GIFT OF Mrs. William L.Cook HAT YOU SHOULD KNOW ABOUT TUBERCULOSIS FSEFUL FACTS FOR THE TUBERCULOUS AND THOSE LIVING WITH THEM PREPARED BY THE NATIONAL TUBERCULOSIS ASSOCIATION 381 FOURTH AVENUE, NEW YORK AMERICAN MEDICAL ASSOCIATION FIVE HUNDRED AND THIRTY-FIVE NORTH DEARBORN STREET CHICAGO PREFACE There is today among the public a great amount of misinfor- mation and misunderstanding about tuberculosis, a misinforma- tion and misunderstanding which has many bad results, partly by causing sufferers with this disease to live unwisely and to do things which are harmful to them, partly by causing the public to be unnecessarily afraid of infection and, therefore, making them look upon those who are afflicted with this disease with needless fear. What is needed, if tuberculosis is to be con- quered in this country, is a better knowledge by the public of what this disease is and what the patients themselves and their friends can do to combat it. The National Association for the Study and Prevention of Tuberculosis realizes that the only way to remove such misin- formation is by the dissemination of accurate knowledge on the subject. The following pages have been written with the aim of making plain to the layman what he can do if he, or one he loves, has developed this disease. This booklet contains the essential facts, and if its teachings are taken to heart and its directions are carefully followed, it should do much to bring about the early discovery and the successful treatment of this prevalent trouble. In any book destined for popular instruction a certain amount of repetition is essential if certain important details are to be impressed upon the minds of the readers, and it is hoped that such repetitions as are found in this booklet will, for this reason, be pardoned. CHARLES L. MINOR, M.D., Chairman, Asheville, N. C. DAVID R. LYMAN, M.D., Wallingford, Conn. WILLIAM H. BALDWIN, Washington, D. C. H. R. M. LANDIS, M.D., Philadelphia, Pa. JOHN H. LOWMAN, M.D., Cleveland, Ohio. Committee on Educational Pamphlet of The National Association for the Study and Prevention of Tuberculosis. fr o /* A i~ i USEFUL FACTS FOR THE TUBERCULOUS AND THOSE LIVING WITH THEM I. DO YOU VALUE YOUR HEALTH? If so, what follows will interest you; read it carefully; it will pay you. II. WHY ARE PEOPLE AFRAID OF TUBERCULOSIS? Because every third person between fifteen and sixty dies of it, or every fourth person between twenty and fifty ; or, in other figures, it kills about one in ten of all people who die at any age. Also because it disables and renders useless and helpless those who have it, and is often the means of beggaring their families. III. WHY SHOULD YOU BOTHER YOURSELF ABOUT IT IF YOU ARE NOT SICK WITH IT? Because you, or some of your family, may develop it at any time ; therefore, by knowing something about it, you can greatly lessen the chance of getting it, or, should you get it, can lessen its danger to yourself and your children. Further, every man and woman worth the name wants to help others who are jn trouble. This pamphlet will teach you how to do that. IV. WHAT IS TUBERCULOSIS? Tuberculosis is a disease caused by the growth in your lungs, or, less commonly, in other parts of your body, of a minute T microscopic fungus-, plant, or. germ called the and if C r ^ tubercle bacillus. This germ produces and throws off poisons which kill the structures around it. Multiplying by division, it spreads, slowly or rapidly, through the whole lung until finally it kills the person in whom it grows. In recent years it has been shown that the germ frequently gets into the body in childhood, but, since it does not grow easily in the human body, many of these germs are killed at once by the tissues. Others lie inactive for a long time in the glands in the chest and do not develop until by some chance the resisting power of the body is lowered suf- ficiently for the germ to begin to grow, the thoroughly healthy body not being a favorable growing place. Overwork, dissipa- tion, dark dirty homes or work-places, bad or scanty food, late hours, drunkenness, and certain sicknesses such as grippe, measles, whooping cough, pneumonia and typhoid fever, and also frequent and closely repeated pregnancies, weaken the body, give the germ the opportunity it needs, and enable it to develop. In bodies thus weakened, the germ can flourish, and, if they are not strengthened in time by proper living, the disease will advance. This advance is usually slow and gradual, so that the patient may live from two to ten years, but in the more rare galloping form its advance is rapid, so that the patient dies in from six weeks to a year. Fortunately for us the germ of tuberculosis does not grow easily in the human body. All animals have a certain degree of resistance to the attack of the germ. In some What is re- this resisting power is very low; in some very sistance? high- The guinea pig, for example, has almost ! no resistance to this disease, while the goat has so high a resistance that it is very hard to infect it at all. Among human beings the Indian and the Negro usually show a very low resisting power, and when infected, are apt to have the rapid and dangerous form of the trouble. The average white man on the contrary has considerable .resisting power, and it takes repeated, prolonged exposure and unfavorable conditions o'f working and living, to infect him, except in early childhood, when, it should never be forgotten, infection is very easy. The first manifestation of the activity of the germ in the body is the formation, usually in the lungs, of a small gray lump, which we call a tubercle. This is about h e G e r m the size of the head of a pirij and> examined ,onquc ing unc j er a microscope, it is seen to consist of a T~ cheesy mass of dead tissue with germs lying in it. The formation of this dead tissue by the poisons of the germ is called "Caseation." Surrounding the cheesy center is a double layer of cells thrown out by the body to protect itself from the invading germ. If the poisons of the germ are sufficiently strong, or if the cells surrounding the germ are sufficiently weak, they too will be destroyed, and by degrees successive layers of tissue will be killed, the trouble thus spreading at the outer border through larger and larger areas of tissue until finally the whole lung is involved. When the mass of dead tissue reaches an air tube it is coughed up and leaves a small cavity behind. When this cavity becomes bigger, other sorts of germs from the outside air may get into it and help the tubercle germ to spread destruction, thus finally pro- ducing what we call "Consumption." If, however, the body is put under favorable conditions of feeding, of fresh air and of wise living, its cells will be so strengthened that when the poison of the germ The Germ attacks them, it will not be able to kill, but only Defeated to irritate them. This irritation causes them to Fibrosis. change from simple round cells to long cells, which gradually turn into scar tissue. Undei favorable conditions this wall of scar tissue slowly gets thicker and thicker, and while this barrier of scar is being built around the trouble, Nature is busy depositing chalk in its center. If this process goes forward successfully, in the course of two or three years there is built up around the disease a strong wall of scar tissue. This process of scar tissue formation shutting in the trouble is what we call "Fibrosis," and it is by such Fibrosis that the body manages to overcome the germ and to free itself from active evidences of disease. Hence the disease is really a struggle between "Caseation" and "Fibrosis," and it is only by doing everything