texas, 72 Thalassic submersion, 63 Time needed to accomplish a cure, 2S4 temperature, and duration of douche, 322 Tonsaasen, Sanatorium of, 126 Torek, Dr. Franz, on Hier's treatment in joint tuberculosis, 274 Training of nurses, 285 school for nurses, 155 Transformation, Calcareous, of tul)ercles, .34 Fibrinous, of tubercles, Traube on respiratory exercises in chronic hemoptysis, 357 'i'rcatmciit. Dietetic, of pulmonary tubercu- losis, 237 educational, of tuberculous pa- tients, 277 in sanatoria, 2cx) of ambulant tuberculous pa- tients, 297 of consumptives at their homes, 302 of consumptives in special hos- pitals, 294 of patients in the dispensary, 297 of (latients sullering from laryn- geal tuberculosis, 268 of pulmonary tuberculosis, Cli mato-thtrapy in the, 200 of tubiMTulosis ot llio child in utero, 81 I'reventive, 79 Tricycle, 291 'i'ro|K)n as food, 24 1 Trudcau. Dr. V.. I,., on sanatoria, 25, 321 Tuberculin, 286 " Tuberculose Infantile," 26 Tuberculosis, liovine, 66 committees and their duties, 322 " F.ndemic," 32^ experimentally [iroduced, 36 in domestic pet animals, 50 in swine, horses, goats, etc., 78 Intestinal, 49 Miliary, 274 of the joints an lous .secretions, 45 Work lor philanthropists, 326 for a central bureau to combat bo- vine tuberculosis, 74 Wyoming, 72 Ziemssen, Dr. von, on the duration of cures in home climates, 203 H l ' I If! !^ i! 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(Lond.), Physician to the German Hospital, Dalston ; Assistant Physician North London Hospital for Consump- tion ; Author of " The Mineral Waters and Health Resorts of Europe;" and Guv Hinsdale, a.m., m.d., Secretary of the American Climatological Associa- tion ; President of the Pennsylvania Society for the Prevention of Tuberculosis ; formerly Lecturer on Medical Climatology in the University of Pennsylvania, etc. Prophylaxis — Personal Hygiene — Care of the Sick. Illustrated. By Harold C. Ernst, m.d., Professor of Bacteriology in the Medical School of Harvard University, Boston ; and Albert Abrams, m.d. (University of Heidel- berg), formerly Professor of Pathology, Cooper Medical College, San Francisco. Dietotherapy. Food in Health and Disease. By Nathan S. 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Ophthalmology. New Edition. 117 Illustrations. A Text-Book by John W. Wright, a.m., m.d., Professor of Ophthalmology and Clinical Ophthalmology in Ohio Medical University ; Ophthalmologist to the Protest- ant and University Hospitals, etc. Second Edition, Revised, Rewritten, and Enlarged. With many new Illustrations. Just Ready. Cloth, $3.00 THE STANDARD TEXT-BOOK Morris' Anatomy %• Second Edition, Enlarged and Improved 790 Illustrations, of which 214 are Colored OcUvo. 1274 Pages. Cloth, $6.00) Leather, $7.00 " Morris' Anatomy" was published at a time when methods of teaching, the art of engraving, and distinct advance in anatomical illustration made desirable a new and modern text-book. The rapid sale of the first edition, its immediate adoption as a text-book by a large number of medi- cal schools, and its purchase by physicians and surgeons proved its value and made it from the day of publication a standard authority. In making this new edition the editors and publishers have used every endeavor to enhance its value. The text has been thoroughly revised and in many parts rewritten ; the editor has devoted himself to the task of making it a harmonious whole; many new illustrations have replaced those used in the first edition, and a large number have been printed in colors, while the typographical appearance has been impioved in several particulars. The illustrations, in correctness and excellence of execution, are equaled by no similar treatise; about |iooo having been expended on new and improved blocks for this edition alone. CIRCULAR WITH SAMPLE PAGES AND ILLUSTRATIONS FREE. A'l Prices are Net. No Discount can be allowed Retail Purchasers. I College, Bir- .c.s. Colored Cloth, li.oo gy- Pennsylvania. Cloth, .40 'essor of Chem- ky University, Cloth, jtl.50 :h a short time is ; selection of the : as a practitioner :h is really essen- ion in the impor- Viiladelphia. itions. halmology and to the Protest- and Enlarged. Cloth, $3.cx) TEXT-BOOK vtx, $7.00 hods of teaching, ical illustration sale of the first lumber of medi- jroved its value iiy. have used every ;hly revised and r to the task of ; have replaced been printed in oved in several ion, are equaled led on new and tail Purchaaefs. From the Soutberu Clinic. " We know of no series of books Issued by any house that so fully meets our approval as these ? Quii-Compends ?. They are well arranged, full, and concise, and are really the bckt line of text- books that could be found for either student or practitioner." BLAKISTON'S ?QUIZ=COMPENDS? The Best Series of Manuals for the Use of Students. Price of each, Oloth, .80. Interleaved for taking Notes, 81.00. JJ®'These Compends are based on the most popular text-books and the lectures of prominent professors, and are kept constantly revised, so that they may thoroughly represent the present slate of the subject upon which they treat. The authors have had large experience as Quiz-Masters and attaches of colleges, and are well acquainted with the wants of students. They are arranged in the most approved form, thorough and concise, containing about 800 illustrations, inserted wherever they could be used to advantage. Can be used by students of any college, and contain information nowhere else collected in such a condensed practical shape. ILLUSTRATED CIRCULAR FREE. No. I. HUMAN ANATOMY. Sixth Revised and Enlarged Edition. Including Vis- ceral Anatomy. Can be used with either Morris's or Gray's Anatomy 117 Illustrations and 16 Lithographic Plates of Nerves and Arteries, with Explanatory Tables, etc. Uy Sami k'. O. L. Potter, m.u., formerly Professor of the Practice of Medicine, Cooper Medical College, San Francisco; Major and Brigade Surgeon, U. S. Vol. No. 2. PRACTICE OF MEDICINE. Part I. Sixth Edition, Revised, Enlarged, and Improved. By Dan'l E. Huohks, M.d., Physician-in-Chief, Philadelphia Hospital; late Demonstrator of Clinical Medicine, Jefferson Medical College, Philadelphia. No. 3. PRACTICE OF MEDICINE. Part II. Sixth Edition, Revised, Enlarged, and Improved. Same author as No. 2. No. 4. PHYSIOLOGY. Tenth Edition, with new Illustrations. Enlarged and Revised. By A. P. Bruhakkr, m.d., Profe.ssor of Physiology in the Pennsylvania College of Dental Surgery; Adjunct Professor of Physiology, Jefferson Medical College, Philadelphia. No. 5. OBSTETRICS. Sixth Edition. By Henry G. Landis, m.d. Revised and Edited by Wm. H. Wei.i.s, m d., Instructor of Obstetrics, Jefferson Medical College, Philau-'lphia. Enlarged. 3 Plates and 47 other Illustrations. 6. MATERIA MEDIC A, THERAPEUTICS, AND PRESCRIPTION WRITING. Sixth Revi=ed Edition. .Same author as No. I. ; ,7. GYNECOLOGY. Second Edition. By Wm. H. Wells, m.d.. Instructor of Oistct- rics, Jefierson Medical College, Philadelphia. 140 Illustrations. 8. DISEASES OF THE EYE AND REFRACTION. Second Edition. Incaid ing Treatment and Surgery and a Section on Local Therapeutics. By George M. Gt)U..l), M.I)., Editor Philadelfhia Mediial Journal, anA VV. L. Pyi.e, M.D. , Assistant .'■'urgeon, Wills Eye Hospital. With l-'ormuUc, Glossary, several useful Tables, and 109 Illustrations. , 9. SURGERY, Minor Surgery, and Bandaging. Fifth Edition, Enlarged and In - proved. By GrviL'. :. HoRwrrz, B.s., m.d., Clinical Professor of Genito- Urinary Surgery and Venereal Disea-es in Jefferson Medical College ; Surgeon to Philadelphia Hospital, etc. With 98 Poiniula; arid 167 Illustrations. No. 10. MEDICAL CHEMISTRY. Fourth Edition. 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By A. E. Tiiayer, m.d., etc. Preparins^. No. 16. DISEASES OF THE SXIN. By Jay F. .Siiiamhkrg, m.d. Professor of Skin Diseases, Philadelphia Polyclinic. Second Edition, Revised. 