we can to favor a satisfactory Fibrosis that we can conquer the trouble. From this it is evident that our efforts at treatment must be chiefly directed to strengthening the patient's body, for whatever strengthens this, strengthens the cells which compose it and enables them to build up a strong wall around the disease. The disease can be compared to a battle between the germs which have gotten into the body and the cells which make it up. If these cells are well nourished and cared for they will win, and will shut in and finally kill the germ ; if not, the germs will by degrees kill them and cause the patient's death. Once the disease has attacked the body, it always leaves scars behind, as a careful examination of dead bodies will show. P *vrt -f Since, however, with careful living, these scars rv[ r g * y w iH remain firm and strong, enclosing the trouble, in which by degrees the germ may die out, patients may justifiably be considered "cured" ; but it must never be forgotten that as a result of dissipation, overwork or sickness, the disease may break out again. The examination of the lungs of those who have been healthy, and have died of some other cause, will show that a very much larger number of people have had active trouble at some time in their lives than ever die of it, the scars of old healed disease being found in such cases. Tuberculosis is not like typhoid fever, or smallpox, or mea- sles, or scarlet fever, which diseases are easily and quickly taken if you come in contact with those who have them, and which develop in from one to two weeks. It is caught much less easily, takes a long time to develop after it is caught, and can be prevented from developing, very often, by wise life, or can be cured, or arrested in a large number of cases if it has not gone too far. Therefore, it is not necessary to despair and give up hope if you, or some one you love, have caught this disease, but it does demand an immediate improvement of your ways of life, and of your surroundings, so as to strengthen your body to the utmost in order that it may be able to shut in, wall up and conquer the trouble. The cure is not as complete as it is in pneumonia, for instance, where after the disease is cured there is no trace of it left in the body. In tuberculosis scars are always left and germs for a long time can be found in these scars, and unwise living can enable them to break out again, but, as ample experience has shown, it can be so successfully walled in that all symptoms of its presence may be lost, and the patient can resume a normal and useful life if only he is willing to live wisely and prudently. However, a relapse is always possible after an arrest, even after many years. V. HOW AND WHEN DO PEOPLE TAKE THIS DISEASE? "The conviction has gradually been strengthened that the first infections from tuberculosis often occur during infancy and childhood, and that extreme care is required Childhood in- if this is to be avoided in tuberculous fami- fection. lies." . . . "It is now generally believed that the first seat of disease is in the lymphatic glands, where the bacilli may lie quiet for many years. If the number and virulence of the bacilli are sufficiently great, disease may follow infection in a short time; otherwise, complete heal- ing may occur without the development of any recognizable symptoms of disease. It seems probable that many of those who develop the disease in adult life have carried the latent infection since childhood and have not received a new infection when symptoms of the disease appear. . "It has also been found by experiment that it is difficult to reinfect an animal that has already been inoculated with tuber- _ culosis. Hence, it is inferred that some degree conger o Q f i mmum 'ty must be thus produced that may j- serve to ward off bacilli which might find lodg- ment in an individual not previously infected. Therefore, it will be understood how mild infections, which are healed, and are present in most persons who have reached adult age, may, and presumably do, offer some protection against further limited invasions of the tubercle bacilli. While persons are in good health, the protection thus offered is an advantage, having some resemblance to vaccination, but only very limited in nature and not complete. Prolonged or intimate exposure, however, or exposure to a severe type of tuberculosis, may result in a new infection, even of those who have overcome a previous mild infection. It is, moreover, by no means certain that in debilitated conditions due to other diseases, to dissipa- tion or to bad environment, new infections may not occur. We know positively that the first childhood infection may under such circumstances break out anew and thus become a doubtful advantage, a real sword with two edges. "Considering the natural and acquired resistance to infection which is unquestionably possessed by adults, much unreasonable fear, or 'phthisiphobia/ has prevailed in late Unreasonable years The resultg of this have some times been " b^ul * U ~ a deplorable neglect or persecution of consump- tives. Because there is no precaution too great for the protection of the young and delicate, this does not jus- tify healthy adults in exaggerated fears for their own safety."* As has been said, this disease is probably caught in most cases in childhood and lies inactive in the body for a longer or . Q shorter time until the conditions are favorable Tuberculosis for {t tQ develop but it can be acquired at any *J. u time or age. Since the germ can, and often does, lie quiet in the body for many years before it develops and is discovered, it is usually difficult or impossible to say just when or under what circumstances the person became * Dr. Hermann M. Biggs, Journal of the Outdoor Life, March, 1914. ' -1 ! 8 infected. It should always be remembered that it is almost always a house or indoor infection, and that it is rarely or never caught outdoors where the sunlight, which is our best disinfec- tant, quickly kills the germ. Thus the great and real danger is from living with careless, dirty consumptives, and especially, in dark, damp, dirty or ill-ventilated houses, sleeping and living rooms, workshops, factories or stores, which have become infected with the germ by the sick people's careless spitting habits. The germ, which is a microscopic rod, invisible to the unaided human eye, is found in millions in their spit from very early in the disease, and it is through this spit almost alone that it reaches others. If we could collect and destroy all the spit of such patients and make them cover their mouths when they cough, we could almost wipe out the disease. Fortunately, when people spit outdoors the danger is not quite so great, since, sooner or later, the sunlight will destroy the germ; but when they spit indoors, as many do, where the sun cannot get at the germ and kill it, it may remain alive and active for a long time. Hence people who spit in this way are a terrible danger to all who live with them, or to those who stay in the places where they live or work. Many people do not know that they have tuberculosis, but think that they have only a "bad cough," when they already have the disease and are bringing up the germs in their spit. Every one, therefore, who spits or has a cough should be just as careful about his spitting as if he knew that he had tuberculosis. If those with germs in their sputum spit on floors or sidewalks, the sputum will be ground under foot, blown around as dust in the air, and inhaled by other people, and will finally reach their lungs. Even when they use spittoons, unless the water be carbolized, flies will get at the sputum and carry it on their feet to other people's food, and thus possibly infect them. In the home the chief danger, as has been said, is to children, although adults may also become infected. The two chief sources of infection for children are, first, con- Infection sumptive relatives or fellow lodgers, and sec- from care- ondly, infected rooms, dwellings or dishes. less per- Children are apt to be kissed and fondled, and sons in the in this way the germs may be carried directly home. to them. Again, they play around on the floors, too often infected with spit, arid thus acquire the trouble. Therefore, the kissing or fondling of little chil- dren by sick relatives or friends should be prohibited, as well as the bad habit of feeding them from the spoons and plates of such people. Indeed, as far as possible, children should be kept away from their sick relatives as long as the latter cough and spit. No one should move into a new lodging without finding out first something about the last lodgers, and making a careful disinfection of the rooms, if the previous resi- T h e danger dents were sick or coughed badly. In the dark of infected corridors of many houses the germ may live for rooms. a long time and unfortunately many people who would not spit on the floor of a bedroom, will do so on the floor of a corridor. If every one who reads this will see to it that his home is kept strictly clean, that as much sun- light as possible is admitted to it, and that no one is allowed to spit there carelessly, it will do much to lessen his family's danger of catching this disease. The dry sweeping of rooms should never be allowed, as it raises clouds of dust, which may contain the germs, which are thus breathed directly into the lungs. Therefore, Dangers o f a ^ broom sweeping should be preceded by strew- s w e e ping ing the floor with damp sawdust, old tea leaves and dust- or bits of wet paper or something similar, and if ing. it is at all possible, vacuum sweeping or cleaning should be used. Outside of the home, there is much danger in shops, work- shops, factories and mills. Experience shows that both clerks and workmen too often spit promiscuously on How work- ^ e fl ors f their work places, and since many ing men in- f them, often without knowing it, have the dis~ f e c t one ease, they infect their fellow workmen, and every another. year thousands of American laborers are made sick in this way. If only our labor unions knew the great danger to their members from the careless spitting habits of sick workmen, they would insist that every one who spits should use a spittoon containing water with a tablespoonful of carbolic acid to the pint, and they would see 1 to it that those who persist in breaking this rule should be dismissed from the union. In this way they could greatly lessen the number of their members who get this disease. 10 Infection also comes about from a patient spraying out and Infection scatter * n aroun d nn e drops of moist spit when f r o m a he cou g hs or sneezes. This could be entirely cough ing avoided if every one formed a habit of covering patient, his mouth with a handkerchief at such times. "Dr o p 1 e t This danger is so real that public opinion should Infection." enforce such a custom. The germ may also be taken into the body in uncooked cow's milk. Cows frequently have tuberculosis and the germ may get into the milk, sometimes in large num- Infection bers. While in grown people this is not a com- through mon source of infection, it is a common source Milk. in little children who drink much uncooked cow's milk. The germs are carried by the milk into the bowels through whose walls they pass and enter the system through the lymphatics, lodging usually in the glands around the roots of the lung, or in those attached to the intes- tines. Therefore, unless one is certain that the cow which sup- plies the milk is free from tuberculosis (which can be told by a test that a good veterinary doctor can easily make), the only safe thing is to pasteurize or boil all milk which is used by the children of the household. There are a. number of other sources of infection, but they are not very important and we need only mention a few, such as the kissing of consumptives ; the regular use Other sources of their unwashed dishes or clothing, and careless o f infec- contact with the pus or other discharges from tion. tuberculous sores. It has been shown that there can be a danger of infection from the unwashed hands of consumptives, and all such patients should wash their hands, faces and mouths frequently. It is now known that tuberculosis is not hereditary, and that it is practically never handed on from the parents to the child before birth. We recognize, on the contrary, that Hereditary the infection comes from tuberculous parents or Infection. relatives, who usually infect the healthily born child a short time after birth, if their habits are careless. Even with much care it is difficult to avoid the infec- tion of the children by their tuberculous parents. When we see a whole family die of this disease, one after another, it does not mean that they inherited it from the parents, but that there was 11 carelessness in the family and that each child in turn acquired the disease from the careless parent, brother or sister. How- ever, in families in which there has been much tuberculosis among the parents or grandparents, there is at times found a lowered resistance to the disease so that the children in such families must be brought up with especial care as to their sur- roundings and life. As has already been shown, when this disease is acquired, it does not usually develop at once, but may lie latent in the body anywhere from one to twenty or more years. Latent T u - During this time it may sometimes cause some berculosis. symptoms which only a doctor would recognize, and which pass off so soon that the patient pays no attention to them. Thus people who are subject to repeated spells of "grippe" or colds every winter, or to attacks of pleurisy now and again, those who suffer from periods of "rundown- ness," or who are obstinately dyspeptic and habitually pale and below normal weight, or are chronic coughers and spitters, are very apt to be really tuberculous, and often, unconsciously, hand on the disease by their cough to others. v From what has been said, it is plain that, if all people who have any spit would destroy it carefully, would cover their mouths when they cough, would refrain from The duty of kissing and would keep their hands clean, and if the patient all milk, for children at least, were boiled before to the com- use, unless it came from veterinarily tested cows, munity. it would not be long before we would get rid of the trouble entirely. ' VI. HOW CAN YOU AND YOUR FAMILY KEEP FROM GETTING THE DISEASE? See that you and your children do not move into any room, house or workplace where a consumptive or a person with a chronic cough has lived, worked or died, until it Thorough ^ as keen carefully disinfected by the Board of disinfection health or your doctor. Any room or house can of homes. be made perfectly safe without very much trouble. First, by formaldehyd disinfection. Hang up by two corners in each room a sheet thoroughly wet with a quart of 40 per cent, formaldehyd solu- tion, which can be gotten cheaply at any drug store, after first 12 i. shutting all the doors, windows and fireplaces, and stopping up all the cracks with strips of newspaper put on with starch paste. Keep the room shut for twenty-four hours, and then keep all windows wide open 'for two days. There are several better but more expensive methods of disinfection with formaldehyd, which you can learn of