105 Illustrations. No. 17. HISTOLOGY. Illustrated. B) II. H. Cushing, m.u. Preparing. 4» No. No. No. No. JUST READY, ONEJ/OLUME A Cyclopedia of Practical Medicine and Surgery A CONCISE REFERENCE BOOK, ALPHABETICALLY ARRANGED OF MEDICINE, SURGERY, OBSTETRICS, MATERIA MEDICA, THERAPEUTICS, AND THE VARIOUS SPECIALTIES, WITH PARTICULAR REFERENCE TO DIAGNOSIS AND TREATMENT COMPILED UNDER THE EDITORIAL SUPERVISION OF GEORGE M. GOULD, M.D. AND WALTER L. PYLF, M.D. Author of "An Illustrated Dictionary of Medicine | " Editor " Philadelphia Medical Journal," etc. Assistant Surgeon Wills Eye Hospital) formerly Editor " International Medical Magazine," etc. AND SEVENTY-TWO SPEQAL CONTRffiUTORS WITH MANY ILLUSTRATIONS LARGE SQUARE OCTAVO. TO CORRESPOND ^XaTH GOULD'S " ILLUSTRATED DICTIONARY." FULL SHEEP OR HALF DARK-GREEN LEATHER, JJO.OOi WITH THUMB INDEX, $H.00» HALF RUSSIA, THUMB INDEX, $ J 2.00, NET The great success of Dr. Gould's " Illustrated Dictionary of Medicine " suggested the preparation of this companion volume, which should be to the physician the same trustworthy handbook in the broad field of general information that the Dictionary is in the more special one of the explanation of words and the statement of facts. The aim has been to provide in a one-volume book all the material usually contained in the large systems and much which they do not contain. Instead of long discursive papers on special subjects there are short, concise, pithy articles alphabetically arranged, giving the latest methods of diagnosis, treatment, and operating — a working book in which the editors and their collaborators have condensed all that is essential from a vast amount of literature and personal experience. The illustrations have been selected with care, only those having been used that are of practical value ; no effort has lieen made to overload the book with useless pictures. The seventy-two special contributors — the names of whom are given on the following page — have been selected from all parts of the '~ountry in accordance with their fitness for treating special suljjects about which they may be considered expert authorities. They are all men of prominence, teachers, investigators, and writers of experience, who give to the book a character unequaled by any other work of the kind. 4a ICAL Y STICALLY GOULD AND PYLE'S CYCLOPEDIA OF MEDICINE LIST OF CONTRIBUTORS SRAPEXJTICS, JLAR YLE, M.D. e Hospital » formerly ical Magazine," etc. ORS -USTRATED ER, $10.00 1 M2.00, NET :ine" suggested I'sician the same le Dictionary is : of facts. The lly contained in long discursive 3 alphabetically ing — a working that is essential en used that are useless pictures. E given on the in accordance ■ be considered 'estigators, and any other work noN Samuel W. Abbott, A.M., M.D., Boston. James M. Anders, M.D., LL.D., Pbila. Joseph D. Bryant, M.D., New York. James B. Bullitt, M.D., Louisville. Charles H. Burnett, A.M., M.D., Phila. J. Abbott Cantrell, M.D., Philadelphia. Archibald Church, M.D., Chicago. L. Pierce Clark, M.D., Sonyea, N. Y. Solomon Solis-Cohen, M.D., Philadelphia. Nathan S. Davis, Jr., M.D., Chicago. Theodore Diller, M.D., Pittsburg. Augustus A. Eshner, M.D., Philadelphia. J. T. Eskridge, M.D., Denver, Col. J. McFadden Gaston, A. B., M.D., Atlanta, Ga. J. McFadden Gaston, Jr., A.M., M.D., At- lanta, Ga. Virgil P. Gibney, M.D., New York. George M. Gould, A.M., M.D., Phila. W. A. Hardaway, A.M., M.D., St. Louis. John C. Hemmeter, M.S., M.D., Baltimore. Barton Cooke Hirst, M.D., Philadelphia. Bayard Holmes, M.D., Chicago. Orville Horwitz, B.S., M.D., Philadelphia. Daniel E. Hughes, M.D., Philadelphia. James Nevins Hyde, A.M., M.D., Chicago. E. Fletcher Ingals, A.M., M.D., Chicago. Abraham Jacobi, M.D., New York. William W. Johnston, M.D., Washington, D. C. Wyatt Johnston, M.D., Montreal. Allen A. Jone /, M.D., Buffalo. William W. Keen, M.D., LL.D., Phila. Howard S. Kinne, M.D., Philadelphia. Ernest Laplace, M.D., Philadelphia. Benjamin Lee, M.D., Philadelphia. Charles L. Leonard, M.D., Philadelphia. James Hendrie Lloyd, A.M., M.D., Phila. J. W. MacDonald, M.D. (Edin.), F.R.C.S. Ed., Minneapolis. L. S. McMurtry, M.D., Louisville. G. Hudson Makuen, Philadelphia. 