from the Board of Health or your doctor. Second, and far more important, by thorough scrubbing with hot carbolized soap suds and water, followed by exposure to fresh air and sunlight. Remember, that mere fumigation with formaldehyd, without vigorous application of soap and water, and the letting in of sunlight and air, will not kill the germs of tuberculosis. Therefore, after the formaldehyd disinfection, wipe down all the walls and ceilings carefully with cloths dampened with some disinfectant solution ; then scrub thoroughly with hot water (in which put two tablespoonfuls of carbolic acid or of chlorid of lime to every quart) all the floors and woodwork. Then open the windows to admit sunlight and air for two days. After such a procedure you need have no fear of infection in that room. See that no one in your house or in the place where you work, whether he thinks himself well or not, is ever Stop promis- a n owe( j to sp j t on t h e floor, or anywhere where fj ^ S his spit cannot be burned up or thrown down the sewer. See that your home or workplace has windows that open out- doors in each room, and never take a room whose windows open on a narrow airshaft, or which is windowless. T . , . . These windows should be opened often and far Light, air . , e r t and clean- enou g n to provide a good supply of fresh air, liness. an( ^ your rooms and corridors should be kept as clean as scrubbing brush, hot water and sun- light can make them. Keep the bodies of yourself and your family strong, healthy and resistant by good, properly cooked, even if very simple food ; by taking at least one warm bath a week; by Care of the the avoidance of late hours, dissipation, drink body. and unduly long hours of work, and by spending all your rest hours as far as possible outdoors and in healthful amusements. 13 Never cramp your lungs by tight or too heavy clothing, or. by stooped shoulders, or by stopped-up noses or throats, which prevent proper air getting to your lungs. If you Clothing and or your children have stooped, hollow, badly exercise. developed chests, practice regular deep breath- ing, keeping the shoulders back, and do easy gymnastics to broaden the chest. If your nose seems stopped up, go to a nose and throat doctor, or to a dispensary, and have it opened by proper treatment. Keep your children out of sick rooms, especially those of Keep your people who have coughs, because children, as has c h i 1 d r en been said, get this disease easily. While you away from need never be afraid of the careful cleanly tuber- c o n sump- culous patient, avoid unnecessary contact with tives. careless consumptives, as it may be dangerous. VII. IF YOU CATCH THE DISEASE, HOW CAN YOU FIND IT OUT SOON ENOUGH TO CURE IT? Remember that this disease can be cured in the majority of cases if it is discovered early, while if it is not found out until it is advanced, it is hard to cure it at all. Early discov- I n early cases, proper food, rest in the open e r y the air by day, and, if possible, by night ; clean great es- surroundings, and if at all possible, the help of sential. an intelligent doctor will do wonders. Since if tuberculosis is to be cured, it must be found out early, it is very important to understand the early symptoms which warn us of its presence. Unfortunately, many doctors do not give especial attention to this disease and overlook it until too late, or mistake it for other things, especially "grippe," "a chronic cold," malaria, stomach trouble and nervous prostration. A careful doctor will always strip your chest to the skin for examination, and no examination through the clothes is of any use at all. Further, he will study your fever every two hours for at least a week, will have your sputum examined in every case and will go very carefully into the past history of your case and your surround- ings. ^If these things are not done it will be impossible to find out the trouble in any but advanced hopeless cases. If you can- not get a doctor to examine you in this thorough way, go at once to the nearest dispensary and have your case studied carefully by some one familiar with this trouble. 14 If you cannot get expert advice, an intelligent study of your symptoms may make you reasonably sure of what you have. The disease may begin in different ways. The Early symp- most common early symptom is possibly a slight toms. cough, usually, but not always, in the morning, and which will not yield to treatment. Every cough that lasts more than three weeks should be regarded as suspicious. A chronic cough with spitting which has lasted for years, even though it has never made its owner sick, is very suspicious. Often, however, before a cougfh appears there are other symptoms which warn us, and of these none is more useful than an unwonted sense of tiredness, exhaustion or weariness, com- ing on without any good reason. This is often supposed to be only laziness, or is ascribed to "malaria," "nervous prostration," or to other conditions. It usually comes on in the afternoon between 2 and 6 o'clock, and may be accompanied by flushed cheeks, bright eyes and feverishness. Often the patient will waken just as tired as he went to sleep. Just as with the cough, so persistent weariness should cause you to consult your doctor. Again, a long-continued hoarseness which does not leave is suspicious. An important symptom of the trouble is a steady and unexplained loss of weight, and this should always excite one's thought. A very suggestive early sign is loss of appetite or persistent indigestion or "stomach trouble." The indigestion may have lasted for years and have had all sorts of treatment, and when a cough appears, it is spoken of as a "stomach cough" ; but the only safe way is to have a careful physician investigate why you are having indigestion and why you cough. Fre- quently the trouble begins with a slight blood-spitting, which may not be followed for a long time by the development of real trouble, and where the doctor can find no changes in the lungs, but such blood-spitting, or blood-streaked sputum, is practically always a sign of tuberculosis and must never be neglected or explained away without a long and careful study of the case. Night sweats will at times be the first symptom, but they are usually preceded for a long time by other symptoms : and are not a common early symptom. A persistent pain in the chest, especially in the shoulder, should be carefully investigated, and not passed off as "rheumatism" or "neuralgia," as at times it is the first manifestation of a tuberculous pleurisy of the top of the lung. 15 Fever is not usually an early symptom, unless we use a thermometer to find it, but at times the patients will notice that they are hot and flushed in the afternoon, and the thermometer will show that while the temperature is normal, or below nor- mal in the morning, in the afternoon it rises from a degree to a degree and a half. Usually after the cough has lasted a little while, some spitting is apt to begin, and this must never fail to be carefully examined often under the microscope by the local Board of Health, or by your doctor. If the germs are found, it is certain that you have the trouble, but even if they are not found, it should never be forgotten that this does not prove the disease is not present, for the germs are often absent from the sputum for a long time. Any or all of these symptoms are suspicious and should cause you to consult a careful doctor. If you cannot get to a doctor you are pretty safe in taking it for Don't wait granted that when a person has a persistent, until it is slight cough, with loss of weight, appetite and too late. strength, with probably some