43 Matthew D. Mann, M.D., Buffalo. Henry O. Marcy, A.M., M.D., LL.D., Boston. Rudolph Matas, M.D., New Orleans. Joseph M. Mathews, M.D., Louisville. John K. Mitchell, M.D., Philadelphia. Harold N. Moyer, M.D., Chicago. John H. Musser, M.D., Philadelphia. A. G. NichoUs, M.D., Montreal. A. H. Ohmann-Dusmesnil, M.D., St, Louis. William Osier, M.D., Baltimore. Samuel O. L. Potter, A.M., M.D., M.R. C.P. (London), San Francisco. Walter L. Pyle, A.M., M.D., Philadelph-a. B. Alexander Randall, A.M., M.D., Phila. Joseph Ransohoff, M.D., F.R.C.S. (Eng.), Cincinnati. Jay F. Schamberg, A.M., M.D., Phila. Nicholas Senn, M.D., LL.D., Chicago. Richard Slee, M.D., Swiftwater, Pa. S. E. Solly, M.D., M.R.C.S., Colorado Springs, Col. Edmond Souchon, M.D., New Orleans. Ward F. Sprenkel, M.D., Philadelphia. Charles G. Stockton, M.D., Buffalo. John Madison Taylor, A!M., M.D., Phila. William S. Thayer, M.D., Baltimore. James Thorington, A.M., M.D., Phila. Martin B. Tinker, M.D., Philadelphia. James Tyson, M.D., Philadelphia. J. Hilton Waterman, M.D., New York. H. A. West, M.D., Galveston, Texas. J. William White, M.D., PH.D., Phila. Reynold W. Wilcox, M.A., M.D., LL.D., New York. George Wilkins, M.D., Montreal. DeForest Willard, M.D., Philadelphia. Alfred C. Wood, M.D., Philadelphia. Horatio C. Wood, M.D., LL.D., Phila. Albert Woldert, PH.G., M.D., Phila. James K. Young, M.D., Philadelphia. Deaver's Surgical Anatomy A Treatise on Human Anatomy in its Application to the Practice of Medicine and Surg;ery ^ J^ By JOHN B. DEAVER, M.D. Surgton-in-Chief to the Girman Hospital, Philadelfihia ; Surgeon to the Children'! Hospital; Consulting Surgeon to St. Agnes', St. Timothy's, and Germantown Hospitals : formerly Assistant Pro/issor o/ Applied < Anatomy, University of Pennsylvania, etc. In Three Royal Octavo Volumes, containing about Four Hundred and Fifty Full-page Plates, nearly all from dissections made for the purpose m. Handsome Cloth, Sai.oo ; Full Sheep, $14.00 ; Half Qreen Morocco, Marbled Edges, $34.00 ; Half Russia, Qllt, Marbled Edges, $37.00 net. 11! U' SYNOPSIS OF CONTENTS VOLUME L— Upper Extremity— Back of Neck, Shoulder, and Trunk— Cranium— Scalp- Face. VOLUME n.—Necfc— Mouth, Pharynx, Larynx, Nose— Orbit— Eyeball— Organ of Hearing- Brain — Female Perineum — Male Perineum. VOLUME m.— Abdominal Wall— Abdominal Cavity— Pelvic Cavity— Chest— Lower Ex- tremity. The book is desig^ned. to aid the general practitioner and surgeon in his everyday work. The text is excellently clear, succinct, and systematically arranged, and contains a wealth of illustrations far in advance of the usual text-book. It is not intended merely, for the surgeon — though to him it will prove invaluable — but for the general physician, who, while called upon to cope with innumerable emergencies and special cases, has not the means or the hospital facilities by which he can readily acquaint himself with every phase of anatomy — supc . ficial and deep — as applied to disease and the most modern methods of treatment of injuries. To the specialist it will prove of great value. The anatomy of the head and neck, the spinal cord, the organs of sense, and the throat appeals directly to the ophthalmologist, aurist, rhinologist, laryngologist, and neurologist, while those sections devoted to the abdomen and pelvic cavity will give the gynecologist and specialist on diseases of the urinary organs, rectum, etc., material regarding the relations of the parts and the operations thereon, unique in many ways, and in a manner never before so exactly and concisely stated. To those devoted to these specialties it will prove a supplement to other text-books that omit special anatomy, and which do not attempt to show the applied anatomy. .TOMY tt't