tiredness and pos- sibly some slight sweating, he has the begin- nings of this disease. Remember also that fever, chills and sweats are just as often caused by tuberculosis as by a malaria, sometimes known as "chills and fever." Even if the doctor cannot find the signs of tuberculosis when some of these symptoms appear, and it is very often impossible to do so at this time, it is much safer and wiser not to wait until he can find them before taking precautions. In some cases this may be a matter of months and may make it too late to do any good. Therefore, in the face of such symptoms, whatever the doctor finds, alter your methods of living at once, increase your fresh air, improve your food, lengthen your hours of sleep and rest, and, if at all possible, lessen your hours of work. Thus you may strengthen your body to the point where it can throw off the beginning disease. He who insists on being absolutely sure that he has the disease before he begins to treat it, will often throw away his best chance for getting well, for when there are such unmistakable symptoms as hollow cough, abun- dant spitting, high fever, profuse sweats, flushed cheeks and great loss of weight, it is usually very much harder, if not impos- sible, to get a cure. 16 VIII. IF YOU HAVE CONTRACTED THE DISEASE, CAN YOU GET WELL, AND HOW? In any given case a sensible doctor can usually tell you whether there is a chance of your getting well. As has been said, early light cases are curable in the majority of instances. More advanced disease, with careful treatment, yields a good percentage of recoveries, and it is worth remembering that a certain number of very bad and apparently hopeless cases do, at times, recover when it seemed impossible for them to do so. Therefore, however bad the outlook, it is sensible not to give up hope, but to start right in to make the bravest fight you can. In any case your chance of getting well depends largely on the early discovery of the trouble and on your grit and courage. _ A brave and determined patient with a bad Recovery de- troub j e generally stands a better chance of recov- er y than a s ^y weak-willed one with much less YOU trouble. Tuberculosis of the lungs may appear in many forms, most of them tending to be chronic, slow and long drawn out; of these a large number are curable ; a few are Your chance acute, rapid, galloping, and these are usually of a cure. hopeless from the start, while there are some intermediate cases which look very bad in the beginning, but which, with great pains and care, may finally be cured. Of the light and medium cases, discovered early, and which can get good conditions of life and sanatorium treat- ment, the majority can be cured so as to allow of a return to suitable work and self-support, provided there is a proper care of the future life and avoidance of harmful influences. Even in more severe and advanced cases with much trouble in the lungs, by a course in a good sanatorium, followed by careful life at home, a fair degree of health may often be regained, so that one need never lose hope. The length of time it will take to be restored to working efficiency varies according to the severity of the case; from six months in the most favorable cases to two or How long three years, or more, in obstinate ones. We will it know that a good number of cases can be and take? are cured; and since some very severe cases recover, it is alv/ays right to hope and strive to get well even if you seem to be very sick. 17 Getting well does not mean the taking of a lot of medicine. There is no medicine which by itself cures tuberculosis while the .., patient keeps on living the old kind of life. Avoidance of Nothing has done more harm in this disease drugs. than the habit of taking patent medicines, which I make lying claims to cure the trouble, when in fact they only stop the cough and pain by the opiates in them, which makes death easier but not any less sure or quick. Hence, any medicine which claims to cure tuberculosis is, on the face of it, a fake and its makef a liar. Avoid all such if you value your life. Some medicines which your doctor can give you are a help, but you are safer with no medicine at all, unless one recommended by your physician. When an intelligent doctor has found out your trouble, make every effort to get into a well-conducted sanatorium for tuberculosis ; or, if this is impossible, at least to Value of San- attend the tuberculosis dispensary in your town a t o r i u m regularly and join the tuberculosis class, if there treatment. is one. If you cannot afford to go to a special climate and get there comfortable and proper conditions, go to the state, city or county tuberculosis hos- pital. The cost of treatment in private sanatoriums ranges from $15 to $30 a week. To get proper conditions at a health resort will demand $65 to $100 a month. There are a few semi-charitable sanatoria where 'the rates are from $7 to $12 a week. In city, county or state hospitals the rate is usually from $4 to $7 a week, but, in almost all, patients who cannot afford this are cared for free at public expense. At the sanatorium you will not only get the advantage of better climatic conditions, or at least of country air, but, what is far more important, constant medical super- vision and the careful teaching and training of physicians and nurses in how to conduct your life and how to care for your case in the future. A complete cure will usually not be accom- plished at the sanatorium, for you would have to stay there too long a time for that. The activity of the trouble, however, will be stopped, you will lose most of your symptoms and will prob- ably feel perfectly well. This is a dangerous time, for you are not really well and you may be tempted to be imprudent, but if you have been a good pupil and have learned how to live, you will avoid this danger, and will know how you must live when you go home. 'By all means stay at the sanatorium as long as 18 the physician there advises, or as long, at least, as your means will permit. When you are discharged as an arrested case, you will usually go home able cautiously to resume your work, and, by carrying out instructions you will generally be restored Life when to good health in two or three years. You must you go remember, however, that unlike pneumonia, home. measles and other acute infectious diseases, after tuberculosis you can relapse and get sick again at any time, when dissipation, overwork, unhealthy conditions of life, or too little food, or certain sicknesses like grippe or typhoid, lower your vitality below the danger point and enable the disease to get a new hold on you. Therefore your staying well will depend upon eternal vigilance and common sense. If there is no dispensary or sanatorium available for you and you cannot possibly get proper conditions and good medical treatment away from home, don't lose heart. Home treat- While change of climate under proper conditions ment when is valuable, without those conditions it is useless, a sanato- and in any case it is never the first or most rium is im- important thing, and it is possible for you to possible. win out with sense and determination by tak- ing the treatment at home. Go to a good doctor, not so much to get medicines as to have him teach you how to live, and to guide your life and watch your case carefully. Keep for him a written record of exactly what you do every day, and how you feel both physically and mentally, and the run of your temperature every four hours. Let him see this once or twice a week and advise you accordingly. Apply the teachings of this booklet to your daily life and carefully follow all its instructions, especially