Hospiial; van ty Full-page Plates, 'OCCO, onet. -Qanium — Scalp — Organ of Hearing— ■Chest— Lower Ex- d surgeon in his atically arranged, ;t-book. It is not lable — but for the emergencies and h he can readily ;p — as applied to of the head and Is directly to the lile those sections ist and specialist le relations of the iner never before Es it will prove a h do not attempt Deaver's Surgical Anatomy The illustrations^ which at the first glance appear as the prominent feature of the book — but which in reality do not overshadow the text — consist of a series of pictures absolutely unique and fresh. They will bear com])arison from an artistic point of view with any other work, while from a practical point of view there is no other volume or series of volumes to which they can be compared. When originally an- nounced, the book was to contain two hundred illustrations. As the work of prepara- tion progressed, this number gradually increased until it is estimated that there will now be more than four hundred full-page plates, many of which contain more than one figure. VVith the exception of a few minor pictures made from preparations in the possession of the author, they have all been drawn by special artists from dissections made for the purpose in the dissecting-rooms of the University of Pennsylvania. Their accuracy cannot be questioned, as each drawing has been submitted to the most careful scrutiny. From The Medical Record^ New York. " The reader is not only taken by easy and natural stages from the more superficial to the deeper regions, but the various important regional landmarks are also indicated by schematic tracing upon the limbs. Thus the courses of arteries, veins, and nerves are indicated in a way that makes the lesson strikingly impressive and easily learned No expense, evidently, has been spared in the preparation of the work, judging from the number of full-page plates it contains, not counting the smaller drawings. Most of these have been ' drawn by special artists from dissections made for the purpose in the dissecting-rooms of the University of Pennsylvania.' In summing up the general excellences of this remarkable work, we can accord our unqualified praise for the accurate, exhaustive, and systematic manner in which the author has carried out his plan, and we can commend it as a model of its kind> which must be possessed to be appreciated." From The Philldelphia Medical Journal. " Many members of the profession to whom Dr. Deaver is well known either personally or by reputation as a surgeon, writer, teacher, and practical anatomist, have awaited the appearance of his Surgical Anatomy with the expectation of finding in it a guide in this difficult branch of medi- cine of niur 'i re than ordinary practical value, and their expectations will not be disappointed." From The Journal of the American Medical Association. " In order to shov/ its thoroughness, it is only necessary to mention that no less than twelve full-page plates are reproduced in order to accurately portray the surgical anatomy of the hand, and it is doubtful whether any better description exists in any work in the English language." From The Soutfiem California Practitioner. " Aside from the merit of this great work, it will be a delight to the lover of books. Its gen eral make-up shows the highest development of the book-making art. The bibliophile, when holding one of these volumes in his hands, would be as careful with it as though he were handling an infant, and to drop it would cause" him the keenest pain. The illustrations, the print, and (lie paper and binding are each and all delightful in themselves, and yet the text is concise and clear, and taken with the illustrations make a remarkably good substitute for the dissecting-room. To have these three volumes on his library shelves will be a source of pride and joy and profit to every practitioner. Dr. Deaver has in these volumes conferred a boon upon the medical profession