those meant to prevent the spread of the disease in your family. Get a bright sunny room with two outside windows and a southern exposure if possible and the use of a roof to sit out on in good weather. If your town is dusty, try to Your room. get rooms on the top floor of a high building, for here you will escape much of the dust which is irritating to your lungs and throat. A special pamphlet on "Directions for Living and Sleeping in the Open Air" will be sent to you free, on request to the National Association for the Study and Prevention of Tuberculosis, 105 East Twenty-Second Street, 19 New York. This will show you how to fix your room, porch, roof or tent so that you can be most comfortable in the open air. Try and get the best and most nourishing food possible, as much meat as you can, once or even twice a day, preferably broiled or roasted, and as much good milk, but- Food. ter and eggs as you can afford. While milk and eggs are valuable if you can digest them well, they will do you no good if they upset your stomach ; other foods can take their place. A good amount of green vegetables in the diet is necessary. If you can stop your work for six months, do so and begin a rest cure at home on your porch or in your back yard, or, if this is not possible, in your room with every window Rest in the wide open and yourself well wrapped up in cold open air. weather. Carry out the cure faithfully by con- v . stant rest in the fresh air in a reclining position, until your fever, for a month at least, has disappeared. Then resume exercise with the greatest care. Keep your body clean by a weekly, or better, a daily bath, and in winter wear sufficient warm but light clothing ; but do not bundle up so warmly as to make you sweat or tire you. Do not muffle your throat up in shawls, nor wear chest protectors. Have your room kept as clean as possible with soap and water and a scrub brush, and keep all blinds and window shades wide open so as to let in all the air and sunlight you can. Remember, it is better to let the sun fade your carpets and pictures than to keep these un faded and kill yourself. If you are properly wrapped up, all the windows can be open day and night in winter as well as in summer. Night air is just as good and just as necessary as day air. If you are not used to fresh air, go about it gradually, opening each window a little further each night until they are all as wide open as they can be, half down from the top and half up from the bottom. Get, if you can possibly afford it, an easy reclining chair with a flat back and with some means of keeping your legs up off the ground, and except when it rains spend your whole day out of doors, but spend very bitter or rainy and windy days in your room with all the windows open. If you have to sleep in a room instead of on a porch, keep all the windows wide open, have plenty of warm but light bed clothes and keep your bed near one of the windows, or use a window tent.' Always dress and undress in a warm room. 20 The control of your exercise is one of the most important things in the treatment. At first, avoid all exercise, for many more consumptives are killed from over-exercise Exercise. than are ever hurt by too much rest. Keep this up until you can notice no fever over 99.5 in the afternoon and until you are gaining weight. When you begin to exercise, let it at first be for not more than two or three minutes, slowly increasing it by a minute or so each day, and stopping at once if it brings back your fever or if it makes you tired or short of breath. Never swallow your spit under any circumstances, because in this way you can infect your bowels and might get a hopeless and terrible form of this disease. If you are Further hoarse, or if your throat is sore, do not talk at all, hints. or as little as possible. Do not smoke and let nobody smoke in your room under any circum- stances, and avoid all smoky and dusty places. By living in this way, people all over this country have been cured, and are being cured every year of this disease, and there is no reason why you should not get well. Do not suppose, however, that you are well as soon as most of your symptoms stop ; the disease is still present and active long after you can notice no signs of it, and if you get careless or forgetful and do imprudent things, it can come back on you. Therefore, keep up a modified form of the cure for at least a year after you feel well, and for all the rest of your life live carefully, remembering what you have escaped. If you fight it out bravely on these lines, drive away the blue devils and insist on being careful, you will be surprised to find how well you will do and how you will gain weight, strength and appetite and lose your symptoms. After most acute diseases are over, the patient is as well as ever, barring complications, and is often somewhat more resis- tant to a new attack of the same malady than a Ttitt-.* .* u* man wno nas never had the disease. Tuberculo- Diiierence DC- , . , . j. i tween "Ar- S1S) nowever > 1S a chronic disease and has no rest" and nm ^ed period of duration, but, untreated, tends "Cure" in * run on indefinitely till it kills the patient. A Tuberculo- cured case is more, not less susceptible to a rein- sis, fection or a relapse than before; hence many doctors prefer to call the final result "an arrest" rather than "a cure." As long as the patient can return safely to work and by wise living be reasonably sure of staying well 21 and workable, it makes little difference which term we use if he is made to understand the facts. t When the tuberculous patient leaves the sanatorium, granted his case was discovered early and was a light one, his trouble is usually what is called "arrested." He has lost The danger all his bad symptoms and often all symptoms time. whatsoever. He has no fever or fast pulse, weighs more than usual and generally has no cough or expectoration. This tempts him to suppose he need take no more care of himself than he did before he was sick, a most dangerous idea. The wall of scar tissue which shuts in the disease is not fully formed and will not be for two or three years, and if he goes home to unwise or unhygienic living conditions the symptoms he has lost will slowly but surely return and others with them, and in a year "the last state of that man will be worse than the first." Many foolish patients, gifted by Nature with fine con- stitutions, have several such relapses, each followed by a new "arrest," and they are almost certain to break down again finally because they do not have the sense or will power to live wisely when they leave off the regular taking of the cure. When, how- ever, the patient has taken to heart the lessons of the sanatorium or home doctor, or this pamphlet, and lives wisely and carefully, he can, slowly but surely, continue to gain strength and build up a strong wall of protective scar tissue around the disease, and finally to accomplish that permanent arrest, with restoration of full working efficiency under reasonable methods of living, which is called a "cure." Much of the world's best work, whether mental or manual, has been done by men who at one time in their lives suffered with tuberculosis.