which has, at least, never been surpassed by any one." From The New Orleans Medical and Surgical Journal. " While the needs of the undergraduate have been fully kept in view, it has been the aim of the author to provide a work which would be sullicient for reference for use in actual practice. We believe the book fulfils both requirements. The arrangement Is systematic and the discussion of surgical relations thorough." ffeS" Large Descriptive Circular will be sent upon application 45 4^ Hcmmctcr^ Diseases of the Stomach. Second Edition^ Enlarged. Illustrated. Their Special Pathology, Diagnosis, and Treatment. With Sections on Anatomy, Analysis of Stomach Contents, Dietetics, Surgery of the Stomach, etc. By John C. Hkmmkter, M.D., PHiLOS.D., Professor in the Medical Department of the University of Maryland ; Consultant to the University Hospital ; Director of the Clinical Laboratory, etc. Second Revised Edition. With Colored and other Illustrations. Octavo. 890 pages. Cloth, ji(6.oo ; Leather, #7.00; Half Russia, #8.00 *^* The rapid sale of the first edition of this book has encouraged the author to revise it very thoroughly and to add much new material (about 100 pages) and a num- ber of new illustrations. About two-thirds of the book has been actually reconstructed. The section on Dietetics will be found particularly useful. " A second enlarged and revised edition appearing in a little over a year from the date of the original publication speaks for the popularity and value of the work. This book easily occupies the first place among its sort in the English language and is particularly free from that enthusiastic hobby riding which is not unknown among gastroenterologists. The bibliographical references are very full and complete, and the work is one of the highest order as well as one of the utmost practical value." — Chicago Medical Recorder. " This edition of Ilemmeter's work on ' Diseases of the Stomach ' contains much new and important material. The following articles have been added : Hypertrophic stenosis of the pylorus, obstruction of the orifices, the use and abuse of rest and exercise in the treatment of digestive dis- eases. Part of the chapter on motor insufficiency, electrodiaphany, hemorrhage from the stomach, and the articles on gastroptosis and enteroptosis have been entirely rewritten. The present edition will undoubtedly gain as many friends as the first edition." — The Medical Record, Nnu York. "Dr. Hemmeter certainly provides a book which is well worthy of a careful study. ... It treats of many subjects in an original manner, and is not only based on a considerable personal experience, but takes due notice of the labors of other well-known workers in this field." — British Medical Journal. " Completely scientific, modern, accurate, and creditable. . . . We co,rimend it." — Journal of the American Medical Association. "We know of no work from which the physician may gain more information than this. " — Australian Medical Gazette. " The consideration of die general methods of clinical examination of the stomach is thor- oughly adequate. ' ' — Boston Medical and Surgical Journal. " We part from Dr. Hcmmeler's book with the sense that it embodies tlie best knowledge of the time." — London Lancet. " We wish to express unqualified approval of the tendency which is shown to emphasize the simple and more practical mi?ihods of diagnosis." — New York Medical Journal. "The best contemporary treatise on diseases of the stomach which we possess, not oidy in America, but in the whole world." — Prof. I. Boas, of Berlin. In Preparation by the same Author Diseases of the Intestines. Original Iflustrations A Complete, Systematic Treatise, Including the Surgical Aspects of the Subject. 46 ► Second ions on Anatomy, h, etc. By John cpartment of the Director of the olored and other falf Russia, #8.00 iped the author to ;i},'es) and a num- illy reconstructed. from the date of the look easily occupies 'om that enthusiastic graphical references s one of the utmost ains much new and nosis of the pylorus, lent of digestive dis- ;e from the stomach, Tlie present edition [ori/, Nru) York. sful study, ... It :onsf(lerable personal this i\AA:'— British imend it." — Journal mation than this." — he stomach is thor- e l)cst knowledge of ivn to emphasi/e the possess, not only in ustrations of the Subject. Gordinicr* The Gross aiid Minute Anatomy of the Central Nervous System. G)Iored Illustrations* By H. C. GoRDiNiER, A.M., M.D., Professor of Physiology and of the Anatomy of the Nervous System in the Albany Medical College ; Member American Neuro- logical Association. With 48 Full-page Plates and 213 other Illustrations, a number of which are printed in Colors and many of which are original. Large 8vo. Cloth, $6.00 ; Sheep, $7.00 ; Half Russia, 58.00. *^ It is universally acknowledged that for a proper comprehension of the normal and abnormal activities of an organ a thorough knowledge of its anatomy is absolutely essential. This is particularly true of diseases of the central nervous system, for in no other way can the disease symptoms be explained. Without this knowledge, clinical and pathologic observations are of little avail. This book is not a theoretic and tech- nical student's book, but a useful working supplement to all works upon general practice and neurology, and as such is destined to mark an epoch in medical literature. " This is an excellent book fln a fascinating subject, and the author deserves the thanks of the English-speaking medical world for his labor in getting it up. There are works enough on genenal anatomy, and dry enough they are, as we all remember only too well; but the anatomy of the nervous system alone is another matter entireiy, for it is one of the most interesting of all subjects of medical sttfdy, at the same time that it is one of the most difficult. For both of these reasons the subject is deserving of a treatise by itself, and should not be briefly discussed in a few pages of a general work on anatomy, or in an introductory chapter of a treatise on diseases of the ner- vous system." — Medical Record, A'ew York. " The author has made an honest attempt to place in the hands of the English student a comprehensive and accur.ite textbook, devoid of the many intricacies of modern thought and speculation. For the average man the work will appe.il strongly ; the facts that he can use are readily found. ' ' — The Journal of A'en'ous and Menhil Diseases, A'nv York. " Throughout the book the descriptions of the gross and minute anatomy are, as a rule, clear, objective, and as easy of comprehension as could be expected of so difficult a subject. The state- ments are most of them quite didactically made, but this we consider an advantage rather than a defect, especially in a text-book for students as well as practitioners. . . . The chapter on cerebral localization is carefully written, and gives the most recent results on the subject." — 7'he American Journal of Insanity, Baltimore. " Represents much painstaking rese.irch, and bears also the stamp of origin.il investigation. It is unusually well written, and the illustiations, many of whicli are original, are well chosen. It is destined to take its place among the standard books of its class." — New York Medical Journal. " This book will be welcomed by teachers, practitioners, and students. It will save teachers and writers on the nervous system the necessity of accompanyinij tlieir lectures and iiooks on diseases of the nervous system with chapters on anatomy. It is really the first thoroughly system- atic work on the anatomy of the central nervous system that has appeared in the English language. The work is the more necessary because diseases of the central nervous system are becoming mote f.nd more recognized, and because the works on general anatomy do not pretend to describe the minute anatomy of the central nervous system. Authors