* Cure, then, is possible, but to maintain it demands, not an invalid's life always scared of a relapse, but a constant intelligent remembering of the facts learned and a denial of certain over-indulgences both of work and of pleasure which medical science has proved are not safe for the recovered consumptive. Finally, remember that your getting well, however good your doctor is, depends chiefly on yourself, on Your common sense, on Your intelligence, on Your determination. Make Your part in up your mind you will get well; be willing to the cure. deny yourself any pleasure, however much you love it, if it is harmful ; be ready to do anything, however tedious and disagreeable, if it be helpful. If you are sick, fight bravely to be cheerful and bright ; if you are well and 22 living with a sick person, be sensible and do not cruelly make him miserable by your fears, but rather render him harmless to you by teaching him to carry out the above rules. In this way many men, women and children can be saved and returned to useful activity, who under the present carelessness as to these matters are doomed to death. IX. IF YOU OR YOUR FAMILY OR SOME ONE IN YOUR HOUSE HAS THE DISEASE, WHAT MUST BE DONE TO KEEP IT FROM SPREADING TO OTHERS? If proper and conscientious care is taken, there need be no danger to you at all from a consumptive living in the house with you. However, it takes eternal vigilance on the Disposal o f part of a patient not to transgress in these mat- sputum, ters and to harm other people. The patient should always spit in a piece of paper, or a paper napkin, which can be burned up immediately, or put in a box or paper bag protected from flies, and the whole burned up later. Such papers should be used but once, and as they cost next to nothing, the use of a fresh one every time will not be expensive. The patient must be careful not to soil his hands from these papers and should, as has already been stated, wash his hands and mouth often. A regular cardboard sputum box, or cup, with a tin frame and paper containers can be bought at any up-to-date drug store for about 25 cents. If this has a lid to keep the flies from its contents, and if it is filled with sawdust when ready for burning and burned up at once, it is satisfactory. If a spittoon must be used, put into it a quart of water and a tablespoon of pure carbolic acid each morning and empty this down the water closet the next mocning. Where no water closet is available, bury it in a hole in the ground far from the house. Such spittoons, however, must be cleaned by frequent boiling if they are to be sanitary. It is most important that the patient cover his mouth with a cloth or paper whenever he coughs, and such cloths or papers must be burned after use. If, by accident, any spit should get on the floor, on the clothes or on the furni- ture, pour over it at once a mixture of two tablespoonfuls of car- bolic acid (which is poison) in a pint of hot water, and let it soak two hours, at least, and then clean the place carefully. See that the patient's cup, glass, plate, knife and fork are scalded in 23 hot water and washing soda and wiped dry after "use. His nap- kins, towels, handkerchiefs, pillow cases and sheets must be well boiled before going to the wash. Avoid raising dust by sweeping, as this scatters the germs around. The use of wet tea leaves, wet bits of paper or wet sawdust on the floor before sweeping can prevent this dust. If possible, keep all flies out of the sick room, but in any case never let them get at the patient's spit, either in the spittoon, on papers or handkerchiefs, or on his hands or lips. If the patient spits much the beard and mustache should be shaved close, for they will get soiled with spit. The best preventive of infection for those around the patient are healthy bodies and cheerful minds. Therefore, see to it that every one who lives with a tuberculous Cheerfulness P atient or especially with a consumptive, keeps a nd good as we ^> strong and cheerful as possible. One who bodily is nursing a consumptive should be careful to get health the a brisk walk in the fresh air for at least an hour best pro- daily. In this way there need be absolutely no tection for danger to any one living with him, nor need he the family be in Danger of reinfecting himself, and it is I'd m ~ ent i re ty unnecessary as well as very cruel to treat these patients, as is so often done, as though they had smallpox and could infect you at once. X. HOW MUST YOU LIVE AFTER YOU ARE APPARENTLY WELL AGAIN SO AS TO REMAIN WELL? The most difficult time for the patient comes after his doctor, or the sanatorium, has discharged him, and he begins to resume his work and his ordinary life. At this time he has to meet the difficult question of a return to active life and to some sort of work by which he can support himself and his family. Whether or not he will remain well after he goes back to work rests largely in his own hands and depends on his will power, his self- control and his common sense, and upon his applying in his daily life all the knowledge which he has gained while under treat- ment. He must never forget that just as the disease has taken many years to develop to the point where it made him sick, so it will be several years, even in mild cases, before his lungs will be entirely healed. i 24 The chief reason why patients become sick again is because, thinking they are just as well as they ever were, they are impru- dent and neglect proper care of themselves. Why you While you can get well of tuberculosis and be must be able to do good, hard work, you can never again careful. risk putting an unlimited tax on your strength regardless of the consequences, and must be always careful to think before you act. On the other hand, do not go around morbidly dreading a return of this disease, for a cheerful, hopeful mental attitude is most important for health. Remember, you are not yet cured, but determine that you will accomplish that cure. However well you may look or feel, the longest part of your cure lies ahead of you. Doctors may have told you "your lungs are as clear as a bell," but even so, do not consider yourself a cure. The doctor cannot always be sure of the condition of the deeper parts of your lungs, and his failure to find trouble at his examination does not prove that there can- not be disease in the lung. When you come home, your family will probably tell you that you look perfectly well and that you are lazy if you do not work as hard as you did or play as hard as you used to. I m p o rtance But do not mind what they say, for such advice to the pa- is dangerous. You know how to handle your 1 1 e n t of case much better than they do, and many patients courage break down because they let their relatives or and mtelh- f r j en( j s convince them that they are able to do ce ' hard work or harder play. Whether or not you will complete your cure successfully and get well, depends largely on the common sense and judgment you use in regulating your daily life. Never forget you have had tuber- culosis, and while not being foolishly anxious, always live twice as carefully as you lived before. Many advanced cases have gotten well by painstaking care of themselves, while many excel- lent early cases have finally died as a result of their own cock- sureness and carelessness. It needs common sense and sand to get well, and you must use both. Tuberculosis is a disease which tends to have intervals dur- ing which the symptoms are less active, and other intervals when the patient relapses and the disease becomes more Return of active again. This is often called "grippe" or symptoms, "just a cold," but do not be misled by such com- forting names, but treat it as a relapse. Such relapses can occur easily even in the mildest cases, and must 25 r always be considered as serious and treated at once. They are usually shown by a rapid or steady falling off of weight, a return of an undue sense of tiredness, a beginning again of cough and expectoration, and the reappearance of a little fever. " If such symptoms appear, do not put off doing something until next week, but go back to