of books on neurology rccogni/e the fact that their readers cannot understand the descriptions of the diseases of the central nervous system without a knowledge of the anatomy of the parts involved. The subject is a difticult one at best, but the stmlent who will make an earnest effort to master the details cannot fail to do so with the aid of this work. The author's descriptions are clear, concise, comprehensive, and profusely and beautifully illustrated." — Pacific Medical Journal, San Francisco. " .As there can he no accurate understanding of the diseases of the nervous system without a thorough knowledge of the anatomy, it fs no wonder tliat the average practitioner is as ignorant of neurology as is unfortunately the c.ise. '1 he present volume is a praiseworthy attempt to remove the approach that h.as thus far re3ted upon English and American neurology." — Boston Medical and Surgical Journal. " We commend Gordinier's chapter on cerebral localization. This will be especially helpful to clinicians, although all the views expressed in it are not yet outside of the domain of controversy. Ve should like to say more about Gordinier's book, but space forbids. It is handsomely printed and copiously illustrated, and we can recommend it as a good text-book of nervous anatomy." — Philadelphia Medical Journal. 47 Sir JUST READY PRACTICAL GYNECOLOGY A Modern Comprehensive Text-Book By E. E. MONTGOMERY, M.D. Profcnor of Gynecology, Jefferaon Medical College t Gynecologist to the Jcfferion Medical College and St. Joseph's Hospitals; Consulting Gyncwloglst to the Philadelphia Lying-in Charity WITH FIVE HUNDRED AND TWENTY-SEVEN ILLUSTRATIONS • Nearly all of which have been Drawn and Engraved Specially for this Work, for the most part from Original Sources OCTAVO. 8J9 PAGES CLOTH, $5.00; LEATHER, $6.00; HALF RUSSIA, $7.00 I- 1 I EXTRACT FROM THE PREFACE This work has been under consideration for the past fifteen years, and much of it has been several times rewritten. An effort has been made to make it a comprehensive work upon the subject, givifig the experience and methods of the most careful men, while my own experience has been utilized to indicate that which I have found most useful and worthy of acceptance. Each general subject is considered with reference to its influence upon the entire ■genital tract, and the work is divided into sections rather than chapters. This course, although a departure from the ordinary text-book arrangement, is that which experience has demonstrated to be most effective in impressing the subject upon the student, and would seem to me preferable to him who uses the book to refresh his knowledge upon some particular subject. The illustrations are arranged solely with the purpose of rendering clear the text and to promote the work of diagnosis and treatment. For the excellence and character of the illustrations 1 am greatly indebted to the generosity of the publishers and to the skill and patience of their artists, Messrs. Shannon and Von du Lancken. To the kindly oversight of Dr. Robert L. Dickinson is due much of the exactness of the drawings. Acknowledgment is due Miss Eleanor A. Cantner for her ability in the preparation of preliminary sketches and of the index. Should it be the means of lightening the work of the student, of making more dear the pathway of the busy practitioner, and, most of all, of benefiting suffering women thiough improved methods of diagnosis and treatment, I shall feel well repaid for the many days and nights of labor which it has cost. 48 .OGY non Medical V-SEVEN lly for this ,$7.00 ars, and much of it e it a comprehensive ; most careful men, I have found most lence upon the entire ipters. This course, hat which experience ipon the student, and his knowledge upon with the purpose of 1 treatment. For the ;d to the generosity of rs. Shannon and Von in is due much of the lor A. Cantner for her X. dent, of making more of benefiting suffermg [ shall feel well repaid