absolute, or partial, rest at once. Often a short period of rest in bed will clear up all these anxious symp- toms, and you will make everything come out all right', but do not sit around and do nothing hoping that all will come out all right. Neglect of these warning symptoms has been the cause of many relapses and deaths. As to your home life, follow the instructions already given about your room and general accommodations, and remember that if you have to work indoors all day to sup- Home condi- P ort yourself it is all the more important that you tions. should have all the fresh air possible out of work hours to make up the difference. When one first returns to work, and may be somewhat overtaxed by it, it is wise to spend all the time out of work hours resting in .the open air, and only when you have determined that you can do the work satisfactorily is it safe to use your hours at home for exercise or recreation. Be very careful in the choice of your amusements. Many of those we like best are foolish or dangerous. Stay away from dances or dance halls, which are always dusty Choice of an< ^ overheated and demand overexertion, and amuse- from "movies," which are rarely well ventilated ; ments. avoid all crowded, close, dusty places where you run a big chance of catching grippe, which so often wakes these cases up again. Try to let your amusements be always in the open air. Until you are very well you should cut out all night amusements. Try to see that your workplace is sunny and airy, and above all, not dusty. Teach your fellow workmen what you have j learned about the importance of fresh air and the Your work- danger of spitting carelessly. Keep regular place. hours and always try to get a little rest after eating before you go back to work. .^ 26 As has been already said, wash your hands and mouth often and be careful to keep your teeth clean and in good condition. If your work proves hard and tiring, spend all Personal hy- Sunday in bed with your -windows open, and be giene. careful not to injure your family or friends by carelessness at such times as they are around you. Go to bed early and always try to get at least eight hours sleep. Take at least one warm bath in the week, and, if you are used to them and they help you, a cold sponge every morning. Do not let yourself become constipated, but do not get into the habit of taking strong medicines. XL WHAT WORK MAY ONE DO AFTER THE DIS- EASE HAS BEEN THOROUGHLY ARRESTED? In the majority of cases it is better for the patient to take up the same work he was doing before he broke down, unless it is very dusty or damp, or exposes him to irri- Your old job tating gases or to severe physical strain, or unless usually the it is one whose conditions caused his first break- best, down. If you will take the best care you can of the fourteen or sixteen hours you are not at work, the other eight or ten will take care of themselves, pro- vided the place where you work has a reasonable amount of day- light, or better, sunlight, and is well ventilated. Take all the rest you can during the lunch hour and rest when you get home in the evening. Try to avoid rushing from your eating to your work, letting a short period of quiet rest intervene, and if you find yourself getting very tired at your work, drink a milkshake in the middle of the morning and the afternoon. It will bring you to the end of your day less tired and feeling much better. Do not look for a "light job on the farm." There are none such. An indoor job you are used to, unless it is very unhealthy, means, despite certain disadvantages, less expo- Difficulty of sure, less physical and mental exertion, more finding regular hours and better wages, and will allow light out- you to get better home conditions. Therefore, door work, if you can, go back to your old work, but when 1 you are off duty devote your entire time to the rest cure for at least the first year, and longer if your case was an advanced one. Very possibly it was not your work, but what you did in your 'fourteen hours of leisure that was responsible for your breakdown. How you spend these hours of leisure will largely decide whether you remain well or not. 27 'V XII. HOW SOON MAY ONE RETURN TO WORK AFTER THE DISEASE IS ARRESTED? This is usually a question of how .long you can stay away from it. You should, if possible? have been without active symp- toms, such as bad cough, free expectoration, fever, sweats, tired- ness, weakness, shortness of breath, for at least six months. The earlier you have to return to work, the more careful you must be. Do not try to see how much you can do, but how much you can save yourself by common sense and forethought. If you can, start on half time or part time until you have tried yourself out, and then gradually increase it. A work which will break you down if you take it up all at once may often be done safely if you take it up by degrees, doing a little more each week until you work full time. It is important that the doctor who will watch you should examine you at the end of your cure, and make a record of his findings, especially if you are returning from a Skilful medi- sanatorium, so that he may know just what your cal supervi- condition is at that time, and thus have a stand- sion. ard of comparison when he re-examines you from time to time. At first let him go over you care- fully every month, then every three months, and then every six months for a long time. Finally, above all things fight for cheei fulness, stop thinking of your own woes and troubles, take an interest in other people and try to help them, and you will find that the sunshine you bring them will be reflected back into your own life. "Look up and not down, look forward and not backward, Look out and not in, and lend a hand." APPENDIX HOW TO PREVENT TUBERCULOSIS IN YOUR COMMUNITY It is the duty of every one who has recovered from tuberculo- sis, or who takes any interest in those sick with this disease, to do all in his power to prevent the further spread Your duty as of tuberculosis in his community and to teach a citizen. others what he has learned as to its proper pre- vention and care. The two chief ways in which its spread may be prevented are, first, through the destruction of the germ ; and second, through the raising of the resisting power of the individual to the disease. In the community these aims can only be carried out satisfactorily by the central authorities, but we all can help to cultivate a strong public sentiment on the subject and thus aid the cause. t. The germ cannot be destroyed unless the authorities know who has the disease and who is spreading it abroad. There- fore, a proper registration law is absolutely nec- Report ing essary, as has been proved in New York, where and regis- it was first applied and where the opposition of t e r i n g doctors to it, which at first was active, has cases. entirely ceased. Try to get such a law in your community. Only as these cases are known and their surroundings and habits studied by visiting nurses and otherwise, can proper measures for their treatment and for the protection of others from the danger be taken. Such measures are the proper disinfection and cleansing of their quarters during life, and especially after death. In this way the notorious "lung blocks" of many big Disinfecting cities, where for years every new tenant became sick rooms, infected from the spit left behind by previous tenants, have been made safe and healthy. Laws against spitting cannot accomplish much, but you can help to cultivate a proper public sentiment against careless Sanitary spitting until it is considered so nasty that no laws. man would wish to indulge in it. 29